Phacoemulsification v1

Phacoemulsification
Phacoemulsification
3rd Edition
Edited by
Sunita Agarwal MS FSVH DO
Athiya Agarwal MD DO
Amar Agarwal MS FRCS FRCOphth
All of Dr Agarwals Eye Hospital, Chennai, India
Associate Editors
I Howard Fine MD FACS
Oregon Eye Surgery Center, Eugene OR, USA
Mahipal Singh Sachdev MD
New Delhi Centre for Sight, New Delhi, India
Keiki R Mehta MD
Mehta International Eye Institute, Mumbai, India
Suresh K Pandey MD
Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Charleston NC, USA
Foreword by
Robert H Osher MD
Professor of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati OH, USA
Volume I
LONDON AND NEW YORK

A MARTIN DUNITZ BOOK
1998, 2000, 2004 Sunita Agarwal, Athiya Agarwal, Amar Agarwal
First published in India in 2004 by

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This two volume book on Phacoemulsification is dedicated to two wonderful people

whom we have come to know and worked with
John Bond
Amy McShane
Contributors
A Belndez MD
Spain
A Fimia MD
Universidad de Murcia
Murcia, Spain
Aamir Asrar MD
Consultant Ophthalmic Surgeon
Amanat Eye Hospital
Pakistan
Abhay R Vasavada MS FRCS
Raghudeep Eye Clinic
Near Shreeji Complex
Opp. Gurukul Road, Memnagar
Ahmedabad-380 052, India
Alejandro Espaillat MD
ELK County Eye Clinic
765 Johnsonburg Road, St Marys
PA 15857, United States
Amar Agarwal MS FRCS FRCOphth
Consultant
Dr. Agarwals Eye Hospital
19 Cathedral Road
Chennai-600 086, India
15 Eagle Street, Langford Town
Bangalore, India
Ana Claudia Arenas MD
Calle 104#46 A 10
Casa 9, Santa Fe De Bogota 8
Colombia
Andrea M Izak MD
40 Bee St#323
Charleston SC 29403
United States
Angel Saiz MD
Department of Ophthalmology
Hospital De Galdakao
Galdakao, Vizcaya, Spain
Anthony Maloof MD
Westmead Hospital
Hawkesbury Road
Westmead, NSW 2145
Australia
Asha B MS
15 Eagle Street
Bangalore 560 025, India
Ashok Garg MS PhD
Garg Eye Hospital
235, Model Town
Dabra Chowk
Hisar, Haryana, India
AT Gasch MD
Department of Health and
Human Services
Bethesda, USA
Athiya Agarwal MD DO FRSH
Consultant
19 Cathedral Road
Bangalore, India
Augusto Cezar Lacava MD
Brazil
Barry S Seibel MD
1515 Vermon Avenue
7th Floor, Station C
USA Los Angeles, California
USA
C Gonzlez MD
Murcia, Spain
Carlos Cortes-Valdes MD
Chairman
Professor of Ophthalmology
Hospital General Universitario
Gregorio Maranon
Madrid
Spain-Europe
C Leon
1A Calle 3080 Zona 7 Utalan I
Guatemala City
Guatemala
Charles D Kelman MD
The Eye Centre, 220 Madison
Avenue at 37th Street, New York
NY 10016, USA
Chi-Chao Chan MD
National Institute of Health
Building 10, Room 10N/206
Bethesda, MD 20892
United States
Clement K Chan MD
Southern California Desert Retina
Consultants, PO Box 2467
Palm Springs CA 92263
USA
Cyres Mehta
Mehta International Eye Institute
Sea Side, 147 Colaba Road
Mumbai-400 005, India
D Aron-Rosa
France
D Bremond Gignac MD
France
David J Apple MD
Centre for Research on Ocular
Therapeutics and Biodevices
Storm Eye Institute
Charleston
USA
David Meyer MD
Faculty of Medicine
Cape Town
South Africa
Demetrio Pita-Salorio MD
Professor and Head
Department of Ophthalmology and
Ocular Morphology Unit
University of Barcelona
Spain
E Villegas MD
Murcia, Spain
Elizabeth A Davis
Minnesota Eye Consultants
9117 Lyndale Aves, Bloomington
MN 55420, United States
Ellen Anderson Penno MD
Gimbel Eye Centre
Calgary, Alberta
Canada
Enrique Chipont MD
Instituto Oftalmologico De Alicante
Alicante, Spain
F Mateos MD
Universidad Miguel Hernandez de
Elche, Alicante, Spain
Francisco Contreras-Campos MD
Clinica Ricardo Palma
Av. Javier Prado Este 1038
PISO 10 San Isidro Lima
Peru
Gabor Rado MD
Budapest, Hungary
George Salacz MD
Hungary
Guillermo L Simon-Castellvi MD
Clinica Oftalmologica Simon
Simon Eye Clinic
Barcelona, Spain
Hampton Roy MD
Hampton Roy Eye Center
9800 Lile Drive, Suite 660
Little Rock, Arkansas, USA
Hiroshi Tsuneoka MD
Jikei University School of Medicine
31918 Nishishinbashi
Minato-ku
Tokyo, 1038461, Japan
Howard V Gimbel MD
Gimbel Eye Centre
Suite 450, 493540, Avenue N.W.
Calgary, Alberta
Canada T3A 2N1
I Howard Fine MD FACS

