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Essential

Principles of
Phacoemulsification
4r
AYPEE. HIGHTIGHTS
#r MEDICAL PUBLISHERS, INC.
T

Hssential Princ{ples
of
Phacoemulstficattdln

Editor

Pascal W. Hasler, MD

d;4
T IAYPEE. HIGHTICHTS
@,
i
l

4t l

AYPEE. HIG HTIGHTS


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EssentiaI Principtes of Phacoemulsification


PascaLW. Haster, MD

97 B-99 62- 67 B- 61 -B

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EDITOR

Pascal W. Hasler, MD
Fettow of the European Board
of 0phtha[motogy IFEB0)
Depa rtment of 0phtha[motogy,
University HospitaI of BaseL,
Base[, Switzerland
rr

Essential Piinciples of Phacoemulsification liilll

FOREWORD
First you have to know that I am a vitreoretinaI surgeon and
lwas rea[ty disappointed about my cataract surgery skitLs. I decided
to change that and found an exceltent and very experienced cataract
surgeon and teacher from lndia, Nirav PateL. The initiaL idea was
to put down in writing the knowtedge of Dr. Nirav Patel, in order to
remember at[ the imporiant steps of phacoemuLsification cataract
surgery during my time as a feltow at the "Advanced Eye Care Ctinic"
in Vadodara, lndia. After coming back to Switzertand I started to draw
important steps and pitfaLLs of the procedure in order to visuaIize the
topic. Dr. Patel showed the first draft to his trainees and he reatized
how they improved faster. lt finatty reached the size of the handbook
that you have in your hands now.
The question rises- why shoutd there be another book on
cataract surgery? WeLt, this handbook is quite different than most of
the other ones. There are a lot of practicaI tips and tricks a cataract
surgeon beginner as we[[ as a more experienced cataract surgeon can
benefit from. The idea was to make the topic straight forward and not
to oversize the content with information which is not of any practicaI
use. Most of the information taken f or this handbook has been given by
Dr. Nirav Patet. Besides, I was abte to compite additionaI information
on cataract surgery from other books, DVD's and homepages which
hel.ped me to write this book. You wil'tfind the list of the references at
the end of the book.
The sentences are short and concise and may sometimes
sou nd even [ike a com mand. Some of this i nf ormation is very im portant,
so I repeat it severaItimes in order not to be forgotten. Dr. Patel and
I decided to offer this handbook to at[ fetlows at the "Advanced Eye
Care Ctrnic" as a help and a guide for phacoemutsification surgery. I
reatty hope it wil.t help you to improve your skiLts!
lwant to thank Nirav Patet, MD who helped me to become a
better cataract surgeon and Frank Sens, who arranged the contact
with him. ldo atso want to thank my surgical teachers Chrisiian
Prünte, Joergen ViLtumsen, Ole Mark Jensen, Sebastian Wotf , Se[im
0rgü1, ULrike Schneider and Jürg Messerli. I want to thank atso Josef
FLammer for the support of ihis advanced cataract surgery training
in lndia. Last but not Least I dedicate the book to my famity, my wife
Deborah and my chitdren Sven and Mira.
PascaI W. HasLer, MD
v
CONTENTS

t. Phaco Methods and Device Settings.... ....... 1

ll. Positioning, M icroscope, Phacodynamics and More.......7


ilt. Wounds.....
Corneal ... . ..13

tv. Capsutorhexis............. ..............21

HydrodissectionandHydrodetineation........... . ...35

VI Grooving.... ........45
vil. Divide & Conquer. .......................57
vilt. Chip&F1ip............ . . .. ...ó5
tx. Stop & Chop.......... .....................69
X, Phaco Chop.......... ..... .. . ..75

xt. Cortex Removat.... ...,......,....,....77


xil Deating with Vitreous in the Anterior Chamber.............85
xilt. lnsertion of the10L............. .......93
XIV. Decision Taking in Cataract Operations . . 105

References ..,...,...,.107

1ndex......... .......,.....109

v,'l
llllllllllillliiiiiillilliiililiiriiiliiiilllrilllillililiillllilillliliillrililiiiiiiiliiiiliiiiililiiiliiiiiiilliiillllilrll n
Phace S4ethsds and
Devire Settings

>- The main four phacoemutsification methods / techniques you


wi[[ have to learn are:

1. Divide ú Conguer

e. Stop & Chop

3. Chip & Flip

4. Phaco Chop

and conquer technique, later the three other phaco-methods".

with the other techniques.

surgery. Three phaco programs shoutd actuatty be enough to


perform the 4 main phaco techniques.
> You have to know very wet[ your phaco machine in order to adapt
the device settings for yoursetf. Try white coming from the safe
side...

l;i
phacoemursirication
illlliillllilllliilil Essentiarpirncipres or iiilliililllllillllillllilililililllllilllililillli

[Abbott Medica[ 0pticsl]:

> You do not have to take over these settings. Use the safest settings
in your hands, but something must happen white you are working
in the eye. Too safe settings witl increase your working time in the

Continuous phaco power.

For chopping you need high vacuum power in order to hotd the
[ens. Therefore you may need to adapt the settings.

Phaco-2 program: for dea[ing with the smatter pieces of the


nucleus. Non-continuous phaco power.
i..-.€.=- -

:=l==:::::t
i,::::...=:..:::=:
, il irli ti r1r 11irtll1iltilii,o"upt"' r:
phaco Methods and Device Settinss iitiiliiiiiliiiiliili
],]l]lii

power.

> To scutpt the nucteus you need low outftow rate and just Littte
VACU U M.

High outfl,ow rate does not increase the speed of nucteus remova[,
but rather creates turbutence and high flow rate through the eye
and since you are not occtuding the phaco tip, you can use low
vacuum white grooving.

lf cataract surgeons tal.k about ftow, they generalty mean the


outftow rate white the pump is operating' This is measured in
mI per minutes.

The outflow rate is the ftow rate at which the ftuid leaves the eye
through the aspirating instrument Iml'/MinJ.
Remember: the bottLe height has no inftuence on the outflow rate
in peristattic pumps Iin venturi pumps there is a retationship: the
higher the pump, the higher the ftow.'.).

The bottLe height has to be adapted to the ftow since the chamber
shoutd stay stabte during work.

A low bottte and a high ftow wiLt lead to a coltapsed anierior


chamber.

The outftow of fLuid cools down the phaco tip whiLe working' Using
onty the phacoemutsification mode wit[ create a corneaI burn "

whiLe scutpting a hard nucteus you shoutd increase the outflow


rate in order to cooI down the phaco tip.

A decreasing loP witt manifest as a shattowing of the anterior


chamber, but there are of course other reasons for a shatlow
anterior chamber lwe wiLt see that [aterJ...
The infusion bottte height wil.ttel"tyou the l0P if the incisions are
tight and you are not operating the pump. The 15 cm bottte height
corresponds to 1 1 mmHg, roughty 15 cm = 10 mmHg'

As soon as you use the operating pump, ftuid witL ftow out of the
eye and the loP wiLt lower down. Look at the anterior chamber
depth white working in the eye. You may have to adapt the bottte
heig ht. ,l
it
3' ir:
. ,l¡
:l EssentialPrinciples of Phacoemulsification' iiilril r,' il il!

> Vacuum is buitding up when the phaco tip is occtuded. You do not
have a vacuum effect without occtusion... f Figure 11.

vacuum wiLt buiLd up in an occtuded tip. The higher the ftow, the
faster you wit[ buiid up vacuum IFigure 11.

is not the same as vacuum. You only have vacuum while the tip
"Flcw
is cccluded. Think about that when you are wo*ing with phaco."."

Fignge I
Vacuum is not important white sculpting the nucteus, but gets
important if you are eating the lens pieces. That's why some
surgeons have two or more programs of vacuum and pump action
during one phaco.
For a given amount of uttrasound power per time unit, more
volume of nuctear material wilt be aspirated white the tip is
occtuded. Therefore using occtusion during phaco is more time
and energy eff icient then without occtusion.

To hotd a piece of nucteus you need high vacuum. First grab it with
aspiration and create a short phaco power in order to get into the
piece and create tip occtusion for vacuum.

Uttrasound power creates a reputsive action meaning that the


aspirated piece is atso pushed away during phaco action. This
repu[sive phaco action has to be overcome by adequate vacuum
power in order to keep the piece at the tip.

4
iiiiiliiilliiiiliiiiil1chapter I: Phaco
Methods and Device Settinss
iif iiljillliiiiilif

opening towards the piece in order to rapidLy create an occtusion.


T'herefore you have to be aware of your tip angte fFigure 2l'

o .s\
r TT
.You have to leam to occlude tfte tip of the phaco
ptobe' You u¡¡ll then
be abls to uss the vac{¡um porsr. ln sofrer cataract you t4'ill need
less phaco power to eal lfie lens..."

Figure 2

Do not press with the phaco tip on the incision. compression of the
incision Lips with the working phaco tip wit[ create a corneat burn.
Especialty the anterior tip is in danger white scutpting deep'

As soon as you have vacuum buitding up, you know then that you
have occtuded the tip. But be aware of the fact that you wilt then
not have ftow cooting the phaco tip...

Do not use phaco power for tong time otherwise you have a corneal
burn.

lf the anterior chamber is ftattening during cataract operation,


then stop at[ maneuvers in the eye, catm down and think about
the reason. You may deal, with a subchoroidaI hemorrhage/
effusion, or an infusion misdirection syndrome lftuid passing
through the zonula or a capsutar tear which then accumulates
in thJ retrocapsutar space), or an instabte anterior chamber
due to inadequate infusion pressure or Leaky incisions, or fLuid
misdirection under the iris ptane in f Loppy iris syndrome or myopic ti,,tr
In
"or's" f Figure 3l'
eyes. A lot of
5l
' tt, t','l
;.j

'itl

I
principres or
1ii tiiiititliiiiii;t Essentiat

The term "positive vitreous pressure" is a descriptive and not ;l


a diagnostic term. lt just means that the anterior chamber is l

flattening... You wit[ have to f ind out why IFigure 3].


flilillrl
lf the anterior chamber is ftattening during cataract operation I
l

you have to pressurize the eye to normal or slightly etevated I

intraocutar pressure. lf the anterior chamber remains shattow


you deaI with either a subchoroidaI hemorrhage/effusion or more
often an infusion misdirection syndrome. lf the anterior chamber
deepens again check the infusion bottte, the infusion Iine and the
incisions IFigure 31.

Jhe descriptive term,,positive vitreous pressure" meañs that the ¿nterict


chamber is flattening. Find out whyl..."

Figure 3

A ftat anterior chamber with normal IOP is usuatty due to an


infusion misdirection syndrome. lf the media are ctear and you
can exclude a subchoroidaI hemorrhage/effusion, then continue
the cataract operation with lower infusion bottte. You may have to
convert to ECCE.
lf you diagnose a subchoroidaI hemorrhage/effusion during
cataract operation, immediatety pressurize and ctose the eye.

6
i|iiiijiiiiliiii iiiiirii ffiffi
Fcstttmmümg, S4ácr*scffiptr,
Fhacmdymermirs eruC
rn&ye

A cataract operation success is depending on each step of the


procedure. lf one step is not nicety performed, you witt pay for it
later in the procedure.
Each step in cataract surgery is important and needs to be we[[
done. Most of the time you have probtems during an operation
because an eartier step was not nicely performed.

Wett-performed cataract operation steps, even if time consuming,


wi[t help you to continue the operation safety.
A cataract operation success starts with a p[an. You have to have
a p[an how you want to operate the patient knowing the possibte
probtems of the patient's eye.

Each step ofthe procedure has a lot of influence on the next steps.
A problem at the end of the operation may have the reason at the
beginning of the operation.

Perform each step of the cataract operation meticu[ous and


accuratety. Don't be [azyl!!

Watch other cataract surgeon working. Watch also videos of


normaI cataract operations and the comptication management.
TaLk with other surgeons about your prob[ems during operation.
That's the way to get better.

,: t,l

7l I

I
lli lliiif iliiii essenttal Principles or Phacoemulsrfication

Ask an experienced surgeon watch your operation and then review


your steps. A good idea is atso to tape/record your operations at the
beginning. Afterwards you always know it beiter, but sometimes
you are not aware of what you are doing wrong.

eyes are then not a probtem anymore.

With a temporaI approach you avoid the brow. You have a better
access to the eye.

You can atso start with a superior approach, but this is a littte more
difficuLt to start with. lt is important to choose your patients and
not to start with these "deep" eyes.

Right foot for the phaco pedaI and left for the microscope or the
other way round. Learn to use both feetl Adapt to the way it is done
at your ctinic.

lf possibLe take your dominant foot for the phaco pedaI and the
non-dominant foot for the microscope footswitch.
Do not start cataract operations at your cLinic with a lot of speciaI
and new stuff onty for you. You have to adapt to the situation and
watch others. Your co-workers witl appreciate that.
First: check if the eye/the face are horizontaL to the microscope.
Often you have to ask the patient to put his chin up.

Then check if the head is not titted to the other eye. The f tuid shoul.d
fLow down away to the temporatside from the operation fietd and
not coLtecting around the operated eye and towards the nose.

You have to adjust your inter-pupitl.ary distance and the corrections


at the microscope before you wear the operation gtoves.

Check if you sit comfortabte, the microscope image is centered


and sharp, and the foot pedaLs are in the right p[ace.

you have atso a smatl. fietd of vision and a bad depth of fietd. With
a low magnification you wit[ not see detaits. Choose the best
magnif ication for your work, but do not use too high magnification.

B
illi]ilo."p."' ir: positionins, Microscope, phacodynamics and more lii]i]f f ljiliilil]i]il

> Start phaco training with retrobutbar or parabutbar anesthesia


[for exampte with Lidocain 2o/ol. A "moving eye" is terribte for a
phaco beginner.

> Do not perform surgery in case of retrobulbar hemorrhage due to


anesthesia. Better waii two weeks.
> Do not open the eyelids too much with the lid speculum. You
produce too much pressure from behind.

> Whenever you reatize that the eye presents with too much pressure
from behind then check first the lid specutum position.

correctty. lf you have had problems during the draping, you witl
have problems later.

> You have to take away the lashes from the operation fietd since
they are a major source of bacteria.

