CATARACT SURGERY PHACO PEARLS

Phaco Machine Settings

BY WILLIAM J. FISHKIND, MD; R. BRUCE WALLACE III, MD; BONNIE AN HENDERSON, MD;
D. MICHAEL COLVARD, MD; UDAY DEVGAN, MD; DONALD N. SERAFANO, MD;
Y. RALPH CHU, MD; ELIZABETH A. DAVIS, MD; AND JAMES P. GILLS, MD

WILLIA M J. FI SHKIND, MD have improved surgical safety. Although the flow-based

During the last few years, manufacturers have introduced option performs well, I prefer to use the vacuum system. I
phaco machines that are strikingly superior to and more re- have found it to be amazingly responsive, which gives me
fined than previous units. Even those that have been in greater confidence in cases of small pupils, shallow anteri-
service for a number of years are eligible for several up- or chambers, and dense nuclei. Because the Stellaris antic-
grades. I asked several surgeons which machine and phaco ipates changes in pressure in the anterior chamber, I am
settings they use and what their phaco settings are. able to use higher vacuum levels than on earlier phaco
I myself presently use the Sovereign cataract extraction machines. My program includes three settings (Table 2).
system (Advanced Medical Optics, Inc., Santa Ana, CA) The dual linear foot pedal allows me to use mostly pha-
and a 19-gauge 0º phaco tip. My preferred technique is coaspiration on the downstroke of the pedal and more
quick chop. I have four settings programmed into the phaco power, when needed, through my foot’s movement
machine (Table 1). I use “phaco 1” solely for the hardest outward. Using this phaco system, I am able to perform
cataracts and only to embed the tip and chop. Once I coaxial phacoemulsification through a microincision of
have completed numerous chops, I switch to “phaco 2” 1.8 mm.
to mobilize and remove the fragments. I generally rely on
“phaco 3” to remove softer nuclear/cortical material and BONNIE AN HENDER SON , MD
epinucleus. Rarely, I employ “phaco 4” for a soft nucleus. I primarily use the Infiniti Vision System with the Ozil
All of the settings are designed to enhance partial occlu- Torsional handpiece (Alcon Laboratories, Inc., Fort Worth,
sion phacoemulsification and to minimize surge. TX). I prefer the 0.9-mm 45º miniflare ABS tip when I
employ a microcoaxial approach, because I feel it delivers
R . BRUCE WALL ACE III, MD the best irrigation flow and provides increased protection
I favor the new Stellaris Vision Enhancement System against surge. I find that this combination allows me to
(Bausch & Lomb, Rochester, NY). Its enhanced fluidics perform safe, effective phacoemulsification for all types of
TABLE 1. DR. FISHKIND’S SETTINGS
Aspiration Rate, mL/min Vacuum, mm Hg Power Whitestar Pulse Setting
Phaco 1 hard chop
Unoccluded 26 linear 350 panel 40% F/b
Occluded 26 linear 220 threshold 40% D/I 31%, CD 43%, CB 60%, DB 67%
Phaco 2 soft chop
Unoccluded 24 panel 275 linear 25% CL 20%, CF 33%, CD 43%, DB 67%
Occluded 26 220 25% CL 20%, CF 33%, CD 43%, DB 67%
Phaco 3 epinuclear
Unoccluded 26 panel 280 linear 15% CL 20%, CF 33%, CD 43%, DB 67%
Occluded 26 panel 200 15% CF 4 long pulses per second
Phaco 4 slow
Unoccluded 24 panel 315 linear 10% C/N
Occluded 24 215 10% C/N
Note: with the Sovereign cataract extraction system.

30 I CATARACT & REFRACTIVE SURGERY TODAY I SEPTEMBER 2008

 DR. HENDERSON’S SETTINGS
Dr. Henderson favors the Infiniti Vision System with the
Ozil Torsional handpiece (Alcon Laboratories, Inc., Fort
Worth, TX).