Oregon Eye Surgery Center
1550, Oak Street
#5, Eugene
USA
I Pascual MD
Departmet I De Optica
Universidad De Alicante
Apartado 99 E-03080 Alicante, Spain
J Agarwal FORCE DO FICS
19 Cathedral Road
Bangalore, India
J Hoyos-Chacn
Instituto Oftalmologico De Sabadell
Barcelona, Spain
J Laiseca MD
Barcelona, Spain
Jack A Singer MD
Singer Eye Center
45, South Main Street
Randolph, VT 05060, United States
J Leon
Chirurgie Oculaire BD G Pompidou
20137 Port-Vecchio, France
Jagat Ram MD
PGI, Chandigarh, India
Jairo E Hoyos MD
Barcelona, Spain
James P Gills MD
Luke Cataract and Intraocular Lens
Institute, 1570 US Highway, 19N
PO Box 5000, Tamponsprings
Florida 346885000, United States
Javier Mendicute MD
Hospital De Gipuzkoa, San
Sebastian, Gipuzkoa, Spain
Javier Orbegazo MD
Chairman
Hospital De Galdakao
Galdakao, Vizcaya, Spain
Jaya Thakur MD
Orbis International Fellow
Tilganga Eye Centre
Kathmandu, Nepal
Jess Costa-Vila MD
Barcelona, Spain
JM Legeais MD PhD
Ophthalmology Department
Hotel Dieu
1 Place Du Parvis Notre Dame
Paris-775181, France
Johnny L Gayton MD
216 Corder Road
Warner Robins, GA 31088, USA
Jorge L Alio MD
Alicante, Spain
Jose L Urcelay-Segura MD
Glaucoma Service-Department of Ophthalmology
Gregorio Maranon
Madrid, Spain-Europe
Jozsef Gyory MD
Hungary
JP Lassau MD
France
JR Fontenla MD
Barcelona, Spain
Juan Carlos Sanchez Caballero MD
Brazil
Julio Ortega-Usobiaga MD
Gregorio Maranon
Madrid, Spain-Europe
Kayo Nishi MD
Nishi Eye Hospital
Osaka, Japan
Keiki R Mehta MD
Mehta International Eye Institute
147 Shahid Bhagat Singh Road
Colaba Road
Near Colaba Bus Station
Mumbai-400 005, India
L Carretero MD
Universidad de Alicante
Alicante, Spain
Liliana Werner MD
Center for Research on Ocular
Storm Eye Institute
Charleston, USA
Lucio Buratto MD
Centre Ambrosiano Microchirurgia
Oculare, Milano, Italy
Luis W Lu MD
Eye Physician-ELK County Eye
Clinic, 765 Johnsonburg Road
ST Marys PA 15857, United States
M Edward Wilson MD
Miles Center for Pediatric
Ophthalmology
Charleston, USA
Mahipal S Sachdev MD
New Delhi Center for Sight
A-23 Green Park, Aurobindo Marg
New Delhi-110 016, India
Marc Canals-Imhor MD
Barcelona, Spain
Mark Packer MD
Oregon Eye Surgery Center
1550, Oak Street, #5 Eugene
Or 97401 United States
Melania Cigales MD
Barcelona, Spain
Namrata Sharma MD
C-18 B, DDA Flats, Munirka
New Delhi
Nilesh Kanjani DO Dip NB
India and Dubai
Okihiro Nishi MD
Director
Jinshikai Medical Foundation
Nishi Eye Hospital
Higashinari Ku Nacuamichi
4426537 Osaka, Japan
P Giardini MD
Camo-Centro Ambrosiano
Microchirurgia Oculare
Milano, Italy
Pandelis Papadopoulos MD
Director Ophthalmological
Diagnostic and Therapeutic Center
Ophthalmo-Check Ltd
42 Poseidon Avenue, Paleo Faliro
Athens, Hellas, Greece
Paul Liebenberg MD
Faculty of Medicine
Cape Town
South Africa
Pradeep Venkatesh MD
AIIMS, Delhi, India
R Fuentes MD
Universidad de Alicante
Alicante, Spain
Raminder Singh MS
Raghudeep Eye Clinic
Opp. Gurukul Road
Near Shreeji Complex, Memnagar
Ahmedabad 380 052, India
Randall J Olson MD
University of Utah
Moran Eye Centre, 50-N
Medical Drive, Salt Lake City
UT 841320001, United States
Richard L Lindstrom
Clinical Professor of
Ophthalmology
University of Minnesota
Minneapolis, MN, USA
Richard S Hoffman
Oregon, USA
Robert M Kershner MD PC FACS
Orange Grove Eye Center
1925 W, Orange Grove Road #303
Tucson, AZ 85710
United States
Roberto Bellucci MD
Camo-Cebtro Ambrosiano
Microchirurgia Oculare
Milano
Italy
RR Sasikanth MD
Consultant
India and Dubai
Rupert Menapace MD
Professor, Universitats-Augenklinik
Vienna General Hospital
Wahringer, Gurtel, Wien
Vienna, Austria
Samuel L Pallin MD FACS
Medical Director
The Lear Eye Clinic
10615 W Thunderbird A100
Sun City
AZ 853513018, USA
Samuel Masket MD
2080, Century Park East
Suite 911, Los Angeles, CA 90067
United States
Soosan Jacob MS FRCS
Consultant
Chennai, Bangalore,
India and Dubai
Steve Charles MD
Charles Retina Institute
6401 Poplar Avenue, Suite 190
Memphis, Tennessee
USA
Steven G Lin MD
Southern California Desert Retina
Consultants, Palm Springs
USA
Sundaram MS
15 Eagle Street
Bangalore 560 025, India
Sunita Agarwal MS DO FSVH (Germany)
19 Cathedral Road
Bangalore, India
Suresh K Pandey MD
Center for Research on Ocular
Storm Eye Institute
Charleston, USA
Susanna Recsan MD
Hungary
T Agarwal FORCE DO FICS
19 Cathedral Road
15 Eagle Street
Langford Town
Bangalore, India
Takako Hara MD
Hara Eye Hospital
Nishi 1111
Utsunomiya, Japan 320 0861
Tetsuro Oshika MD
Tokyo University School of Medicine
731, Hongo, Bunkyo-Ku
Tokyo, Japan 113 8655
Tobias Neuhann MD
Founder and Medical Director
Aam Augenklinik AM Marienplatz
Marienplatz 18, Munich
Germany
TR Indumathy Dip NB DO
India
Tsutomu Hara MD
Hara Eye Hospital
Nishi 1111
Utsunomiya, Japan 3200861
Valerio De Iorio MD
Alicante, Spain
Virgilio Centurion MD
Instituto De Molestias Oculares
AV, Ibirapuera
624, CEP, Sao Paulo, Brazil
Warren E Hill MD
7525 E Broadway Road
#6 Mesa, AZ 852082057
United States
Wataru Kimura MD
Kimura Eye Hospital
2328 Nakadori
Kure City
Hiroshima
Japan 737
William J Fishkind MD FACS
Fishkind and Bakewell
5599 North Oracle Road
Tucson
Arizona 857043821, USA
Foreword to the Third Edition

Authoring a medical textbook is a labor of love. For months and months, the act of
writing, correcting, rewriting, editing, proofreading, corresponding, negotiating, etc.
replaces hobbies and recreational pursuits. Yet when all is said and done, an immense
sense of satisfaction embraces the author, who by this time has aged considerably.
The authors of the third edition are to be congratulated for bringing this collaborative
work to fruition. The encyclopedic table of contents in combination with an erudite and
highly experienced international faculty offer two volumes of information to the reader.
Moreover the microphacoemulsification section reflects the leading contribution that Dr.
Agarwals group is making in the evolution toward even smaller incision surgery.
Being on the cutting edge can be a mixed blessing, but investing the time and effort
necessary to share information is always a rewarding task for those surgeons who have
contributed their work. I hope that the reader is also rewarded by becoming a more
knowledgeable cataract surgeon after digesting the contents of the third edition of this
textbook on phacoemulsification.
Robert H Osher MD
Professor of Ophthalmology
University of Cincinnati
College of Medicine
Medical Director Emeritus
Cincinnati Eye Institute
Foreword to the Second Edition

Dr Amar Agarwals brilliant mind has captured the idea of presenting the most advanced
techniques of Cataract Surgery, at the dawn of the new millennium in this splendid book,
Phacoemulsification, Laser Cataract Surgery and Foldable IOLs.
The reader can enjoy not only a skilful description of classic cataract surgery, but also
Dr Agarwals great experience, opening new horizons in this field. I whole-heartedly
recommend the book and am honored to Foreword this second edition which will almost
certainly be as great a success as the first one. I am very proud to share the knowledge
arising from Dr Agarwals book who is one of the leaders in the field of cataract surgery
and a great colleague and friend.
Spyros Georgaras MD
President of the
Hellenic Union of Specialized Ophthalmologists
Greek Intraocular Implant and Refractive Surgery Society
Research & Therapeutic Institute Ophthalmos
Ophthalmological Center Hygeia-Ophthalmos
Foreword to the First Edition

One of the great joys and honors in my life was my frequent visits to India and my
meetings with great clinicians, surgeons, teachers and human beings of the Indian
ophthalmological communityamong them, the wonderful Agarwal family of Chennai.
So I am very much honored by their request to write a Foreword to the new book edited
and written by them and by other superb surgeons and teachers such as Keiki R Mehta,
Mahipal Singh Sachdev, Kenneth J Hoffer, I Howard Fine and all the other
internationally known and respected teachers and experts. The table of contents, both
concerning the titles of the chapters and the authors, speaks for itself. Some of the
worlds greatest authorities on the subject, speaking from both scientific and clinical
experience, are gracing this book. Every aspect of modern successful cataract surgery is
covered, so the book will be extremely usefulnot only for the beginners, but also for
the accomplished surgeons who need to look at some different points of views and
approaches to surgery or for information. The worldwide brotherhood of ophthalmic
surgeons, researchers and teachers is deeply and greatly indebted to the editors of the
book who assembled the panel and chose the topics and to the writers of the chapters who
devoted their time and knowledge to this undertaking. I congratulate and thank the
authors and wish them Gods blessings.
John J Alpar MD FACS
Clinical Professor at Texas Tech University
Honorary Member of All India Ophthalmological Society
Preface to the Third Edition

A lot of toil, blood, tears, and sweat has been poured through these pages from so many
authors working in so many countries serving so many people. This two volume book on
cataract surgery in its most advanced fashion, is an attempt to spread knowledge and
letting you know that each one of us believes a much greater force has helped us compile
this into fruition.
We may have claimed many a research project, however each one who has done any
research knows fully well and can hear fully well that inner voice calling out. Every time
we write whether it is for our own gratification or towards a more sublime learning and
teaching once again whether we want to accept it or not we know that it is something else
that makes us do these things. It is something far more powerful than we can ever
imagine that guides our thinking, our hands, our profession or whatever direction the
guide wants us to. And yet there is a choice of free will given to all of us. And yet we
choose to burn the midnight oil, we choose to forsake sensual pleasures in a quest of that
something that gives us much more peace and understanding of the world, much more
joy than owning all the gold in Fort Knox would ever give us.
Here my dear friends is where we are today to say Thank You to the world to the
Cosmos to everyone of you who read this and to those who benefit through your reading
because this may just be a small drop in the ocean of knowledge, yet it is a small drop in
the right direction. In the spirit of serving the human race and all who come after us our
attempt is to give them a springboard where they can take off where we have left off.
Editors
Preface to the Second Edition

