Irrigation! Surgeon: Thank you! 9 10 Phaco step 4 : Phaco  Basic Technique  2. Phaco chopping  Chopping the nucleus into small pieces  Tips  NO occlusion  Each stroke depth~1/3-1/2 phacotip  Chop into small pieces  Irrigate frequently Phaco chopping 1 2 3 4 5 6 7 8 9 10 11 12 13 14

1. Nawat Watanachai
Chiangmai University Hospital
2013

2. Cataract
 “Even we have had the much advanced treatment for
it for a while and we keep doing better, but
sometimes, in some occasions, cataract can be very
challenging disease that we, ophthalmologists, will
be the ones to treat.”
 Prof. Ian Jeffrey Constable
 Director of Lions Eye Institute, University of Western
Australia
 first president of APAO

3. terms
 phakos (Greek) - Lens
 Katarraktes (Greek)
 a down rushing, or
waterfall
 Originally thought that
congealed brain fluid
was flowing in front of
lens.

4. Timeline of
Cataract Surgeries
Femto
cataract
2010
Phaco
1967

5. History :
at the beginning
--- Couching -- Sushruta (Hippocrates of India), 600 BC
 The Indian tradition of cataract surgery
 Couching with jabamukhi salaka
 soaked with warm butter and then bandaged

6. History : Couching

7. History:Couching
 India
  Egypt Greek, europe
  Burma thaichina
 Rome (29 AC)
 De Medicinae,
(Aulus Cornelius Celsus)
 Persia (100 AC)
 Choice of Eye Diseases
(Ammar ibn Ali)

8. History : Couching
 Large lens shadow
 severe uveitis
 retinal detachment/ VH
 Endophthalmitis

9. History : ICCE and ECCE
 1753 Jaques Daviel (FRA) : ECCE
 Uveitis from left cortex
 High incidence of PC tear
 Success rate ~30%

10. History : ICCE and ECCE
 1752-53 Intra Capsular
Cataract Extraction ICCE
Sharp, de la Faye.
 1900 Henry Smith (IRE):
ICCE
 Erysophake
 Capsule forceps
 >20,000 ICCE Sx

11. History : ICCE and ECCE
 1949 Harold Ridley (GB) : ICCE c IOL
 29 Nov 1949 : the first IOL was implanted  failed
 8 th Feb 1950 : the first permanent insertion of
intraocular lens
 1953 Harold Ridley (GB) : ECCE c IOL

12. History :
ICCE and ECCE
 1957 Joaquin Barraquer
(SPA):

chymotrypsin
 1961 Krawicz (POL):

Cryo-extraction

13. History : ICCE and ECCE
 1964 Baron and Strampilli (GB) :
 angle-type AC IOL
 1968 Binkhorst (NED) :
 Iris-claw AC IOL

14. History : ICCE and ECCE
 ICCE : cons
 Vitreous loss
  RD, VH
  disfigured pupils, ACG
 Wound integrity/ astigmatism
 AC IOL : cons
 Corneal decompensate
 UGH syndrome
 Unable to dilate pupil

15. History : ECCE(and PE)
 1967 Charles Kelman (US): PE
 (1966 Peristaltic Pump First Phaco on animals)
 4 hrs, 3 L of fluid
 sonic-ultrasonic device made by Cavitron
 1974 American Intraocular Lens Implant Society* (US): ECCE

*- American Society of Cataract and Refractive Surgery (ASCRS)

16. History : ECCE(and PE)
 1975 AILIS (US)
 PC IOL
 1980 Pape and Balazs
 Hyaluronic acid
 1980 Danielle Aron-Rosa (FRA)
 Nd:YAG capsulotomy

17. History : ECCE
 ECCE : pros
 Much safer than ICCE
 Simple instruments
 Little more skill is needed
 ECCE : cons
 Wound integrity/ astigmatism
 Long op time

18. History : PE
 1983 Clifford Terry (US):
astigmatic keratotomy
 1986 Mazzoco (US), Barrett (AUS) :
foldable IOL
 1986 Kimiya Shimizu (JAP) :
topical ansthesia
 1987 Gimbel (CAN) :
CCC and hydrodissection
 1995 Howard Fine (US): temporal clear corneal incision

19. Phacoemulsification
 Pros
 Small wound
 Better wound integrity
 Less astigmatism
 Perserve conj/ less bleeding
 Short op time
 Cons
 Needs more skill/ learning curve
 Needs more instruments/ maintainance

