REFERAT

PHACOEMULSIFICATION

Tutor :
Dr. dr. Gilbert W.S Simanjuntak, SpM (K)

Arranged by:
Si Putu Agung Ratih S. Dewi 1261050191
Dudi Barham 1261050196
Hardianti Selviani 1261050217
Sartini Roma Dame Nainggolan 1261050261
Pek Vania Mugland Devi 1261050300
Theresia Verawati .Lumban Gaol 1361050035
Puti Aisha 1361050083

DEPARTMENT OF OPHTHALMOLOGIC MEDICAL FACULTY

CHRISTIAN UNIVERSITY OF INDONESIA
PERIOD JULY 23, 2018 – AUGUST 25, 2018
JAKARTA
2018
 PREFACE

The praise and gratitude of the author is to the Almighty God, for all His love,
blessings and grace, so that we can accomplish this Referat's duty. This task is
organized as one of the requirements of the clinic's clinic of Eye Disease Faculty of
Medicine, Christian University of Indonesia in RSU UKI period July 23, 2018 -
August 21, 2018.
In the process of preparing this Referat task is not possible without support,
guidance, and assistance from various parties. Therefore, we would like to thank the
supervising doctors, as well as the colleagues of the Clinic of Stage Eye Disease
clinics at RSU UKI.
We realize that in the preparation of this Referat's task there are still
shortcomings, therefore we expect criticism and suggestions as a constructive input to
make this task even better. As for the existing shortcomings, we apologize and
hopefully this task can be useful and useful.
Jakarta, 29 july 2018

Author

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 TABLE OF CONTENTS

Pages

PREFACE......................................................................................................... i

TABLE OF CONTENTS............................................................................... ii

LIST OF FIGURES ....................................................................................... iii

CHAPTER 1 INTRODUCTION .................................................................. 1

CHAPTER 2 REVIEW OF THE LITERATURE ...................................... 3

2.1 Definition of Phacoemulsification......................................... .. 3

2.2 The Concept of Phacoemulsification…………………………. 3

2.3 Procedure of Phacoemulsification...………………………….. 3

2.4 Hydro Procedures……………………………………………... 11

2.5 Irrigation and Aspiration……………………………………… 13

2.6 Indications and Contraindications of Phacoemulsification..…. 16

2.7 Advantages and Disadvantages of Phacoemulsification

Operation Techniques………………………………………... 16

2.8 Complications Related to Incision……………………………. 17

CHAPTER 3 CONCLUSION................................................................... 18

REFERENCES.......................................................................................... 19

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 LIST OF FIGURES
Pages
Figure 2.1. The of main and side port incision…….…………………………. 4

Figure 2.2. Capsulorhexis in phacoemulsification……………………………. 5

Figure 2.3. Technique of capsulorhexis……………………………….………. 6

Figure 2.4. Cataract Splitting and Aspiration on phacoemulsification………... 9

Figure 2.5. Cataract Splitting and Aspiration on phacoemulsification.………. 9

Figure 2.6. Cortical Irrigation in phacoemulsification…..……………………. 10

Figure 2.7. Intra-Ocular Insertion Lens on the Rear Room…..………………. 11

Figure 2.8. Procedure: site of Hyderodeline- ation, Hydrodissection

Hydrodelamination ……….…………………………………………………… 12

Figure 2.9. Procedure: site of Hyderodeline- ation, Hydrodissection

Hydrodelamination ……….…………………………………………………… 13

Figure 2.10. Placement of irrigation-aspiration canulamis

horizontal………………………………………………………………………. 14

Figure 2.11. Preferably catch the bulk of soft tissue and Lifting of subincisional

cortex………………………………….……………………………….………. 14

Figure 2.12. Removal of tissue by catching the epinucleus sheet under the
Hood……………………………………………………..……………………... 14
Figure 2.13. At 6 o’ clock position, soft tissue catchment with tilted bevel up