Coming from a background where ophthalmology ordained the dining table conversation
for over seven decades and three generations it is not surprising that the need for revised
second editions was thought necessary and mandatory. Especially since our
understanding of cataract surgery has been in a perpetually accelerating flux.
Sometimes revelations have been quite by accident however most often progress is
steady and slow, depending on many factors like available resources and necessity The
more we read and more we try to assimilate information the more we realize how far we
are from the understanding of the topic.
Of late it is difficult to understand progress in the coming years of the new millennium
without the assistance and utilization of lasers, computers and advanced technology.
More often than nought the space traveler it seems enjoys more information and
technological advancements than does the mundane operation theater of medical
personnel. However even this equation seems to be changing and much like a science
fiction movie our operation theaters reel away progress only thought of to exist in future
centuries.
Retaining the same concept of cataract surgery this edition throws much light on the
why and wherefores with an insight into the modalities of treatment. Along comes
research from the offices of Dr David Apple, a person who has brought glamor into
ocular pathology and the understanding of different treatment types, along with Dr SK
Pandey have explained the reasons why they have come to a conclusion where there
seems to be no difference between intracameral anesthesia, topical anesthesia, and now
venturing into new groundsNo anesthesia itself.
However good a surgery comes to nought when plagued with bacterial or microbial
invasion, many ophthalmic surgeons have gone through sleepless nights in the pursuit of
infection control and its management. This leads us to believe that it was essential to have
detailed chapter written on the subject. Much to our chagrin there was hardly any
material on the topic of Sterilization. It seems to be we all know about it, understand its
importance in the surgical field, yet have never really written about it. The maximum one
finds in known literature is something written as a chapter of a microbiology book. Still
nothing much from a clinicians point of view, still nothing much in terms of explaining
to us what works best, and still nothing more telling us how to work it. Quoting a cop
friend of mine, An assassin has to be lucky just once, I have to be lucky every day,
every instant. In the same light we as surgeons have to be on our guard every time,
every instant, the bacteria need be lucky only once. Add to this is sometimes the
diplomatic approach of instrument engineers who wave aside grave consequences to
patients wellbeing in the interest of their product image. Sometimes we overlook the
obvious, just like we look for the source of light standing right under the sun, similarly
the internal tubing of an ultrasound machine that gauges the pressure inside the eye, is
actually the prime source of infection in phacoemulsification.
With the Mediterranean influence of L Burrato we have a new chapter on the

adversities of a small pupil and still manage to perform phacoemulsification with the
greatest of finesse, Pushing an elephant through a keyhole. Giving importance to
Incisions is S Pallin, small steps of the surgery which go a long way in its success.
Posterior Polar Cataract has new light from A Vasavada whose immense knowledge on
phacoemulsification makes him a leader in this field.
Coupled with this progress is the inroads made by Indian ophthalmology along with
Indian engineering and scientific skill that have been displayed for all to see at the
pinnacle body internationally as far as cataract and refractive surgery are concerned, the
American Society for Cataract and Refractive Surgery (ASCRS) were witness to live
surgery telecast from India to America at the 1999 ASCRS meeting. This instruction
course made history with it being the first time such an event had occurred and displayed
liveNo Anesthesia Laser Phakonit (under 1 mm) Cataract Surgery. Thus all that we had
written about came to pass when delegates were able to see the surgery in its full form.
Such feats would be repeated more often at different meetings since seeing is believing!
As the volume of knowledge has expanded, so too the need for multiple contributors.
To strengths of diversity and multiple forms of expertise, this trend has created a burden
on the editorial. Thus consistency of writing form is difficult to maintain, however this
also adds to the texts value as a learning and teaching tool. The whole volume of the
book has therefore extended and with more color plates and more reading material, we
hope dear reader you enjoy reading this as much as we have in writing it!
Editors
Preface to the First Edition

Forewords rarely touch the readers heart unless the writer sends them out from the same
location. That gives us a fighting chance, because we have spent our entire life in the
pursuit of ophthalmic sciences and still count this as one of our good friends that always
reserves its gratitude and encourages our chances of discovering further and further in its
wake.
To write a book today in the world of entertainment with video, movies and the
whirlwind of computers seems gratuitous. Still the beauty and magic of reading will
never fade and the history of writing that dates back more than 5000 years can never be
surpassed. To the memory of the writers of yore and to encourage the many more writers
to come, we have taken the task of bringing you the latest synopsis of the trends in
cataract surgery through the nineties.
The scientists and researchers of today are full time clinicians who have placed their
energy in the development of new ideas. In fact if you go back in time, most discoveries
and inventions have been made by the person attempting to correct human malady, and
while doing so perchance steps onto some discovery or invention.
It was in this same manner the father of Intraocular lenses while treating pilots from
the Royal Airforce during the Second World War came to the conclusion that IOLs were
a possibility. He noticed that pieces of windshield material lay immersed in ocular tissue
producing no reaction and were transparent and could thus be implanted into the eye (in
the place) of spectacles. Dr Harold Ridley thus brought about one of the greatest
advancements in this century as far as ophthalmic sciences are concerned. To him and his
batch of pioneers, ophthalmology down the ages will always have a place of honor.
Salutations to such torchbearers and more to come.
When we look down at the achievements that the human mind has achieved in the
realm of ophthalmology and its progress, we are baffled by its enormity especially when
we know that there is still so much more to be discovered and so much more to be
invented. The scientific progress that has occurred in the last 100 years has bypassed all
that could have occurred in the last 5000 years from the Neanderthal cousin of ours, and
that which will occur in the next decade itself will be a renaissance in ophthalmology. We
still know only a drop in the ocean of the ophthalmic sciences and we realize that what
we can dream, we can certainly achieve in the forthcoming years. This book aims at
giving you dear Reader not only food for thought but also in contributing to this
Renaissance, thereby, achieving the dreams our forefathers had in this beautiful world of
Vision.
Through the reading of this book you will find subjects divided into six basic
structures to ease you in the understanding of what cataract and its management mean
today. The contributing authors are themselves authorities on the topics of their choice.
All stages of learning have been taken care of through these six stages from the learner
through the advanced surgeon, bringing you to bear down on mayhap a forgotten episode,
for we all know Trifles make perfection, though perfection is no trifle.
The computer has brought into our world a dream of precision and this has come to
become a part of every machinery developed in the modern world. In fact when we look
into what robotics have done to this factor, we realize we are very close to making the
blind man see. Many have been the times that patients have asked their eye surgeon,
Cannot you change my eye itself? Yes, now we can reply them with the idea of
repositioning a video camera and sending the signals into the brain directly. Unthought of
till only yesterday, and today will soon be a reality.
A surgeon in the midst of surgery in his or her home town can now think of operating
in orbit around the world with a little help from satellites and robotics. Now most distant
of patients can get the precise expertise from the dexterous experience of the surgeon.
Very soon no one will be bereft of resourceful opinion and/or surgery in this world and
that beyond the stars.
Marching towards the next millennium we have accessed cataract surgery with an
intraocular lens insertion under the 2-mm mark with the latest laser cataract surgery,
becoming a reality. Coupled with changes in ultrasound technology it will create many
newer trends in the years beyond 2000. Phakonit has brought the incision of cataract
surgery to 0.9 mm. Computers and lasers have crossed many marks, and intrastromal
lasers will soon see the light of the day. Spectacles will not be worn for the want of
refractive errors with the latest modalities of the LASIK laser and its contemporaries.
This reading hopes to take you down the lane from humble beginnings of a retrobulbar
to peribulbar anesthesia and now to the present exodus of topical anesthesia to the
advanced No anesthesia ophthalmic surgery, taking its first few steps of infancy in
India. After all, have we all not seen sudden injuries to the eye reflecting no pain to the
patient? It hopes to give you food for thought and may be rethink the corneal reflex,
rethink the anatomy and physiology of the eye itself and delve into the basic sciences of
our specialty, the eye.
It is said that the pen is mightier than the sword (here the surgical knife) and in this
case both go hand in hand, and thus, whatever the knife has done the pen has put it down
for you to read.
Contributing authors have already left footprints on the sands of time. Let us further
your objective in strengthening the armor of ophthalmology.
Editors
Contents
VOLUME I
Section I: Cataract and Preoperative Evaluation

1. Cataract Etiology
David Meyer, Paul Liebenberg
2. Biochemistry of the Lens
Ashok Garg
3. History of Phacoemulsification
Charles D Kelman
4. Biometry
Sunita Agarwal
5. IOL Power Calculation After Corneal Refractive Surgery
Jairo E Hoyos, Melania Cigales, J Hoyos-Chacn
6. IOL Master for Determining the IOL Power at the Time of Surgery
Hampton Roy, Warren E Hill
7. Corneal Topography in Cataract Surgery
Athiya Agarwal, Sunita Agarwal, Amar Agarwal, Nilesh Kanjani
3
52
64
75
85
97
101
Section II: Instrumentation and Medication

