Phacoemulsification refers to modern cataract surgery in which the eye's internal lens is emulsified with anultrasonic handpiece and

aspirated from the eye. Aspirated fluids are replaced with irrigation of balanced salt solution, thus maintaining the anterior chamber, as well as cooling the handpiece. Phacoemulsification is a modified version of extracapsular cataract extraction (ECCE) and is the most common surgical procedure for removing cataracts. As in other forms of ECCE, phacoemulsification involves removing the eye's natural lens while leaving in place the back of the capsule, which holds the lens in place. The difference with phacoemulsification is that the cataract is broken into tiny pieces that are suctioned from the eye through a smaller incision than that required by other forms of cataract surgery. Healing and rehabilitation are faster with this procedure, and there is little, if any, discomfort.

Etymology
phaco- (Greek word: phako-, comb. form of phaks lentil; - lens ) + emulsification

History
Charles Kelman introduced phacoemulsification in 1967 after being inspired by his dentist's ultrasonic probe. One of the cataract surgery techniques that Kelman developed, phacoemulsification, has become today's standard. Inspired by his dentist's ultrasonic tools, in 1967 Kelman introduced the technique that uses ultrasonic waves to emulsify the nucleus of the eye's lens to remove the cataracts without a large incision. This new surgery removed the need for an extended hospital stay and made the surgery less painful. It has helped 100 million people nation-wide. "Dr. Kelman, who received the National Medal of Technology from President George H. W. Bush in 1992, was inducted [in February 2004] into the National Inventors Hall of Fame in Akron, Ohio. Neurosurgeons have improved upon the technique and used it to remove tumors from the brain and spinal cord." (Boston Globe)

Preparation and precautions

Being a delicate organ, the eye requires extreme care before, during and after a surgical procedure. An ophthalmologist must diagnose a cataract and conduct or appropriately supervise the conduction of the operation. University programs typically allow patients to specify if they want to be operated upon by the consultant or the resident or fellow. Proper anesthesia is a must for ocular surgery. Topical anesthesia is most commonly employed, typically by the instillation of a local anesthetic such astetracaine or lidocaine. Alternatively, lidocaine and/or longer-acting bupivacaine anesthestic may be injected into the area surrounding (peribulbar block) or behind (retrobulbar block) the eye muscle cone to more fully immobilize the extraocular muscles and minimize pain sensation. A facial nerve block using lidocaine and bupivacaine may occasionally be performed to reduce lid squeezing. General anesthesia is recommended for children, traumatic eye

injuries with cataract, for very apprehensive or uncooperative patients and animals. Cardiovascular monitoring is preferable in local anesthesia and is mandatory in the setting of general anesthesia. Proper sterile precautions are taken to prepare the area for surgery, including use of antiseptics like povidoneiodine. Sterile drapes, gowns and gloves are employed. A plastic sheet with a receptacle helps collect the fluids during phacoemulsification. An eye speculum is inserted to keep the eyelids open.

Surgical technique
In phacoemulsification cataract surgery, the surgeon makes a very small incision -- about 1/8th of an inch -- in the white of the eye near the outer edge of the cornea. A small ultrasonic probe is inserted through this opening and, oscillating at 40,000 cycles per minute, is used to break up (emulsify) the cataract into tiny pieces. . Phacoemulsification surgery involves the use of a machine with microprocessor-controlled fluid dynamics. These can be based on peristaltic or a venturi type of pump. The phaco probe is an ultrasonic handpiece with a titanium or steel needle. The tip of the needle vibrates at ultrasonic frequency to sculpt and emulsify the cataract while the pump aspirates particles through the tip. In some techniques, a second fine steel instrument called a "chopper" is used from a side port to help with chopping the nucleus into smaller pieces. The cataract is usually broken into two or four pieces and each piece is emulsified and aspirated out with suction. The nucleus emulsification makes it easier to aspirate the particles. After removing all hard central lens nucleus with phacoemulsification, the softer outer lens cortex is removed with suction only.The front (anterior) section of the lens capsule is removed along with the fragments of the natural lens. The back (posterior) portion of the capsule is left in place to hold and maintain the correct position for the implanted intraocular lenses. After removal of the cataract, a prescription intraocular lens, or IOL, is permanently implanted in the lens capsule to replace the natural crystalline lens of the eye that was removed during the surgery. This lens is rolled inside a tiny hollow tube and inserted through the same incision that was used to remove the cataract. The folded lens is pushed out of the tube by a tiny plunger and, as it unfolds, is positioned by the surgeon in the center of the lens capsule. The new lens is held in place by microscopic, spring-like wires that are attached to the implant. It is then inserted and placed in the posterior chamber in the capsular bag (in-the-bag implantation). Sometimes, a sulcus implantation may be required because of posterior capsular tears or because of zonulodialysis. Because a smaller incision is required, few or no stitches are needed and the patient's recovery time is usually shorter when using a foldable IOL.