Take the lashes out of the operation fietd!

Start the irrigation for the phaco tip or l/A-tip before you enter the
eye Ikick the pedal, first horizontaLl.y to the teft or the way you have
programmed your phaco device).

Enter the eye always with infusion on. First, because you witl. have
less air bubbtes in the anterior chamber and second, because the
anterior chamber wiLt fiLt more contro[[ed.
You can program your foot pedaI as you want. Here is an exampte
with four positions: Position 0 - everything is off, Position 1 -
irrigation is on Iremember to start the infusion before you enter
the eye!), no pump, no uttrasound. Position 2 - irrigation is on,
pump is on, no u[trasound. Position 3 - irrigation is on, pump is on,
and uttrasound is on.

> You may atso program your phaco device differentty, but you have
to know exactly what is going on while you are pressing the foot
peda l.

> ln G4 or white cataract better operate in retrobutbar anesthesia.


The eye is not moving and it is easier to convert in ECCE or even
pars p[ana vitrectomy.

9-,
phacoemursirication
illlllliliiiillllllj Essentiar Friircipres or lllilllllllllliiilliliillliiiiiilililliiiiiiliiillll

Assess the difficuLty factors of the operation as soon as you look at


the eye: is there a risk of zonular Laxity [due to Pseudoexfoliation
IPEX] syndrome, history of trauma or Marfan's syndromel? ls it
a deep eye with big brow Limiting the superior access? Narrow
ang[e with littte space in the anterior chamber? ls the cornea
clear Icornea guttata, other dystrophy, scar)? Do you have a poor
red reftex [due to white or btack cataract, vitreous bLeeding]?
SmatL pupiL size [due to PEX-syndrome, long-term use of miotics,
posterior synechias, diabetes after [aser treatmentl? ls the patient
claustrophobic / nystagmus / monocuiar / cannot lie f [at, etc.?

It is not a sign of weakness if you feet not being the right surgeon
for this eye. Better be [ore before the operation than be stumped
during and after the operation.
The goaI of phacoemulsification is to remove [ens with minimaI
ultrasound power to reduce damage io the cornea, but safe phaco
does not mean low power. Appropriate phaco power is demanded.

Stop phaco power if you are not working ctose to the [ens!

It is forbidden to use the phaco tip ctose to the endothetium, the


iris or the incisions!

surgeryl
lf visualization gets poor during cataract surgery something is
wrong. You have to analyze the prob[em. Stop, look, anatyze and
act!

lf visuatization is getting worse due to corneaI epithelium edema,


you may use a topicaI hyperosmotaric sotution, Like gtycoL. This
witL give you better vision for about 5 minutes. lf this doesn't work
you may even perform a corneaI abrasion. You reatty need to see
somethi ng du ring phacoemu [sification procedure.

lf you do not have red ref tex then check the microscope parameters.
lf you stitt not have a red reftex then you have a white or btack
cataract, a vitreous hemorrhage or a totaI retinaI detachment, a
[arge retinaI tumor or a [arge retinaI hemorrhage. Better color
the lens capsute before doing capsutorhexis in these cases.
,,,,1O
l

iillrlliliillitillilr
tl iirllirliiil,liii;i
I

li ilill ; 0,"pter il: Positioning, Microscope, Phacodynamics and more l,lii'lirliiriiiil


I

> As a beginner it is easierto cotorthe lens capsutewith a dye. You


reatty see the anterior capsul.e better and can concentrate on your
movements in the eYe.

> A sma[[ pupiL is nothing for a cataract surgeon beginner' You have
to ditate this pupiL or if not possibte ask an experienced surgeon to
take over [Figure /*1.

,,Well, this pupi¡ is too sm¿ll ts start the cataract


proeedure for a beginner...*

Figure 4
lf the pupiL is smatl you are in troubte, since it may not get bigger
during ihe whote procedure. First try to ditate it with OVD and
additionat topicat mydriatic drops. You may atso put adrenatin in
the anterior chamber. Wait for severaI minutes untiI you see an
effect. lf the pupiL is stitL too smatI you need mechanicaI entargers
Like iris hooks or a Matyugin ring.

Forcataract surgeryyou need to have a ptan. This plan may change


during the procedure, but do not change the plan too fast. You may
have to try more than one time to be successful..

lf you trembte too much with your hands during the cataract
surgery, better remove the instruments of the eye and try to calm
down for several minutes and then continue. Don't let you be
siressed by others! You may atso drink coffee after the operation
instead of before.
11
ljiliiiiiliiililiiji Essentiar Fii¡cipres or phacoemursincation iiliiliiilliijiiiiliiillllilllllllliilllllllliiiiii

perform a stow, but safe procedure than a fast and dangerous one.
The speed of operation witl come after more experience.

certain situations.

in troubte even before the operation, then ask a cottege that you
may need his hel.p.
ffiT
Corneal Wounds

To create a paracentesis wound you shoutd enter the cornea ctose


to the [imbus and paratlet to the iris plane. This is safer for a
beginner. You wiiL have less probabiiity to touch the [ens and due
to smat[ hemorrhage at the entry site you wit[ have less probtems
to find the entrance Later f Figure 5f .

You may go more and more to a ctear corneal approach for


paracentesis as soon as you are getting more experienced. The
risk of iris protapse is less then since the distance from the iris to
the cornea increases.

A tittLe bteeding from the Limbal. vessets created during


paracentesis creation doesn't matter and wit[ hetp you to find the
access tater IFigure 51.

,,Little bleedings indicate you


*
the pa rac*ntesis-rites...
Figure 5

15 ]i :
illiiiilliiiillliiii Essentiar
principres of phacoemursification iiiiliiilliliiiillliiijlijillliiirliiiiiliiliilllliiii

,,Avcid too short and tso long tunnels...'


', 'Ftgure 6

As a beginner you have a high risk of destroying the wound


architecture during manipulations in the paracentesis wounds.
This is a problem in short tunne[s since the wound may stay open
at the end of the surgery.

You need to pass through the totaI thickness of the cornea white
creating the paracentesis or the tunne[. Especiatty you shoutd pass
the [argest part of the blade through the endotheLium (Figure 71.

the €ye completely wh¡le you are perfoming the wounds.


"Enter
You hav€ to pass the eüdotheliu$ with the laryest part of the blade...

Figure 7
¡;: l;:¡¡.:$¡f[
-_

lirI Chapter III: Corneal Wounds

A very tight paracentesis wil.[ aLways make probtems when you


want to enter the eye. lf you finatly have entered the eye you
probab[y aLso have destroyed the wound morphotogy and it wiLL
not be watertight any more. Enlarge it or make a new one at the
beginning of the procedure...

lf you perform your paracentesis scLera-cornea[, you wiLI atways


have prob[ems to enter the eye because of the conjunctiva. yáu
may even have conjunctivaI baltooning...

wi[[ have to work with these incisions later [Figure g).

prob[ems manipulating with your hands close together IFigure B].

,Jhink about where you püt the paracentesis..

Figure 8

>- Avoid extreme etevation of the phaco tip or the l/A hand piece
during intraocuLar maneuve[s. you are stretching the wound and
it may not be sel'f -seaLing any more...
Perform the ctear corneaI incision as peripheraI as possibte. You
wit[ have less astigmatism thereafter and witl. be abte to work in
the eye with betier visuatization f Figure 9f .

,,A peripheral tunnel does cr*ate less lolds in th* cornea


during manipulaüons a*d you will have better visiofi..""

Figure 9

meridian. The more centraI you put the ctear corneaI incision the
more you have astigmatism.

cornea than a temporaI incision.

You need an adequate size of the main incision in order to work


property in the anterior chamber with the phaco tip. A snug
and therefore tight incision witt he[p you to reduce intraocular
turbutences and iris protapse. You wit[ be abte to etevate the
infusion bottte and work in a stabte and deep anterior chamber.
Better stabitize the eye with a second instrument during
paracentesis and tunne[ preparation. This instrument shoutd hotd
the eye 180o from where you want to work lFigure 101.

:16
Chapter III: Corneal Wounds

Stabil.ize the eye white performing the incisions, but don't press
too much on the gtobe. Better hotd it with a forceps for exampte
IFigure 10].
Fixating the eye during ctear corneal incision is safer. You can
use a cotton tip, a fixation ring or even the finger opposite to the
incision side IFigure 10).

,.$tabili:e the eye cpposite af the ir¡clsion site


during the tunnel cieatiün.-."

Figure 10

Do not use extensive pressure to hotd the eye with the second
instrument. lt is better to hold it with a forceps then.
Take care not to create the paracentesis or the tunnel too ftat. You
may hit the endothetium after coming into the eye.

with 0phthatmic ViscosurgicaI Device f0VD] prior to tunneI


preparation f Figure 111.
in t*e OWD from thr oppo$ite side. You w¡ll have a nice lilled
"Fill
Anlerior chamber and will b'e sble to push out !¡tlle air bubbles..."

Figure 11

lf you loose a cannuta f rom the syringe whil.e injecting OVD or BSS,
then remember to tighten it better next time...
lfyou nick the [ens capsute during paracentesis or tunneI
preparation, then remember to include the nick during
capsutorhexis, Use it as the starting point of the rhexis...

lf you nick the iris, do not worry. This is usualty not a big deat.

lf you put the paracentesis at the wrong ptace, then make another
one... IFigure 81.

lf the paracentesis is too smatt, then entarge it or make a new one.


lf too big/l.arge, then you may suture it later.

lf you start the tunnet scterocorneal. Ithrough the conjunctival then


open the conjunctiva parattel to the [imbus in this area. You can
avoid conjunctivat baItooning lFigure 121.

lf the main incision is performed through the conjunctiva and the


wound does not seaIwetl during manipulation you wi[[ experience
a battooning of the conjunctiva IFigure 12).

ln case of batlooning of the conjunctiva, you have to perform a


conjunctivaI incision ctose to the conjunctivaI opening or entarge
the conjunctivat opening in order to create a passage for the ftuid.
You have to open the Tenon too to push out the water. Press out
the water firmLy IFigure 12).
18
]iiiiiiiiiiii]iiiiiiril

,,A sclerc-cornealtunnel creates often a conjunttival ballooning


during phakoemulsificaüon. You have to act aga¡nst it.'."

Figure tz

ConjunctivaI baLlooning wil"I decrease the visibitity for the cataract


procedure since water witl cottect in front of the cornea.

lf you know that you have to deat with a rock-hard cataract then
put the phaco tunne[ backwards, meaning that you do not perform
a cLear cornea incision, but a sctero-corneaI incision. The cornea
witl. benefit from this position since corneaI burns may occur due
to excessive phaco power.

A scterocorneaI approach is normatLy atso safer, brings less


corneaI burns, is seLf-seating and induces less astigmatism.

Check the eye pressure before you enter the eye! EspeciaLty after
having performed a retrobutbar injection or in eyes with known
high intraocutar pressure. lf the lOP is too high then first press
on the eye for 1-2 minutes. lf stitL too high then do it again. lf stitL
too high you may even use intravenous mannitoL to lower down
the pressure Itnot working wel.t in vitrectomized eyes...), and check
with anesthesioLogist, if patient is abLe to take mannitoU.
lf you know that you have a high intraocutar pressure before the
operation, give carboanhydrase inhibitors preoperativeLy. This
is also a good idea if you have a patient with shattow anterior
cha mber.

19
KW
Cnpsutnrhexis

Since it is a very important step: take your time!

You shoutd exercise the procedure on an a[uminium fltm, a tomato


skin or other tissues before trying it on a human eye.
You may have the opportunity to use preformed cystotomes or
cystotomes bended by your operation staff. lf not, then you need to
practice the bending.

lf the needte is not bended correctty, you need another one.

lf you do not want to work with the cystotome, you may pinch
the capsute on purpose during the paracentesis or tunneting
procedure. lt is easier then to grab the borderwith the forceps.

As a beginner you shou[d start with a col.ored anterior capsute.


Use a dye [Vision Btue for exampte) in order to concentrate on your
maneuvers in the eye.

You may directty inject the dye through the paracentesis Ibefore
OVD!) or you may f irst inject an air bubbte in the anterior chamber
and then put in the dye. Afterwards you need to ftush the anterior
chamber severattimes untityou have a clear view.
Capsutorhexis must be around 5mm, not too big and not too sma[t,
but better a Iittte too big then too smat[.
2t
___-...-.-tl

Essentiar principres or phacoemursirication liliiiiliilllllllllllllllllllilililllllllillllllilllll


llillillillllliiiillll

plan to put in.

pupit. This witt give you a nice rhexis.

into the zonutes f Figure 131.

is the safe ¡ane f*r capsulorhexis. The ronules are u*ually


"This
inserting around this I r*m dianreter...'

Figure'15

Must be curvitinear and round. The correct name for the good
capsu[orhexis is CCC for "continuous curvitinear capsu[orhexis".
Just do it Like the name says f Figure 141.

:ZE
continuous curvil¡near capsulorhexis...
"CCc =

Figure L4

As a beginner you better start the capsutar incision in the center


or paracentraL. This gives you a certain security margin. You wit[
then be abte to create a ftap and curve the rhexis before it reaches
the periphery (Figure 151.

,,As a be8¡nner do not gtart the rhexie in the periph€ry..."

Figure 15
23
l,rtililiiii;i;;ill Essentiar
principres of phacoemursification
lillillilliilliliiliiiiililliillllllllllliilllllllillll

> As a beginner, use two hands during this procedure. The dominant
hand is hotding the rhexis instrument and the other one hetps to
guide it.

paracentesis woundsl, pivot your hands in the opposite direction


that you want to have your instrument tip to move. lf you want to
have your tip moving downwards, then your hands must move
upwards [Figure 1óf .

,,U¡e the wound during manipulatians as a pivot."."

Figure 16

incision and sma[[ paracentesisl. The paracentesis approach


witL heLp you to keep a deep anterior chamber, but you have less
mobiLity of the instrument. The main incision approach gives you
more space to move, but OVD can also come out easier and ftatten
the anterior chamber.

forceps not...

Do not push too much down on the cornealwound white doing the
rhexis. OVD may come out and the chamber wit[ ftatten and you
may atso experience fotds in the cornea with reduced visibil,ity.