Soft lenses
Sculpting
• Ozil amplitude—85% (all torsional, no longitudinal),
linear pedal control
• Vacuum—90 mm Hg, linear pedal control
• Aspiration—24 mL/min, fixed pedal control
• Bottle height—95 cm
Chop/quadrant removal
• Ozil amplitude—80% (all torsional), linear pedal control
• Vacuum—400 mm Hg, fixed pedal control
• Aspiration—35 mL/min, fixed pedal control
• Bottle height—105 cm

Medium lenses
Sculpting
• Ozil amplitude—85% (all torsional), linear pedal control
• Vacuum—100 mm Hg, linear pedal control
• Aspiration—24 mL/min, fixed pedal control
• Bottle height—95 cm
Chop/quadrant removal
• Ozil amplitude—80% (all torsional), linear pedal control
• Vacuum—400 mm Hg, fixed pedal control
• Aspiration—35 mL/min, fixed pedal control
• Bottle height—105 cm

Dense lenses
Sculpting
• Ultrasound longitudinal power, 35% linear, 10% on
time, 22 pulses per second, combined with Ozil
amplitude, linear 100%, 90% Ozil on time
• Vacuum—90 mm Hg, linear pedal control
• Aspiration—24 mL/min, fixed pedal control
• Bottle height—95 cm
Chop/quadrant removal
• Ultrasound longitudinal power, 40% linear, 5% on
time, 10 pulses per second, combined with Ozil
amplitude, linear 100%, 95% Ozil on time
• Vacuum—400 mm Hg, fixed pedal control
• Aspiration—35 mL/min, fixed pedal control
• Bottle height—105 cm

lenses. It is possible to remove cataracts of all densities

with a single phaco setting due to technological improve-
ments in the forms of (1) aspiration bypass systems that
prevent the buildup of heat, (2) stiffer tubing that main-
tains the chamber’s stability, and (3) linear and fixed
 CATARACT SURGERY PHACO PEARLS

TABLE 2. DR. WALLACE’S SETTINGS

Phase Submode Power Pulses per Second Duty Cycle Bottle Height, cm Vacuum, mm Hg
Sculpting 1 0 to 45% 250 50% 85 0 to 50
2 0 to 60% 250 50% 85 0 to 60
3 0 to 60% 85 0 to 50
continuous
Segment 1 10% to 28% 50 40% 108 0 to 390
removal dual linear
2 10% to 40% 50 40% 108 0 to 390
dual linear
3 0 to 12% dual 50 40% 108 0 to 390
linear
Epinuclear 1 0 to15% 100 0 to 325
continuous
Note: with the Stellaris Vision Enhancement System. Submode 1 for standard nuclei, 2 for dense nuclei, and 3 for soft nuclei.

TABLE 3. DR. COLVARD’S SETTINGS

Setting Aspiration Rate (mL/min) Vacuum Limit (mm Hg) Power
Phaco 1 (sculpting) 22 60 60%
Phaco 2 (segment removal) 35 350 60%
Phaco 3 (epinucleus) 35 180 20%
Note: with the Sovereign Compact.