position….………………………………………………………………………………………...………. 15

Figure 2.14. Once the edge of epinucleus is caught aspiration is very fast.…. 15

Figure 2.15. 9 o’ clock position soft tissue caught by placing irrigation-

aspiration canula in bevel sideway position……………………..…..………………. 15

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 CHAPTER 1
INTRODUCTION

1.1 INTRODUCTION
Cataract or lens opacities are a major cause of visual impairment and
blindness in the world, including in Indonesia (51%). Factors aged over 50 years
to be the main factor of cataracts, about 65% cause visual impairment and 82%
cause blindness, although this age group is only 20% of the world population. In
addition to age, there are other factors that can increase the risk of cataracts,
including trauma, toxins, diabetes mellitus, hypertension, smoking, and
hereditary. The estimated incidence of cataracts is 0.1% per year or annually
among 1000 people there is a new cataract patient. Indonesians also tend to suffer
from cataracts 15 years faster than the population in the subtropics, about 16-22%
of cataract patients who are operated under 55 years of age. The highest
prevalence of cataracts in Indonesia according to Riskesdas 2013 is North
Sulawesi Province and the lowest in DKI Jakarta. 1,2
There are still many cataract patients who do not know if suffering from
cataracts. This can be seen from the three reasons why cataract surgery has not
surgery, ie 51.6% are unaware if suffering from cataract, 11.6% can not afford to
pay, and 8.1% are afraid of surgery. Cataract Surgical Rate (CSR) is the number
of cataract surgeries per one million population per year. In 2006 WHO
mentioned the number of CSR Indonesia around 465, while in 2012 according to
Perdami CSR Indonesia figures ranging from 700-800. This number will increase
in accordance with the increasing number of population and the increase of life
expectancy since cataract patients mostly occur at age> 50 years. Estimated
incidence of cataracts (new cases of cataracts) is 0.1% of the population, so the
number of new cases of cataracts in Indonesia is estimated at 250,000 per year.2
Treatment of cataracts is a surgical action that aims to produce the
optimization of vision function characterized by rapid recovery, measured with
minimal side effects, long-term stability, and provide satisfaction in patients.
Most of the normal vision can be restored through opacifier lens lifting surgery,
facilitated by intraocular lens implantation (IOL). Not all cataract surgeries reach
the goal, many factors that affect it include surgical complications. Complications
of cataract surgery vary widely depending on the time and scope.3

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 Complications can occur in the intraoperative period such as irrit prolapse,
iris trauma, hifema, tearing posterior capsule and vitreous loss.4 Postoperative
complications include corneal edema and endophthalmitis, bullous keratopathy,
intraocular lens malposition / dislocation (LIO), cystoid macular edema (CME),
retinal detachment, uveitis, increased intraocular pressure and posterior capsular
opacification. There are a variety of cataract surgery techniques, including Extra
Capsular Cataract Extraction (ECCE), Intra Capsular Cataract Extraction (ICCE),
Small Incision Cataract Surgery (SICS), and phacoemulsification that has their
respective advantages and disadvantages.5
A common surgical method for adult or childhood cataracts is to leave the
posterior portion of the lens capsule so that it is known as Extra Capsular
Cataract Extraction (ECCE). Intraocular lens planting is part of this procedure.
Incisions are made on the limbus or peripheral cornea at the superior or
temporal.6
In ECCE the expression of the nucleus, the lens nuclei is removed intact, but
this procedure implies a relatively large incision. With the rapid development of
technology, the technique was discovered using phacoemulsification and
experienced rapid development and has achieved refractive surgery because of its
advantages, rapid visus rehabilitation, mild postoperative complications, and mild
to moderate astigmatism. This technique is useful in congenital, traumatic, and
most senile cataracts. This technique is less effective in dense senile cataracts,
and the advantage of a small limbus incision is somewhat less if an intraocular
lens is inserted, although it is now more commonly used intraocular flexible
lenses that can be inserted through such small incisions.6
The phacoemulsification technique also has more advantages than the SICS
technique because in SICS techniques the risk of astigmatism, corneal edema,
posterior capsule opacities, and higher iris lesions. According to some studies,
compared with phacoemulsification there is a risk of milder astigmatism and
rehabilitation for visus return as well as wound healing faster than ICCE
techniques. 6