Recovery
The tiny incision made during phacoemulsification surgery generally requires no stitches and heals itself in a few days. Antibiotic and steroid eyedrops may be given to diminish inflammation, to prevent infection, and to keep the eye moistened for several days following surgery.

To understand how the phacoemulsification technique works, it is important to understand what a cataract is and how it interferes with vision.
CATARACT The lens of the eye, the part that helps focus light onto the retina which in turn sends the visual signals to the brain (See Anatomy of the Eye), is made mostly of water and protein. When too much protein builds up, it clouds the lens blocking some of the light and impairing vision. That protein build-up is the formation of a cataract. It is not a growth, but rather a clouding or hazing of the lens. How many people get cataracts? A significant number of people ages 65 or older have some degree of cataract. In fact, developing cataracts is a normal part of aging. That does not mean, however, that every senior will need treatment for cataract problems. What causes cataracts? The cause of cataracts is generally unknown. Most often, cataracts occur as a person ages, called age-related cataracts or more scientifically, nuclear sclerotic cataracts. Cataracts can also result from a variety of environmental conditions and injuries and are called either secondary or traumatic cataracts. Some babies are born with cataracts, called congenital cataracts. Generally, potential risk factors for developing cataracts include but are not limited to: 65 years of age or more Family history of cataracts Smoker or former smoker Grossly over- or underweight Diabetes Have taken steroids or certain other medications Suffered a blunt or penetrating eye injury Excessive, long exposure to UV light

CLINICAL MANIFESTATIONS Diminished visual acuity, disabling sensitivity to glare, painless, dimmed or blurred vision with distortion of images, poor night vision. Other effects include myopic shift, astigmatism, monocular diplopia (double vision), color shift (aging lens becomes progressively more absorbent at the blue end of the spectrum), brunescence (color values shift to yellow brown), and reduced light transmission. Yellowish, gray, or white pupil Develops gradually over a period of years; as the cataract worsens, stronger glasses no longer improve sight May develop in both eyes, although one is more compromised than the other ASSESSMENT AND DIAGNOSTIC METHODS Degree of visual acuity is directly proportionate to density of the cataract. Snellen visual acuity test Opthalmoscopy

Slit-lamp biomicroscopic examination A-scan ultrasonography MEDICAL MANAGEMENT There is no medical treatment for cataracts, although use of vitamin C and E and beta-carotene is being investigated. Glasses or contact, bifocal, or magnifying lenses may improve vision Mydriatics can be used short term, but glare is increased. SURGICAL MANAGEMENT Two surgical techniques are available: intracapsular cataract extraction (ICCE) and extracapsular cataract extraction (ECCE) including phacoemulsification. Less than 15% of people with cataracts require surgery. Indications for surgery are loss of vision that interferes with normal activities or a cataract that is causing glaucoma. Cataracts are removed under local anesthesia on an outpatient basis. Lens replacement may involve aphakic eyeglasses, contact lens, and intraocular lens (IOL) implants. When both eyes have cataracts, one eye is surgically treated at a time. NURSING MANAGEMENT Because surgery is performed on an outpatients basis, instruct patient to make arrangements for transportation home, care that evening, and a follow-up visit to the surgeon the next day. Withhold any anticoagulants the patient is receiving, if medically appropriate. Aspirin should be withheld for 5 to 7 days, nonsteroidal anti-inflammatory drugs (NSAIDs) for 3 to 5 days, and warfarin (Coumadin) until the prothrombin time of 1.5 is almost reached. Administer dilating drops every 10 minutes for four doses at least 1 hour before surgery. Antibiotic, corticosteroid, and NSAID drops may be administered prophylactically to prevent postoperative infection and inflammation. Instruct patient to wear a protective eye patch for 24 hours after surgery to prevent accidental rubbing or poking of the eye. After 24 hours, eyeglasses (sunglasses in bright light) should be worn during the day and a metal shield worn at night for 1 to 4 weeks. Provide postoperative discharge teaching concerning eye medications, cleansing and protection, activity level and restrictions, diet, pain control, positioning, office appointments, expected postoperative course, and symptoms to report immediately to the surgeon. Instruct patient to restrict bending and lifting heavy objects. Caution patient that vision may blur for several days to weeks. Inform patient that vision gradually improves as the eye heals; IOL implants improve vision faster than glasses or contact lenses. Reinforce that vision correction is usually needed for remaining visual acuity deficit.