20. Let start doing cataract Sx

21. Extracapsular
Cataract
Extraction

22. ECCE :
Steps
 1. +/-Bridle traction suture
 2. Peritomy (Conj opening)
 3. Partial thickness corneoscleral wound and AC Entering
 4. Can-opener capsulotomy
 5. Extend corneoscleral wound and Lens extraction
 6. remove cortex +/- suture
 7. IOL implantation and close wound

23. ECCE step 1 :
Superior Bridle suture
 Grab bulbar
conjunctiva and tenon
from the superior
fornix
 Pull the globe down
 Pass needle through
conj-tenon-sclera
 Potential cpx
 driving needle into vitreous
 cryo
 check for RD/ VH

24. ECCE step 2 :
conj opening (peritomy)
 Conjunctival flap
 fornix-based flap
 Radial snip
 Blunt dissection of conj-tenon from sclera
 Create limbal wound
Surgeon view
 Another radial snip
 150-180’
 Clean tenon/ stop bleeding

25. ECCE step 3 : Partial thickness
corneoscleral wound and AC Entering
 Blade no.15 (not 15’ blade)
 Partial thickness wound depth 50-80%
 Enter the AC with 15’blade/ needle/ razor
blade
 +/-stain capsule c ICG,trypan blue
 Air bubble
 Dye
 Washout
 fill the AC with OVD
Surgeon view

26. ECCE step 4 :
Can-opener capsulotomy
 Cystotome
 Complete the circle
 Make it LARGE
 May do CCC with relaxing incision

27. ECCE step 5 :
Extend corneoscleral wound
and lens extraction
 Extend corneoscleral wound
 Corneal scissor
 150-180’
 Make sure this wound fit to the size
of the necleus
 Avoid hitting endothelium/
DMMB
 Inside-out technique
Surgeon view

28. ECCE step 5 :
extend corneoscleral wound
and lens extraction
 Lens extraction
 Instruments
 Forceps
 Lens loop
 Hooks
 Corneal Suture
 cryo

29. ECCE step 5 :
extend corneoscleral wound
and lens extraction
 Lens extraction
 Major problems
 Small wound
 Wrong lens
direction
 Keys
 Big wound
 Tilt the nucleus

30. ECCE step 6 :
IOL Implantation and close wound
 Put 2-3 stitches to hold the





AC
Remove cortex with
simcoe double barrel
cannula
Fill the bag+AC with OVD
Insert IOL
Put more sutures
Remove OVD with simcoe

31. ECCE step 6 :
IOL Implantation and close wound
 Closing corneosclearl wound
 3-7 stitches of Nylon 10-0
 Terry notches
 Aim : little WTR astigmatism
 Close conj wound
 Topical steroid/ ABO/ miotic

32. Phacoemulsification

33. Phacoemulsification
: Steps
 1. Capsulorhexis
 2. Corneal/ scleral incision
 3. Hydrodissection
 4. Phacoemulsification
 5. Cortex removal/ capsule polishing
 6. IOL implantation

34. Phaco step 1 : capsulorhexis
 Paracentesis
 Inject OVD
 capsulorhexis

35. Phaco step 1 : capsulorhexis
 paracentesis
 Needle, #75 blade, or other knife
 stabilize the eye
 Bond/ 0.12 forceps/ fixation ring/
cotton bud
 Paracentesis 1-2
 1 for 2nd instrument
 2 for 2nd instrument and CCC

36. Phaco step 1 : capsulorhexis
 Paracentesis
 Potential complications:
 put in wrong place  make another paracentesis
 too small  make another wound
 too big  suture later
 nick lens capsule  include nick during
capsulorhexis
 nick iris  not serious and forget about it 

37. Phaco step 1 : capsulorhexis
 Inject viscoelastic
 Slow and steady
 Push the aqueous out

38. Phaco step 1 : capsulorhexis
 Potential complications:
 shoot loose cannula into anterior chamber
 tighten it better next time
 Air bubbles
 remove air with syringe +BSS
 place OVD distal and force out

39. Phaco step 1 :
capsulorhexis
 CCC :
 Continuous Curvilinear Capsulorhexis
 Aim
 Complete circle without radial tear
 Centration
 Size : 0.5-1.0 mm less than optical part of the IOL (5-6
mm)
 Too large  more iris capture
 Too small anterior capsule phimosis

40. Phaco step 1 : capsulorhexis
 3 basic techniques
 Cystitome
 Forceps
 Combo
 initial cut with cystitome
 most of tear with forceps
 *Need major wound to use
forceps

41. Phaco step 1 :
capsulorhexis with cystotome

42. Phaco step 1 : capsulorhexis with
cystotome/ forceps

43. Phaco step 1 : capsulorhexis
 Keys for good CCC
 Adequate viscoelastic/ dilation
 Balance the pressure
 Good visualization : may need staining eg.
Trypan blue, ICG
 Control eye mobility

