...

evolving since 1967

Moderator: Dr Veena Bhaskaran

Presenter: Dr Vartika Kinra

Dr. Charles Kelman

An ophthalmologist and a
pioneer in cataract surgery

The idea of
phacoemulsification took
birth in Dr Charles
Kelmans mind during a
visit to the dentist, where
he found an ultrasonic
device being used to
remove plaque and debris.
The concept took almost
two decades (1948 to 1967)
to make itself accepted.

Anterior chamber (Kelman 1967)

Iris plane (Little 1979)
Posterior chamber ( Maloney 1988)
Endocapsular

 Cleaning, draping and exposing the

eye
Side port incision
Wound construction
Capsulorhexis
Hydroprocedures
Nucleotomy and phacoaspiration
Epinuclear plate removal
Cortical aspiration
IOL implantation

 Made inside the clear cornea, parallel to the iris

surface with the help of a sharp pointed MVR/ 15

Degree blade.
Size is 1- 1.5 mm square tunnel.
Location: 2 to 3 clock hours away from the main
incision.
Two side port incisions, when made, the second
should be 180 deg apart from the first, which is
about 2 to 3 clock hours away from the main
incision.
Technique: enter with knife pointed towards the
ciliary body 150 to 180 deg away creating a
uniplanar 1.5mm x 1.5mm square tunnel.

 Provides access for introduction of

viscoelastics, saline, anaesthetics and

antibiotics in the AC.

To introduce the second instrument to stabilize

the globe, manipulate the nucleus, removal of

cortex and insertion of IOL.

3 TYPES:
Sclerocorneal tunnel incision
Limbal corneal tunnel incision
Clear corneal tunnel incision

 Preferred when non-foldable

(PMMA) IOL is to be implanted.

Size : 3-3.5 mm( 1.5 mm scleral
part + 1.5-2 mm corneal part)
Length needs to be enlarged to
5.5 mm before IOL implantation
Technique : same as for SICS
An ideal tunnel would be square,
self sealing, lying within the
astigmatic neutral funnel

ADVANTAGES
Less astigmatism.

DISADVANTAGES
cannot be performed under
topical anesthesia.

Less chances of infection due

to wound being covered by
longer time & greater
conjunctiva.
precision are required.
Early healing & stabilisation
of wound due to vascular
scleral part of incision.

bleeding may be
troublesome sometimes
Instrumental manipulation is
difficult due to wider tunnel.

Iris prolapse may occur during

instrumental manipulation.

 It is a good compromise between a clear corneal and a

posterior limbal incision

Size: 3-3.5 mm square tunnel
Technique:
external vertical groove in anterior limbal area
Limbal-corneal tunnel
Internal corneal incision made entering the anterior chamber

ADVANTAGES

Less astigmatism
Early healing

Provides a wider
tunnel and valve than
the clear corneal
incision

DISADVANTAGES
ballooning of the

conjunctiva and
bleeding into the
anterior chamber
when incision is
enlarged prior to IOL
implantation

 Most commonly used when

foldable IOL implantation is

planned
External wound is positioned

anterior to limbal vascular arcade

(0.5 mm anterior to limbus)
Three types:
Uniplanar clear corneal incision
Biplanar clear corneal incision
Triplanar clear corneal incision
Hinged incision

ADVANTAGES
No need of conjunctival flap

DISADVANTAGES
Technically difficult

No need of cautery and no bleeding Possible increased risk of

while extending the incision
endophthalmitis
Can be performed under topical
anaesthesia & takes less time and
fewer instruments
Instrumental manipulation is easy
No distortion of cornea with phaco
handpiece and no compromisation in
the view of intraocular structures

Aesthetically better as eye does not

appear to be operated

Instruments distort cornea

 Position: with respect to corneal curvature, the

incision can be positioned in :

1. Temporal quadrant
2. Superior quadrant
3. Obliquely (superotemporal quadrant)
4. In the axis of greatest curvature
Choice of position: induced astigmatism and

ergonomics of the operation

ADVANTAGES

DISADVANTAGES

Surgeons hand can rest

on patients forehead

orbital edge impairs

access for the surgical
field, specially so in deep
set eyes

Incision is underneath
the upper lid and causes
less discomfort

more surgically induced

astigmatism

ADVANTAGES
Less induced astigmatism

DISADVANTAGES
Tendency of the patient for turning
the head away from the surgeon

Access to surgical field is good

Bells phenomenon does not pose a
problem under topical anaesthesia
Glaucoma filration bleb or future
trabeculectomy is not compromised