pedal settings that enhance surgeon control. Neverthe- Sovereign Compact units (Advanced Medical Optics,
less, I vary the parameters for lenses of different grades Inc.), and I am extremely happy with this system. I use
(see Dr. Henderson’s Settings). I mainly use the stop-and- Whitestar pulse settings (Advanced Medical Optics, Inc.),
chop technique. and, regardless of the density of the nucleus, I never seem
to need more than 60% of the machine’s phaco power.
D. MICHAEL COLVARD, MD Table 3 shares my parameters.
Over the years, I think I have tried virtually every phaco
technique I have ever seen or read about, and I have UDAY DEVG AN MD
taught myself the same lesson over and over again. The I use several different phaco machines at a private sur-
best way to ensure that the cornea will be crystal clear on gical center as well as at the Olive View UCLA Medical
the day after surgery is to stay away from it. Techniques Center to teach ophthalmology residents. The newer
that tend to bring the nucleus into the anterior chamber phaco platforms are far better than their predecessors. If
are faster but not as gentle to the cornea as those that you are using a machine that is a few years old, you owe
encourage the surgeon to stay below the iris plane. it to yourself to test drive the newer models.
Except for very soft lenses, which I can subluxate above I prefer large-bore phaco needles for dense cataracts,
the iris by means of hydrodissection and then simply aspi- because they allow for more efficient phaco aspiration of
rate, I perform a central groove and then a series of verti- the nuclear material. On the new Stellaris Vision
cal and/or horizontal chops, as described originally by Enhancement System, I prefer the MicroFlow Plus needle
Paul Koch, MD.1 The groove, which is cracked before in combination with the high-vacuum tubing, and I like
chopping, allows me to chop at lower vacuum levels. using a phaco pulse mode. The concept of increasing the
Much more importantly, the groove provides an empty phaco power level for dense cataracts is well known. In
space below the iris plane where I can safely perform pha- addition, I increase the duty cycle of the pulse mode as
coemulsification. Denser nuclei need to be chopped into the nuclear density increases, with as low as 20% for a soft
smaller segments, but the basic phaco parameters I use lens and as high as 80% for a brunescent one. I keep the
are the same for all cases. My surgery center has several pulse rate high (between 80 and 120 pulses per second),

32 I CATARACT & REFRACTIVE SURGERY TODAY I SEPTEMBER 2008

 CATARACT SURGERY PHACO PEARLS

TABLE 4. DR. DEVGAN’S SETTINGS

Phaco Parameters Fluidic Parameters
Nucleus’ Grade Power Level Pulse Rate Duty Cycle Bottle Height, cm Vacuum, mm Hg Aspiration, mL/min
(pulses per second)
I 5% to 10% 80 to 120 20% 100 300 to 500 35 to 50
II 10% to 20% 80 to 120 40% 100 300 to 500 35 to 50
III 20% to 40% 80 to 120 60% 100 300 to 500 35 to 50
IV 40% to 60% 80 to 120 80% 100 300 to 500 35 to 50
Note: with the Stellaris Vision Enhancement System using a MicroFlow Plus Needle, peristaltic pump, and high-vacuum tubing.

TABLE 5. DR. SERAFANO’S SETTINGS

Phase Amplitude Vacuum Aspiration Flow Rate

Prephacoemulsification 20% linear 180 mm Hg fixed 30 mL/min linear

Sculpting 100% linear 90 mm Hg linear 22 mL/min fixed

Quadrant 100% linear 400 mm Hg fixed 38 mL/min fixed

Epinuclear 20% linear 320 mm Hg linear 32 mL/min linear

Note: for a 2.75-mm incision with Ozil continuous torsional ultrasound on the Infiniti Vision System.
Phase Amplitude Vacuum Aspiration Flow Rate

Prephacoemulsification 20% linear 180 mm Hg fixed 30 mL/min fixed

Sculpting 100% linear 90 mm Hg linear 22 mL/min fixed
Quadrant 100% linear 350 mm Hg fixed 38 mL/min fixed
Epinuclear 20% linear 320 mm Hg linear 28 mL/min linear

Note: for an incision smaller than 2.40 mm with the Infiniti Vision System.