8. The Phaco Machine: How It Acts and Reacts
William J Fishkind
9. The Fluidics and Physics of Phaco
Barry S Seibel
10. Air Pump to Prevent Surge
Sunita Agarwal, Amar Agarwal, Athiya Agarwal
11. Microseal and Other Phaco Tips
Hampton Roy
12. Sterilization
Sunita Agarwal
13. Local Anesthetic Agents
Ashok Garg
116
134
149
154
158
203
14. Anesthesia in Cataract Surgery

Ashok Garg
15. Mydriatics and Cycloplegics
Ashok Garg
16. Update on Ophthalmic Viscosurgical Devices
Suresh K Pandey, Jaya Thakur, Liliana Werner, Andrea M Izak, David J
Apple
219
241
251
Section III: Phaco Steps

17. The Dynamics of Sutureless Cataract Incisions
Samuel L Pallin
18. Incisions
Luis W Lu, Alejandro Espaillat, Ana Claudia Arenas, Francisco ContrerasCampos
19. Capsulorhexis
Tobias Neuhann
20. Hydrodissection and Hydrodelineation
I Howard Fine, Mark Packer, Richard S Hoffman
280
288
296
310
Section IV: Phaco Techniques

21. Divide and Conquer Nucleofractis Techniques
Howard V Gimbel, Ellen Anderson Penno
22. Single Instrument Phacoemulsification through a Clear Corneal
Microincision
Robert M Kershner
23. The Use of Power Modulations in Phacoemulsification of Cataracts:
The Choo Choo Chop and Flip Phacoemulsification Technique
24. Lens Quake Phaco
Jack A Singer
25. Supracapsular Phacoemulsification
Aamir Asrar
26. New Non-laser Phacoemulsification Technologies
320
343
351
360
366
396
Section V: No Anesthesia Cataract Surgery

27. No Anesthesia Cataract Surgery with the Karate Chop Technique
Athiya Agarwal, Sunita Agarwal, Amar Agarwal
405
28. No Anesthesia Cataract Surgery

Tobias Neuhann
29. No Anesthesia Cataract Surgery: Comparison Between Topical,
Intracameral and No Anesthesia
Suresh K Pandey, Liliana Werner, Amar Agarwal
30. Ocular Anesthesia for Small Incision Cataract Surgery
Samuel Masket
420
428
442
Section VI: Phakonit

31. Phakonit
Amar Agarwal, Athiya Agarwal, Sunita Agarwal
32. Microphaco: Concerns and Opportunities
Randall J Olson
33. Ultrasmall Incision Bimanual Phaco Surgery and Foldable IOL
Hiroshi Tsuneoka
34. Corneal Topography in Phakonit with a 5 mm Optic Rollable IOL
Amar Agarwal, Soosan Jacob, Athiya Agarwal, Sunita Agarwal
35. Phakonit with the Acritec IOL
Amar Agarwal
450
470
480
498
506
Section VII: Laser Cataract Surgery

36. Laser Phaco Cataract Surgery
Sunita Agarwal, J Agarwal, T Agarwal
37. Erbium-YAG Laser Cataract Surgery
Demetrio Pita-Salorio, Guillermo L Simn Castellvi, Jess Costa-Vila,
Marc Canals-Imhor, JR Fontenla, J Laiseca
38. Cataract Surgery with Dodick Laser Photolysis
Jorge L Alio, Valerio De Iorio
521
533
559
Section I
Cataract and Preoperative
Evaluation
1. Cataract Etiology
2. Biochemistry of the Lens
3. History of Phacoemulsification
4. Biometry
5. IOL Power Calculation After Corneal Refractive Surgery
6. IOL Master for Determining the IOL Power at the Time of Surgery
7. Corneal Topography in Cataract Surgery
1
Cataract Etiology
David Meyer
Paul Liebenberg
Introduction
The term cataract is derived from the Latin cataracta and from the Greek katarraktes
which denotes a waterfall or a portcullis. Analogously a cataract is a complete or partial
opacification of sufficient severity, on or in the human lens or capsule, to impair vision.
Vision is one of the most valued senses. Proper vision is achieved by a series of eye
tissues working harmoniously in concert. Most eye debilities involve dysfunction in the
lens or retina, and hence this chapter will focus on and elucidate etiological factors which
may affect the proper function of the lens as target organ.
The lens is an elegantly simple tissue. It is made up of only two types of cells.
Epithelial cells, which have not yet completely differentiated and not yet elaborated the
major gene products, and
Fiber cells, in which these processes have been initiated or even completed.
Cataract is one of the major causes of visual impairment leading eventually to blindness.
In the USA alone 1,35 million cataract extractions are performed annually. In developing
countries the magnitude of the problem is overwhelming.
Management of this age-old impairment of vision requires one of the three following
approaches, or a combination of these approaches.
1. Surgical, i.e. extracapsular lens extraction (either manually or by phacoemulsification)
and intraocular lens (IOL) implantation;
FIGURE 1.1 Mature senile cataract
Phacoemulsification
2. Development and application of drug-related strategies to counteract the development

of cataract;
3. Identification and elimination of risk factors.
It is now well established that cataract formation is a multifactorial disease. Several of the
etiological factors are constitutional and hence difficult to manipulate. Others are
environmental in nature and a little easier to control whilst a significant number are
behavioral in nature and fall well within the individuals own ability to control or modify.
This review will briefly touch on congenital and infantile cataract but will focus on
etiological factors in adults (Fig. 1.1) and especially those implicated as risk factors in
age-related cataract.
Congenital and Infantile Cataract

Congenital cataract is numerically the most important cause of remediable blindness in
children, being far more common than, for example, retinoblastoma or congenital
glaucoma.
The prevalence of infantile cataract has been reported to be between 1.2 and 6 cases
per 10,000 births. Furthermore it has been estimated that between 10 percent and 38.8
percent of all blindness in children is caused by congenital cataract (Figs 1.2 to 1.4) and
that one out of every 250 newborns (0.4%) has some form of congenital cataract.
The etiology of infantile cataract (Table 1.1) can be established in up to one-half of
children with bilateral cataract, but in a smaller proportion of infants with unilateral
cataract. Infantile cataract most commonly occurs secondary to genetic or metabolic
diseases, intrauterine infections or trauma. Less commonly they may occur as a side
effect of treatment with certain medications or radiation therapy.
FIGURE 1.2 Anterior polar congenital

cataract
Cataract Etiology
FIGURE 1.3 Congenital cortical

cataract
FIGURE 1.4 Congenital coronary

cataract
Genetic
Infantile cataract may be inherited as autosomal dominant, autosomal recessive or Xlinked recessive traits. Autosomal dominant cataract are most commonly bilateral nuclear
opacities, but marked variability can be present even within the
TABLE 1.1 Etiology of Infantile cataract

A. Idiopathic
B. Intrauterine infection
1. Rubella
2. Varicella
3. Toxoplasmosis
4. Herpes simplex
C. Drug induced
Corticosteroids
D. Metabolic disorders
1. Galactosemia
2. Galactokinase deficiency
3. Hypocalcemia
K. Inherited with systemic abnormalities