44. Phaco step 1 : capsulorhexis
 Potential complications:
 Poor red reflex
 stain with Trypan Blue or ICG
 Tear starting to go radial
 add OVD
 Use forceps, your senior
 (and pray)
 Radial tear
 Use scissors to restart in other direction
 Can opener +/- conversion to ECCE
 Debulk lens by sculpting out bowl prior to
hydrodissection

45. Phaco step 1 : capsulorhexis
 Potential complications:
 too small
 Fill more OVD and do the larger one with forceps
 enlarge after placing IOL
 too big
 forget about it because this is not a serious issue
 Miostat to prevent capture
 zonular laxity
 consider placing iris hooks/ CTR to stabilize the
capsular bag

46. Phaco step 2 :
corneal/ scleral incision

47. Phaco step 2 :
corneal/ scleral incision, table
Scleral
tunnel
Leakage
Clear cornea
Less
More
Management of burnt wound Easier
More difficult
Sx-induced astigmatism
Less*
More
Infection
Less
More
Time consuming
More
Less
Bleeding/ conj scar
More
Less
Handpiece mobility
Less
more

48. Phaco step 2 :corneal incision
 3 types
 Single-plane
 Williamson incision
 Langerman incision

49. Phaco step 3 : Hydrodissection
 Aim : to free the nucleus/ epinucleus/ cortex
from the capsule

50. Phaco step 3 : Hydrodissection
10:00
2:00
Create fluid wave at 10
and 2 o’clock

51. Phaco step 3 : Hydrodissection

52. Phaco setp 3 : Hydrodissection
 Option : Hydrodeliniation
 Separate nucleus from epinucleus
 Golden ring sign (Abe T, JJO 2001)

53. Phaco setp 3 : Hydrodissection
 Potential complications
 Radial tear

54. Phaco setp 3 : Hydrodissection
 Potential cpx : capsular blockage syndrome
 Small CCC
 Large/hard nucleus
 Fast injection
 If everything is too late
 don’t scream, stay calm and call your retina surgeon.

55. Phaco setp 3 : Hydrodissection
 Potential
complications
 No fluid wave
 try again in different
spot
 increase force
 use bursts and gently
push on nucleus
between bursts

56. Phaco setp 3 : Hydrodissection
 Iris Prolapse
 Remove dispersive OVD. If using a clear
cornea wound, then use sub-incisional iris
hook
 Prolapse nucleus
 Brown technique or Pop n Chop, flip into
ciliary sulcus, or push back into bag

57. Phaso step 4 :
Phacoemulsification
 Peizoelectric crystal  ultrasound
 35,000-40,000Hz, 1/1,000 ‘’
 Low freq  less effective
 High freq  more heat
 Phaco power
 Stroke length
 Duration : pulse mode, burst mode
 Bevel (0, 15, 30, 45, 60’)

58. Phaso step 4 :
Phacoemulsification
 The goal is to remove lens with the minimum u/s
 Trend is to use increasing vacuum and decreasing
u/s power
 Techniques
 Endocapsular - keeping the nucleus in bag during phaco
 Supracapsular - prolapsing nucleus into sulcus during phaco
 Anterior chamber shell - prolapsing shelled out nucleus into anterior
chamber
 ½ bag ½ anterior chamber --tipping nucleus on side ½ in bag; ½ in
anterior chamber – a.k.a., Brown Technique, Pop-n-Chop.

59. Phaco step 4 : Phaco
 Basic Technique
 1. Divide-and-conquer
 Grooves
 Width 1.5-2x of phaco tip
 Depth : close to the posterior
cortex
 Tips
 NO occlusion
 Each stroke depth~1/3-1/2
phacotip

60. DIVIDE & CONQUER
1
2

61. DIVIDE & CONQUER
4
3
5
6

62. sculpting
3
DO NOT occlude the tip during sculpting

63. DIVIDE & CONQUER
7
8

64. DIVIDE & CONQUER
12
13

65. cracking

66. Divide and conquer

67. Phaco step 4 :
Phacoemulsification
 Basic technique
 2. slow-motion phacoemulsification
 Divide-and –conquer with Low flow rate, low
vacuum
 For beginner/ soft nucleus-PSC-posterior
polar

68. Phaco step 4 : Phacoemulsification
 Basic Technique
 3. phacochop
 Kunihiro Nagahara 1993
 Tip 0, 15, 30’
 High flow rate,high vac
 Bevel down>up
 Phacochopper
 Chop/ quick chop
 Not recommmeded for soft
nucleus