Natural drainage of irrigating fluid

Less chances of locking of
instruments
Red reflex is comparativey better in
temporal approach

Tendency of the eye to roll nasally by

the phaco hand piece
frequent change in the setup for the
right and left eyes of patients
more chances of discomfort and
infection than the superior incision

 It is a prerequisite for phaco as intact CCC strengthens capsule,

withstands IOP fluctuations, allows posterior chamber phaco

Ideal size: -6 mm, should cover 0.25 mm of IOL

circumferentially
Site:
Mainport- easy maneuverability, more leakage
Sideport- stable AC, difficult to stabilize the eye
Technique: needle or forceps
Requisites: good illumination, high magnification, well

pressurized eye

HYDRODISSECTION
Separates the cortex from the capsule by a

mechanical fluid wave

Fluid is injected with a 2ml syringe & a 25-30G
cannula underneath the anterior capsule
Remove visco first to avoid inadvertent increase in IOP
Done from the mainport, causing tenting of the
capsule margin
Inject atleast 1 mm beneath the capsular rim
Watch for: fluid wave, loss of glow and popping up of
nucleus

 Creates a cleavage between the epinucleus and the

hard endonucleus
The aim of this maneuvre is to create the smallest
possible nucleus with the thickest possible epinuclear
plate
This allows for the minimal use of phaco power with the
maximal cushioning effect
Technique: fluid is injected with a 26G cannula passed
into the nucleus until it meets resistance. A typical
golden ring is seen in immature cataracts.
Hydrodelineation is not effective in white or densely
brunescent cataracts

 The eye should be well pressurized with viscoelastic substance

Types:

One hand technique

Two hand technique
Instruments used: sinskey hook or chopper

The instrument should be placed close to the CCC, even inside

the CCC if possible and the nucleus is pushed towards the

periphery of the lens and then rotated
Difficulty in rotation occurs in:
Soft nucleus
Inadequate hydrodissection
Loose zonules which can cause the bag to rotate instead of the
nucleus

One hand technique

Two hand technique

Central safe zone (CSZ) - central area within the capsulorhexis

margin
Smaller CSZ

Larger CSZ

Hypermetropia

Myopes

Narrow pupil

Zonular stress syndromes

Small CCC

Vitrectomized eyes

Peripheral unsafe zone (PUSZ) - capsular fornices and angle of

anterior chamber

 AIM: to remove the lens(9-10mm) through a small

incision (2.8-3mm) without damaging the adjacent

structures.
The technique and parameters vary according to

the density of the nucleus.

 It refers to the process of debulking the cataractous nucleus. It is

accomplished by shaving action of the phaco tip, which is never

occluded during the manoeuvre
Indications:
Trenching, i.e. formation of a deep groove in the centre of the
nucleus.
It should be performed at low vacuum settings(i.e. 20+/- 10
mmHg), since we are trying to sculpt the nucleus and dont want
to hold it. The power setting will depend upon the grade of the
nucleus.
Power = grade of nucleus x 15 + 25
Crater formation, i.e. debulking of the most of the anterior part

of the central nucleus, forming a remaining bowl of posterior part

of the nucleus with a peripheral nuclear rim.

It refers to divide and fragment the dense

nucleus rim after sculpting all that can be safely
sculpted. It is also known as fracturing or
cracking.

It refers to the technique of splitting the nucleus

into pieces with the help of chopper, after
impalling the nucleus with the phaco tip.

The most popular methods of nucleotomy include:

1. Divide & conquer
2. Chopping
3. Stop & chop
4. Flip & chip

 Introduced by Howard V. Gimbel in 1986

Two variations:
1) Trench divide and conquer : for soft to

moderately hard nucleus

2) Crater divide and conquer: for moderately hard
to very hard nucleus

 Steps:
- Deep maltease cross trenching
- Fracture of the nucleus in four quadrants
- Phacoemulsification of each quadrant
Dimensions of the trench should be:
Length: 4-5 mm in the zone of capsulorhexis
Width: 2 tip diameter to accommodate the sleeve
Depth: 3 tip diameter. Sculpting should be

continued till a red glow is visible in the trench.

 Moderate flow, low phaco power, low vacuum and 30 deg U/S tip

should be preferred for trenching and the sculpting should be done

by a shaving action movement without occluding the tip. On return
stroke, the foot pedal should be at position 1 (irrigation only).
Trenching should be stopped just of CCC margin and care should be

taken to avoid iris. Epinuclear bowl should be spared as it acts as a

cushion protecting the PC
Fracture/ splitting of the nucleus can be done using two

instruments ( either phacoprobe and a chopper or two

choppers/sinskey hooks)
Lens fragment phacoemulsification should be done using minimum

phaco power, more aspiration and the procedure should be done in

the central safe zone

 Recommended for hard nucleus(grade III +)

High flow, high vacuum and low U/S power is used
A large crater is sculpted, leaving a dense peripheral rim that can

be fractured into multiple sections

Once the fracture is complete, each pie shaped wedge of nuclear
rim is brought to the CSF & emulsified.