Chromosomal abnormalities
1. Trisomy 21
2. Turner syndrome
3. Trisomy 13
4. Trisomy 18
5. Translocation 3;4
6. Cri-du-chat syndrome
7. Translocation 2;14
Craniof acial syndromes
Cerebro-oculo-facio- skeletal syndrome
(COFS)
Mitochondrial abnormalities
Phacoemulsification
4. Hypoglycemia
5. Mannosidosis
E. Trauma
1. Accidental
2. Non-accidental
F. Miscellaneous
Complex I deficiency
L. Skeletal disease
1. Smith-Lemli-Opitz syndrome
2. Conradi syndrome
3. Weill-Marchesani syndrome
M. Syndactyly, polydactyly or digital
abnormalities
1. Radiation
1. Bardet-Biedl syndrome
2. Laser photocoagulation
2. Rubenstein-Taybi syndrome
G. Other ocular diseases
N. Central nervous system abnormalities
1. Microphthalmia
1. Zellweger syndrome
2. Aniridia
2. Meckel-Gruber syndrome
3. Persistent hyperplastic primary vitreous
3. Marinesco-Sjgren syndrome
(PHPV)
4. Prematurity
4. Infantile neuronal ceroid-lipofuscinosis
(Battens disease)
5. Peters anomaly
6. Corneal guttata
O. Dermatological
7. Endophthalmitis
1. Crystalline cataract and uncombable hair
2. Cockayne syndrome
H. Dental anomalies
1. Nance-Roran syndrome
3. Rothmund-Thomson syndrome
4. Atopic dermatitis
I. Cardiac disease
Hypertrophic cardiomyopathy
5. Incontinentia pigmenti
6. Progeria
J. Renal disease
1. Lowe syndrome
7. Ichthyosis
2. Hallermann-Streiff-Francois syndrome
8. Ectodermal dysplasia
same pedigree. In an extended pedigree of 28 patients with autosomal dominant nuclear

cataract, Scott et al reported that 19 of the affected family members had unilateral
cataract while 9 had bilateral cataract. Less commonly, anterior polar, posterior polar, and
posterior lentiglobus cataract can be autosomal dominantly inherited. In the United
States, infantile cataract are most commonly inherited as autosomal dominant traits,
however, in countries where there is a high prevalence of parental consanguinity,
infantile cataract are more commonly inherited as autosomal recessive traits. In Egypt
where one-third of all marriages are consanguineous, Mostafa et al reported autosomal
recessive inheritance for six of seven pedigrees with inherited infantile cataract. Linkage
analysis has been used to determine the genetic loci of certain autosomal dominant
cataract. Coppock-like cataract has been linked to the gamma E-crystalline gene on
chromosome 2, Coppock cataract to chromosome 1q21q25, Marner cataract to 16q22,
and cerulean cataract to 17q24. The Cerulean cataract links closely to the galactokinase
gene, but galactokinase levels in these patients are normal.
Metabolic
The most common metabolic disturbance causing cataract during infancy is galactosemia.
Galactosemia may be caused by a transf erase, galactokinase or epimerase deficiency.
Galactose-1-phosphate uridyl transferase (GALT) deficiency occurs in 1:40,000
Cataract Etiology
newborns in the United States and 1:23,000 newborns in Ireland. A homozygous

mutation of Q188R on exon 6 of the GALT gene on chromosome 9 is found in two-third
of children with the transferase deficiency. This results in the accumulation of galactose
4-phosphate in the blood. Galactose is then converted to galactitol in the crystalline lens,
resulting in an influx of water into the lens by osmosis. The hydration of the lens then
disrupts the normal structure of the lens fibers, resulting in a loss of transparency. Early
on, these lens changes have the appearance of an oil-droplet in the center of the lens.
These changes are initially reversible with the elimination of galactose from the diet. If
left untreated, a lamellar cataract develops which may then progress to a total cataract. In
addition to cataract, these children have failure to thrive as infants, which may lead to
death if milk and milk products are not eliminated from their diet. Later in childhood,
these children may have delayed development, abnormal speech, growth delay, ovarian
failure and ataxia. While eliminating galactose from the diet can prevent the lifethreatening problems which occur during infancy, dietary compliance does not always
correlate closely with the formation of cataract in later childhood or with the associated
abnormalities of late childhood. The N314D mutation of the GALT gene causes the
milder Duarte form of galactosemia. Combinations of Q188R, N314D and unknown
mutations may result in phenotypically different forms of galactosemia.
Galactokinase deficiency may cause cataract with few or no systemic abnormalities.
The galactokinase gene is on chromosome 17 and has recently been cloned and found to
harbor homozygous mutations in some patients with cataract. Heterozygotes for
galactokinase deficiency have half normal values on blood tests. Conflicting results have
been reported in the literature as to whether partial loss of enzyme activity leads to
presenile cataract. Alpha mannosidosis can also be associated with early onset cataract.
Lamellar cataract may also develop in children with neonatal hypoglycemia or
hypocalcemia. Neonatal hypoglycemia is more common in low birth weight infants.
Infectious
The congenital rubella syndrome was one of the most common causes of congenital
cataract in the United States until the widespread employment of the rubella vaccine.
During the rubella epidemic in the United States during 196364, 16 percent of all
children with the congenital rubella syndrome developed cataract. Infantile cataract also
occur occasionally in children after intrauterine varicella, toxoplasmosis and herpes
simplex infections, or after bacterial or fungal endophthalmitis. Cataract may also
develop after a varicella infection during early childhood.
Prematurity
Transient cataract occur occasionally in premature infants. They are usually bilateral and
begin as clear vacuoles along the apices of the posterior lens suture. They may progress
to posterior subcapsular vacuoles. In most cases, they clear completely over the course of
several months. All of the premature infants with transient cataract reported by Alden et
al were septic and had been treated with Kanamycin, 80 percent of these infants also had
an unexplained metabolic acidosis. These authors suggested that osmotic changes in the
lens of these infants might have caused these cataract.
Phacoemulsification
Trauma
While trauma is not a common cause of cataract during infancy it should be considered,
particularly when a cataract is associated with other ocular signs suggestive of a
traumatic injury. The trauma can be either blunt or penetrating. Nonaccidental causes for
the trauma must always be considered. Eyes with suspected traumatic cataract should
also be examined carefully for both retinal and optic nerve injuries.
Laser Photocoagulation
Laser photocoagulation has been used in recent years to ablate the avascular retina of
infants with threshold retinopathy of prematurity (ROP). Laser-induced cataract are
transient in some instances, but progress in some cases to total opacification of the lens.
Drack et al reported cataract in six eyes following argon laser photoablation of the
avascular retina in four infants with threshold retinopathy of prematurity.
Radiation Induced
Radiation used to treat ocular and periocular tumors may induce cataract in children. A
radiation dose of 15 Gy has been shown to be associated with a 50 percent risk of cataract
formation. Radiation usually causes posterior subcapsular cataract, which typically have
their onset 1 to 2 years after the completion of radiation therapy.
Medications
Systemic corticosteroids cause cataract in up to 15 percent of children once a cumulative
dose of 1000 mg of prednisone or the equivalent has been reached. This cataract usually
begin as central posterior subcapsular opacities, but may progress to involve the entire
lens.
Idiopathic
In most series, at least 50 percent of bilateral infantile cataract are idiopathic. The
percentage of idiopathic unilateral infantile cataract is even higher.
Age-Related Cataract
Personal Factors
Gender
It has often been observed that more females than males have cataract and undergo
cataract surgery. This is partly explicable by the longer life span of women and therefore
their over-representation in the age groups where cataract is most common. It does appear
however that there is an additional effecta true excess risk of cataract in females. In
Cataract Etiology
Nepal the prevalence of cataract was greater in females than in males at all ages. The
overall risk ratio was 1.4, which would be detectable only in larger studies. In most casecontrol studies the two groups were age- and sex-matched so that the effect of sex could
not be explored. Hiller et al had to combine the results from three earlier studies in the
United States and India to find a significant excess relative risk of 1.13 in females. This
follow-up study of data from the National Health and Nutrition Examination Survey
(NHANES) also suggested that such an excess risk for women is specific to cortical
cataract. In a population-based prevalence survey in Beaver Dam, Wisconsin, women had
more cortical opacities compared to men within similar age groups. The Beaver Dam
Study reported a protective effect for nuclear opacities with current use of
postmenopausal estrogens. Older age at menopause was associated with decreased risk of
cortical opacities, suggesting hormonal influences in cataractogenesis. It was also
suggested that hormone replacement therapy (HRT) may protect against cortical cataract.
The Epidemiology of Cataract in Australia study found that a protective relationship of
HRT and cortical cataract exists at the univariate level, but that this relationship was not
significant in multivariate analysis. Nuclear cataract cases were more likely to be female
in the above study, even after age adjustment. They were however unable to support the
hypothesis that HRT is protective against nuclear cataract.
Tavani et al studied 287 Italian women who had undergone cataract extraction and
1277 control subjects who were in the hospital for acute, non-neoplastic,
nonophthalmologic, nonmetabolic, nongastroenterologic diseases in a case-control study
in Northern Italy. The results of this study support the association in women between
cataract extraction and diabetes, (OR 4.6 for those younger than 60 years and 1.7 for
those age 60 and over) current overweight, (OR 2.2) history of clinically relevant obesity,
(OR 1.5) hypertension (OR 1.5) and hyperlipidemia (OR 1.8). They suggest that these
factors may have some biologically independent impact on the risk of cataract in women
and therefore supports the association in women between cataract extraction on the other
hand and diabetes, current overweight, history of clinically relevant obesity, hypertension
and hyperlipidemia on the other.
Body Mass Index
Body mass index (BMI) is computed as weight in kilograms divided by the square of the
height in meters (kg/m2) and is frequently identified as a risk factor for cataract, but the
nature of the association is unclear. Several mechanisms may play a role:
BMI affects glucose levels, which are associated with increased risk of cataract
Higher BMI also increases uric acid concentrations and the risk of gout, which were
associated with cataract in some studies
BMI is also an important determinant of hypertension which has a controversial
relationship with cataract.
Experimental evidence also supports a possible protective effect of restriction of energy
intake on the risk of cataract by protection against oxidative stress to the lens.
In developing countries some studies have associated low BMI with cataract. A recent
case control study in India however failed to confirm this association.
Phacoemulsification
Hankinson et al in a prospective study examined the association of BMI with cataract