2
 CHAPTER 2
REVIEW OF THE LITERATURE

2.1 DEFINITION OF PHACOEMULSIFICATION

The phacoemulsification comes from 2 words, namely phaco (lens) and
emulsification (breaking into a softer form). Phacoemulsification is one of the
surgical techniques of cataract surgery using ultrasonic equipment that will
vibrate and break the eye lens nuclei into small fragments, then the lenses that
have been destroyed to pieces will be removed using a phaco tool.7

2.2 THE CONCEPT OF PHACOEMULSIFICATION

Phacoemulsification is a cataract extraction technique using a small
incision of about 1.5 mm to 3 mm by implantation of a foldable intra-ocular lens
so that the wound closure can be seamless. How the phacoemulsification system
works is to destroy the lens through an ultrasonic probe that has a needle tip that
can vibrate with a very high frequency that is equivalent to the frequency of
ultrasound waves. The mass of the crushed lens will be aspirated through the
cavity in the phacoemulsification tip to be removed from the eye through the
aspiration tube in the phacoemulsification machine.8

2.3 PROCEDURE OF PHACOEMULSIFICATION

The patient's preparation to be performed before surgery is as follows:
1. Patients should be hospitalized overnight before surgery
2. Providing informed consent
3. The pupils are dilated with a drip of midriatics about 2 hours before surgery
4. Eyelashes are cut and cleansed with povidone-iodine 5%.8

The technique of cataract surgery with phacoemulsification is as follows:8

a. Giving mefenamic acid 500 mg or Indomethacin 50 mg orally 1-2 hours
before surgery.
b. Local anesthesia in the eye to be operated by injecting directly through the
upper and lower palpebra.

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c. The operator presses the eyeball with his hand to see if there is a possibility
of bleeding, and can also lower the intraocular pressure.
d. The operator makes an incision approximately 3 mm on the side of the
anesthetized cornea. Due to the careful construction of the incision and its
small size, this incision usually closes on its own. Also called 'no-stitch' type
operation.
e. All incisions should always be directed towards the center of the eye. This is
because the movement arc of the instruments is equal in both the sides from
the center and thus all the instruments can reach at any part of the eye
without any hindrance offered by the ends of the incision. For this the
surgeon should be very careful while creating incision, the direction of all
instruments should be exactly towards the center of the eye.8,9

Figure 2.1 Shows site of main and side port incision (blades are
directed towards the center during the incision).9

f. The anterior capsule is by the needle of the capsulotomy through a small

incision of the cornea. This procedure is called capsulorhexis. Capsulorhexis
is the process of peeling of the anterior capsule of the lens in a central
continuous curvilinear fashion.

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 Figure 2.2 Capsulorhexis in phacoemulsification.8

g. Make a nick in the center of the anterior capsule and elevate the flap The
direction of the flap is towards the 6 o’clock when done through the right
side port, at 9 o’clock (if sideport is at 10 o’clock then the direction of the
nick in capsulorhexis is towards the 7 o’clock), and is continued in an
anticlockwise direction.

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7
 Figure 2.3 Technique of capsulorhexis. (A and B) Capsulorhexis by 26-gauge
cystitome; (C) Capsulorhexis is completed by capsulorhexis forceps; (D)
Capsulorhexis is completed by microcapsulorhexis forceps.9

h. After the incision is performed, a viscoelastic fluid is inserted to reduce

vibration in the intraocular tissue.
i. Conducted hydrodisection and hydrodilemenesi to separate the lens core
from the cortex and then performed phacoemulsifikasi with horizontal choop
technique using fako unit machine. phacoemulsification is a procedure where
ultrasonic vibration is used to break the cataract into small parts. These
fragments are then aspirated out using the same tool.