which I feel provides better followability and less risk of D ONALD N. SER AFANO, MD
built-up heat at the phaco tip (Table 4). I use the Infiniti Vision System with the Ozil Torsional
For dense cataracts, my main advice is carefully to handpiece for cataracts of all grades. Ozil with a 45º
modulate the phaco power, to recoat the corneal mini-flared Kelman tip can emulsify a cataract of any
endothelium periodically with viscoelastic, and to take grade with only a setting of basic continuous torsional
your time. If you are using a phaco machine from the ultrasound and moderate fluidic settings. Because tor-
previous generation such as the Millennium microsurgi- sional ultrasound almost eliminates repulsion and
cal system (Bausch & Lomb), you can still implement increases thermal safety, I do not change my phaco
some of these techniques to improve surgery on dense parameters based on the density of the nucleus.
cataracts. With the Millennium, you can program a vari- Instead, I base my phaco parameters on the steps of
able duty cycle and a wide range of power modulation the procedure (Table 5). For instance, just before phaco-
parameters, although not quite up to the range available emulsification, I establish flow by using moderate fluidic
on the Stellaris. Older phaco machines may have a ten- settings with a very low torsional amplitude. The sculpt-
dency for more fluidic imbalance and surge, so it is advis- ing phase is nonocclusive with continuous linear torsion-
able to use more conservative settings, including lower al ultrasound and moderate fluidics. In the quadrant
flow and vacuum and perhaps a higher bottle. phase, I only adjust to a higher vacuum setting with a

SEPTEMBER 2008 I CATARACT & REFRACTIVE SURGERY TODAY I 33

 CATARACT SURGERY PHACO PEARLS

TABLE 6. DR. CHU’S SETTINGS

Setting Aspiration Vacuum Power, % Whitestar Pump Ramp, % Bottle Height,
Rate, mL/min Pulse Setting cm

Phaco 1 36 250 L 50 16/24, 70, 70 85

Phaco Flip 14/16,12/11 10/8
Variable
Unoccluded Whitestar 1

Pulse Shaping 1% to 12% 0 to 70%

CASE Vacuum N/A

Phaco 2 20 40 L 65 7/3, 70% duty 70, 70 55

Grooving
Pulse Shaping 1 to 12% 0 to 70%
CASE Vacuum N/A

Phaco 3 36 325 L 50 16/24, 70, 70 85

Phaco Flip 14/16,12/11 10/8
With CASE Variable
Whitestar 1
Unoccluded

Pulse Shaping 1% to 12% 0 to 70%

CASE Vacuum 250 CASE 290 mm up 75 mm down time 500

(used) vacuum milliseconds
Phaco 4 24 200 L 50 16/24, 70, 70 60
Tamsulosin Low 14/16,12/11 10/8
Flow Variable
Whitestar 1
Unoccluded
Occluded

CASE Vacuum N/A

Note: with the Whitestar Signature System with Fusion Fluidics. CASE = Advanced Chamber Stabilization
Environment (CASE) technology.

slight modification in minimum ultrasound. During this Y. R ALPH CHU, MD

phase, I use continuous Ozil torsional ultrasound but I currently prefer the Whitestar Signature System with
adjust the linear amplitude to start at 20%. Fusion Fluidics (Advanced Medical Optics, Inc.). I use
I do, however, slightly change my parameters based on the phaco flip setting for the majority of cataracts. I
the size of the incision. For instance, I have certain set- generally use a 19-gauge phaco tip, but I employ a
tings for my standard 2.75-mm phaco incision. I reduce Dewey Radius phaco tip (MicroSurgical Technology,
vacuum somewhat for microcoaxial phacoemulsification, Redmond, WA) for soft nuclei. For dense nuclei, I prefer
in which the incisions are 2.40 mm or smaller, to com- a phaco tip with a chiseled edge such as the Chu Chisel
pensate for the decreased flow. I use the Intrepid Fluid (Mastel Precision, Inc., Sioux City, SD). Table 6 shows my
Management System (Alcon Laboratories, Inc.), which settings, including those for when a grooving method is
reduces my need to adjust my settings or the bottle’s necessary. For extremely hard nuclei, I sometimes incor-
height when adopting microcoaxial phacoemulsification. porate a second mode of phaco flip, which includes

34 I CATARACT & REFRACTIVE SURGERY TODAY I SEPTEMBER 2008

 CATARACT SURGERY PHACO PEARLS

TABLE 7. DR. GILLS’ SETTINGS

Phase Pulses per Second Torsional Percentage or Aspiration Flow Vacuum Limit
Amplitude Burst on Time Rate
Sculpting 0 35% linear 0 23 mL/min fixed 350 mm Hg linear
Quadrant 0 85% linear 0 20 to 40 mL/min 370 mm Hg fixed
linear
Epinuclear 10 75% linear 75% on time 30 mL/min linear 300 mm Hg linear
Note: with the Infiniti Vision System, Ozil Torsional handpiece, and a bottle height of 105 cm.