extraction in a large cohort of women and found elevated rates of cataract in those with
higher BMI. Women with BMI of 23 or above had significantly elevated rates of
extraction, between 46 percent and 65 percent higher than those with BMI of less than
21. Glynn et al in a prospective cohort study of a total of 17,764 apparently healthy US
male physicians aged 40 to 84 years who were free of cataract at baseline were followed
for 5 years. In this group higher BMI was especially strongly related to risk of posterior
subcapsular and nuclear sclerotic cataract and was also significantly related to risk of
cataract extraction. Furthermore BMI below 22 appeared especially protective against
posterior subcapsular cataract, with reductions in risk of 50 percent or more relative to
each of the groups with a higher BMI. They concluded that BMI appears to be a strong
and independent risk factor for cataract in this well-nourished and socioeconomically
homogenous study population. Even modest elevations in weight were associated with
increased risk.
In so far as BMI index is modifiable, cataract caused by overweight is therefore
potentially preventable.
Social Economic Status
Less education and lower income are related to increased morbidity and mortality from a
number of diseases, even after controlling the known risk factors. These relations have
been attributed to underuse of health care resources, high-risk behaviors, exposure to
noxious work or adverse home environment, and poor nutrition. In population studies,
less education and lower income consistently have been associated with impaired vision
and cataract. The relationship of education, income, marital status, employment status to
age-related cataract and impaired vision was addressed in the population-based Beaver
Dam Eye Study.
A private census of the population of Beaver Dam, Wisconsin, was performed from
September 15, 1987 to May 4, 1988. Eligibility requirements for entry into the study
included living in the city or township of Beaver Dam and being 43 to 84 years of age at
the time of the census. A total of 5924 eligible people were identified. Of these, 4926
(83.1%) participated in the examination.
While controlling for age and sex in this study, less education was significantly
(P<0.05) related to higher frequency of nuclear sclerotic and cortical cataract. Lower
reported total household income was significantly associated with higher frequencies of
cortical and posterior subcapsular cataract. These relations between total household
income and cataract were observed in both men and women.
Less education has been associated with higher frequencies of history of heavy
drinking, cigarette smoking and less vitamin supplement intake, all of which have been
found to be related to specific types of cataract. However, the association of education
and income with cataract persisted, despite controlling these exposures in their
population. It is possible that poorer nutrition occurring earlier in life, may be related to
the development of age-related cataract. A second possible reason explaining the relation
of education and income to cataract is that people with less education or lower income
are less likely to see an ophthalmologist or have cataract surgery.
Cataract Etiology
11
Marital status is a measure of social support which is postulated to be an important

factor in developing and managing complications associated with disease. While
controlling for age and sex, people who were never married had a higher frequency of
impaired vision than those currently married. This may be due to the fact that married
people may have more social pressure to seek health care and to maintain familial
responsibilities, and they may have more transportation assistance than their
unmarried/widowed counterparts.
In summary, less education and income are related to cataract and visual impairment,
but not to age-related maculopathy. These data suggest that access to medical, surgical,
and low vision care may be of benefit to people with low socioeconomic status.
Social Factors
Smoking
Tobacco is the leading preventable cause of disease, disability and premature death.
Tobacco smoking is considered a major risk factor for 6 of the 15 leading causes of
death. An individual who smokes has about twice the risk of premature death as a nonsmoker, and the heavier the cigarette consumption, the higher the risk.
Of the 4,000 active substances in tobacco smoke, most are hazardous to human health.
More than 40 of these chemicals are carcinogens and many others are deleterious to the
cardiovascular and the pulmonary systems. They include nicotine, tars, nitrosamines,
polycyclic aromatic hydrocarbons, hydrogen cyanide, formaldehyde, and carbon
monoxide. Cigarette smoking is also a substantial source of intake of heavy metals and
toxic mineral elements, such as cadmium, aluminum, lead, and mercury, all known to be
poisonous in high concentrations.
Tobacco smoke also contains numerous compounds with oxidative properties; their
existence is linked to the pathogenesis of several of the most common eye disorders, such
as cataract and age-related macular degeneration.
Epidemiological data link cigarette smoking to several ophthalmologic disorders like
ocular irritation, ocular ischemia, age-related macular degeneration (AMD), cataract,
thyroid ophthalmopathy, tobacco-alcohol amblyopia, primary open-angle glaucoma,
conjunctival intraepithelial neoplasia, uveal melanoma, Leber hereditary optic
neuropathy, type II diabetes, ocular sarcoidosis and strabismus in the offspring of
smoking mothers. The effects of smoking on ocular disorders show significant dose
dependence; higher levels of smoking increase the risk of developing cataract. It is
important to note, however that the interpretation of results of different studies may be
inherently biased, as smokers in these studies use cigarettes of different types, containing
different concentrations of toxic substances. Moreover, some of the cigarettes have filters
and others do not. Smoking habits may also be associated with other potentially noxious
habits, such as excessive alcohol consumption, which may contribute a further bias to the
results.
Table 1.2 summarizes five very thought-provoking studies all supporting the view that
smoking is associated with the development of cataract.
Phacoemulsification
10
Several authors have reported a significant link between tobacco smoking and an
increased risk of cataract development. Nuclear sclerosis appears to be the type of
cataract most commonly associated with smoking.
In the Beaver Dam Eye Study, the relationship between cigarette smoking and lens
opacities was examined in 4926 adult subjects. A significant correlation was found
between severe levels of nuclear sclerosis and the number of pack-years smoked. For
both sexes, the odds ratio associated with 10 years
TABLE 1.2 Smoking and the risk of cataract

Study
Relative risk 95%

(RR)
Cl
Leske et al, 1991 1.68

Hankinson et al, 1.63
1992
Christen et al,
2.16
1992
Klein et al, 1993 1.09
West et al, 1995 2.40
0.96
1.94
1.8
2.26
1.46
3.20
1.04
1.16
1.00
6.00
Comments
Association was found to nuclear cataract
Conducted on 50,828 women; RR for developing
posterior subcapsular cataract is 2.59
N=22,071 males; RR for nuclear cataract is 2.24 and for
posterior subcapsular, 3.17
Beaver Dam Eye Study; same RR for women and men
Conducted on 442 watermen of the Chesapeake Bay
was 1.09 (confidence interval, 1.041.16). The frequency of posterior subcapsular

