Dr. Gede Pardianto. SMEC Jakarta Jl Pemuda 36 Rawamangun Jakarta Timur. Sumatera Eye Center Jl Iskandar Muda 278 Medan. Tel 628155000300.

1. LearningLearning
PhacoemulsificationPhacoemulsification forfor
TremorTremor SurgeonsSurgeons
GedeGede PardiantoPardianto

2.  Dr. Gede Pardianto.
 SMEC Jakarta Jl Pemuda 36 Rawamangun Jakarta
Timur.
 Sumatera Eye Center Jl Iskandar Muda 278 Medan.
 Tel 628155000300.

3.  GraduateGraduate
– Doctor of MedicineDoctor of Medicine Universitas AirlanggaUniversitas Airlangga
– OphthalmologistOphthalmologist Universitas AirlanggaUniversitas Airlangga
 OfficeOffice
– Sumatera Eye Center, MedanSumatera Eye Center, Medan
– Dr Komang Makes Naval Hospital, BelawanDr Komang Makes Naval Hospital, Belawan
– Universitas Sumatera Utara, Medical SchoolUniversitas Sumatera Utara, Medical School
 MemberMember
– IOAIOA
– InaSCRSInaSCRS
– ESCRSESCRS
– ASCRSASCRS
No Financial InterestNo Financial Interest
GedeGede PardiantoPardianto

4. Phaco surgeryPhaco surgery
 Phaco surgeryPhaco surgery  only a little thing we doonly a little thing we do
 All of our timeAll of our time  we practicewe practice
 Practice makes perfectPractice makes perfect

5. PhacosurgeryPhacosurgery
 MicrosurgeryMicrosurgery
 Advanced surgeryAdvanced surgery
 Refractive surgeryRefractive surgery

6. Tremor surgeonsTremor surgeons
 Tend to failTend to fail
 High ‘mortality’ in learning processHigh ‘mortality’ in learning process
 But possibly to successBut possibly to success  don’t be surrender ordon’t be surrender or
giving up easilygiving up easily
 Being gentle and carefullyBeing gentle and carefully  patient’s sight ispatient’s sight is
everythingeverything
 Know the pitfall and limitationKnow the pitfall and limitation
 Know what should do and do notKnow what should do and do not
 Learn more, practice moreLearn more, practice more

7. PhacoPhaco
 Same proper procedure in entire processSame proper procedure in entire process
of surgery with ‘little bit’ pressure in a viewof surgery with ‘little bit’ pressure in a view
techniquetechnique
 Pre phacoPre phaco
 Peri phacoPeri phaco
 During phacoDuring phaco
 Post phacoPost phaco

8. Pre-phacoPre-phaco
 Patient selectionPatient selection
 Optical biometry scanned immatureOptical biometry scanned immature
cataractcataract

9. Peri-phacoPeri-phaco
 Adjust your microscopeAdjust your microscope  resetreset
 Adjust your seatAdjust your seat
 Adjust your patient’s positionAdjust your patient’s position
 Protect the fellow eyeProtect the fellow eye
 Place your drape properlyPlace your drape properly
 Cut to open your drape properlyCut to open your drape properly
 Place your speculum properlyPlace your speculum properly
 Now place your hand gently firmNow place your hand gently firm

10. Better but you don’t have toBetter but you don’t have to
 General or local anesthesiaGeneral or local anesthesia
 Fixing the eye ballFixing the eye ball

11. Microscope (again)Microscope (again)
 Your foot pleaseYour foot please  stay on pedalstay on pedal
 PDPD
 IlluminationIllumination
 MagnificationMagnification
 FocusFocus
 Reset (again)Reset (again)

12. During phacoDuring phaco
 IncisionIncision
 CCCCCC
 HydrodissectionHydrodissection
 SculptingSculpting
 CrackingCracking
 Segment RemovalSegment Removal
 Epi-nucleus removalEpi-nucleus removal
 Capsule polishCapsule polish
 Irrigation/AspirationIrrigation/Aspiration
 Lens InsertionLens Insertion
 Wound closureWound closure

13. IncisionIncision
 Second IncisionSecond Incision
– Proper two- or three-Proper two- or three-
planed incisionplaned incision
– Optimum sizeOptimum size
– Direction controlledDirection controlled
 Main IncisionMain Incision
– Proper two- or three-Proper two- or three-
planed incisionplaned incision
– Precise sizePrecise size
 ‘‘Third’ IncisionThird’ Incision
– Minimum sizeMinimum size Mahatme V, 2005

14. Incision: PitfallIncision: Pitfall
 Early anterior capsuleEarly anterior capsule
teartear
 ‘‘Not enough’ portNot enough’ port
 Leaking portLeaking port
 Leaking woundLeaking wound 
shallow ACDshallow ACD
 Iris prolapseIris prolapse
– More limbalMore limbal
– Direct one-planedDirect one-planed
 Post operativePost operative
astigmatismastigmatism  positionposition
Mahatme V, 2005