8
 Figure 2.4 Cataract Splitting and Aspiration on phacoemulsification.8

j. The operator creates a groove on the cataract and then breaks the cataract
into small parts using the tip of phacoemulsification and the second device is
inserted through a smaller incision on the other side of the 'side port'.

Figure 2.5 Cataract Splitting and Aspiration on phacoemulsification.8

k. The lens cortex is removed by means of aspiration irrigation using the phaco
unit machine. The posterior capsule is left to support the intraocular lens
(IOL).

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 Figure 2.6 Cortical Irrigation in phacoemulsification.8

l. The intraocular lens insertion of foldable in the rear cavity is performed in

the bag, having previously been given viscoelastic material to reduce the
complications.

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 Figure 2.7 Intra-Ocular Insertion Lens on the Rear Room.8

m. The viscoelastic material is removed by irrigation aspiration using the

phacounit machine.
n. The surgical wound was closed without stitches.
o. Given a shot of antibiotics (Gentamicin) 0.5 ml and corticostroid (Corticoster
Acetate) 0.5 ml, subkonjungtiva.
p. Post-surgery is given antibiotic eye drops (Neomycin-Polymixin B) and anti-
inflammatory (Dexamethasone) 0.1 ml., Every 8 hours.8,9

2.4 HYDRO PROCEDURES

Hydrodelineation is a process for separation of layers of lens by fluid.
Hydrodelineation is a process of separation between inner hard core of nucleus
and adjacent epinucleus. Hydrodelamination is a process of separation of the lens
at different zones of epinucleus. Hydrodissection is a process of is separation of
the cortex and capsule.9

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 Figure 2.8 Procedure: site of Hyderodeline- ation, Hydrodissection,
Hydrodelamination.9

Hydrodelineation with a 2-cc syringe filled with balanced salt solution

(BSS) or ringer lactate with beveled canula is used for hydrodelineation. Fill the
anterior chamber with viscoelastics to normal depth so that the anatomy of the
lens will be at its position, which is very important to reach at specific points of
separation of layers. In shallow anterior chamber one cannot reach to proper
anatomical plain and anterior chamber can still become more shallower and this
restricts the further hydro procedures.9
Needle should pass first towards the left side of the nucleus which is more
approachable and the author’s favorite site is at 11 o’ clock position Pass the
needle behind the capsulorhexis and in the substance of lens to reach at border of
hard core of nucleus and pass the fluid very slowly and as the separation starts
one can tap the nucleus and pass the more fluid to complete hydrodelineation
Final result is visualization of golden ring.9
During hydrodelineation water current sometimes passes through the
layers of epinucleus so along with typical golden ring one can see one to two

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 more rings of separation of various layers of epinucleus. This is
hydrodelamination.9
During the Hydrodissection, pass the needle behind the anterior capsule
and push the fluid parallel to the anterior capsule. This will separate the capsular
bag from the cortex. This water current will move from one plain to other plain
and classical fluid wave can be seen. This is the sign of completion of
hydrodissection. Following this the nucleus is tapped at the centre towards the
posterior capsule to avoid capsulolenticular block.9

2.5 IRRIGATION AND ASPIRATION

This step is one of the most important steps in phaco surgery. Posterior
capsule rupture is common during this step. Irrigation and aspiration by one tip is
called as coaxial irrigation-aspiration. Coaxial irrigation-aspiration is an
automated system. Irrigation is from two sides of the tip 180 degree apart.
Aspiration port is a single aspiration port situated just away from the tip (Concave
side of the curved tip). The lumen is from 0.2 mm to 0.7 mm and commonly used
is 0.3 mm. This irrigation-aspiration tip can be with or without sleeve.9