 Introduced by Nagahara in 1993

Chopping refers to the technique of splitting the nucleus

into pieces along the natural cleavage planes with the

help of an instrument called chopper after impaling the
nucleus with phacoemulsification tip.
Advantages of chopping over nucleus cracking technique:

Reduction in surgical time

2. Reduction in total phaco energy used
3. Decreased incidence of posterior capsular tear
4. Decreased incidence of corneal complications
1.

 Types:

-Horizontal chopping
a) Peripheral
b) Central
-Vertical chopping
Technique: phaco probe with bevel down is kept flat
on the anterior surface of the nucleus.

With a short burst of energy, the nucleus is entered.

Vacuum is allowed to built up and the nucleus is
chopped.
The grip is usually superficial and complete split is not
always obtained.

 It is Kochs modification of Nagaharas direct chop

technique
Deep trench is sculpted & nucleus cracked into two

halves similar to divide and conquer technique. At

this point, quadrant cracking is stopped and chopping
begins and so the name stop and chop was given to
this technique.
The probe can easily be embedded into the hard body

of the nucleus and a vacuum seal created for

chopping into pieces.

Moderate flow and moderate vacuum is

required

No U/S energy required

Chip and flip method

The size of the epinuclear plate is reduced

by chipping the peripheral part from under

the anterior capsule
The remaining part can be flipped with the
second instrument (round or rod shaped iris
repositor) and then phaco-aspirated

 Methods:

1. Automated irrigation & aspiration

Coaxial irrigation & aspiration
Bimanual irrigation & aspiration
2. Manual irrigation & aspiration
Technique:
Keeping the aspiration orifice facing forward, go close to &
underneath the anterior capsule & create a vacuum seal by
occluding the port with the cortical fibres, pressing the foot
pedal between position 1 & 2 (in I&A mode, there is no position
3).
Striae on the capsule is an indication of inadvertant holding of the
capsule & the foot pedal should be released immediately.

 Required to prevent formation of PCO

Can be done with rounded repositor/ sand blasted capsule polisher /

ring capsule polisher

Technique: the bag is inflated with VES to make the PC stretched and

concave. The IOP should be 30 mmHg. The PC is then gently scrubbed.

It can also be done using phaco I/A in cap-vac mode in which

vacuum is kept between 0 to 40 mmHg; keeping the aspiration orifice

down , capsule is gently held with the cannula with a force sufficient
to bring it to the orifice for scrubbing but not enough to tear it.

 PMMA IOL:
Phaco profile PMMA IOLs are available in 5, 5.25 and 5.5 mm size.

Accordingly, after pressurizing the eye with OVD, the incision is

enlarged to 0.5 mm less than the size of the IOLs optic.
Insertion technique is same as in SICS.

FOLDABLE IOL:
Holder- folder system- sparingly used
2. Injector system- commonly used
IOL is loaded into the cartridge & the cartridge is inserted into the
injector. The nozzle of the injector is introduced into the main
wound bevel down. The tip is positioned in the plane of the rhexis.
Once the leading haptic is near the CCC, guide it under the rhexis
margin & then push the optic into the AC. The plunger is advanced
like a syringe and the IOL is delivered into the capsular bag.
1.

 Aspiration of the residual OVD

Sealing of side port and main incision
Check the self sealing nature of the incisions
Subconjunctival injection of antibiotic and

steroid
Patching of the eye

MICROINCISION PHACOEMULSIFICATION (MICS)

Jorge Ilio in 2001 used this term to denote all cataract
surgical techniques which could be performed through a
microincision of 1.5 mm or less. MICS procedures include:
1.
2.

3.
4.
5.
6.

Phakonit
Truly endocapsular microincision cataract surgery (TECMIS)
Laser phacolysis
Aqualase
High aspiration controlled chop (HACC)
Catarex technology/ Vortex phacoemulsification

 Phacoemulsification: Principles and techniques,

Second edition. Lucio Buratto

Phacodynamics, mastering the tools and

techniques of phacoemulsification, Fourth

edition. Barry Seibel
A guide to phacoemulsification, AIOS CME Series

21. Harbanshlal