15. OVDOVD
 Right OVDRight OVD
 Tight anterior chamberTight anterior chamber
 SpaceSpace
 StructureStructure

16. CCCCCC
 Fixed eye ballFixed eye ball
 Stained capsuleStained capsule 
compulsorycompulsory
 Tight anterior chamberTight anterior chamber
 Curve tearCurve tear
 Gently movementGently movement
– PosteriorlyPosteriorly
– Toward centerToward center
 Keep alertKeep alert
 Proper sizeProper size
Mahatme V, 2005
Mahatme V, 2005

17. CCC: PitfallCCC: Pitfall
 EscapeEscape
 Too largeToo large
 Too smallToo small
 WeakWeak

18. Hydrodissection: PitfallHydrodissection: Pitfall
 InadequateInadequate
 Difficult to rotateDifficult to rotate
 Early drop nucleusEarly drop nucleus

19. HydrodissectionHydrodissection
 Direction of canuleDirection of canule
 Position of hand,Position of hand,
syringe and needlesyringe and needle
 Amount of waterAmount of water
 Power of pressurePower of pressure
 Speed of injectionSpeed of injection
 Time of injectionTime of injection
Mahatme V, 2005
Mahatme V, 2005

20. HydrodelineationHydrodelineation
 Traumatic cataractTraumatic cataract
 Posterior polePosterior pole
cataractcataract
 Post vitrectomyPost vitrectomy
cataractcataract
 Hard brown cataractHard brown cataract
Mahatme V, 2005

21. Rotating the nucleusRotating the nucleus
 Be sureBe sure  nucleusnucleus 
movablemovable
 Beware of zonularBeware of zonular
weaknessweakness
 Use two toolsUse two tools
Mahatme V, 2005

22. During phaco: PitfallDuring phaco: Pitfall
 Wound burnWound burn
 Endothelial burnEndothelial burn
 SurgeSurge
 Broken CCCBroken CCC
 PCRPCR
 Drop nucleus or segmentDrop nucleus or segment
 Iris damageIris damage

23. Sculpting and CrackingSculpting and Cracking
 Nearest areaNearest area
 Position of phaco tipPosition of phaco tip
 Direction of tip’s bevelDirection of tip’s bevel
 Position and direction of chopperPosition and direction of chopper
 Make sure those in right handling, right place,Make sure those in right handling, right place,
right setting, right maneuver of hands and feetright setting, right maneuver of hands and feet
 Beware of the edge of CCCBeware of the edge of CCC

24. Sculpting and CrackingSculpting and Cracking
Mahatme V, 2005 Mahatme V, 2005
Mahatme V, 2005

25. Segment removalSegment removal
 Smaller segmentSmaller segment 
easier to removeeasier to remove
 Position of phaco tipPosition of phaco tip
– CenterCenter  center of iriscenter of iris
plane areaplane area
– Irrigating controlledIrrigating controlled
 Direction of bevelDirection of bevel
 Mind your foot on pedalMind your foot on pedal
 Mind you secondMind you second
instrumentinstrument
Mahatme V, 2005

26. Last pieces and epinucleusLast pieces and epinucleus
removalremoval
 Mind your irrigationMind your irrigation
 Bevel-upBevel-up
 Mind your secondMind your second
instrumentinstrument
 Mind your foot on pedalMind your foot on pedal
 Don’t hesitate to addDon’t hesitate to add
OVDOVD  lift epinucleuslift epinucleus
anteriorlyanteriorly
 Don’t to fast move to I/ADon’t to fast move to I/A
modemode
Mahatme V, 2005

27. Irrigation/Aspiration andIrrigation/Aspiration and
Capsule PolishCapsule Polish
 Mind your illuminationMind your illumination
 Mind the posterior capsuleMind the posterior capsule
 Always from equator or edge areaAlways from equator or edge area
 Venting controlledVenting controlled
 Stop without moveStop without move

28. PitfallPitfall
 SurgeSurge
 Bitten capsuleBitten capsule
 PCRPCR
Mahatme V, 2005

29. Inserting the IOLInserting the IOL
 Zoom outZoom out
 Gently loading IOL from pack to cartridgeGently loading IOL from pack to cartridge
 Zoom in, focusedZoom in, focused
 Inserting the IOLInserting the IOL
 Mind the edge of CCC aheadMind the edge of CCC ahead
 Firm your handFirm your hand  no retreadno retread
 Under OVD or hydro-insertionUnder OVD or hydro-insertion

30. Inserting the IOLInserting the IOL

31. Wound closureWound closure
 Direction of needleDirection of needle
 Amount of waterAmount of water
 Speed of injectionSpeed of injection

32. Wound closure: PitfallWound closure: Pitfall
 InadequateInadequate
 Loss of fluidLoss of fluid
 Fast overload anterior chamberFast overload anterior chamber

33. Post phacoPost phaco
 Release the speculumRelease the speculum
 Release eye drapeRelease eye drape
 Instill some eye dropsInstill some eye drops
 Place eye shieldPlace eye shield

34. Sail of the 150 years of Gold Rush in California USA, 1999
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