Advanced Chamber Stabilization Environment technol- DR. DAVIS’ SETTINGS

ogy (Advanced Medical Optics, Inc.). This feature is par-
Dr. Davis favors the Stellaris Vision Enhancement System
ticularly helpful in situations requiring high vacuum. My
from Bausch & Lomb (Rochester, NY).
fourth phaco setting is low flow, which I find extremely
useful in patients who are taking tamsulosin or in those
Vacuum Mode Using the Advanced Flow System
with small pupils. This setting effectively maintains the
• 300 to 400 mm Hg dual linear vacuum
chamber’s stability and thus minimizes the turbulence
• 1% to 30% ultrasound power, 50 pulses per second,
in the eye that could disrupt the iris.
60% duty cycle
• Bottle height of 125 cm
ELIZABETH A . DAVI S , MD
Phaco energy—although useful for emulsifying nuclear
• I/A
material—can create inflammation, cause corneal edema
• 0 to 550 mm Hg
and the loss of endothelial cells, and damage other intra-
• Bottle height of 125 cm
ocular structures. Minimizing phaco energy is therefore
important in cataract surgery. In addition to the use of
Flow Mode Using the Advanced Flow System
power modulations to reduce total energy, one can also
• 40 mL/min flow
employ high vacuum so that aspiration, rather than
• 350 to 450 mm Hg vacuum
ultrasound, evacuates lenticular particles. High vacuum
• 1% to 30% ultrasound power, 50 pulses per second,
levels can only be achieved safely when fluidics are opti-
60% duty cycle
mized and postocclusion surge is avoided.
• Bottle height of 125 cm
I prefer a high-vacuum supracapsular approach. Work-
ing in the iris plane minimizes capsular complications and,
• I/A (vacuum mode)
in eyes with small pupils or floppy irides, enhances visuali-
• 0 to 550 mm Hg
zation. By combining the Stellaris Vision Enhancement
• Bottle height of 125 cm
System with high-resistance outflow tubing such as
Bausch & Lomb’s Stable Chamber tubing or Cruise
Above setting combined with Stabile Chamber tubing
Control from STAAR Surgical Company (Monrovia, CA), I
(Bausch & Lomb) or Cruise Control tubing (STAAR Surgical
am able to use aspiration alone, without phaco energy, in
Company, Monrovia, CA).
at least 80% of my patients (see Dr. Davis’ Settings). I also
enjoy performing sub-2-mm coaxial surgery on this phaco
system and have used both the flow module (which of the soft material is vacuumed with moderate or little
allows me to switch between flow and vacuum control use of ultrasound.
even within a single case) and the vacuum module with To address lenses of medium density, I switch to a
success. divide-and-conquer approach and, providing the visuali-
zation is good, use a combination of vertical and hori-
JA ME S P. GILL S , MD zontal chop. In the event of poor visualization, I attempt
I use the Infiniti Vision System with the Ozil Torsional a quick chop, sculpt out the central part of the nucleus,
handpiece, a 45º Kelman mini-flare tip, and a phaco divide it, and fragment the lens into six or eight pieces
chop/divide-and-conquer surgical technique. prior to its removal. I frequently use this approach in the
For soft lenses, I use the lowest settings (Table 7). I typ- eyes of patients taking tamsulosin.
ically start with a horizontal chop and will frequently cut For hard lenses, I employ slightly higher flow and vacu-
off or use modulated torsional power, because so much um settings; I sometimes use 100% continuous torsional