Capsutorhexis procedure can be performed either by a shearing


technique or a ripping technique. You may use both techniques
during one operation f Figure 171.
,,There aretwo ways to pull the capsule. you can eather shear (an the left sid*)
or you can rip {on the right sida}. Ouring one c*psulorhexls procedure you may
have to use both te{hn¡que$,.."

t7

direction of the wanted direction f Figure 181.

,,Shearing techn¡quei üttack the llap along the culgr berder


and always pull ln the direc*on of the desired t+ar dirEction
in ¡ curviline*r mar¡n9r.,."

Ftgure 18
: :, .taalf

¿5,, .. l'ili
i: l' i:: l:ii,'
The ripping technique consists in putl.ing the fLap more towards
the center of the capsute. You have to pul.t the ftap at a point much
ctoser to the tear than with the shearing technique f Figure 191.

With the ripping technique you putl the tear more towards the
center of the pupil. IFigure 19].

,,tip9lng technique: attack the flap close to the flap btss,


pull the flap rnore towa¡di the cénter ánd stay on the
surf¿ce of the le¡s ?vhile pulling.,."

re 19

You have to train these two capsutorhexis methods first. Use an


atuminium fiLm, a tomato skin, other fitms or skins, or try it in a pig
eye. You witI be more confident to approach a human eye.

Watch atways the direction of your tear. lf it is going straight


outwards (radiatJ, then it wiLt keep on going out untityou react. lf it
is circutar, then it witI normatty stay in a circutar path f Figure 201.

....,26t.
,,Stop pullingl The ¡hexis is run*ing cut.
Stay calñ, and ftrst flll in OWO..."

- "'Figur€'.,,!Q.:',;i:

inject 0VD over the tear, and then use the forceps to make a sharp
turn inwards to prevent radiatization: grab the end of the ftap right
where the rhexis is heading out and then put[ inwards, somehow in
the direction in between radiaItowards the center and tangentiat!
And stay atways on the surface of the [ensl f Figure 211.
> To redirect the tear you have to act on the ftap ctose to the
evatuating tear lFigure 211.

,lo Jtrp th€ l€ff rlnilifiS out, yc! h¿ve td ritsck th¿ flig slore tü the Aát
¿nd pq,l th€ fláp parsc¿ntÉlly,,. snd dó rot forg€t OWD-állinÍ bsfofe..."

Figure 21

':t
¿
Essential Principles of Phacoemulsification llllllllllllllllllillllllillllli'iliiil'illi1ii lll

lf you are unabte to redirect the tear since it extended peripheral'l"y


then begin a new tear on the opposite side with cystotome, with
capsutar scíssors or change to etectro-capsu[orhexis procedure.

Do not move the cystotome or the forceps in the anterior cortex.


You witl. have difficutties to distinguish the border of the fl'ap'

lf you have difficul.ties to identify the border of the flap then inject
OVD towards the probable direction of the running flap' lf you stiLl
cannot see the fLap margin then use capsular scissors to create a
new tear or use the etectro-capsutorhexis device.

Avoid doing a discontinuity of the rhexis. Therefore do not hit the


capsute during paracentesis or tunnel preparation and finish the
rhexis from outside in and not the other way round.
lf you have a discontinuity in the rhexis, then repair it if possibLe.

Beginners shoutd cotour the anterior capsute with dye. lt is easier


to see the rhexis margin and safer. Ftush out the dye just after dye
injection with BSS lyou have to go in the anterior chamber with the
tip of the cannuta to f tush out at[ the dye). But do not mix up the dye
with OVD, otherwise you wit[get a btue mass and bad visuatization.
PEX-syndrome, uveitis and retinitis pigmentosa wil[ increase the
difficuLty to perform a capsutorhexis due to thickened anterior
capsute Ibe prepared, but not scared!!!]. Create an adequate rhexis
size in these eyes, since shrinkage occurs more often here over
time and you shoutd not end with a capsutar shrinkage syndrome
/ capsutar phimosis here.
AtypicaI CCC behavior atso in chitdren and juvenites' ln these
cases do not perform a targe rhexis, since the rhexis wi[l enLarge
0.5-1 mm after comp[etion of the rhexis due do etastic behavior of
the anterior capsule.
Put OVD with the blunt needte tip starting at the otherside of where
you enter the eye. This wil,L push away at[ bubbLes back through the
main incision. Press the inferior Lip of the tunneLa littLe down- the
bubb[e wit[ come out easier IFigure 1 1).

A shalLow anterior chamber indicates that the vitreous pressure


is higher than the anterior chamber pressure Of course there
are some eyes with anatomicalty shattow anterior chamber...
Whatever, you need to deepen this anterior chamber in order to
work safe in the eye IFigure 22).
:28
I

L-
,,4 positivr vitreous pressur€ creaies ananterior disBlacemeñt of the lens
with zonular stress. The anterior capsule is under teñ5ioñ too,
Capsulorhexis will always run out in this situation,.."

Figure 22
> A shattowing anterior chamber results in an anterior displacement
of the lens and therefore zonuLar stress. These forces are creating
tension on the anterior Lens capsute. Performing capsutorhexis
under these circumstances wi[[ lead to peripherat propagation of
the tear IFigure 22).
>= You need atways OVD ready to inject white performing the rhexis
f Figure 231.

> Always deepen the anterior chamber!!! ln doubt / if the rhexis is


going outwards / if the chamber ftattens / if the fLap is not seen
cLearly, then refiItthe anterior chamber for safety f Figure 231.

,,OWO in the anterisr chamber counteract$ the positive v¡treous pre$s$re


and relieves the ten$¡on on the ¡onula and the anterior capsule.,,"

Figure 23

29

t
ii iiiiilliiiliilililil Essentiar?iincipres or phacoemursincation liiiiiiliiiiilliiillllilililljlllliiiillllilillliliiliililllill

towards the periphery, then never ever tet the anterior chamber
fLatten. Put ViscoeLastic even before exiting the chamber with the
irrigation instrument Iphaco tip or l/A-t¡p).

The rhexis is easier performed with OVD since the anterior


chamber is more stabte.
:r- lf the iris is protruding through the wounds, you have a major
probtem. But you wit[ have to deaI with it. Remember, that if the
iris protrudes once, it witL come again and again'.. The probtem
is that the iris is very mobite and the pupiltary margin is [ocated
ceni.lalto the inner corneaI wound opening. Try to get the iris out
from the paracentesis with a spatuta. Reduce the flow in the eye
Iput the bottte down) and deaI with minimal" OVD for the rhexis.
Eventuatly you have to perform another tunnet.

stretching due to smaLt pupi[s, posterior synechias, etc' and in


f Loppy iris syndrome" ln these cases do initiatLy not f iLtthe chamber
from the other side with OVD, but start directty at the tunnet,
eventuatty start even through a paracentesis and put 0VD under
the tunnet. This witL give you some space. And do not overinftate
the anterior chamber.

etc.l and "dispersive" (tike Viscoat,l. Speciat products Iike Heaton


5, Duovisc and Discovisc inctude both behaviors, cohesive and
adaptive. Cohesive describes the physicaI pattern that the f Luid
wants to stay together [best to maintain space and create space).
Dispersive means that it provides good tissue protection Ibest to
seaI off and to coat].
>' Remove air bubbtes in pLacing OVD distat from the entry site and
force them out. Then put BSS or Methytcettulose or Viscoat on the
cornea before doing capsutorhexis. Adjust the microscope to have
the anterior capsute sharpLy visuatized. You shou[d have a perfect
vision white performing the rhexis.

i ntu mescent cata racts.


li€, '. , ::::,
::1'.'.,..
''.30
Chapter IV: Capsulorhexis iiiiiiiiiiiiiiiiiiii

>= Use needLe first, as [ong as possibte. lf rhexis is going out, then
refiLt the anterior chamber and then use the forceps. PutL the
rhexis margin directty at its end, ftat on the surface of the Lens,
towards the center and a littte in the direction the ftap shoutd go.
This witL redirect the f Lap IFigure 21).

pinch the anterior capsute with the cystotome [or even directty
with the forceps) and then continue with forceps.

the fLap, otherwise your rhexis wiLI run out f Figure 241.

*AMay$ $tay on the surface sf the lens while performiilg


the capsulorhexis, e$pec¡ally wilh the forceps. You have
much better control of ths flap..."
Figure 24

3' Do not go too much in the periphery, especiatly in wideLy dilated


pupiLs. You may get into the zonutes and witL be in troubLe
IFigure 131.

>" The most difficuLt part of the rhexis is the 12 o'clock position (if
you work with the main incision approachl since corneaIstriae are
often produced by wound distortion. You can avoid this diff icutty by
changing from the main incision to a paracentesis.

3L ,"i',

.:i
princrpres or phacoemursirication iliilliilililliilllliiiiiilililiiiliillililllillllllllllllll
tiltnittiittttltl Essentiar
ii

al.though the chamber is deep, then use forceps and be quick!!!


The target is then to make a smat[ rhexis, but CCC-type' Even
when the rhexis is smatt, it is stiLt better than a rhexis running
out. You can atways entarge the rhexis, but a tear wiL[ stay a tear.'.

stabte chamber and the rhexis can be performed safety.

is not the most important, but if it is too smatl it has to be entarged,


where it is easier to access. Use scissors and come through the
main port. Use them in a horizontaI manner, meaning thatyou do
not have to cut the anterior rhexis vertica[ [ike you cut paper. Just
put one scissor end under the anterior capsute and cut fast [onty
oncel.
>- A too smat[ rhexis wil.t Lead to problems during aL[ the fotl"owing
steps. Therefore better entarge it in the capsutorhexis procedure:
after 3ó0 degree just pass outside of the initiaI beginning of the
rhexis and continue the rhexis there as much as possibte lcatLed
"spiraI entargement"]. lf this does not work, then use scissors and
entarge with forceps.

t0L.

issue...You may have the [ens coming out of the bag during
hydrodissection and you wiLt have to put it back in the back
afterwards. At the end of the surgeryyou wittthen have to be sure
that the haptics are both in the bag. lf the l0L shows a tendency to
put[ forward, use a miotic agent in order to keep the l0L where it
shoutd stay.

lf ftuid is coming out of the bag, continue with the forceps [since
there is a ftuid fitLed bag, the need[e has no contra-pressure and
needle rhexis does not work properl,y). Try to perform a very smat[
[the rhexis wiL[ always try to run out!] and quickty performed
forceps rhexis. This wil.t give you a normaI sized rhexis. lf, after
initiaL puncture of the capsute, there is no fLuid coming out, then
i=
needte rhexis is possibte, but perform it quick and atways fiLt the
chamber with OVD.

::,:. .32
liillllilllllilillliiiiilililililllltilllliiiillillilllililliiliiilliilliililillliiliiliiiiiliii chapter IV: capsu,orhexis liiililiiiililiiiiii rl

ln white cataract or "cataract under tension" try to perform a


smat[ rhexis Ido it quick!), even if it is too smat[ at the beginning. lt
is easier to entarge it with scissors and then with the forceps than
having a capsutorhexis tear going out.

Remember: in a tense bag the rhexis wit[ atways try to run out.
Atways deepen the anterior chamber and be quick!!! lf you are to
s[ow, the rhexis may run out without doing anything... I think you
remember the Argentinean ftag sign...
lf there is evidence of zonutar l.axity during the case, then consider
ptacing iris hooks to stabitize the capsutar bag. You do not have
to place 4 iris hooks, but just enough to ho[d the bag at the place
where zonuta support is gone.

lf you expect a posterior capsutar defect [ike in congenitat posterior


cataract then make a smatler capsulorhexis. lf the posterior
capsule is defective you ptace the l0L in the sulcus and capture
the optic within the anterior capsutotomy.

nothing for beginners...

Do not overinf late the anterior chamber with OVD white putting the
iris retractors. You wit[ have probtems to reach the pupiL margin
since it is way back.

ln eyes with smatI pupiLs try first to entarge the pupit


pharmacotogicatl"y with ditating drops or intracameral. with
epinephrine 1%. lf this does not work, try to stightty overinftate
the anterior chamber with OVD (OVD-diLatationl and stretch the
pupiI mechanicatty with two instruments and retease posterior
synechiae. lf the pupitis stiittoo smatt then use 3-4 iris retractors
90 degrees f rom each other or a Matyugin ring.

:\'

33 !.

ll:'
ffiydrmffiámmwmt'&mryru /
Mydrmdm&ümmm&ámm

from the adhesion to the capsute. The appLied forces during


phacoemutsification and manipulation wit[ be less forwarded to
the zonutes.

successful. You can check that with the injection cannuta or


another instrument.

shoutd know how the lens is built. From outside you have first the
Lens capsu[e, then the cortex, the epinucteus and [ast the nucteus.
You have to understand the anatomy in order to realize what you
are doing f Figure 25).

LayÉrs cfth* l*r$:

,,Hydrodassectlon": separating lens cap$ulo from cortsx


,,Hydrodel¡neation": separating epínucleus fiom inner nucleu$

35
iiliililiiliillljilij Essential
principres or phacoemursirication,
iljlijjjllllljiljllliliillillllliiiilijjjiiillillillll

Atways perform a hydrodissection !!l But be carefuI in posterior


potar cataract, perforating [ens trauma or post vitrectomy cataract.

ln congenitaI posterior cataract you have to be carefuI since a loi


of these cases do have a posterior capsutar defect. A good way to
deaIwith that is to perform first a hydrodelineation and to remove
the nuc[eus. Afterwards you may perform a hydrodissection and
remove the cortex.

lf you drop a piece of nucteus into the posterior chamber you may
probabLy have to ask a vitreoretinaL IVRJ surgeon to remove it f rom
there. A cortex loss is usualty less of a probtem. Therefore it is
safer f irst to perform hydrodetineation in cases where you expect
to have a posterior capsutar weakness in order to remove the
nuc[eus.

Put the infusion cannuta between [ens capsu[e and cortex 1mm
from the border of the rhexis towards outside and flush relatively
quick fFigure 2ó1.

put the infusion cannula at léast one mill¡meter


"Hydrod¡ss€ctioñ:
from the border of {ha rhexis befiA,esn len* capsule and cortex.....

Figure ,26,,

the tip of the cannuta up to


the capsute before you are injecting. The water wiLt find the way
easier Like that f Figure 27).

