Principles of PHACOEMULSIFICATION

Health Care Technology Unit

ORBIS Flying Eye Hospital
Basic Eye Anatomy
Basic Eye Anatomy
Basic Eye Anatomy
 Basic Eye Anatomy

Distant objects require Closer objects require

a long focal distance a short focal distance
created by a thinner created by a thicker
lens lens
 CATARACT

„ Cataract is an opacity of the lens

„ From the Greek word for “water
fall”
„ Estimated 20 million people
suffering from Cataract
„ Major cause of blindness
Lens and Cataract
 Lens and Cataract

Age Diabetics

Drugs
Congenital
( Steroids )

Irradiation
Trauma ( Ultraviolet )
Eye diseases
( chronic uveitis )
Cataract
 History of Cataract Surgery
„ 5th Century BC: Couching
„ 29AD: First written description of cataract and
its treatment (De Medicinae)
„ Mid 1700s: First actual removal of cataract
–Jacques Daviel (Paris), Samuel Sharp
(London)
–Introduction of Intra Capsular Cataract
Extraction (ICCE)
„ Mid 1800s: Introduction of general anesthesia
 Early Cataract Surgery
„ 1867: Use of sutures for cataract surgery
„ 1884: Introduction of local anesthesia (cocaine
eye drops)
„ Early 1900s: First use of Extra Capsular
Cataract Extraction (ECCE)
„ 1940s: Introduction of Intraocular Lenses
(IOLs)
„ 1960s: Development of a technique to emulsify
the cataract using ultrasound
(Phacoemulsification) by Charles Kelman
(New York)
 Couching

Reproduced from Duke-Elder S. Diseases of the Lens and Vitreous; Glaucoma and Hypotony. St. Louis: Mosby;
1969. In Basic Clinical Science Course, Foundation of the American Academy of Ophthalmology. 2003 - 2004.
 Couching

Reproduced from Wertenbaker L. The Eye: Window to the World. New York: Torstar Books 1984. In Basic Clinical
Science Course, Foundation of the American Academy of Ophthalmology. 2003 - 2004.
Couching
The Intracapsular Cataract
Extraction (ICCE)

•Requires a large incision (10-12mm)

•Can cause complications with retinal detachment
and disturbances in the delicate structures
The Improved Technique of
ECCE
The Extracapsular Cataract
Extraction (ECCE)
A technique of removing a
portion of the anterior capsule,
allowing extraction of the lens
nucleus and cortex, and leaving
the remainder of the capsule
structure intact.

•Still requires a large incision (10-12mm)

•Can cause clouding of the posterior membrane
(secondary cataract)
General Considerations of
ECCE instrumentation
ECCE Requires:
• Operating microscope and better illumination
• Microsurgical hand-held instruments
• Irrigation-aspiration systems

A manual irrigation-aspiration system An automated irrigation-aspiration

for removing lens cortex System for cortex removal
 Phacoemulsification
– Phacoemulsification was invented and developed by
Dr. Charles D Kelman in 1967.
• His objective was to perform the ECCE through a small
incision.
– Phacoemulsification is a technique which employs
the ultrasound energy and fluid dynamics to
facilitate the removal of nucleus and cortex of the
lens in the cataract surgery.
 The Principles of
Phacoemulsification

• The fluid from an irrigation line enters the eye.

• Ultrasound tip break the lens in to fragment and emulsify the material.
• The emulsified material is subsequently aspirated by an aspiration line.
 The Principles of
Phacoemulsification

1. A very small "No Stitch" incision is made in the side of the cornea.
Such an incision promotes fast and more comfortable recovery
2. The bag of the lens is opened and the ultrasonic probe
(phacoemulsifier) removes the cloudy lens.
3. A small artificial lens is inserted through the small incision to replace
the cataract lens (IOL)
4. In case of opacification of the capsule (secondary cataract), YAG laser
can be used for treatment
 Phaco Requires a
Microscope

Surgical Ophthalmic Microscopes cost between $5,000 and $100,000

Intraocular Lenses (IOLs)
 Treatment of Secondary
Cataract using YAG Laser

Secondary Cataract occurs in about 50% of the cases and it may

occur a few months or even years after the surgery
 Treatment of Secondary
Cataract using YAG Laser
The Phacoemulsification
Machine

The first phacoemulsification machine was patented in 1971.