Post-Op Complications
Major intraoperative complications occurred in 15 of 320 cases (4.7%). The 15 major complications included: Vitreous loss (10 cases, three of which included dropped nuclear fragments and one of which included corneal wound burn) Two malpositioned IOLs, which necessitated reoperation One wrong IOL power, leading to a second operation One corneal wound burn One post-op iris prolapse, which led to wound revision

A further 28 minor complications included failure to complete a capsulorrhexis (18 patients), iris prolapse (eight patients), and unexpected hyperopic refractive outcomes (four patients). Major complications were strongly associated with challenging case features,. Cases with mature lenses or potential zonular pathology (antecedent trauma or pseudoexfoliation) presented the highest odds of a major complication: 18.9 and 26.2 respectively. Specifically, 4 of 7 cases (57%) with mature cataracts had major complications. Three of 6 cases (50%) with potential zonular pathology had complications. In univariate analysis, major complications were statistically significantly associated with challenging cases, wound type, phacoemulsification technique, and pre-op visual acuity. Looking at the data in more detail, however, shows that not all challenging cases increase risk for major complications. Although small pupil size cases are undoubtedly challenging, for example, the feature did not lead to an increased risk of a major complication. This may be due to proactive pupil management strategies used because of an increased awareness of intraoperative floppy iris syndrome, Dr. Naseri wrote. Further, he reported, Small pupils, corneal disease, monocular patients, shallow chambers, post-vitrectomy cataracts, and combined procedures were not strongly associated with major complications. Phacoemulsification technique factored into whether or not patients were likely to experience complications, but only in a minor way. The divide and conquer technique compared with nuclear chopping was borderline statistically significant for increased odds of major complication, Dr. Naseri reported. All residents learned phacoemulsification with the divide and conquer technique and then transitioned to chopping, which would suggest that perhaps resident inexperience was responsible for the association between the technique and complications. The researchers do not believe the divide and conquer technique is flawed. Notably, resident experienceor the lack thereofwas not associated with increased complications, which contrasted with researchers expectations. Attending surgeon features also did not factor into higher complication rates. Because most (87%) of the phacoemulsification cases were attended by two VA [vascular] attendings, one might anticipate a higher complication rate among cases attended by visiting attendings, who were not as familiar with the residents surgical skills, the operating room equipment, and staff, Dr. Naseri noted. This, however, was not the case. Finally, although previous research found that individual skill was a factor in complication rates, this study did not. The low complication rate was not driven by a few excellent resident surgeons, Dr. Naseri reported. John D. Sheppard, M.D., professor of ophthalmology, microbiology, and immunology, Eastern Virginia Medical School, Norfolk, Va., has found other difficulties with residents beyond what was noted in this report. My residents have trouble with pseudoexfoliation, Dr. Sheppard said. Any problems with a bad capsule can make things difficult. Uncooperative patients also pose big difficulties, he said. In the context of a resident having trouble with an uncooperative

patient, anxiety level is increased and the complication rate is increased, he said. Dr. Sheppard agreed that resident problems do not seem to be affected by the nature of the attending surgeons. He also added that a shallow orbit makes things easier, and therefore a deep orbit makes cases more difficult for residents.

Instruments for phacoemulsification

(The following are instruments designed for cataract extraction and implant. Forceps, viscoelastic and sutures are not shown here.)

Disposable keratome. This instrument is designed for clear corneal phacoemulsification. The width of the wound created will allow the entry of the phaco tip without it being too narrow or too wide.

Cystotome needle. This needle is designed with for easy manipulation in the anterior chamber. The sharp bent tip is used to tear the anterior capsule and initiate the capsulorrhexis.

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Utrata forceps. This forceps has bent sharp tips. It can be used instead of cystotome needle for capsulorrhexis. Alternatively, it can be used to pick up the anterior capsular flap created by the cystotome needle to complete the capsulorrhexis.

Phaco probe

Phaco needle with sleeve Phacoemulsification probe. The phaco needle is used to emulsify the nucleus. The sleeve is placed over the needle during phacoemulsification. The sleeve is incompressible and serves as an insulator. Water which flows between the sleeve and the needle acts as a coolant and avoids burnt to the cornea.

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There are many designs of nucleus rotator. The instrument is one of the many types of nucleus rotator. It can also be used to divide the nucleus. with the help of the phaco tip.

Simcoe irrigation-aspiration cannula. This instrument is used to remove any cortical material left after phacoemulsification. It has two ports: one for irrigation to maintain the anterior chamber and the other for aspiration. It can also be used to remove viscoelastic material at the end of the surgery.

Folding forceps. This instrument is designed to fold the lens at right angle and implant it into the capsular bag.

Sinskey hooks. Straight and bent. The hook is used to dial the haptic into the capsular bag.

Case Analysis:
Phacoemulsification with Posterior Chamber Intraocular Lens
Kristine Joie A. Danan