36
Chapter V: Hydrodissection / Hydrodelt"eatto" iiiiii I il

,,Hydrodi*section: press lh* cannula $oftly anteriorly


against the capsule..."

Figure 27

may btowout the posterior capsuLe... But if you push the syringe
too Iittte, nothing wiLt happen f Figure 28).

,,Hydrodissection: overinflating the capsular bag


can result ¡n a capsular tear..."

Figure 28

37
[,,,,,,'',,,,"',,,,,,

You may start to inject fLuid just before entering the subcapsutar
space during hydrodissection. Push then the cannu[a forward and
continue to inject fluid until. you see the wave passing to the other
side.

Remember to inject continuousty during hydrodissection/


hydrodetineation and not to withdraw the cannuta during injection.
As soon as you move the cannuta backwards the water may found
an easier way to get out of the subcapsutar area instead of passing
behind the [ens.

Overinftating the capsutar bag during hydrodissection can produce


a shattowing of the anterior chamber or a capsutar rupture.
Depress the nucteus severaI times during hydrodissection in order
to push to ftuid back in the anterior chamber f Figure 291.

do not overinflate tho capsular bag!


"Hydrodi$seclion:
D€pre$s the lans saveral time$ during hydrod¡ssection..."

Figure 29

Push the lens back in the back after every injection phase. First,
to avoid protapse of the [ens in the anterior chamber, especialty
in [arge capsu[orhexis. Second, to avoid high pressure in the
posterior between [ens and bag due to compartment syndrome
[you may break the posterior capsuteJ f Figure 301.

Hydrodissection at one position may be enough to loosen the


capsutar-cortex connections, but better perform it at two positions.
With hydrodissection you cteave the cortex f rom capsuLe. Look for
a ftuid wave. Don't stop titL the wave is passing to the opposite
side! lFigure 301.
lr 38
"Hydrodisseclion: lock for the
progressing fluid wave at ths porler¡or parl
of the lens, but do ilot $top the flushing until it pas$es 10 the other side..."

q'-*** _J
-Iig*rs f9*_**_

HydrodeIineation Ic[eaving the epinucteus from the nucteusJ is


certainty not atways mandatory for cataract surgery, but it is a good
hetp in case of zonutar [axity and congenitaI posterior cataract.

ln congenitatposterior cataract you have to look at the waterwave


as it passes the posterior poLe. lf it behaves strange, then perform
hydrodetineation. A good advice is atso to avoid turning the [ens in
the bag in these cases. These cataracts are normaLtyvery soft and
can be removed mainty by suction.

Hydrodissection in an OVD-overfiLted anterior chamber can be


dangerous since it may cause a posterior capsutar rupture.
You may retease some OVD through the main injection prior to
hyd rod issection.

:!= Use the main incision [tunnet] for hydrodissection and


hydrodelineation. You push in ftuid and if you woutd go through the
paracentesis wounds, the pressure in the anterior chamber woutd
increase and hetp to rupture the posterior capsutar bag. Working
through the main incision wiL[ permit water to come out of the eye
and compensating for the fluid you are flushing in f Figure 311.
39
phacoemursirication'
liijiiililiilliiiiiil Essentiatprincipres or lllliilllliiliiililllliillillillllilllillilillllllllllll

,,p€rforfi hydrodissection throught the main ¡ncisiofi {tunnel},


You will have ror¡e fluid corning otJt of the eye during llushing
and thir compeñsates for the fluid coming in.,."

Figure 31

forward in the [ens untityou see the tens moving sl"ightLy. You wit[
be then at the right position to inject f Luid. Look for the gotden ring
sign creation during fl,uid injection f Figure 321.

.Hydrod*lineatisn: psint the cannula forward in tnc léns


unlil the lens moves slightly, tnen inisct fluid.-."

Figure 52
Chapter v: Hydrodissection / Hydrodelineation IiiIif Iiiiii Iiiiiiii

untiI you see the [ens

the bag! Rotating the lens ensures that the job is done" lf the tens
does not rotate then you witL not be able to perform the cataract
extraction niceLy f Figure 331"
>' A [ens that dropped out of the bag during hydrodissection shouLd
be pushed back if possib[e. You do not have to rotate it thereafter
since it is aIready free...

,.Check if the lem is turning in the bag after hydrodissection,.."

Figure 33

put ftuid in the eye and the fLuid shoutd have no problems to get
out of the eye IFigure 31].
ts Look for a ftuid wave passing behind the Lens. Do not stop injecting
as soon you can see it. Continue untiI it reaches the other side
IFiqure 30].

4L
iliiillii]illiill]]liiiiljj rssentiar Principres or Phacoemursiricationy lilliiiilliiiiilliiiiiillrrllllririlliilliiillililillli

After each try, push the [ens back into his bag. With this maneuver
you break the firm equatoriaI cortico-capsu[ar adhesions and
the [ens gets free. Otherwise you just push more BSS behind the
lens creating high pressure there and risking a posterior capsutar
rupture IFigure 28).

With a very soft cataract it is diff icutt or even impossibte to put the
[ens back in the bag. Therefore do not overdue the dissection.

lf hydrodissection faits, then try again at a different spot, increase


force, or use bursis and gentty push on nucteus between bursts.
But remember: be carefuI in posierior potar cataract, perforating
tens trauma or earty post vitrectomy cataract. lf it does not work
in the first attempts in these cases then skip it and perform
hyd rode lineatio n.

Hydrodetineation is separating ihe outer epinuclear shet[ f rom the


compact mass of the harder inner nuclear materia[ lendonucteusJ.

To perform hydrodetineation point the cannuta in the [ens untiI it


moves [you reached the harder endonucteus...] and now gent[e
inject BSS untityou see a gotden ring or a dark circl.e IFigure 291.

lf Hydrodissection stiLt faits, then perform hydrodetineation.


lf the rhexis is too smat[ or not curvitinear due to a tear towards
the equator, then ftush slowty. "Soft" hydrodissection is used atso
in a very soft cataract [the Lens wit[ otherwise be expetled to the
anterior chamber and you witt not be abLe to put it back in the bagl
and in posterior potar cataract.

ln case of a posterior potar cataract or extended rhexis do not


persist in doing Hydrodissection. lf it does not work in a soft
manner or if you cannot turn the lens in the bag, skip it and
perform hydrodetineation.

42
Chapter V: Hydrodissection / Hydrodelineation , i ,i i li,,ii i I

The sign of nicety performed hydrodetineation is the "goLden ring


sign" Iin hydrodissection you see onty the ftuid wave passingl.
lf the [ens is not turning after hydrodissection, then perform the
hydrodissection again. lf stitt not working Ieven if you have seen
the waterfront passing behind the [ens), then don't try hard Ithere
may be a peripheraI or posterior corticat-bag adhesion lscar,
which does not loosenl. Make a hydrodel"ineation and then one
centraI groove with phaco. Crack directty and then try to turn the
nucleus just a littte whiLe hotding the phaco tip towards the wat[
of the nucteus [catted obtique chopping). Ptant the phaco tip in the
nucleus and then chop one piece and eat it directLy" Continue this
procedure and finish the [ens Like this.

ln mature white cataract there is not much cortex [eft. perform


hydrodissection, but slowty. Even when you are not ab[e to see the
waterfront turning behind the lens try to turn the lens in the bag.
Normalty it works quite wett. lf not then hydrodissection is used
again and try to turn again. lf the [ens is not turning, then leave it
and start phaco with one centraI groove.

than with the cannutal. You shoul.d clearl.y see that the lens is
turning IFigure 331.

a perfect hydrodissection. Do not try to rotate the nucteus untiI


you are certain that the hydrodissection is wel[ done and rotate it
with as Iittte stress for the zonu[a as possibte, eventualty use two
instru ments for rotation.

43
Wffi
Grooving

lf you do not use the phaco tip property, it is more a weapon in the
eye than a hetp for you IFigure 341.

,,Ne asp¡ration ior phakc power) in this situation. You do not have
fluid corning in the eye afld th€ anterior chamber will coltapse..."

Figure 34

45 ' ,:'.,11
lil iliilililiiliiiillil Essentiat princip,es or phacoemursincation liiliiillliilillliiiiillllrllililllliiillllliliiliillllilll

phacoemutsificaiion procedure IFigure 351.

use the phaco tip through a smat[ incision and thereafter entarge it
for l0L imptantation. But be carefuLbecause of the corneaI burns
since the sleeve can easier be occtuded in smatI wounds. And you
can etevate the infusion bottLe if you have performed a good and
tight incision. A teaky incision witI otherwise increase the flow in
the eye and create turbutences.

stightl,y increased intraocutar pressure. You wit[ encounter less


corneaI fo[ds and therefore have better visibitity. The eye is more
rigid and the maniputations are getting easier. The abiLity to attract
lens fragments is also increased.

ctose to the rhexis rim, ctose to the iris, ctose to the endothetium,
or close to the posterior capsute and at the inferior nuctear rim
f Figure 351.

.,Avo¡d th€ proximal and distal iris during aspiratiün ánd ph¿ko power...

Figure 55

phaco tip moves in the eye. Learn to use the incision as a futcrum.
Otherwise you witL encounter corneaI striae with a bad visuatization
and a leaky wound tFigure 3ó1.

46
,,Try ta p¡vst the phakc probe in the incision. You will have less
ccrneal folds and a better vision..."

Figure 36
Atways futt speed at the beginning in the safe you
want to make a race and the tights turn green: with
Phaco-1 program IFigure 37).

From the border of the proximaI rhexis to the other one. That's
your race distance [Figure 371.

,fhal 's yor.rr rácing distafice for groovifig.


Never go further,.."

Figure 37
4V
t--

I
il I i i i i lil f i I i i i i i I Essential Principles of Phacoemulsification

Be carefuIwith the phaco power whenever you [eave the centraI


safe zone! [Figure 35).

Go deep centratty, but not too deep peripheral,!l! The [ens is


sphericatand not Like a brick (Figure 381.

,Groove deep centrally, büt not tao deep peripheral,


The lens is spherical and not a cube..."

Figure 38

The groove wiLt be deeper opposite to the tunnel. But do not forget
to groove the proximaI part atso...

lf the is moving downward during grooving for example,


gLobe
then insert a spatuta through a paracentesis to counteract this
movement.

lf the lens is moving downward during grooving and you have


enough phaco power, you have [ax zonutes. You may counteract
the force by using a second instrument on the [ens.
ln a lax zonuLe situation you shoutd not put[ or push on the [ens.
You may have to increase the phaco power and then Lei the tip
of the phaco work on the lens without pushing the lens forward
f Figure 39f .

ln lax zonute situation some surgeons are holding the capsutar


bag with iris retractors hooked at the capsutorhexis margin.

48
Chapter VI: Grooving

the len$ is movins lsrward during grooving, you push too much on lhe lens.
"lf
You are pulli¡g on the zonüles. Move slower andlor increase phako power..."

Figure 39

You may occtude the steeve the deeper you groove and wi[[ then
have reduced irrigation f Figure 401.

,,A n¿rrow grouv€ wlll obstruct the silicone sleeve, ssp€cially ln the periphery.."

Figure 40

:.i
':'ll
::.3
4ei j
I
.l
'I¡
Essentiar princrpres or phacoemursirication liliiiililillllililllilf lliliilliliilliiiilliliilf
f ilillllll

Do not perform a [arge groove width in a soft nucleus. You witl


have probtems to crack it and end up in a [ens bow[.

The deeper you get, the more you have red reftex. The red reftex
shou[d shine l.ike a down going sun. Then you are deep enough
IFigure 411.

Jhat's a deep central groovel You are


ready to crack the lens now,.."

Figure 41

As soon as the groove get's quite deep, you shoutd not go futl
power any more...

lf you have to attack the centraI deep f ibers, then dividing is easier.
But remember to stay always on the safe side. Too deep is too
deep...

You have to considerthe grooving to the posterior pote as a "potar


expedition". Go aLl. the way down until you reach a thin layer of
epinuctear materiat. You have to get there!!l That's a key of success
f Figure 421.
,,You nred to groove deep. Only by this polar expedition
you will be able lo crack ths nucleus..."

Figure 42

advantage required to fracture the entire Lens lFigure 431.

divide th* lrns, plaüe th* instruments deep in the groove,


"To
press slightly dawn and then to thc side..."

Figure 43

51
Essential Principles of Phacoemulsification 11lil1;ill11liliiiiiiliiiiiiiiiiiii.i

lf the center of the nucteus is not thin enough you wiLl not be
successfuI in dividing IFigure 42).

Remember: a very soft cataract wiLL be grooved with just one or


two futl. power races.

white grooving, especiatLy in hard cataracts. The zonutes may not


forgive you that... increase the phaco power and let the tip make
the work. ln between the races you shoutd tet the phaco tip cool
down with a pause. The cornea witl benefit from this pause
f Figure 4/*1.

not pr€ss tos murh on the lens during rnanipulations"


"Sa
You are pulling on the usnul€s"..**

Figure 44

Grooving a hard nucteus stresses the zonutes. You may use a


second instrument to counterforce the forward movement of the
phaco tip and stabitize the nucteus.

lf the zonutes are extremety lax, then convert to ECCE or eLevate


the nucteus and perform phaco in the anterior chamber. You can
also put iris hooks and stabitize the [ens capsu[e at the rhexis.
A hard nucteus must be scuLpted very deepty before cracking and
you may stit[ not see the red reftex... Shiny reflective and fasery
lens materiaI wit[ indicate you that you are deep enough
IFigure 41).
:,' 5¿
Chapter VI. Grooving

A hard nucl'eus is difficuLt to crack, especiatty the centraIportion.


You stitt may be not deep enough. ln these cases after having
performed one centraI groove, you can try to crack the nucLeus
first in two hemi-nuctei. Thereafter you groove the two parts to
prepare for cracking too.

The Lens should not move much during grooving. Optimal. grooving
is achieved when the [ens nearty does not move. This impticates
that in hard nucteus you have to increase the phaco power. lf the
Lens stitl moves then go fu[[ power, but stowty. lf the Lens stiLt
moves, then do not groove with the tip comptetety embedded in
the nucleus IFigure 39).
As a beginner try the divide and conquer technique f irst. You witL of
course have to learn at[ four techniques at the end to be a comptete
cataract surgeon.
Turn the nucleus either with the second instrument or with the
phaco tip untiI you have it in the optimaI position. Use the wat[of
the groove as a counter bearing to turn (Figure 451.