Figure 2.9 Procedure: site of Hyderodeline- ation, Hydrodissection,

Hydrodelamination.9

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FIGURE 2.10 Placement of irrigation-aspiration canulamis horizontal. Catching the apex of soft
tissue and Removal of epinucleus under visualize ation.9

Figure 2.11 Preferably catch the bulk of soft tissue and Lifting of subincisional cortex,
by keeping the irrigation-aspiration tip vertically down, under observation.9

Figure 2.12 Removal of tissue by catching the epinucleus sheet under the hood.9

14
 Figure 2.13 At 6 o’ clock position, soft tissue catchment
with tilted bevel up position.9

Figure 2.14 Once the edge of epinucleus is caught aspiration is very fast.9

Figure 2.15 9 o’ clock position soft tissue caught by placing irrigation-

aspiration canula in bevel sideway position.9

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2.6 INDICATIONS AND CONTRAINDICATIONS OF
PHACOEMULSIFICATION
Indications of cataract surgery using phacoemulsification techniques are
as follows:
a. Patients have no history of endothelial diseases
b. On the examination found a deep chamber of eyeball
c. The patient's pupils can be dilated up to 7 mm.10

Meanwhile the contraindications to the phacoemulsification technique are:

a. There were signs of infections
b. The existence of a lens or subluxation of the lens.10

2.7 ADVANTAGES AND DISADVANTAGES OF PHACOEMULSIFICATION

OPERATION TECHNIQUES

In theory the operation of cataracts with the technique

Phacoemulsification i experiencing rapid development and has reached the level
of refractive surgery because it has several advantages of fast visus rehabilitation,
complications after light operations, astigmatism due to minimal surgery and
rapid wound healing.10

The advantages of using phacoemulsification techniques on cataract

operations according to Kanski and Bowling in Clinical Ophthalmology A
Systemic Approach are as follows:10

a. Kinder cut, more comfortable cutting for the patients

b. Smaller incision, the previous incision is usually 2.7 mm, with the MICS
only 1.8 mm. The implication is that the incision is too small to cause an
abnormally curved cornea, and cause astigmatism (a common side effect of
cataract surgery) and the low incision also greatly reduces the risk of
infection.
c. Easy to operate, because very little fluid that may come out of the micro
incision so the pressure on the eye tends to be stable, making it easier for
doctors to perform surgery.

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 d. Heals faster, after 1-2 days of action, the patient can get back on the move.
Discomfort after surgery, disappear within 3 days.

The purpose of this surgical technique is for cataract patients to obtain the
best sharp vision without correction by making the incisions as small as possible
to reduce the induction of postoperative astigmatism. This procedure is efficient,
especially if smooth surgery is generally associated with good vision results. The
incidence of CME in phacoemulsification techniques with intraoperative
complications was lower due to the construction of small incision wounds and
greater stability compared to other cataract surgical techniques.
Phacoemulsification disadvantages include expensive machines, longer learning
curves, and high surgical costs.10

2.8 COMPLICATIONS RELATED TO INCISION

a. Conjunctival hydration
b. Bleeding in the Tunnel
c. Iris prolapse
d. Bleeding in the anterior chamber
e. Capsulorexis
f. The detachment of the Descemet membrane
g. Small pupil.9,10