69. 2
1
Phaco
chop
3

70. Phaco
chop
5
4
6
7

71. Phaco
chop
8
10
9
11

72. Phaco
chop
12
13
14
15

73. Phaco step 4 : Phacoemulsification
 Basic technique
 4. Stop and Chop
phaco
 For very hard nucleus
 Create groove as in
divide-and-conquer
 Crack
 Rotate the nucleus 6090’
 phacochop

74. Stop and chop
1
2
3

75. Stop
and
chop
5
6
7
8

76. Phaco step 4 :
Phacoemulsification
 Basic technique
 5. Chip and Flip (Bowl-out)
 For very soft nucleus
 Complete hydrodissection+hydrodeliniation
 Emulsified the nuclear core
 Flip the nuclear shell
 Emulsified the shell (low power, low vacuum,
high flow rate)

77. Phaco step 4 : Phaco
 Some other techniques
 Quick chop
 Phaco flip (supracapsular)

78. Phaco step4:
phacoemulsification

79. Phaco step 5 :
Cortex removal
 I/A handpiece
 Start at the area under the phaco wound
 1. Rotate tip 90’ for safe occlusion
 2. Pull to the center/ tip up
 3. max vacuum
 4. re engage

80. Phaco step 5 :
Cortex removal
 Situation : problem removing cortex
under the wound
 Solutions
 U-shape I/A tip
 Use the side port + blunt tip cannula
 Place IOL and then I/A

81. Phaco step 5 : cortex removal
 Capsule polishing
 For less/ later PCO
 Anterior capsule : high vac
 Posterior capsule
 vac 5-10 mmHg, flow rate 5-6 cc/min
 Slow tip movement
 Not recommend in
 Loose capsule eg. PXS
 Radial tear
 Zonule lysis

82. Phaco step 6 :
IOL implantation
 Inject viscoelastic to fill the capsular bag/ AC
 Do not pierce the PC with your blunt needle
 Insert IOL
 Rigid IOL
 need to extend the wound
 IOL diameter 5-5.5 mm
 1-3 stitches
 Foldable IOL
 Use injector or forceps
 0-1 stitch
 Remove viscoelastic : bag  AC

83. Phaco step 6 :
IOL implantation

84. Phaco step 6 :
IOL implantation
 Potential complication
 Place IOL up-side down
 Can leave as is - accept myopic shift
 Take one haptic out of wound with Sinsky
hook
Fill with OVD above and below IOL
One hook above and one below -- Flip IOL

85. Phaco step 6 :
IOL implantation
 Inadvertent sulcus placement
 Fill with OVD -- Rotate into bag with hook
 If a 3 piece can leave in sulcus with myopic shift
 Do not leave single piece acrylic (eg. Alcon
SA60) in sulcus

86. Phaco step 6 :IOL implantation
 IOL doesn't center Usually one haptic in
sulcus one in bag
 dial both into bag or both into sulcus
 Possible zonular dialysis
 if nearly centered leave it alone
 rotate IOL carefully for best centration
with 3 piece often haptics best at weak area
 check wound for vitreous, miostat
 consider placement of CTR

87. Phaco step 6 : IOL implantation
 Tear in Descemet's
 Double AC sign
 Use care to not extend
tear
 Place Air Bubble at end
of case – post op
position wound up -bubble seals Descemets

88. Phaco step 6 :
IOL implantation
 Lens Material behind IOL
 Rotate haptic 90 deg from wound
Toe down with I/A and get under IOL
With aspiration tip showing at all times
aspirate
 Note – make sure that you have an
INTACT capsule

89. Special IOL Placement
Conditions
 Anterior Capsular Tear
 Single piece acrylic in the bag - creates little
tension on the bag
 3 piece with both haptics in the sulcus
 Zonular Dialysis
 Capsular Tension Ring with any IOL
 3 piece IOL with PMMA haptic oriented toward
weak area of zonules

90. Special IOL Placement
Conditions
 Posterior Capsular Tear
 Dispersive OVD in the post capsular hole -- gently place
IOL into bag
 Place 3 piece in sulcus +/- capture of optic by centered
anterior CCC
 No Capsular Support
 AC IOL: there are 3 sizes depending on white to white
size
 Iris Sutured PC IOL
 Scleral Sutured PC IOL

91. Phaco step 6 :
IOL implantation Viscoelastic
removal
 OVD is removed with I/A device
 As always keep tip opening up
 Go under IOL to remove OVD, especially
if you have been having IOP problems
post op

92. One Last Step
 Check the wound integrity
 Stop leaking
 Corneal stromal hydration
 Fill AC with air bubble

93. The New Comers
 Femtosecond cataract surgery
95

94. Femto cataract, Hx
 2005
 Image-guided laser cataract surgery was first
conceptualized
 D. Palanker and M. Blumenkranz

patents US 8394084; US 8403921; US 8425497
 2005-2010
 OptiMedica Corp. developed and tested
 integrated Optical Coherence Tomography
and femtosecond laser

Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond laserassisted cataract surgery with integrated optical coherence tomography. Sci
Transl Med 2010;2:58ra85.