\*l

,,Don 't be lazy. Turn the lens 90 degree for the second groove...''

Figure 45

53
r lriiiiiliiiiilriiiiii
Essential Principles of Phacoemuisification iiiliiiiiiiiiiiliiriilliiiiiiiliiiiiiiiiiiiiiiiiiiiiii

hydrodissection: perform first one groove and then divide. lf


"chip & ftip",
dividing is not possibte then try to chop or change to
especiatty in a very soft cataract.

G1 cataract you may have to groove once or twice with fu[[ power
to be through the nucteus, in G2 twice orthree times, in G3 and G/+
more than three times.

Try, if not working then you have to stop & chop or even chip & ftip.
Adapt to the situation !l!

harder the cataract... Sometimes you have to get these bubbtes


out for better visuatization !!!

fragments of phacoemuLsificated nucLeus, cortex or epinucteus


pieces, and air bubbLes. Get rid of these and then continue. You
have to see what you are doing!

not pushing on the posterior wal.[ of the tunnet. You are creating a
lot of outftow white pushing on the wound lFigure 4ó1.

.,tf the ¿nteriar ihamber is getting flat, yüu have to know why" Here due to
manipulation with the phakc tip or a toa lar6e incision, you have a wound leaking...'

Figure 46

54
iiiiiliiiiiliiiiiiilii

that you are not pressing on any wound. You may even have to
remove the other instrument and stay in the eye onty with the
phaco tip f Figure 471.

,,lf the anterior chamber flaüens, then check the wounds for leackage...'-

Figure 47

on the wounds, then increase the bottLe height, check the tubing
and fLuid Level. and decrease the ftow. lf the corneaI wounds are
leaking then consider suturing the leaky wound or just one end of
the wound.

55
'
.l
:a:i
.Wffiffi
ffi*wa$e & ffimwkqe#ffitr

at atLl!!

ihen divide into 4 pieces IFigure 411.

> After 2 deep grooves in the nucleus put the phaco tip deep in the
center and the Nagahara chopper in front of it Inot beside!), push
first down and then to the side to divide IFigure 43).
Put the instruments as deep as possibLe within the groovel

lf you try to divide the [ens in his center or above, you compress the
ftoor of the [ens instead of dividing it f Figure 481.

divide the lens, p!*ce the in$trümrnts deep in the groove. lf


"To
you are not deap enough y*u will *omptess ths floor of the
lens instead of dividinE it..."

Figure 48
57
Essential Frincipres of phacoemulsification llllllllillllliillliilllliillillilllllllllllllllllllllll

Push the [ens first down and then to the side! [Figure 43).

It does not matier to which side you push each instrument


lchopper or phaco-stick], but push first down and then opposite to
each other to the sidel!!

instruments. Dividing in a cup is quite difficutt...


Do not destroy your watts white scutpting not precisety.

lf you try to crack the nucteus but you act not deep enough then
you may separate the two watts of the nuc[eus, but the posterior
part of the nucteus witL be more compressed instead of being
cracked IFigure 48).
Be sure that the cracking is comptete. You may have to crack
severaI times... WeLt, the centraI part or the very peripheraI part is
sometimes not wet[ cracking f Figure 491.

,,lnc{rmplete cracking ;fl the ce¡ter.


You are not deep enolgh there..,"

58
llff I fi ii i cr,upt"r.VII Divide I conquer

,,You cracked nicely! Now You are ready ts take


the four quadrants out of the bag..."

Figure 50

nucleus piece in the anterior chamber is too big to be eaten fast,


then chop it.
>" "You have to feet/see the weakness
of each cataract and cataract
piece. Attack it at his weakest point, but remember: always be
safe!" lFigure 511.

carelul while you are laking out the nucleus quadrants.


"Be
Do not attack them anter¡or otherwise the inferior sharp
edge of the nucleus may hurt the capsule..."

t- :, Yr":_:1_ _J
59

i
j

i essential Principles of Phacoemulsification

grooving then groove deeper, especiatty in the center and try again
cracking.

nucteus Ino watls any more from the grooving), then change to the
chip and ftip strategy. Take one ha[f out of the bag into the anterior
chamber and then chop it vertica[ty.

towards the pieces. This wil.tcreate a faster occtusion lFigure 521.

,,B€tter attack nucleus quadrands in the middle of the nucleus.


The nucleus will not rolate ánd you can mova ¡t áway
from the posterior capsule..."

Figure 52

phaco opening to the side or downwards (the cornea witt took


better the next day...).

may bite the posterior capsute) f Figure 531.

60
opening sf thc phako tip shoirld never
"The
ever be directed lcwards the capsule..."

Figure 53

leakage wil.t be prevented and the chamber stabil.ity witt be


excettent [an easy way to prevent surgeJ.

last pieces too aggressivety with phaco power towards the capsute
f Figure 541.

pheko tip should neyer act in the Feriphery..."


"The
Figure 54

61 '':,
t
I

lit Essentiar piincipres of phacoemuisincation iiiillliiliilllillliiliiiililllliiiillililll


i llt I i i li11 i I I i I liil

and then Lift it up in the aspiration mode towards a safer zone for
phacoemutsif ication f Figure 551.

lhe last piece of nucleus up before you eat it.


"Lift
YorJ work in a safer zone regarding ths posterior capsule..."

Iigure 55
Stay in the center of the anterior chamber with the phaco tip
whi[e eating the pieces. Do not put[ out the tip whi[e doing phaco
power or aspiration, otherwise the anterior wit[ cottapse since the
infusion is located behind the tip opening and may get out of the
eye (the posterior capsute is in danger...J

lfyou are ab[e to perform a crack in soft to very soft cataract, then
continue in divide and conquer [groove deeper and try atso the 90o
groove). lf stitl. not possibte to crack, then skip to chip and ftip.

Remember. lt is stitL easier to deaI with the grooved nucteus or


even better with hatf of the nucteus than with the whote [ens...

Try first to get the sma[[ pieces out in the anterior chamber after
cracking. lt is easier thereafter to get out the bigger one...
lf there are some nuc[ear fragments that want to come out. So let
them come out of the capsul.ar bag and eat themlTake the easier
one f irst. The others wi[[ then come easier...

To takethe nucteus fragments out you have to adjust the phaco tip
opening to the piece. Turn the opening to the side or tiLt it a tittte

.62
''..,
'. Chapter VII: Divide I Conquer i

down in order to create a good occtusion at the tip. You have to


learn to ptay that game. It witL get easier with time and less time
consu m¡ng.

As soon as you have one piece of nucteus left in the bag, you may
change the phaco machine settings from phaco-2 into phaco-1.
You reduce the vacuum and therefore are in safer settings for the
posterior capsute.
lf you get out a quite big piece in relativety soft cataract then try to
hoLd ii on one side Inot in the center]. You witL probabty be abte to
eai it up easier tike that. ln harder cataract you take them out in
the center and then chop them.
lf one piece is too big and [ies in the anterior chamber, then make
it smatler, especiatty in hard cataracts, meaning that you have to
chop it horizontatty. Otherwise the corneaLendotheLium suffers.

seconds, especiatty during conquering of hard nucteus pieces. Let


the phaco instrument cooI down and then re-use phaco power.
the nucleus fragment cLose to the tip during phaco
pauses IcooIing pauses.."], use just aspiration. The piece witt
have time to readjust towards the phaco tip.

with phaco power!!!


)n Use high vacuum for a soft nucteus. lt wiLt hetp you to bring the
peripheratnucleus towards the safe zone.
lf th e cha m ber is u nsta bte, th e n watch out for the reaso n. The re may
be too much flow coming out from the cornea wounds. Especial,ty
[ook for the paracentesis wound of the second instrument. Taking
out the second instrument white finishing with the quadrants, may
stabilize the anterior chamber and make the surgery safer...
lf you ptan to do divide & conquer, or what technique ever, then
do it. Do not change the technique too fast, just because it did not
work in the f irst attempt. You may end in troubLe since no technique
witLfinalty hetp you to get the [ens out of the eye...

63
liilriilrlliiiiliiiiii
Essential Piinciples of Phacoemulsification iliiiiiiiiiiiiiiiiiiiiiiiiitiiiiiiiiiiiliilililillllllll

then search it! They are often difficul.t to find in eyes with wel.t-
estabtished arcus senitis or with smat[ pupits. You may ftush the
side ports and the main incision to find them f Figure 5ó1.

Jhese rr€ the hidding places of tha small


nucleus remnant piects..."

Figure 56
Never leave a nucleus piece in the eyelYou wit[ have probtems after
the surgery with pro[onged inftammation and high intraocutar
p ress u re.

lf you have an epinucteus cup left after taking out the nucteus, try
to aspirate it on side and fl.ip it.0therwise use a b[unt instrument
to push it towards your phaco tip and eat it, white taking care of the
posterior capsute fFigure 571.

ygu turn the eplnucleus. Aspirate the border of the cup


"That's the $ray
and {lip it in occlusier mode. Yolj may also use a blunt instrumef}t
to b{ng it towards the phako tip..."

57

64
i.i..ii..i.ri.riiiii.riiiiriti.urirr'.iririi.i.liif Wffi Kffi
ffi$atp S
Ft*p

is not possib[e any more due to cupping of the nucteus or soft


cataract IPhaco-3 programJ.
First you perform a hydrodissection, otherwise too much stress is
exerted towards the zonutes.

There are two ways of chip & f tip.

one groove centraI and then make grooves paracentraI in each


direction to bowl out the nucteus lFigure 58).

,,Chip & Flip: the first way. You bowl out the lens""."

Figure 58
65
iiiiliiililliliilliliiii Essentiar
princip,es of phacoemu,sification iliiliiiilliililliililliiiiiiiiiilliiiililliillliiillllllill

deep groove centraI and then divide the nucteus Like in divide &
conquer, thereafter you bowl out the nucleus f Figure 591.

,,Ship & flip; the s€cond way. You perform a nice and deep groove and theñ divide...'

Figure 59

cortex with vacuum [do not use phaco power if possibtel at


different ptaces in the periphery untiIthe [ens wil.tfLip, then phaco
(Figure ó01.

v -u

,,Chip & Flip: that's the way ycu turn the epinucleus.
Aspirate ihe border of the cup and then pull it away in occlusion
mode. lt is rsally a kind o{fl¡pp¡ng out of the bag..."

Ftgwe 60

66
=.
?:
y- Take care of the capsute white chipping... lFigure ó11.

,,Chip & Flip: So not u$e phaka püwer there.


You rnay n6ed jLrst a liitle phako power tCI g*t occlusion,
but then no phako power a$y more
untilyou tumed the cup...-'
Figure 61

fl.ip. Then you have to hotd it with the phaco tip. Use just LittLe
phaco power to emu[sify the nucleus.

in two pieces (atternative way of chip & f tip).

lf you are ab[e to divide the nucteus once in soft cataracts, you can
also chip one ha[f out of the bag and finishing it and then the other
one. lt is realty a nice method to deaIwith softer cataracts.

The chip & tip method is a nice method safety variant if you
destroyed your wat[s in divide & conquer method and you are not
abl.e to crack the nucteus any more. Changing to the ctassicaI chip
& f tip is a perfect way to comptete your cataract operation in these
cases.
irliliiliiiililillilrirlllirritrrrrrrlrrlrririiiiiiiriirllrlrrlrrrirrlrliiilliii mW
Stwp &
thwp
A good method to avoid stress towards the zonutes"

ln case of zonutar dehiscence you better chop than groove. You


produce less stress towards the zonutes white chopping.

p rog ra m)

Stop & chop is a nice way to learn chopping.

For moderate to hard cataracts. Not ideatfor soft cataracts..

You perform one deep groove and then divide the nucteus in two
pieces by cracking it. You stop the divide & conquer method at this
point and start chopping fFigure ó21.

,,Stop & chop starts like good-old divide and coñguer rnethod:
you perform a nice and deep groove and then divide..."

Figure 62
69
Essentiai'Principles of Phacoemulsification
:,:i ¡1: i : t:; i'll::,:ll ;i

First perform a deep groove. You may eventuaL[y turn the [ens 180'
to groove a[so in the otherdirection. Then crack it and turn 90o and
Letthe phaco tip work his way in the centraL nucteus with some
power. Then hotd the nucLeus hatf with vacuum and chop either
horizontaI or verticat.
To attack the nucLeus with the chopper it is better to remove the
epinucteus first.

Removing the epinucteus in the area of the opened capsute wiL[


altow you to get directly in contact with the nucteus.
HorizontaL chopping is when you come around the nucteus from
behird towards the phaco tip. ln verticaL chopping you ptant the
chopper into the nucteus from upwards and then chop towards the
phaco tip.

Chopping in the bag is normatty done in a horizontatway, but as


you get more experienced you can chop verticaI in the bag.

Chopping out of the bag is either horizontaI or obtique. You cannot


chop verticaI out of the bag.

Not at[ chop instruments are adequate to perform aL[ types of


chopping. The Nagahara Karate Chopper for examp[e is abte to
perform verticat, horizontaI and obtique chopping.
The chopping is performed with the chopper in left hand and the
phaco tip in the right. Chopping movement is [after correctty placed
the instrumentsl chopper towards left side. Crossover movements
are not wetl working in chopping lin contrast to cracking the
nucteus in divide and conquer].

Stop the nucteus from moving with pLanting the phaco tip deep in
the nucteus [first give a tittte phaco power, then hoLd the nucteus
with vacuum).
Remember: you cannot hoLd the nucteus white you are using phaco
powerl The phaco power is to get deep in the nucteus.
To prepare for chopping you have to bring the phaco tip at least in
the middte of the nucteus and keep it there. You may impaLe the
tip into the nucleus with first a tittte phaco action and then hoLd it
with aspiration, but you don't need atways to hotd the phaco tip in
aspiration mode. Adapt to the situation!

VQt,,
]]rrr]li]rlti]iiiiiii

The second instrument is getting behind the nuc[eus and is driven


towards the phaco tip. You can perform it in the bag, but take care
of the bag...Ionty for advanced phaco surgeons...l f Figure ó31.

