PHACOEMULSIFICATI

ON FOR CATARACT
EXTRACTION
PART
AAO READIING
1
In Phacoemulsification, using ultrasound energy to emulsify a
lens with the use of modes such as pulse and burst allow for…. 1
▪ a. most continuous delivery of phacoemulsification power 
▪ b. intermittent delivery of phacoemulsification power 
▪ c. direct control of the vacuum level only
▪ d. control aspiration flow rate and set a vacuum limit 
A new alternative technology to assist in cataract extraction
is… 2
▪ a. ICCE/ECCE
▪ b. mSICS
▪ c. Femtosecond laser platforms 
▪ d. All options above are true
Although there are several types of phaco machines, the major
components are essentially the same such as…

▪ a. handpiece, foot pedal, irrigation system

3
▪ b. handpiece, foot pedal, irrigation system, and aspiration
pump
▪ c. Phaco machine, phacobrobe, foot pedal, irrigation system,
and aspiration pump
▪ d. Phaco machine, phacobrobe, foot pedal, irrigation line and
vacuum line
The following statements are true about phaco tips, except…

▪ a. available with bevels of 0°, 15°, 30°, 45°, and 60° 4

▪ b. the phaco tip according to personal preference 
▪ c. steeper bevels which is have larger opening may be more
easier to occlude to achieve full vacuum 
▪ d. A tip with a steeper bevel has an oval port with a larger
surface area, which can generate more holding force and
greater cutting efficiency 
The following statements are true about pulse-mode

5
phacoemulsification, except…

▪ a. involves setting the number of pulses per second while the

foot pedal is in position 3
▪ b. the number of pulses per second means the number of
intervals during which phaco power is turned on 
▪ c. When the foot pedal is fully depressed in position 3, each
pulse will have the preset maximum power 
▪ d. intervals alternate with “rest” intervals during which phaco
power is the lowest 
• Two main types of aspiration pumps are used in phacoemulsification
HIGHLIGH
TS
machines: flow pumps (eg, a peristaltic pump) and vacuum pumps (eg, a
Venturi pump). Flow pumps allow the surgeon to directly control
aspiration flow rate and set a vacuum limit. Vacuum pumps allow direct
control of the vacuum level only.
• Phacoemulsification uses ultrasound energy to emulsify a lens. Modes
such as pulse and burst allow for intermittent rather than continuous
delivery of phacoemulsification power, thereby decreasing the total amount
of energy required for cataract extraction.
 HIGHLIGH
TS
• Femtosecond laser platforms provide an alternative technology to assist
in cataract extraction.
• Studies demonstrate that more than 90% of eyes achieved a postoperative
spherical equivalent within 1.00 diopters (D) of that predicted by
preoperative biometry.
INTRODUCTION
▪ The modern era of cataract surgery began in 1967, when Charles Kelman invented
phacoemulsification. In this procedure, an ultrasonically driven tip is used to emulsify the lens
nucleus and remove the fragments with an automated aspiration system. This paradigm shift
allowed cataract surgery to be performed via smaller corneal incisions, resulting in a lower
incidence of wound-related and vitreous-related complications and more rapid rehabilitation of
vision. Although phacoemulsification was initially met with strong resistance, the procedure
gained popularity by the 1990s, coinciding with the invention of ophthalmic viscosurgical
devices, the evolution of intraocular lens design, and a change to performance of cataract
surgery on an outpatient basis. Today, phacoemulsification is the most commonly performed
method of cataract extraction in developed areas.
▪ In developing areas, however, the high cost of phacoemulsification technology and its
associated disposable equipment have limited its adoption. Instead, extracapsular cataract
extraction (ECCE) and manual small-incision cataract surgery (MSICS) remain the most
common procedures. The use of historical techniques such as intracapsular cataract extraction
(ICCE) and couching are rare..
▪ Phacoemulsification (often referred to as phaco) makes use of
ultrasound technology as well as vacuum. Although there are
INSTRUMENTAT
several types of phaco machines, their major components are
ION
essentially the same: a handpiece, foot pedal, irrigation
system, and aspiration pump.
The phaco handpiece has been likened to a
combination of a jackhammer, vacuum, and
garden hose. The surgeon uses the handpiece to
simultaneously emulsify and aspirate the
crystalline lens while keeping the tip cool and
maintaining anterior chamber depth. The
mechanical energy of phacoemulsification is
produced by the to-and- frooscillation generated
by piezoelectric crystals in the phaco handpiece.
The amplitude of the movement, or stroke length,
is variable and increases when the power is raised.
▪ As the phaco tip moves forward, compression of gas atoms in solution occurs; as the tip
moves backward, expansion of gas atoms occurs, and bubbles of gas form (known as
cavitation). The bubbles are subject to the same compression and expansion. When the
bubbles implode, they release heat and shock waves, which disassemble the nucleus at the
phaco tip. Nonaxial vibrations generated by a torsional or elliptical motion of the tip can
augment the primary oscillation and aid the mechanical breakdown of nuclear material. These
mechanisms are specific to the type of phaco machine used.
▪ Mastering use of the phaco foot pedal is critical to successful phacoemulsification technique. All current phaco

machines have foot pedal controls with at least 3 positions.