opacities was also increased (odds ratios, 1.05 [confidence interval, 1.001.11] for men
and 1.06 [confidence interval, 0.981.14] for woman). Cortical opacities were not found
to be linked to smoking. Leske et al studied, 1380 patients with cataract, aged 40 to 79
years, in an attempt to identify possible risk factors for the development of cataract,
current smoking was correlated with the risk of developing nuclear cataract (odds ratio,
1.68; confidence interval, 0.961.94), but not other forms of cataract. The City Eye Study
reported epidemiological data concerning 1029 volunteers, aged 54 to 65 years, from
London, UK. The findings showed a significant relationship between nuclear lens
opacities and moderate to heavy cigarette smoking. The relative risk for nuclear-type
cataract ranged from 1.0 for past light smokers to 2.6 for past heavy smokers, and 2.9 for
current heavy smokers.
Klein et al presented evidence that smoking has a detrimental effect on the
development of cataract in the type II diabetic population.
Several prospective studies have investigated the relationship between cataract
formation and cigarette smoking. In an 8-year prospective study, Hankinson et al
examined the association between cigarette smoking and the risk of cataract extraction in
50,828 female nurses aged 45 to 67 years. The age-adjusted relative risk among female
smokers of at least 65 pack-years was 1.63 (confidence interval, 1.182.26).
Smoking was also strongly associated with posterior subcapsular opacities for smokers
of 65 or more pack-years (relative risk 2.59). In a 5-year prospective study of 22,071 men
aged 40 to 84 years, current smokers of at least 20 cigarettes a day showed a significantly
increased risk of developing cataract (relative risk 2.16; confidence interval, 1.463.20).
When calculated for the different types, the relative risk was 2.24 for developing nuclear
Cataract Etiology
13
sclerosis and 3.17 for posterior subcapsular cataract. Past smokers were also at increased
risk of developing posterior subcapsular opacities (relative risk 1.44), whereas current
light smokers had the same chance of developing any type of cataract as subjects who
had never smoked. In a study of 838 watermen from Chesapeake Bay, Maryland, West et
al found a significantly increased risk of development of nuclear opacities associated
with cigarette smoking (relative risk 2.40; confidence interval, 1.006.00).
A 5-year prospective study of this cohort of subjects reported an increase in the
incidence and degree of nuclear opacities with increasing age. The risk of progression of
nuclear opacities from, less than grade 3 at baseline to grade 3 or worse was 2.4-fold
higher among current smokers than among ex-smokers or non-smokers.
A significant increase (18%) in the risk of cataract progression was associated with
each pack-year that a subject had smoked during the 5-year study period.
Mechanism The way in which smoking induces cataract formation is probably through its
effect on the oxidant-antioxidant status of the lens. Oxidative damage plays a major role
in cataractogenesis. Animal, laboratory clinical, and epidemiological data support the
relationship between cataract prevention and diets rich in nutritional factors with
antioxidant properties, such as riboflavin, vitamins C and E, and the carotenoids.
Smoking appears to further impair lenticular function by imposing an additional
oxidative challenge as well as by contributing to the depletion of endogenous anti-oxidant
pools. Tobacco smoke also contains large amounts of heavy metals, such as cadmium,
lead and copper, which appear to accumulate in the lens and exert further toxicity
The above data strongly support an association between tobacco smoking and cataract
formation. Given the magnitude and seriousness of the cataract problem, an important
preventive measure in fighting this disorder is to quit smoking. It is important to note that
smoking is on the increase in the developing world, where cataract surgery is not always
readily available.
Alcohol
Excessive alcohol use is associated with numerous chronic health problems, such as liver
disease, varicosities, blood dyscrasias, and elevated blood pressure. Some studies have
reported a relationship between alcohol consumption and cataract, while other studies
have found no relationship. One study reported that both abstainers and heavy drinkers
were more likely to have cataract than moderate users, while another found that total
abstainers were more likely to have cataract than alcohol users.
As far back as 1973 Sabiston clinically observed in 40 patients over a 5-year period a
definite correlation between alcohol intake, Dupuytrens contracture, and cataract. He
stated that the mechanism of cataract formation was uncertain, but that an element of
chronic dehydration was possible. In New Zealand, where he did his observations, heavy
drinking often commenced with the ingestion of large quantities of beer. The national
average consumption of beer there is 100 liters per head annually, with manual labourers
ingesting a daily total of 4 liters of beer per person per day on average. These persons
were almost invariably heavy cigarette smokers as well. He further noted that the cataract
commenced in a posterior subcapsular position, and could progress to almost full
maturity in six months. There was almost universally a history of heavy cigarette
smoking as well. Malnutrition was only sometimes seen.
Phacoemulsification
12
Drews in 1970 also drew attention to the association of ethanol and cataract. Two
decades later he writes: A patient in his or her 40s or 50s who appears with a posterior
subcapsular cataract should be investigated for alcoholism In the authors practice,
about 25 percent of patients younger than age 65 years who present with cataract are
found to be alcoholic on careful investigation. It has been his experience that if the
opacities are incipient and if the consumption of alcohol is stopped completely, the
posterior subcapsular changes may reverse and even disappear.
Two decades later attention is once again drawn to the possible link between alcohol
and cataract in the Archives of Ophthalmology by two different sets of authors. Munoz et
al from the Wilmer Eye Institute, Baltimore, MD, USA conducted a follow-up study of
surgical cases of posterior subcapsular cataract (PSC) and their controls to evaluate the
possible association of alcohol intake and posterior subcapsular opacities. Two hundred
thirty-eight cases and controls were interviewed. Current alcohol intake and usual and
maximum weekly consumption ever were assessed. In this population, 57 percent of the
cases and 56 percent of the controls were nondrinkers, 22 percent of the cases and 36
percent of the controls had an average of seven or fewer drinks per week, and 17 percent
of the cases and 8 percent of the controls had more than seven drinks per week. Heavy
drinkers were more likely to be cases than were nondrinkers (odds ratio, 4.6; P<0.05),
and light drinkers were not at an increased risk. Light drinkers, defined as those who
drink less than 91 g/wk (i.e. one drink or less per day), were at a lower risk than were
nondrinkers, although this difference did not reach statistical significance. Moderate to
heavy drinkers, that is, those drinking an average of more than one drink per day (more
than 91 g/wk) were 2.7 times more likely to have PSC. This U-shaped relationship
between alcohol and the risk of PSC was more pronounced in the logistic regression
model when controlling for all the factors found to be related to PSC. Some studies have
suggested that heavy drinking patterns are associated with lower socio-economic status.
In this study after adjustment for education level, the risk of PSC was still higher among
drinkers. Smoking was also not related to PSC. Heavy alcohol use has been linked to
poor nutritional status, so the presence of PSC may be related to poor nutrition rather than
alcohol consumption per se. Dietary assessment however, was not performed in this
study. In summary, this study concluded that moderate to heavy alcohol consumption is
associated with a four-fold increase of PSC cataract whereas light drinkers, those
consuming one drink per day or less, were not at an increased risk.
The second study reported in the same journal was on alcohol use and lens opacities in
the Beaver Dam Eye Study group of patients. The relationship between alcohol use and
lens opacities was examined in a large (N=4926) population-based study of adults.
Alcohol history was determined by a standardized questionnaire and the cataract severity
was determined by masked grading of photographs obtained using a slit lamp camera and
retroillumination. Several significant findings were made and conclusions drawn:
In both sexes and every age group, a higher percentage of current heavy drinkers had
late nuclear sclerotic changes. Similar results were seen for cortical and PSC changes.
Past heavy drinkers were found to have increased odds of nuclear sclerosis (OR, 1.34;
95% confidence interval [CI], 1.12 to 1.59). There was an additional significant effect
of past heavy drinking on the severity of cortical opacity (OR, 1.36; 95% CI, 1.04 to
1.77). The presence of posterior subcapsular opacity was also significantly associated
with past heavy drinking (OR, 1.57; 95% CI, 1.10 to 2.25).
Cataract Etiology
15
Wine was associated with less severe nuclear sclerosis (OR, 0.84; 95% CI, 0.74 to 0.94)
in general. Participants who drank liquor were less likely to have severe nuclear
sclerosis than those who did not (OR, 0.81; 95% CI, 0,72 to 0.95). Liquor use was also
associated with lower frequencies of any cataract (OR, 0.83; 95% CI, 0.72 to 0.94) and
fewer past cataract surgeries (OR, 0.75; 95% CI, 0.57 to 0.98).
A significant relationship was found between beer consumption and cortical cataract.
Those who drank larger amounts of beer were more likely to have cortical cataract
than those who drank smaller quantity of beer. An increased risk of cortical cataract
was associated with increased beer consumption. An increased risk of cortical cataract
was not associated with consumption of wine, hard liquor, or a combination of alcohol
types when considered as continuous variables. These different relationships for the
different types of alcohol (wine and hard-liquor consumption was generally associated
with ORs or less than 1, while beer consumption was associated with ORs of more
than 1) raises the possibility that other components of wine or hard liquor confer
protective effects on cataract development. However, no such theoretical links have
yet been established.
Alcohol has many metabolic effects, and modifies the absorption of drugs and dietary
components. These effects may be important in the alcohol-cataract relationship.
However, one cannot exclude the possibility that alcohol itself, especially when
consumed in high volume, may be a direct toxin to the human phacos.
Metabolic Factors
Diabetes Mellitus
Juvenile diabetic cataract classically known as the snow flake cataract is now
uncommon with the advent of effective hypoglycemic therapy. It occurs in insulindependent diabetics whose onset was before the age of 30. The limited period over which
snow flake cataract may occur (chiefly in the first two decades of life) contrasts with the
extended period over which lenticular change occurs (from youth into the eighth decade).
It is of interest that snow flake cataract occurs at a period of life when the lens is
undergoing a major physiological shape change, with negligible sagittal and major
equatorial expansion. It may very well be that the mechanisms for refractive change and
cataract are the same but age-related factors such as the decreasing ability of the lens to
swell may protect the older lens from this type of cataract formation. Other typical
features of this type of cataract are subcapsular and cortical snow flakes, and
polychromatic opacities and vacuoles (Fig. 1.5). These may proceed to mature cataract
within weeks or months and rarely, may be reversible after normalization of blood
glucose over some weeks or even as rapidly as 24 hours.
The rat sugar cataract model is an attractive model for juvenile diabetic cataract in
terms of its acute development and other features. It is also relevant to human
galactosemic cataract, in which the lens is exposed to high levels of aqueous galactose.
The first visible indication of galactosemic cataract is the oil-droplet change on
retroillumination, due to a change in refractive index between the inner and outer parts of
the lens.
Phacoemulsification
14
FIGURE 1.5 Diabetic cataract