,,Stop & Chóp: horl¡ontal chcpping. Place the chopping instrurnent between
epinucleus and nucleus in the distal periphery of the lens.
Then slide towards the phako tip...'

Figure 63

the chopper behind the nucteus without damaging the capsute...

between the epinucteus and the nucleus white stiLt being in contact
with the nucteus. lt is easier to reach the periphery if you titt your
instrument paratLetto the iris ptane and rotate it back as you reach
the equator IFigure ó4i.

nucteus whi[e you are moving the chopper towards the phaco tip.
Towards the center the [ens is getting bigger f Figure ó41.

7L
Essential Principles of Phacoemulsification

After removing the epinucleus to the capsulürhtxi$ border you rotsts the
choppa ¡n order to slip b€tter in belween epinudeus and nucleus and
a$ you reach ihe periphery you rotatelle instrument back. Then
move lhe t¡p deep towards the phako tip..."

Figure 64

IS
hoLding the nucteus with vacuum and the second instrument is
pLanted deep in front of it and pulted to the side fFigure ó51.

,,stqp & Chop: vertical rhcpplng. Plant th* chopping instrilment aboüt
o*e millimeter antcrlor to the phacs tip, Do nüt put it rnore di$tal
since you will break the o*clu$¡on sf the tip due to vectsr forces.,."

*_*_ __*_ I_i_s_-yr-_e-- -q-s


"

72

I
l, :,, r, Chapter lX: Stop S Chop

lf the cataract is too hard then verticaIchopping is difficuLt. During


ptanting the chopper in the Lens you may push the [ens backwards
whil'e stressing the zonutes. Better go under the capsutorhexis
and try to chop horizontalty in the bag.

0bLique chopping is for speciaL situations where the rhexis situation


is unctear and therefore hydrodissection is not or incompletety
performed and the nucleus is atready divided into two hatf pieces.
Then turn the nucteus just a tittte and attack the nucteus [hatf
piece) in the centerwith the phaco tip opening turned towards the
nucLeus hatf piece. First give a Littte phaco and then hotd the piece
with vacuum. Now chop from the periphery in an obtique manner
towards the phaco tip. Take the first chopped nucteus part and eat
it directly. Repeat that maneuver as much as possibte.
ln very hard cataract you may start with one groove and then chop.
You may atso directty start with chopping in G2 to G3 cataracts.
Since you wit[ need a lot of phaco power in hard cataracts, better
use the phaco tip opening downwards or to the side whiLe eatinq
the pieces.
:'* lf the [ens turns in the bag, then start with one centraI groove and
then crack. Turn 90 degrees and ptant the phaco tip deep in the
nucteus and chop horizonta[ty.
9- Do a lot of chopping. SmaL[ pieces of hard materiaI are easier to
eat then [arge ones.

73
Phaco Chsp

with the phaco tip and then chop as much as you can.

get a direct access to the nucteus.

Regarding chopping techniques see atso chapter lX. Stop & Chop.
Probabty the fastest method Iin the hand of an experienced
surgeon- you reat[y have to know a [ot about cataracts before you
can deaI with itJ.

[east not be soft.

Fut[ power with phaco program 1 towards the center of the


nuc[eus, then ptant the chopper in front of it and chop verticatty, or
chop horizontatty, but take care of the rhexis f Figures 6ó and ó71.

Good for weak zonules or even subluxated lenses.

ii;
al
73 I
i
l':
rl:
Essential Principles of Phacoemulsification lii l

,,Fhaco Chop: vertical chopplag. Plant the chopping instrument ábout


ofie millirneter añterior to the phaco tip. Do not put it more distal
sinte you will break the occlusion of the tip due to vector forces... "

Figure 66

.,Fhaco Chop: horirontal chopping. Place the chopping instrurneñt betw€en


epinucleus and nurleus in the distal periphery of the |en$.
Then slide tewards th€ pha{o tip",."

67

Phaco chop is a nice way for moderatety dense or dense nuclei,


but you wiL[ have probtems to chop a rock hard nucteus or a sofi
one.

Phaco chop is a persistent threat to the anterior capsuLe integrity.


Be sure not to hit the capsuLe whiLe chopping!l!
76
ffi*w€ffiK ffimrcmqsmH

There are one hand and two hand l/A tips. Both are usefut, but
both have to be used a Litt[e different.

Stay atways in the middte of the capsute with the irrrgation tip in
two hand l/A f Figure ó81.

,,Stay ¡n the fiiddle of the capsular bag in bimanual llA.


You will É€t an inflated b¿9..,"

Figure 68

77
t

into the bag towards the periphery f Figure ó91.

,,Go under the antér¡or rhexis in tns périphery, as$rafe wn;b me opeil¡ng
sf the aspirat¡ón t¡p shorjld be upwards, try to get ocslu$ion añd tneil püll
towards th6 cÉnter of the bag" ...'"

Figure 69

side to side [this wi[[ [oosen the cortex therel and then putt under
aspiration towards the center lFigure 701.

,,Move the aspirHion tip peripheral under the antefior c*rtex


from side to side. This will engage more csrtex and loosen
it from the cassule..."
Figure 70
Atways [ook for the rhexis margins and posterior capsutar folds.
ln doubt immediatety stop aspirating and wait l"stay at the same
ptace but stop aspiration!!1"1. Do not remove the tip untiI you
.'i ,78
¡,.,.. .'
cortex Removal lillllllltlltiii

are sure that you did not have caught the rhexis margin or the
posterior capsu[e. Eventuatty you have to pu[[ out the l/A content
lFigure 711.

,,lf you aspirate the posterior capsule ánd then stap asp¡ralion,
ths poslericr capsular w¡ll be released..."

Figure 71
v- Sticky cortex needs patience...

The most difficutt part of cortex to remove is the subincisionatone


meaning the temporaLor superior one...

'1+ The most difficutt part of lens cortex removal is the superior
subincisionaI area. An angutated one hand l/A tip hetps to get to
this area. ln two hand l/A instruments you may have to perform
a third paracentesis at ó o'ctock to reach the area or remove the
cortex with bimanual. l/A (Figure 72!.

Jhe subincisional cortex is sometimes d¡fficu¡t to get.


Perform an addiüonal parace ntesis and get it from there..."

79
L ,lir'. .,,

,'
,li ;i il,l ll;i Essenttal Principles of Phacoemulsification iliiiiiiliilillilliltiiillliliililiilllllliitililiilllilll

loose zonutes. Use lower aspiration ftow rate there.


> To access the subincisionaI cortex move the one hand l/A tip in a

rotationaI movement from left to right [or the other way roundJ
and turn during that movement the opening first downwards and
then upwards again.
> Another point regarding subincisionaI cortex removaI for the two
hand tips is that the paracentesis shoutd not be too ctose to the
phaco tunne[. You better access the cortex if the paracenteses are
positioned away from the main incision.

be sure that you have not engaged the rhexis border. ln doubt,
stop the suction immediatety and leave the l/A tip where it was. To
panic now is not the right moment...

the cortex you have engaged the posterior capsute in the tip. You
are now tearing on the capsute and the zonutes... Stay ca[m, stop
aspirating and leave the tip there. Don't move! Now you can use
reftux or the capsute witL be free since you stopped aspiration
f Figure 731.

,,See the small starfolds in the ptrster¡or capsular ba6? Stcp aspirating
and ds, nst move the aspiration tip.""

Figure 73
:i..,:.1¡8$.,
Chapter XI: Cortex Removai

>-' lf you move the aspiration tip white you have engaged the posterior
capsute, you wit[ create a tear f FigureTl*1.

,,lt you aspiratr the pósterior capsule and thÉn pull back, you will have a

74

you are not moving the tipl Therefore release the foot pedaI and
even push the ref Lux IFigure 71).

in order to safeLy ctean the posterior capsute. This program has


very low ftow and very low vacuum parameters.
>- lf you encounter [arge star fotds during corticaI remova[, be aware
of possibLe zonutar rupture. lf you are attacking the peripherat
cortex in this area you may even create more ruptures [Figure 751.

,,These long starfold$ in the poste¡ior capsular b¿g indicate you


Isose ¿ónules or evÉn a large lonular ruptuts.,."
l" --"*"""*""'* "*--'

81
l-
I

princrpres or phacoemursincation
ili Essential
j]
ii ili i] if l il if iiiiiiiliiiiliiriiilliiiiiiiiiiliiiliiiiliiliiiiiiiiii iliiiilüilil
il i I

lf you have created a hote in the posterior capsute then don't go i


out with the instruments. Be sure that the aspiration tip is free
of vitreous and then take it out white leaving the infusion in. Then
fiLl, the anterior chamber with dispersive OVD. Now you can go I

out with the irrigation and you have time to think... lf no vitreous
i

is present and the ho[e is sma[[ then put the lens in the bag. Do
not use too much aspiration white taking out the OVD... Check for
vitreous in the corneaI wounds. lf you have vitreous in the anterior
chamber protapsing from the hole then you have to perform
anterior vitrectomy. But remember: never try to put[ the vitreous.
You may puLL the retina with it..." Vitreous has to be cut away or
released f rom the corneaI wounds (Figure 7ó1.

,,lf you $ee a ps$teriür e*psular te*r; you h¿ve to $eal it with
OWO ¡s soon á$ Bossible. But nevér removÉ thc irrigatiün
canula ort of the eye until OWD is in th€ éye..."

Figure 76

> Vitreous in the anterior chamber has to be cut or vitrectomized!!!


Never ever putI on the vitreous!

lfyou encounter pieces of nucteus or epinucteus, you have to hetp


the l/A opening eating the cortex with a second instrument. You
just move it over the opening and/or push it in.
lf the nucteus or epinucteus remnants are ioo big /hard, you can
either try to get them out by the tunneI in aspiration mode or take
the phaco tip again. Do not chase the remnants, just wait untiI it
wit[ come to the tip. You may have to go in and out of the eye again
to create turbutences fFigure 771.

fl*
,,Let the lens fragrnent csrne to you.
The flow wlll work for you..."

Figure 77

lf you stitt have probtems to remove the subincisionaI cortex, then


perform another paracentesis at ó o'ctock. You witt be abte to
access this cortex easier. Remember: don't be Lazy. Just do it after
some unsuccessfuI trying. Stay on the safe side IFigure 72].

lf you have a rhexis tear or in very thin and mobite capsute, then try
to get out as much cortex as possibte and eventuatty teave smat[
cortex amounts. You can either take them out while the lens is
in the bag or leave it there. A YAG-capsutotomy is safer than a
ruptured posterior capsute during phaco surgery...
A ftaccid posterior capsute is difficutt and dangerous to poLish.
Put some pressure with a finger on the sctera in order to increase
the pressure from the posteriorsegment and you wi[[ have a taut
posterior capsute that is easier to potish...
Do not overdo the posterior capsu[e potishing. A YAG-capsul.otomy
[ater is sti[[ better than a capsutar tear...
Do not potish the posterior capsute too much. you may potish
vitreous at the end...
. .'..:' :
:: :il
:.::

83,,,,.
XffiX
üealtng wtth Vitrepus tn
the Anterior Chamher

lf you deaI with vitreous in the anterior chamber then you have to
think about the cause. This may guide your surgicatway of treating
the probtem and may hetp you to decide where to put the IOL tater
f Figure 781.

So, why do you have vitreous protapse? Most common it is an


anterior capsutar tear extending posteriorly or a primary posterior
tear from your instruments. Besides tears zonutar diatysis can
atso lead to vitreous protapse. You may have used too much
force whi[e rotation or pushing / putLing the lens or the capsute
IFiqure 78).

you enccunter vitreouc during cataract op*ration


"lf
You have to know why and franr where it is eoming frorn,
$earch fnr eaps*lar tears and ronular damager*.."

Figure 78

,,,¡ ]
,: rlil
. '."'''rlll
$9,": ll
'. ,',,','rli.|i
"' ' "'tril
I
Basics of Phacoemulsification Cataract Surgery

the residuaLtens materiaI is no [onger centered or does not move


norma[[y, that [ens partictes no [onger come to the phaco needle,
then you are into troubte... These are signs of vitreous protapse in
the anterior chamber f Figure 791.

,,lf the nucleus pieces do not rncve ai they normally do


durin6 aspiration" you have to check f*r a capsular tear
and vitrecus in the bag..."

Figure 79
lf [ens pieces sink to the back of the eye you definitively know that
you are in troubte...

Before the [ens particte sinks, better use an instrument, for


exampte a spatuLa, to prevent it from fatl.ing back f Figure 801.

,,lf a nuele*r piece is trying to leave the bag posteriorly


you have to put an instrumefit ber¡eath, hold it and
bring it íntú the anterior chamb€r..."

Figure 80

86
crrapter Xil: Dealing with vitreous in the Anterior chamber ¡ li i ll
ijii ' t

the anterior chamber, then you may be lucky, or do not see the
vitreous... lf there is real.ty no vitreous, seaI the capsu[ar wound
with OVD and continue the phacoemulsification or the l/A or
whereveryou are. But do it in a stow manner, reduce the flowand
work away from the tear, that's safer IFigure 7ó).

capsu[ar tear, then try to create atways a comptete occtusion of


the phaco tip. This wi[[ avoid suction to the vitreous.
lf you have a sma[[ posterior capsutar tear, no vitreous prol.apsing
through and stittneed to remove the cortex, then use l/Awiih l"ittte
ftow. Take first the cortex out away from the tear and at the end
the one ctose to the tear. Eventuatty, when it seems too dangerous,
leave it and put first the l0L in the bag [or if the tear entarged, put
it in the sul.cusJ.
lf you deatwith vitreous in the anteriorchamber, then it is important
to take into consideration in what stage of the cataract operation
you are. lf vitreous presents earl'y in cataract operation, white you
stit[ have a lot of nuc[ear materiaI in the eye then ctean up is the
most difficul.t. The vitreous is often around the nuctear pieces and
it can be very difficutt to get posterior enough with the cutter to cut
off the vitreous at its source. The risk of Losing pieces through the
capsutar tear is quite high...lt is time to make the decision whether
you convert to ECCE or not. ln hard nucLei and in nearly untouched
nuctei better go for ECCE.