36 I CATARACT & REFRACTIVE SURGERY TODAY I SEPTEMBER 2008

CATARACT SURGERY PHACO PEARLS

ultrasound to perform a vertical chop with a sharply at the Keck School of Medicine, University of
pointed manipulator. When creating these pie-shaped Southern California School of Medicine in Los
divisions, I take extra care not to chop the anterior cap- Angeles, and he is Director of the Colvard Eye
sule during phacoemulsification. I divide the lens into Center in Encino, California. He is a consultant
eight, 12, or 16 pieces using a combination of vertical and to Advanced Medical Optics, Inc., and Bausch
horizontal chop. ■ & Lomb. Dr. Colvard may be reached at (818) 906-2929;
[email protected].
Section Editor William J. Fishkind, MD, is Co- Elizabeth A. Davis, MD, is Adjunct Clinical
Director of Fishkind and Bakewell Eye Care and Assistant Professor at the University of Minnesota
Surgery Center in Tucson, Arizona, and Clinical in Minneapolis and Director of the Minnesota Eye
Professor of Ophthalmology at the University of Laser and Surgery Center, Minnesota Eye Con-
Utah in Salt Lake City. He is a consultant to sultants, Bloomington. She is a consultant to
Advanced Medical Optics, Inc. Dr. Fishkind may be reached Bausch & Lomb and STAAR Surgical Company. Dr. Davis
at (520) 293-6740; [email protected]. may be reached at (952)-567-6068; [email protected].
Y. Ralph Chu, MD, is Founder and Medical Uday Devgan, MD, is a partner at the Maloney
Director of the Chu Vision Institute in Edina, Vision Institute in Los Angeles. Dr. Devgan is Chief
Minnesota. Dr. Chu is also Adjunct Associate of Ophthalmology at Olive View UCLA Medical
Professor of Ophthalmology at the University of Center and Associate Clinical Professor at the
Minnesota in Minneapolis and Clinical Professor UCLA School of Medicine. He is a consultant to
of Ophthalmology at the John Moran Eye Institute, Univer- Bausch & Lomb. Dr. Devgan may be reached at (310) 208-
sity of Utah, Salt Lake City. He is a consultant to Advanced 3937; [email protected].
Medical Optics, Inc. Dr. Chu may be reached at (952) 835- James P. Gills, MD, is Founder and Director of
0965; [email protected]. St. Luke’s Cataract & Laser Institute in Tarpon
D. Michael Colvard, MD, is Associate Clinical Professor Springs, Florida. He is on the speakers’ bureau
for and is a stockholder in Alcon Laboratories,
Inc. Dr. Gills may be reached at (727) 938-2020;
[email protected].
Bonnie An Henderson, MD, is Assistant Clinical
Professor of Ophthalmology at Harvard Medical
School in Boston and is a partner in Ophthalmic
Consultants of Boston. She is on the speakers’
bureau for and has received grant support from
Alcon Laboratories, Inc. Dr. Henderson may be reached at
[email protected].
Donald N. Serafano, MD, is in private practice in
Los Alamitos, California, and is Clinical Associate
Professor of Ophthalmology at the University of
Southern California in Los Angeles. He is a consult-
ant to Alcon Laboratories, Inc. Dr. Serafano may
be reached at (562) 598-3160; [email protected].
R. Bruce Wallace III, MD, is Medical Director
of Wallace Eye Surgery in Alexandria, Louisiana.
Dr. Wallace is also Clinical Professor of Ophthal-
mology at the LSU School of Medicine and
Assistant Clinical Professor of Ophthalmology at
the Tulane School of Medicine, both in New Orleans. He is a
consultant to Advanced Medical Optics, Inc., and Bausch &
Lomb. Dr. Wallace may be reached at (318) 448-4488;
[email protected].

1. Koch PS, Katzen LE. Stop and chop phacoemulsification. J Cataract Refract
Surg. 1994;20:566-570.