Basic Components of a
Phaco Machine

Irrigation Hand piece

Controls

Aspiration

Foot Switch
 The Basic Elements of
Phacoemulsification Machine

Storz Premier phacoemulsification machine

 Phacoemulsification
Machines

Storz Premier

Alcon Accurus Alcon Legacy Alcon 10000

Phaco machines cost between $25k and $100k
Phaco Handpieces

Phaco handpieces cost around $2000

 Phaco Sets

Alcon Accurus Alcon 10000 Storz Premiere

Sets cost between $130 and $450 each

 Comparison of Cataract
Surgeries
Procedure Advantages Disadvantages

„Inexpensive „Can cause retinal detachment

„Less skill required „Large incision-complications
ICCE „Less equipment required related to sutures and infection
„Can cause damage to delicate
eye structures
„Not much equipment required „Requires surgical microscope
„Less possibilities of damage to „Large incision-complications
ECCE
eye structures and retinal related to sutures and infection
detachment „Secondary Cataract
„Excellent control of each phase „Requires surgical microscope
of cataract removal „Expensive equipment
PHACO „Smaller incision-less suture and „Expensive consumable sets
infection related complications
„Secondary Cataract
 Considerations for
Introducing Phaco Surgery
„ Must have Ophthalmic Surgical Microscope
„ Must have Yag Laser for treatment of secondary
cataract
„ Ability to practice and perfect technique
„ Ability to pay for sets
„ Ability to properly sterilize handpieces and sets
„ Ability to maintain equipment
„ Availability of IOLs/Glasses
„ There may be other surgical techniques that are more
appropriate
 Advantages of
Phacoemulsification
• Smaller incision: fewer suture and less suture related complications,
more rapid anatomical healing.

• Allowsexcellent control of each phase of the

operation for cataract removal: better and more complete
removal and aspiration of the cortex.

• Stimulated the development of planned extracapsular

surgery.
 The Basic Elements of Phacoemulsification Machine

• Ultrasound hand-piece:
• ultrasound transducer
• titanium tip

• Irrigation-aspiration system:
• irrigation liquid container
• irrigation-aspiration lines
• aspiration pump Controls

• waste container

• Electronic control system:

• power supply
• computer (or control circuits )
• ultrasound generating circuits
• electromagnetic valve controls
• control panel and foot switch
 The Ultrasound Hand-piece
The ultrasound hand-piece consists of a probe containing a transducer
connected to a titanium tip.

A piezoelectric transducer hand-piece

 The Basic Concept of Ultrasound

The ultrasound refers to acoustical waves with frequency above 20kHz.

( the frequency of ultrasound utilized in phacoemulsification ranges between
28k to 60kHz. )

Acoustical impedance* of different materials:

Material Za ( 106 Rayls)

Air 0.0004
Water 1.48
Fat 1.38
Other soft tissue 1.63
Bone 7.80

* Acoustical impedance is a measure of its opposition to the propagation of ultrasound:

Za ( acoustical impedance ) = r ( density of medium ) x V ( velocity of sound )
 The Ultrasound Transducer

The ultrasound transducer is a device that converts

alternative current oscillations into acoustical vibrations.

There are two type of devices:

Piezoelectric crystal

Piezoelectric crystal

Ac power supply

The phenomenon of Piezoelectricity

 Piezoelectricity
„ The piezoelectric effect is a phenomena resulting from a coupling
between the electric and mechanical properties of a material.
When mechanical stress is applied to a piezoelectric material, an
electric potential will be produced. Likewise, when an electric
potential is applied to the material a mechanical change will
occur.
„ Piezoelectric materials thus have numerous applications as
electro-mechanical transducers - devices which can convert
electrical signals into mechanical motion and vice-versa.
Commercial applications of piezoelectric devices abound, for
instance in speakers, spark generators inside electronic igniters,
strain sensors pressure gages and as presice time-keepers in
electronic clocks. A few types of basic piezoelectric devices
include crystals, tubes, unimorphs, bimorphs and stacks.
„ Piezoelectric crystals involve a non-uniform charge distribution
within the unit cell of the crystal. When exposed to an electric
field, this charge distribution shifts and the crystal will change its
shape. The same polarization mechanism can cause a voltage to
develop across the crystal in response to mechanical force.
 Piezoelectricity
„ Because the force and displacement created by a pure
piezoelectric material is relatively small, methods have been
developed to allow amplification of the piezoelectric effect. One
approach (known as a unimorph) is to apply a thin layer of a
piezoelectric material to a layer of inactive material. When the
piezo expands or contracts, the device will then bend in
response.
„ By combining more than one piezo, it becomes possible to further
increase the amount of transduction. For instance, an elongating,
bending or twisting device can be created by placing two layers
of piezoelectric material on top of one-another, and by controlling
the polarization direction and the voltages such that when one
layer contracts, the other will expand. Such a device is known as
a bimorph.
„ By stacking of piezo materials into layers, it becomes possible to
combine their displacement to create what is known as a piezo
stack. Such devices are capable of higher displacements and
larger forces.
 The Ultrasound Transducer