Sometimes even with an earty loss of vitreous with the


remaining nuctear materiaI you can carefutLy continue with
phacoemutsif ication. The most important is to create some
separation between the space with vitreous and the area of
phacoemutsif ication. You use oVD to create more distance between
these two. And you have to stow down the working pace with a
low bott[e height and low vacuum, keeping the phaco tip occLuded
in the [ens as much as possib[e to avoid puU.ing on the vitreous,
working with one or two [arge pieces Irather than chopping into
many smal.[ bits that easity fatt downwards]. The right way to
continue is therefore "s[ow motion phaco"...

:.

87 rr
Basics of Phacoemulsification Cataract Surgery
I
lfyou knowthat you have vitreous proLapse in the anterior chamber,
then first stop phaco/aspiration in l/A, but keep the instruments in I
the eye!!! Use your other hand to put in dispersive Inot cohesive!]
OVD in the anterior chamber and then you can come out. You wiLL
seaI the wound and press the vitreous back IFigure 7ó].

lf you have a tear but no vitreous protapse, then continue after I

having appl,ied OVD!!! lf the anterior vitreous membrane is not


broken, then you may be [ucky and wiLL be abte to finish the case
I

without deaLing with vitreous.


Vitreous is tike a "bastard" in phaco surgery. lt is difficult to get rid
l

of it, but whatever, get rid of him.

Never ever putt too much on vitreous. You may pul.t the retina too...
"You have to cut the vitreous!!!". Use scissors or use a vitreous
cutter. Whil.e using the scissors you have to cut fast, severaI times.

Try first with the scissors. lf a piece of nucteus is embedded in the


vitreous, then take it with phaco probe and cut betow the piece
with the scissors. Cut fast, but controtted, since there are some
other important structures around...
lf you realize that it is not working atone with the scissors, then
use the cutter. But be carefuL, it is quite a weapon in the eye... It
easity can eat up the iris, the capsute and the retina.
Take the cutter in your dominant hand and go with the infusion in
the other hand in the eye through the paracenteses wounds. The
chamber shou[d then be deep.
Remember: you have to timit the amount of vitreous expression
and its risk of retinaL detachment! lf you encounter too much
ftow outwards then suture the wound. The probtematic wound is
usuaIty the tunnet...
Remember not to go out of the eye with the irrigation before having
put dispersive OVD IFigure 7ó).

Put the irrigation just in the eye and put the cutter deeper. You
create a pressure gradient downwards towards the cutter. lf you
irrigate in the area of the cutter you may push the vitreous away
from the cutter and even worse more anterior toward the wound.

88
Chapter Dealing with Vitreous in the Anterior Chamber

The typicaLtime to have a vitreous protapse is white removing the


last pieces of nuctear materiaIor during corticaI remova[. The goat
is then to remove any residuaI nucteus. Smat[ amounts of corticaI
materiaI cLinging to the anterior chamber or in the posterior
chamber often present no difficutty.
Ptace the cutter into the posterior capsutar rupture and perform
vitrectomy just in the neighborhood of the tear. Do not go too deep
and too much in the periphery. Remember atso to preserve the
capsu[e for [ens ptacement in the sutcus lFigure 811.

the vitrous with the cutter under thc capsul* and towards th*
"Cut
center of the vitreous absut U4 ta Ll3 of the p$ster¡ür
thamb*r deep."."
Figure 81

eye. The cutter shou[d be taken out of the eye in the fast cutting
mode and no aspiration. Put again some dispersive OVD and
check the wounds for vitreous protapse [using a cotton tip or a
triangular tipl. ln doubt you have to check the wound from the
opposite paracentesis with a spatuta instrument, especiatty look
for incarcerated vitreous in the tunnet f Figure 92f .
,,Check always the wounds for v¡tréous strands" Vitreou$ is
trañsparent, you have to search it".."

Figure 82

To visuatize the vitreous, you can use triamcinoLone. But this can
make the overview of the situation even worse, especiatly if you
put a lot of triamcinotone...

lf you are too much in troub[e, then cal[ a VR surgeon... Wett it is


even better to catI for hetp at an eartier stage...

lf possibte, meaning if you think it is stabte enough, put in an l0L,


in the bag (if tear is central and not going to the peripheryl or in
the sulcus (if the posterior capsute is stitl. there in the periphery
at teast).Otherwise do not put an IOL in the eye and tet the VR
surgeon decide. A bad idea is to put as an initiatstep an iris-fixated
lens, since the diLatation witI be bad and the vitrectomy difficutt...

lf you take an instrument out of the eye with vitreous protapse in


the anterior chamber, be sure that the vitreous wil.t foLtow you out
to the wound f Figure 831.

=.:¡¡;.$Q,¡
l r:::.¡¡::,::::r:
i]iliiillliii]iiiiiii chapter: XII: Dealins with vitreous in the Anterior chamber

,,lf you trkÉ out an instrument while yau hav* a caps*:lar tear;
you mty pull the vitresus with you.","

Figure 83

,,Vitresus has always the tendency to get o$i of the eye since it follows
Pressure gradients" Furtherrnofe it behaves like glue and you cün nüt
Suck it away. You have to cut it. PleasE check the i*cisions for vitrecus..."

Figure 84

is coming out of the eye, vitreous witl foltow


f Figure 851.

9t
foolws always pressure gradiÉnts. Where ffuid ccmes out
"¡Vitreous
of the eye, yoü may encountar vitr€ous also,.."

Figure 85
lf you think that you have cteaned the anterior chamber of vitreous,
then perform one [ast step: create a miosis with topicaI drops or
better intracameraIand look for unusuaLcorners in the pupiL. The
vitreous may stit[ be around f Figure 8ó1.

,After hav¡ng placed the lens in the bagy'sulcus {if pos$ble), create a mioris
and look for the pupillary marg¡n. ¡fthere is sr there are corners th€n
you haw süll vilreous around... Vi$eous is trá¡s¡arent...'

Figure 86
92
iiiiiijriiiiijijjjjiiiiiiiiiiiiiiiiiiiiiiiiiiiiitjiiiiiiijriiiijjitiiiiiijiiiiiiiiiiiiiiiiiiliiijjjiliiiijiiijjjjj
Kfitr[
Xnsertimvn c¡f tkre lffiL

shou[d know the size of you tunnel br.ade and then just check what
kind of [ens you want to imptant.

capsute (Figure 871.

,,Filtthe bag with OVD before entarging the wound and


putting in the lens. This is safer for the postsrisr c*p;u|e.....

Figure 87

93
Ii ll
j j
iiiIiiii iII iii i Essential FÍinciples of Phacoemulsification iiiiliiiiiiiii r rlllirililiiiiiiiiiiiiiiiirlrlirliliiillli

During entargement you have to be sure that you stay in the tunneI
and then go stowty under the anterior capsute [compteteLy - the
[argest diameter shoutd pass the corneaLendothelium].

White coming out with the btade, open a littte more towards one
side of the port. This witl make it easier to introduce the [ens.

Remember: a nicety constructed wound that is [arge seaLs better


than a stretched sma[[ wound.
Deepen the anterior chamber before enLarging the tunne[.
Otherwise you may hurt the posterior capsuLe.., But you may atso
pierce it with the btunt needte of the OVD IFigure 871.

Do not pierce the posterior capsute with the OVD-cannuta or


white entarging the tunneLwith the btade. Start to fiLtthe anterior
chamber with OVD as soon as you enter the tunnel.

lf you pierced the posterior capsute then put dispersive [sea[s


better than cohesivel OVD in the posi capsutar hote and gently
ptace l0L into the bag.

ln smatl capsutar tears you stitl can put the lOL in the bag. ln
larger tears better p[ace it in the sutcus if you sti[[ have enough
support by the zonutes fFigure 881.

AA
]- 7\
,,ln srnall posterior capsular rupture. you still can put the lens in the bag.
ln larger one, you should put the haptics in the sulcus ..."

Figure 88

94
Chapter XIil. Insertion of the IOL

:- lf there is a smalL rupture of the posterior capsuLe, then put the


[ens into the bag. With a Larger rupture, first put it into the sulcus.
ln case of a nice rhexis tCCCl, which is atso smaLter than the optrc,
then think about putting the optic in the bag and [eaving the haptics
in the sutcus IcatLed "rhexis fixated lOt') lFigure 89).
¡= A rhexis f ixated IOL avoids decentering / rotation of the l0L. The
catcu[ated power is simitar to the bag [ocatization and it prevents
vitreous protapse and iris chafing IFigure B9).

,.ln larger posterior capsular rupture, you shouid put the hapdcs ín the sulcus,
but you still can put the ophc in the bag. You will then have a rhexis fixated lens..."

re' CompLetety fiLt the anterior chamber and the bag with OVD before
putting in the lOL. Be sure that the tunnel is atso fitLed with 0VD
Then, the IOL or the shooter stips better into the eye f Figure 901"

,,While filling the bag with OVD, check for the OVD propagation line
deep in the bag {called the,,Orgül wave"}..."

Figure 90
95
lf you put it in the bag the first haptic shoutd be in the bag from the
beginning (Figure 911.

,,lf yos want to put the IOL in the bag, put the first haptic in the bag while
you are still psshing in ths lOL,.."

Figure 91

capsutar bag (Figure 92f .

s
tu
,,,fr5;Ey-,,
lot in the sulcus, you have to put the first haptic
,,lf you want to put the
between thé irir a¡d the zofiulesllens capsute""."

Figure 92

lens with OVD f Figure 931.

96
chapter Xrrr rnsertion of the rol I l]lliiliiii l

,,lf you want to put the IOL in the sulcus, prepare the lscaüon by injecting
OVD between the iris and ttre ronules/lens capsule..."

Ftgure 93

> The IOL shoutd go ín forming a"Z" with the haptics side Inot an
"S"... which woutd mean "stop", do not imptant Like thatl. lnstead
of "2" you may prefer another acronym Like "7-0-L-even" which
is the same... This design is actuatty for right-handed surgeons
in order to easity rotate the haptics in the bag Ictock-wise)
IFigure 941.

Jhe lüL should go in the eye fcrming a ,,2*'with the haptic$ and not a,,S"
,,5" would mean stop and turn the lCIL!".."

Figure 94

97
ilr ]iiii Essential principles of Phacoemulsificarion iiliiiiiiiiiiiiiii r

lf you put in the t0L the wrong way, then you have three possibil.ities.
First ftip it within the eye [better for more experienced surgeonsl,
second leave itas it is Iit is nota catastrophe, butyou mayencounter
more posterior capsute opacification and the l0L power may not
be adequate) and third, you take out the [ens and put it in correctly.

lf you are not shooting the lOL, but inserting it with a [arge wound,
put the first haptic directty in the bag and the optic shou[d have
passed the corneaI endotheLium with the [arger diameter. Then
press the optic [with the Y-instrument] first down untiI hatf of the
optic is over the rhexis margin [and in the bagl and then turn the
haptic ctockwise. This wil.t put both haptics in the bag f Figure 951.

,,lf one hapüc is in the bag and the sther is still outside, then push the optic
forward in tht bag, press the lens d*wn and turn the IOL clockwi$e there.
The IOL will be in the bag then...'

Figure 95

l0L. Be sure that the first l0L haptic is going in the sutcus. lf it
turns out to be in the bag and you stitL push the l0L in the eye, you
may need a vitreoretinaI surgeon (Figure 9ó1.

98
chapter Xrrr: rnsertron of the rol ijijjiijijiijjijjiiji

,,lf you want to put the fOL in the sulcus {in targe posterior capsular rupture!
and you put the first haptic in the bag wlile still pushing in the tü! yóu may
loose the IOL ¡ilta th€ post€rior {hamber..."

Figure 96
lf you are in doubt whether the haptics are in the bag, then check
with Nagahara chopper or Y-instrument: push iris at the pupiil.ary
margin out and [ook for the haptics. Eventuatty the [ens has to be
turned in the bag to visualize both haptics.
Both haptics in the bag or both in the sutcus is OK, but never leave
one in and the other oui. The l0L wit[ decenter towards the haptic
in the su[cus. This by the way is the most common reason for IOL
decenteri ng.

Do not p[an to leave a singl.e-piece acryt IOL in the su[cus. lt ls too


smat[ for the su[cus and wit[ decenter... lf you know that you wiil.
imptant in the sutcus, choose a [arge optic lOL.
lf the IOL centers by itsetf, then haptics and optic are very probabty
in the bag.

lf the l0L is just a littte decentered, then leave it or rotate the IOL
carefutty for better centering.

lf the l0L doesn't center then check the haptics Itocated both in
the sutcus or in the bag? lf so, then put them in correctty), look for
zonular diatysis Iif so, then put a capsutar tension ring if tess than
5 ctock hours diatysis, otherwise put [ens in sutcusJ, check wounds
for vitreous lwith cotton tip or miotic agent injection), check for
haptic damage [you may have to reptace the lOL...).

gg,,' :ii
parts away f rom the tear.
lf you have just a sma[[ posterior capsutar tear in the center, then
put the lens in the bag. lf the tear is going towards the periphery
then put the [ens in the sutcus.
lf you have a rupture of the zonutes of less than 5 clock hours with
unstab[e capsute, then put a capsutar ring, if you have more than
5 hours, then put the [ens in the sulcus.

Even with the lens in the sutcus due to unstabte zonutes, a capsutar
ring heIps to stabitize the eye.
ln zonutar diaLysis the lens shoutd be imptanted in the axis of
the diatysis, meaning that the [ens haptic is pushing towards the
diatysis.

lf you use a capsu[ar ring then try to put it in the direction of the
diaLysis. According to the position of the unstabte zonutes you may
use a paracentesis to inject it.

Put in the capsu[ar ring with an injector orwith two forceps. 0ne
forceps guides the capsutar ring and the other one pushes forward.
lf you have to put the lens in the sutcus then decrease the IOL
power of about 0.75-1 dpt! {PLacement in the sutcus creates about
a 0.75 D myopic shift in g[asses).

lf you have a rupture of the posterior capsute, then be sure that no


vitreous is in the anterior chamber or has connection to a corneaI
wound. Remember:vitreous is very difficuLt to see!!! (Figure Bó).
lf you are looking for vitreous in the anterior chamber, then check
for indirect signs Iike pupitmargin deformation, strange behavior
of OVD in the anterior chamber and stretched appearance of the
capsutar rupture. Check the outside of the corneaI wounds with
a cotton tip the presence of vitreous incarcerated in the wound.
Check the inside of the corneaI wound with a spatula. ln doubt, put
in some triamcinolone in the anterior chamber to hetp visuatizing
the vitreous.