▪ Position 1 activates irrigation, with the infusion pressure determined by irrigation bottle height or its equivalent.

▪ Position 2 engages the aspiration or vacuum mode at a fixed or variable rate.

▪ Position 3 adds ultrasound power at a fixed or variable level.

▪ In the fixed power mode, the level may be set from 0% to 100%, and the chosen power level is delivered

immediately when the foot pedal is depressed into position 3. With variable ultra sound, the surgeon controls the
amount of phaco power delivered by varying the depth of depression of the foot pedal while it is in position 3.
PHACO TIP AND PEDAL
PHACO HANDPIECE
I/A HANDPIECE
KEY CONCEPTS AND
ADVANCES IN PHACO
POWER DELIVERY
▪ The delivery of phaco power can have both favorable and unfavorable consequences.

Cavitation, shock waves, shear forces, and heat buildup at the tip may facilitate disassembly of
the lens nucleus. However, more power is not necessarily better; the longitudinal stroke of the
phaco tip tends to push nuclear fragments away even as the aspiration attracts them, resulting
in chatter. In addition, heat buildup from the delivery of phaco power may cause thermal
injuries such as wound burns or damage to the corneal endothelium.

▪ Many parameters can be adjusted to deliver phaco power more efficiently and safely. The size

and angle of the phaco tip can be altered to increase cutting efficiency. Intermittent rather than
continuous phacoemulsification modes, such as pulse and burst, can also be used. Various
mechanical strategies, including torsional and elliptical movement of the phaco tip (rather than
only longitudinal movement), may also minimize heat generation.
▪ Phaco tips vary by angle and size of the lumen. Phaco tips are available
PHACO TIP
with bevels of 0°, 15°, 30°, 45°, and 60°. The surgeon generally
chooses the bevel angle of the phaco tip according to personal
preference.
▪ A tip with a steeper bevel has an oval port

with a larger surface area, which can

generate more holding force and greater

cutting efficiency. The disadvantage of

steeper bevels is that the larger opening may

be more difficult to occlude to achieve full

vacuum. End configurations can be round,

ellipsoid, bent, or flared.

▪ To reduce the total energy delivered into the eye, the surgeon
can use an intermittent rather than a continuous mode of
PULSE AND
phacoemulsification. The delivery of phaco power for only a
BURST MODES
portion of the cycle also reduces repulsion of material by the
vibrating tip (ie, reduces chatter) and improves followability.
This method of breaking up the delivery of ultrasonic power
into smaller packets of pulses and bursts is called phaco
power modulation.
Pulse­versus burst­mode phacoemulsification. A, In pulse mode, foot pedal excur­sion provides linear control of ultrasound power,
with a fixed duty cycle (50% in this case) and number of pulses per second. B, In burst mode, foot pedal excursion provides linear
control of number of bursts per second, with a fixed ultrasound power (25% in this case) and burst duration. (Data modified from
Seibel BS. Phacodynamics: Mastering the Tools and Techniques of Phacoemulsification Surgery; 4th ed. Slack; 2005:121, Fig 1-
55.)
▪ Pulse-mode phacoemulsification involves setting the number of pulses per second (ie, the
number of intervals during which phaco power is turned on) while the foot pedal is in position
3. These intervals alternate with “rest” intervals during which phaco power is off. The phaco
power of each pulse increases as the foot pedal is depressed farther in position 3. When the foot
pedal is fully depressed in position 3, each pulse will have the preset maximum power.

▪ Burst-mode phacoemulsification involves delivery of preset power (0%–100%) in single bursts

that are separated by decreasing intervals as the foot pedal is depressed through position 3.
When the foot pedal is fully depressed in position 3, the power is no longer delivered in bursts
but is continuous. Burst mode allows the tip of the phaco needle to be buried into the lens, an
essential step for chopping techniques.
▪ The ratio of “power on” time to total time is referred to as the duty cycle. The traditional pulse
mode has a default duty cycle of 50%, with the phaco energy on and then off for equal periods
(50:50). Modern pulse modes allow detailed control of the duty cycle and the number of
pulses per second. As mentioned previously, during burst-mode phacoemulsification, foot
pedal position 3 allows linear control between minimum and maximum set duty cycles, with
the maximum usually being continuous.
▪ Other advances in phacoemulsification technology can also reduce chatter and
TORSIONAL AND
the total amount of phaco energy used. For example, in torsional
ELLIPTICAL
PHACOEMULSIF
phacoemulsification, the piezoelectric crystals of the phaco handpiece
ICATION
produce an oscillatory (torsional) movement, which is amplified by use of a
bent phaco tip (eg, a Kelman-style phaco tip).
 TORSIONAL AND
ELLIPTICAL
▪ The greater side-to-side movement at the tip may allow for greater shearing
PHACOEMULSIF
forces to assist in nucleus disassembly. Another system utilizes a combination
ICATION
of transverse and longitudinal modalities; the resulting elliptical cutting
pattern may enhance nucleus emulsification.
THANK YOU