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 CHAPTER 3
CONCLUSION

Cataract or lens opacities are a major cause of visual impairment and

blindness in the world, Treatment of cataracts is a surgical action that aims to produce
the optimization of vision function characterized by rapid recovery, measured with
minimal side effects, long-term stability, and provide satisfaction in patients.5 With
the rapid development of technology, the technique was discovered using
phacoemulsification and experienced rapid development and has achieved refractive
surgery because of its advantages, rapid visus rehabilitation, mild postoperative
complications, and mild to moderate astigmatism. 6
Phacoemulsification is a cataract extraction technique using a small incision
with implantation of a folding intra-ocular lens (foldable) so that the wound closure
can be done without sutures. This technique is done by destroying the lens through an
ultrasonic probe that has a needle tip that can vibrate with a very high frequency that
is equivalent to the frequency of ultrasound waves. The mass of the crushed lens will
be aspirated through the cavity on the phacoemulsification tip to be removed from the
eye through the aspiration tube in the phacoemulsification machine.11 The purpose of
this surgical technique is for cataract patients to obtain the best sharp vision without
correction by making the incisions as small as possible to reduce the induction of
postoperative astigmatism.10,11 This technique is also said to be more convenient for
the patient due to the slight incision and the wounded surgery can heal faster while for
the doctor who perform the surgery, this technique simplifies the action because only
a small amount of fluid may get out of the incision so that the eyeball pressure is more
stable.12
However, this technique also has its own disadvantages, such as expensive
machines, longer learning curves, and high surgical costs, as well as complications
that can be found from this technique is cataracts hipermatur or cataracts are hard due
to the difficulty of breaking and separating the lens nucleus.12,13
Hopefully, in line with the development of cataract management surgical
techniques, cataract patients can also be diagnosed early and can immediately obtain
treatment procedures to improve the quality of life of patients.

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 REFERENCES

1. Departemen Kesehatan RI. 2009. Data Penduduk Sasaran Program

Kesehatan Tahun 2007-2011. Jakarta: Pusat Data dan Informasi
Departemen Kesehatan RI.
2. Kementrian Kesehatan RI. 2014. Situasi Gangguan Penglihatan dan
Kebutaan. Jakarta: Infodatin
3. Sihota R. dan Tandan R. 2007. Parson's diseases of the eye. Elsevier, 247-69.
4. Henderson B.A., Kim J.Y., Ament C.S., Ponce Z.K.F., Grabowska A., dan
Cremers S.L. 2007. Clinical pseudophakia cystoid macular edema: risk
factors for development and duration after treatment. Journal of Cataract &
Refractive Surgery, 33:1550-1558.
5. Gofate P. 2010. Comparison of various techniques for cataract surgery, their
efficacy, safety, and cost. Oman Journal of Ophtalmology, 3(3): 105-106.
6. Minassiana C., Rosenc P., Dartb J. K. G., Reidyd A., Desaid P., dan
Sidhue M.. 2001. Extracapsular cataract extraction compared with small
incision surgery by phacoemulsification: a randomised trial. British Journal of
Ophtalmology, 85: 921.
7. Nishino M., Eguchi H., Iwata A., Shiota H., Tanaka M., dan Tanaka T. 2008.
Are topical essential after an uneventful cataract surgery?. The Journal of
Medical Investigation, 56:11-15.

8. Soekardi I. dan Hutauruk J.A. 2004. Transisi Menuju Fakoemulsifikasi,

Langkah-Langkah Menguasai Teknik & Menghindari Komplikasi. Edisi 1.
Jakarta. Kelompok Yayasan Obor Indonesia. p 1-7.

9. Toshniwal N. 2013. Simplified Phacoemulsification, ed.1. New Delhi:

Jaypee Brothers Medical Pub.

10. Goncalves, J. M. S. 2005. Phacoemulsification in hard cataracts: the “chop,

trip and free” technique. Arquiovos Brasileiros De Oftalmologia, 67(4):603-
605.

11. Purba D.M., Hutauruk J.A., Riyanto S.B., Istiantoro D.V., dan Manurung F.M.
2010. A sampai Z Seputar Fakoemulsifikasi. Jakarta: Info JEC. p. 17-51.

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12. Soekardi I. dan Hutauruk J.A. 2004. Transisi Menuju Fakoemulsifikasi,
Langkah-Langkah Menguasai Teknik & Menghindari Komplikasi. Edisi 1.
Jakarta. Kelompok Yayasan Obor Indonesia. p 1-7.

13. Bellarinatasari N., Gunawan W., Widayanti T. W., dan Hartono. 2011. The
role of ascorbic acid on endothelial cell damage in phacoemulsification.
Journal Ophtalmology Indonesia, 7 (5).

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