Remove the OVD over and behind the lOL f Figure 971.

-ii .

+1",'100
jijjiiiiiiiiilijiiljiiiiiiiiiiiiijiiliiiiiiiiiiiiiiiiiiiiiiiiiiiiiiji Chapter XIII: Insertion of the IOL

,,fiemernber to remave the OV$ behind the lSL..."

Figure 97

ln [arger tunneI incision [for exampte more than 5 mmJ you may
have to suture the cornea with 1 to 3 stitches (Nyton 10-01. But
remember that a nicety performed tunneL witt be tight even if
larger than 5 mm.
Better sutu re the tu n neI if you th in k that it is not tig ht or the patient
witt rub his eyes after surgery.

nucteus G4), witt often need a suture, since it represents a tissue


shrinkage and the tunne[ wit[ not be tight.

chamber wit[ stay deep and the cornea witt benef it f Figure 981.

A\
ffi@
,,4 positive vitreous pressure creater afi anterior displacement ofthe loL and may luxate
it orrt of the bag. Create coi¡nt€rpressure with an air bubble ¡n thE anterior chamber snd
check your wounds. They are probably not water thight...'

Figure 98

to3
ll,, essenttal Principles of Phacoemulsification

Do not "over"-hydrate the corneaI wounds. Postoperative you wit[


have more Descemet fol.ds and remember: a corneal wound wi[[
not get much more ctosed if you are overhydrating it. lf you are not
getting the tunnelor a [arge corneatwound tight, then suture with
Nyton 10-0 and remove the suture after 7-10 days.

Take out the OVD after having ptaced the [ens. The dispersive OVD is
harder to remove lshort molecutes don't stick together during l/A,
but short motecutes create less post op l0P spike...). The cohesive
OVD is easier to remove lLonger motecules stick together], but
these Longer motecutes bLock the trabecutar meshwork resulting
in big l0P spikes.
Use intracameraI antibiotics after cataract operation, but avoid
giving aminogtycoside antibiotics in the eye since they are
retin otoxic.

Postoperative tan*
TetL the patient that he shoutdn't rub or put pressure on the eye
after cataract operation.
The patient shouLd wear a protective eye shietd during the night
for one to two weeks after cataract operation.
lnstruct the patient that he shoutd avoid sptashing water directty
in the operated eye during the first days after operation.

Body bath, meaning washing betow the neck, is altowed, but the
patient shoutd not take a bath or go in the swimming pootfor two
weeks.

lnstruct your patient to show up if he has pain, after a trauma to


the eye, decreasing vision or if he sees new ftashes/dark spots.
The patient shouLd avoid situations where he might get a hit
towards the eye and keep physicaI activities light.

lnstruct the patient that stight redness, mi[d watering and


irritation, gtare and Littte conjunctivaI bl,eedings are normaI after
cataract operation.
Antibiotic and steroid drops combination 4x daity.

fa?.
treatment.
lnstruct your patient how to put the eye drops.
lnstruct the patient to wash his hands before apptying the eye
d rops.

wiLI give you faster a catm eye.

ln posterior capsutar rupture start giving NSAIDs drops and keep


them for 8Io 12 weeks postoperativety. The risk of postoperative
cystoid macu[ar edema is higher in these eyes.

Eventuatly a tropicamid drop just before going to bed the day of


the operation.

for the first night.

The cornea is not heaLed, but the IOL is more stabte in the eye after
some days.

and after 3-4 weeks.

The first postoperative day you can expect corneaI edema,


especialty at the tunnel site and proportionaI to the uttrasound
time, and cetl,s [1 to 2+] and ftare in the anterior chamber. The
pupiLshoutd be round and the l0L in ptace.

The eye pressure shoutd atways be measured at the postoperative


visits.

A ctear cornea the first day after surgery, i.e. a cornea with onty
a Littl,e amount of edema/endotheliaL fotds, is a good sign after
surgery.

Be atways aware of endophthatmitis. TeLt the patient that he


shouLd see an ophthatmotogist if he has pain in the eye some days
after the operation.

1CI3
xtw
ileeüsimn Thking in
tataract üperatücns

1. Stage the cataract: G1-G3: normaI ctear cornea incision, G4 or


white cataract: sc[ero-corneaI incision + dying the anterior [ens
capsute + in white cataract just pinch the center, if ftuid is coming
out then forceps rhexis.
2. Capsulorhexis? Norma[: continue c[assic procedure, tear: carefuI
hydrodissection, if [ens not turning then hydrodetineation, no
stress to capsute, repeated OVD insertion during atl. steps, S&C or
D&C if [ens turning, obtique chopping if [ens is not turning. Smatt
rhexis: entarge. Too [arge rhexis: take care white putting the [ens
in the bag.

3. Hydrodissection? Good: push [ens back and turn the [ens in the
bag. lncomptete: repeat at another point, if not working then
hydrodetineation (see 2.1.

1. Grooving: Very soft cataract: try cracking, if not working then


C&F. lf very hard: after first groove [grooved from both sides] try
to crack then 5&C. lf lens not turning: crack after first groove
[without turning 180"...J and then ob[ique chopping. lf not nicel.y
grooving but more cupping: change to C&F.

5. Cracking: Good: be sure that the cracking is comptete. Continue


normaI procedures. Not possibte: groove deeper and try again, if
not working then chop in harder cataracts or C&F in softer.

105
Ii iif iI i ii iii ii] iiii I Essentiar Piincipres or Phacoemursirication iiiiiiiiiiiiiiillliriiiiiiiiiiiiiiiiiiilriliiiliiirilillll

6. Cortex removat: Comptete: check, if realty every cortex is out


and if the capsu[e is not injured. Continue normaL procedures.
lncomplete: try bimanuat l/A, EV. make another paracentesis on
the opposite side of the remaining cortex. lf very adherent then let
it be.
7. lOL insertion: Good: are you sure the [ens is in the bag, in doubt
check... ln sutcus: then put it in the bag... ls it centered?: lf not
then check for IOL [ocation. lf both haptics in the bag then turn the
[ens in the bag. lf stitI de-centered, then check forweak zonutas...

8. OVD removat and finishing: Comptete: are you sure that there
is no OVD behind the Lens? EventuaLty press a littte on the lens
or go behind the [ens. Then check the wounds. Tight wounds?:
lf not then hydrate the paracentesis or suture the wound with
Nyton 10-0.

106
¡lirlliriill1iiiiiiiiitliltlrrlr1rlrlrrlrrrlr;iilr;iiliitiiiiiiliiiiiliiiiiiiiiiiiiiiii

ffim#mw#Kruffiffis

o Nirav Patet. PersonaI Communications, 2011.


a Phacodynamics, fourth edition. By Barry S. Seibet. Stack
incorporated, 2005.
SurgicaITechniques in 0phthaLmotogy. Cataract Surgery. By Garg
and Atio. Jaypee Brothers MedicaI Pubtisher, 2010.

Essentia[s of Cataract Surgery, By Jae Young, Stack incorporated,


2007

Phako Chop: Mastering Techniques, Optimizing Techno[ogy, and


Avoiding Comptications. By David Chang, Stack incorporated, 2004

Cataract Surgery: Expert Consutt- 0ntine and Print,3e. By Roger


F. Steinert, Saunders Etsevier, 2009

Cataract Surgery from Routine to Comptex: A Practical Guide. By


RandatIJ. O[son, Stack incorporated, 2011
Premium Cataract Surgery: A Step-By-Step Guide. By John
Hava nesian, Stack i ncorp oraled, 2012
Cataract Surgery And lst Comptications, óe. By Norman S. Jaffe,
Mosby,1997

Phacoemutsification,3rd Edition, Votume 1. By Robert H.Osher,


Kindte edition,2009
]i i i I i i i i I I i i i i i i I i I i Essential Frincipres of Phacoemursification liiiiiiiiiiiliiiiiiitiillliiiiiiiiilillliiililiiilliiiiiliilil

A PracticaI Guide to Phacoemutsification. By Mahipat Singh


Sachdev, ALpha Science lntl Ltd., 2003

Phacoemutsification Made Easy. By Aaheet H. Desai, Anshan Ltd.,


2005

Video AtLas of Eye Surgery - lnternationaI Edition.


Phacoemutsification. 1. Basic Techniques tDVDl. Eye Movies Ltd,
2005.

Comptications During Cataract Surgery. Anterior Capsute IDVD].


By David Osher. American Academy of 0phthatmol"ogy, 2009.

http://ca ta ractsu rge ryfo rg reen ho rns. b [ogspot.com/.

Videos f ro m www.yo utu be.co m a nd www. eyetu be.o rg.

xo8
iliiiijiiiiiiiiiiljiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiijiiiijjiiitiliiiliiiiiiiilliiiliiiiliilillliliiiiitiliiililiiiji

XNMHX

Anesthesia 9
Antibiotics 102
Astigmatism 16,19

n
Batanced sa[t solution [see BSS)
Battooning [see conjunctivat bal.tooningl
BSS Ibatanced salt sotution] 18,28,30, /.
Burn [see corneaI burnJ
Bottte height 3, 55, 87

Capsutar ring 99, 100


CCC lcontinuous curvitinear capsulorhexisl 22, 28,32,95
Chip & Ftip 1,54, 60, 62, 65, 66, 67
Cohesive OVD 30, 88, 94,102
ConjunctivaI baltooning 15, 18, 19
Continuous curvitinear capsu [orhexis [see CCCJ
Cornea guttata 10
CorneaI burn 3, 5, 19, 46,63,101
Cup 58, ó0, 64, 65, óó, 1 05
Cutter 87,88, 89
Cystotome 21,24,28,31

Diatysis Isee zonu[ar diatysisl


Dispersive OVD 30,82,88, 89, 94,102

1ü9
I i I
j
] i i I i I I I i
j
I i I I i i i Essentiar Piincipres or Phacoemursirication ilililiiiiiliiiiiililililiiiiillliiiiiiiiilillilriillilillli

Divide 1 , 46, 49,53, 57, 62, 63, 66, 67 , 69,70,73


Draping 9
Dye 11,21,28

ECCE [extracapsutar cataract extraction) 6,9,52, 87


EndonucLeus 42
Endophthatmitis 103
Endothetium 10, 14, 17, 46, 63, 67,94,98
ExfoLiation syndrome [see PEX)

FLow 2, 3,4, 5, 8,30, L6,54, 55, ó3, 80, 81, 87, BB


Forceps 17,21, 24, 27,28,31,32,33, 100, 105
Fulcrum L6

Gotden ring sign 20,42,43


Guttata [see cornea guttataJ

FI

Haptic 32, 95, 96, 97, 98, 99, 100, 10ó


Hemorrhage 5, ó, 9, 10, 13
Hooks lsee iris hooks]

l0P Iintraocutar pressurel 3, 6, 19,102


lnf usion misdirection syndrome 5, ó
lris hooks/retractors 1 1, 33, 48,52
lris retractors Isee iris hooksJ
L

Lid specutum 9

Magnification B
Mannito[ 19
Marfan's syndrome 10
Misdirection syndrome [see inf usion misdirection syndrome]

Nagahara Chopper 57,70,99

OVD [ophthatmic viscosurgicaI devicel I t, 17, 18,21,24,27 ,28,29,


30, 32, 33, 39, 82, 87, 88, 89,
93, 94, 95, 96, 100, 102, 105

Paracentesis 13, 1 1, 15, 16, 17, 18,21,24,28,30,31, 39, 48, 63,79,


80, 83, 89, 1 00, 1 0ó
Pedal. B, 9, 81
PEX 10,28,43
Pseudoexfotiation syndrome (see PEX)
Pupit B, 1 0, 1 1,22,26,30, 31 , 33, 64,86,92, 1 00, 1 03

Retinitispigmentosa 28
Ring lsee capsutar ring or ring signl
Ring sign [see gotden ring sign)
Rupture 38, 39, 42,81,83, 89, 95, 98, 100, 103
I Essential Principles or Phacoemulsirication
j
ii ii ii ii il iii ii iii

Scissors 28,32,33, 88
Settings 1,2, 63
Shearing 24,25,26
Spatuta 30,48, 8ó, 89, 100
Specutum [see iid specutum)
SubchoroidaI hemorrhage 5, ó
Sutcus 33,87,89, 90, 94,95,96,98,99, 100, 10ó
Suture 1 8, 88, 101, 102,1 03, 1 0ó
TI

Tenon 18
Trauma 10, 3ó, 42,102
Triamcinoton 90, 100

tt

Uttrasound 2, 4,9, 10, 103


Uveitis 28 I

v l

Vaccum 2, 3, 4, 5, 63, 66, 70, 72, 73, 81, 87


Vitreous 6, 10,28,82,83,85, 8ó, 87, 88, 89, 90, 91,92,95,99, 100
Vitreous cutter [see cutter or vitrectomy]
Vitrectomy 9,36, 42,82, 89 ,90

Zonutar dialysis 85, 99, 100


Zonute 22.31,35, 43, 52,65,69,73,75, 80, 94,96,100
Essential
Principles of
Phacoemulsification
The book "Essential Principles of Phacoemulsification"
presents all the important steps of phacoemulsification
cataract surgery. lt is not just another book on cataract
surgery. lt has a lot of practical tips and tricks a cataract
surgeon beginner, as well as a more experienced cataract
surgeon can benefit from.

The sentences are dynamic, easy to read, clear and to the


point, in order to present how each step works. You will
develop a clear understanding of every move made by the
phacoemulsification surgeon as well as the basics of the
equipment, many times difficult to interpret.

"Essential Principles of Phacoemulsification" is a


continuing education textbook oriented to provide an
instant mental picture of the surgical steps in
phacoemu lsification cataract surgery.

tsBN 978-9962-678-61-8

4-
AYPEE. HIGHTIGHTS
$r MEDICAL PUBTISHERS, INC.
ilililililJilt|[ilffiil[
Ava i I able onl i ne at wwwjph med ical.com

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