phaco experience as a beginner.
patient selection,operative difficulties and their overcoming tips,post operative complications .
how minimize complications ,learning with short period
2. Road to Phaco
• To be thorough with the phaco theory, phaco machine, dynamics,
complications and their management.
• To be an ideal learner, not an ideal surgeon
• To select Ideal patient & Ideal cataract
• Ensure ideal operation theatre environment with proper OT table,
operating stool and provision of proper anaesthesia.
3. Criteria for ideal case selection
1. Cornea: Good clarity
Normal thickness
Healthy endothelium
2. Normal anterior chamber depth
3. Well dilated pupil
4 . Intact zonules
5. Type of cataract : Nuclear sclerosis grade II & III
4. Cataract Exclusion for Beginner
• Soft nucleus grade +
• Nuclear grade +++
• Intumescent cataract
• Mature cataract
• Traumatic cataract
• Deep set eyes
5. Phaco Warrior Has to Know
• Conventional cataract surgery
• Suture less MSCIS
For -
Proper capsulorrhexis
Proper hydrodissection
Proper nuclear rotation
Suture technique
7. Phaco dynamics
Various functions of phaco machines and their
interrelationship is called phaco dynamics.
Fundamental components:
• Ultrasound energy or power
• Irigation and aspiration (fluidics)
13. Phaco Power Settings
STEPS
PHACO POWER
(traditional
longitudinal)
%
MODE OF
ENERGY
DELIVARY
VACUUM
mmHg.
ASPITATION
FLOW RATE
cc/min.
BOTTLE
HEIGHT
cm.
SCULPTING 50- 60% Continuous Low: 60-80 Low: 15-20 70-80
CHOP 40-50% Burst mode
(best)
Pulse mode: 2
pulse/ sec
High: 400-450 High: 24-26 100-110
QUADRANTS 60- 70% Pulse mode
(best): 6 pulse/
sec
High: 300-350 High: 24-26 100-110
EPINUCLEUS 0% I- A mode High: 300-400 High: 24-26 100-110
OVD 0% I- A mode Vacuum, panel:
600 mm Hg
Aspiration,
linear:
maximum 50
cc/min
100-110
14. Intraoperative Difficulties
Clear cornea Incision and site port related:
• Site of incision
• Size of incision
Capsulorhexis related
• Loss of integrity
• Inappropriate size
Nucleus rotation
15. Phacoemulsification related
a) Improper posterior incision
b) chopping
c) Miosis
d) Iris injury
e) Zonular dehisence during primary nuclear rotation
f) IOL insertion following PC rent
g) Phaco in hard cataract
16. Intraoperative Complications
Difficulty in incision making 4
Zonular dehisence 1
PC rent with nucleus drop 1
Pc rent with vitreous loss 4
Iris trauma 2
Intraoperative miosis 6
Hazy cornea due to unhealthy
endothelium
1
17.
18. For Better Outcome
• Proper Patient Selection
• Proper Biometry
• Adequate Sterility
• Safe Surgery
• Less Post Operative Complications
19. VISION ON 1ST POD
SNELLEN’S VISION NO OF CASES
6/12-6/6 4
6/60-6/18 12
CF-6/60 4
<CF 0
TOTAL 20
20. VISION ON 7TH POD
VISION NO OF CASES
6/12-6/6 12
6/60-6/18 4
CF -6/60 3
24. Post-operative findings
At 1st POD
1. Striate keratopathy
2. High IOP
3. Wound leakage
At 7th POD
1. Striate keratopathy
25. Port construction
Rule 1
Stay peripheral
Rule 2
Make the incision symmetric
Rule 3
Keep the incision architecture consistent
Learning from difficulties
29. Capsulorhexis:
Pitfall and How To Prevent
• Escape
• Too Large
• Too Small
• Grab The Cornea Forceps
• Viscoelastic substances
• Centripetal force.
• Optimal diameter of Capsulorrhexis should be Just 0.5mm
smaller than optic size of IOL
30. Hydrodissection:
Pitfall and How to Prevent
• Inadequate Hydro Causes Problems In Nuclear Rotation
• Difficult To Rotate more hydro
• Because No Nuclear Rotation No Phaco
• Early Drop Nucleus Ensure Fluid Flow Out Through
Incision
• Avoid Injecting More Than 1ml Fluid In One Go
31. • End point is the convex
fluid wave seen crossing
the field.
• Shallowing of AC
• Dullness of red glow
• Free rotation of nucleus
32. Sculpting and Cracking
• Nuclear sculpting should be done adequately
• To make a tunnel of about 1½ phaco probe width and
2½ phaco probe deep.
• Difficulty in cracking
• Incomplete cracking
• Inequal cracking
33. Phaco Chop:
Pitfalls and Prevention
• Not hooking the nucleus equator with the chopper
• Tips:
- Confirm the chopper inside the bag
- Not holding the capsular bag with chopper
• Inability to pull the nucleus and chop it
• Tips:
- Adjustment of foot pedal
- Practicing left hand more
34. Ruptured Posterior Capsule But No
Nucleus Drop
Occur due to
• Vacuum surge
• Damage by dialer/chopper
• Sucked up during I/A
• Sudden occlusion breaking
35. • Inject viscoelastic
• Enlarge incision
• Remove the nucleus
• Ant. Vitrectomy
• Give PCIOL in sulcus/bag
Management
36. PC Tear With Nucleus Drop
Actions to Be Taken By Anterior Segment Surgeon
• Thorough Cortical Cleanup
• Anterior Vitrectomy
• Suturing The Wound
• PC IOL in sulcus
• Referred To VR Surgeon.
37. Difficulties in IOL insertion
• IOL placed in sulcus
• IOL placed in bag sulcus
38. How to Manage?
• Capsular bag formed with viscoelastic
• One haptic must confirm in bag
• Hold at the optic-haptic junction by a lens dialer
• Press little deep & below
39. TAKE HOME MESSAGE
First step is to BELIEVE IN YOURSELF that you too
The learning curve of phacoemulsification is pretty long so
don’t despair and be perseverant.
Precise knowledge of various steps is essential and
consequences of ignoring such minute events can be
disastrous.