95. Femto cataract, Hx
 2008
 first used clinically in cataract surgery
 Prof. Zoltan Nagy
 Budapest, Hungary
 2010 Dr Steven Slade in the USA
 2011 Dr Michael Lawlwss in Asia/ AUS

”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of
Ophthalmology, Subspecialty Day, Chicago, November, 2012

96. Femtosecond cataract Sx
 cone pattern  To avoid distortion of the incoming
laser beam on gas bubbles and tissue fragments
 applied first posterior to the target
 advances anteriorly

97. Femtosecond cataract surgery
 What femto can do?
 Create corneal flap/tunnels
 CCC
 Nuclear fragmentation
 LRI

98. Femtosecond
clear corneal
incision
 corneal incision
 Controlled
 reproducible
 configuration
 less risk of wound
leak
 --> less infection

99. Femtosecond capsulotomy
 near perfect, round opening in the anterior capsule
 strength of the capsule
 as good as or greater than a manual capsulorhexis
 smoothness of the capsulotomy edge
 similar to manually created openings

100. Femtosecond capsulotomy
incidence of anterior capsular tears
 Manual CCC
 0.79% in very experienced hands
 5.3% within teaching institutions
 Marques et al
 40% of anterior capsular tears extended to the posterior capsule
 20% required further surgery
 Lawless in November 2012
 0.2% incidence of anterior tears
 throughout his initial 500 cases

Marques FF, Marques DM. Fate of AC tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.

Unal M, Yücel I, Sarici A et al. Phaco with topical anesthesia: Resident experience. J Cataract Refract Surg. 2006;32:13615.

Marques FF, Marques DM. Fate of anterior capsule tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.

Lawless M. ”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of Ophthalmology, Subspecialty
Day, Chicago, November, 2012

101. Femtosecond capsulotomy
 Precised CCC means
 Less tear/ nucleus dropping/ uveitis/ VH/ RRD/ endophthalmitis
 Less IOL decentration
 Lawless : mean circularity
 0.942 in 29 lasered eyes
 0.774 in 30 manual eyes
 12X improvement in the precision of the capsulotomy diameter
 Freidman : deviation from intended diameter
 29 µm ± 26μm for laser capsulotomies (mean deviation 6%)
 337μm ± 258μm for a manual technique (mean deviation 20%)

Friedman NJ, Palanker DV, Schuele G. Femtosecond laser capsulotomy. J Cataract
Refract Surg. 2011 Jul;37(7):1189-98.

102. Femtosecond
phacofragmentation
 reduce the average time and energy
required to break up and remove the lens
by approximately 50-98%

Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in
cataract surgery. J Refract Surg 2009;25:1053-60.

Batlle JF, Feliz R, Culbertson WW. OCT-guided femtosecond laser cataract & surgery: precision and
efficacy. Association for Research in Vision and Ophthalmology Annual Meeting. A4694 Poster #D633.
Fort Lauderdale, FL; 2011. www.arvo.org

Edwards K, Uy HS, Schneider S. The effect of laser lens fragmentation on use & of ultrasound energy in
cataract surgery. Association for Research in Vision and Ophthalmology Annual Meeting. A4710 Poster
#D768. Fort Lauderdale, FL; 2011. www.arvo.org

103. Femtosecond LRI
 better refraction correction
 --> + visual outcomes
105

104. Femtosecond cataract surgery :
Video
106

105. Femtosecond cataract surgery :
Video
107

106. Femtosecond cataract surgery :
cons
 Need suction
 Rise IOP
 SCH
 Can not do well in some dense cataract
 Failure during PC scanning
 PRICE

107. Machines
 Alcon LenSx
 (Alcon Laboratories, Ft Worth, TX, USA)
 OptiMedica Catalys
 (Optimedica Corp, CA, USA)
 LensAR
 (LensAR Inc, FL, USA)
 Technolas
 (Technolas Perfect Vision GmbH, Germany)

108. Now you guys are ready
to ROCK!!!!