Magnetostrictive metal

Electromagnetic field
Coils

Metal

U/S Frequency
Oscillation Circuits Ultrasound waves
Comparison of the Ultrasound Transducers

Piezoelectric transducer Magnetostrictive transducer

light heavier
easy to manage bulky
easy to sterilize difficult to sterilize
homogeneous U/S depend
do not need cooling need cooling
popular in new hand-piece popular in old hand-piece
delicate and easy to break last longer
 The Ultrasound Tip of the Hand-pieces

U/S tips made up of titanium is suitable for the frequency of the

ultrasound vibrations

Different angles of U/S tips:

• 0o for Phaco chop
• 15o tip has a greater occlusion capacity
• 45o tip has a greater cutting capacity
• 30o tip is an compromise between the two

U/S tips is covered by a silicone sleeve, which allows BSS to flow into the
anterior chamber through both the distal opening and the lateral
opening. It is also important for cooling the U/S tip when functional.
 The Importance of the Hand-piece Tuning

Transducer & Tip Maximum

efficiency

Tuning

Self-tuning between the ultrasound

Ultrasound
hand-piece and the generator
generator
inside the machine
 The Irrigation and Aspiration system

Irrigation tube

Bottle with BBS

Aspiration tube

Eye Aspiration Pump

 The Aspiration Pumps

Aspiration Pump creates the pressure difference that attracts the liquid
and the materials toward the aspiration orifice.
Aspiration pump can be one of three types:
• Peristaltic
• Venturi
• Membrane diaphragm
The hydrodynamic parameters related to the aspiration pump:
• Flow rate
• Vacuum and rising time
• Occlusion
• Venting
• Reflux
 Peristaltic Pump

Peristaltic pump consists of a rotating drum fitted at regular intervals with

cylinders that compress the aspiration tube wound around the rotating drum. The
rotation of the drum will produce the peristaltic wave that will draw the liquid in
the direction of rotation.

The direction of rotation and

the peristaltic wave

Rotation
drum

Aspiration
tube Peristaltic pump on Alcon Universal II
 The Venturi Pump
The Venturi pump consists of a compensation chamber connected on one side
to the aspiration tube and on the other to a chamber containing compressed air.

80 -100 psi

Compressed
air

orifice

Aspiration
Vacuum tube
 The Membrane Pump
The membrane pump consists of a compensation chamber connected on one
side to the aspiration tube and on the other to a chamber containing compressed
air.

membrane
membrane
exhaust
Direction of
movement

One way valves

Aspiration

Direction of Vacuum
rotation
 The hydrodynamic parameters

The hydrodynamic parameters related to the aspiration pump:

• Flow rate indicates the quantity of liquid that is aspirated through the
tube over the time unit. ( cc/min )
• Vacuum indicate the negative pressure in the aspiration line.
• Occlusion occurs with the obstruction of U/S tip or aspiration line. The
occlusion activates the increase in vacuum along the aspiration line and
therefore increases the capacity of the pump for aspirating.
• Venting is designed for interrupting the aspiration, when the wrong
material ( e.g. the iris and capsule) is aspirated during the surgery.
• Reflux is to create a positive pressure inside the aspiration line. It can
avoid tearing the tissue that has occluded the aspiration orifice.
The Cartridges for Different Brand of Phaco Machines

Alcon Accurus Alcon 10000 Storz Premiere

 The Aspiration Pumps

Aspiration Pump creates the pressure difference that attracts the liquid
and the materials toward the aspiration orifice.
 Handpiece Flushing and Sterilization

Flushing
• Use warm distilled water
• Do not use chemical agents to flush the hand-piece.

• Do not draw flushing fluid back through the hand-piece.

Sterilization
• Standard steam sterilization ( 121 0C, 103 kPa, 20 min )
• Flash sterilization ( 132 0C, 206 kPa, 5 min )
• High vacuum ( 132 0C, -64 cm Hg, 4min )
 Acknowledgements

ALCON Laboratories