It has been noted that there are difficulties in accepting a role of aldose reductase in
human cataract. Even though sorbitol is found in increased amount in the human diabetic
lens, the amounts detected have been quite low, and insufficient on a lens mass basis to
account for osmotic damage.
Data on a cell-to-cell basis, which would be appropriate, are not available.
Although Vadot and Guibal considered that there was sufficient sorbitol in young
diabetic lenses to induce cataract, Lerman and Moran could not demonstrate the
accumulation of significant amounts in sugar-incubated lenses over the age of 20 years.
There is no information about levels in juvenile diabetic cataract itself. Jedziniak et al
found a higher aldose reductase activity in the young lens than in the adult lens and
calculated that it was sufficient to generate a significant osmotic stress. However, these
calculations referred to the lens epithelium and assumed that sorbitol was not removed.
Since polyol dehydrogenase is more active than aldose reductase in the human lens, the
calculated levels would be expected to be lower. Lin et al demonstrated accumulation of
dulcitol and loss of myoinositol in 72-hour cultures of infantile human lens epithelium in
a 30 mlQI galactose medium, associated with vacuolar changes at ultrastructural level.
Sorbinil and AL1576 reversed these changes. Similar changes have been produced in dog
epithelial culture within 6 hours. Lin et al suggest that damage in the human lens may
reflect compartmentalization of aldose reductase activity, for instance in the epithelium.
If sorbitol accumulation in the epithelium (and not the fibers) were the basis of juvenile
cataract, then a failure of epithelial permeability or pumping functions would be a more
likely cause of lens swelling and cataract than an osmotic mechanism. There is no
information available as to whether an oxidative mechanism, dependent on the polyol
pathway or not, is operative in juvenile diabetic cataract.
Cataract in diabetic adults Cataract has a greater prevalence in diabetics with a greater
risk for women, and is dependent on the duration of diabetics. The morphology is no
different from that of age-related cataract, although the frequency of some subtypes is
increased.
Klein et al in a population study found cataract to be more prevalent in early and late
onset diabetes with significant association with age, severity of retinopathy and diuretic
usage. Diabetes duration and the level of glycosylated hemoglobin were also associations
in early onset diabetics. In a second report, cataract was found to be the second most
Cataract Etiology
17
common cause of severe visual loss in adult onset diabetics. Various other reports have
shown an association between cataract, and diabetes duration or retinopathy.
The frequency of cataract extraction is greater in diabetics than non-diabetics. The
Framingham study showed a significant excess risk in the 50 to 64 year age group
(relative risk 4.02), while the HANES study showed a relative risk of 2.97 in this age
group and 1.63 in the 65 to 74 year age group. Both studies reported an excess prevalence
of cataract in diabetics in 50 to 64 year age groups, which disappeared at an older age.
This has been attributed to the higher mortality in diabetics with cataract. However, a
case-control study in Oxford found an increased risk for cataract extraction in diabetics in
the age group of 50 to 79 years, and a small increase in risk for women relative to men.
As has been noted the morphology of cataract in the adult diabetic resembles that seen
in age-related cataract in the absence of diabetes. Thus the major features are nuclear
cataract (increased nuclear scattering and brunescence) and cortical spoke and posterior
subcapsular cataract. In the Lens Opacity Case Control study, diabetes increased the risk
of posterior subcapsular, cortical and mixed forms of cataract. Individual features may
not have an identical etiology, but it is likely that those metabolic changes identified in
experimental cataract are relevant for the human are in varying degrees. There is no
relation between cataract type, and the level of either sorbitol or myoinositol in lens
epithelium from patients with cataract and diabetes.
It has been suggested that the increased nuclear scattering and brunescence in diabetic
lenses is likely to be the result of increased glycation and the formation of advanced
glycation end products.
There is evidence for a fall in free lysine amino groups in the human diabetic lens. It is
also possible to induce a change in tertiary structure in alpha-crystalline (bovine)
incubated with glucose and glucose-6-phosphate.
A three-fold increase in glycation was measured in diabetics and controls by Vidal et
al but there was no correlation with the degree of browning of the lenses measured
spectrophotometrically, and they concluded that other chromophores were responsible for
the browning at the relevant wavelengths.
Certainly a number of other factors have been proposed to contribute to nuclear
brunescence of the non-diabetic lens, but since the diabetic state is not anticipated to
increase their concentration, glycation products are still the most likely candidates
responsible for diabetic cataract.
Cortical cataract can be caused experimentally by agents which interfere with
membrane permeability, ion and water control. The non-diabetic, aging human lens, free
of cataract, has an increased membrane permeability which parallels the increase in
optical density which occurs from about the fifth decade. There is evidence of
degradation of the lens protein MIP26 with age in non-diabetics, which could be
responsible for a functional abnormality. This channel protein has until recently been
regarded as the gap junctional protein, but may in fact serve as a volume regulating
channel. Disturbance of either function could increase the risk of cataract. It would be of
interest to examine these events in the diabetic lens. The greater thickness of the diabetic
compared to the non-diabetic lens could be relevant to this point. The disturbance in Na
K-ATPase kinetics reported by Garner and Spector during exposure to glucose-6phosphate is similar to the change noted in diabetic human lenses. Hydrogen peroxide is
present in normal human aqueous, and present at raised levels in the aqueous of patients
Phacoemulsification
16
with cataract. Higher levels are found in the aqueous of diabetic patients with cataract.
Simonelli et al have also shown an increase in malondialdehyde in cataractous compared
with non-cataractous lenses which is greater in the cataract of diabetic patients.
Malondialdehyde is a product of lipid peroxidation of cell membranes, and is regarded as
an indicator of oxidative membrane damage. These are important findings, although the
methods of measurement are not entirely specific.
The potential role of the sorbitol (polyol) pathway in juvenile cataract was discussed
earlier. Recent studies of cultured lens epithelium from cataract patients have shown
negligible or absent levels of sorbitol in the epithelium of non-diabetics. In diabetic
epithelium sorbitol levels are higher than blood glucose levels, while there is an inverse
relationship between blood glucose and myoinositol.
It has been noted that oxidative stress may cause lens membrane damage
experimentally. It may also cause damage to DNA. Subcapsular cataract may be regarded
as due to an aberration of lens mitosis and lens fiber differentiation, and could be the
result of oxidative damage. There are no data, which link this to human subcapsular
cataract.
Other cataract-related events A higher rate of capsular rupture reported in diabetics
undergoing intracapsular or extracapsular extraction could be related to structural and
chemical changes which are known to occur in the capsule. There is an increased risk for
death in patients with cataract and diabetes. Cohen et al found lens opacities to be a
powerful predictor of death, independent of other factors and with an odd ratio of 2.4
(95% confidence interval 1.53.9).
Dyslipidemia
Lens opacification and cardiovascular disease are two of the main causes of morbidity
worldwide. Lens opacity, manifesting as cataract, is responsible for an estimated 40
percent of the 42 million cases of blindness in the world. On the other hand, heart disease
is the single greatest cause of death in developed countries. The relationship between
cholesterol and cardiovascular heart disease is well documented. The relationship
between cholesterol and lens opacity is, however, far less well appreciated.
Issues relating to drug safety and inherited defects in enzymes mediating cholesterol
metabolism have brought renewed attention to a possible interrelationship between lipid
metabolism and cataract induction in humans. The lens is unique in that it contains a
relative abundance of cholesterol in the fiber cell plasma membrane, (the highest of any
cell group in the body) and furnishes its needs for cholesterol by onsite biosynthesis. It
has been shown that inhibition of cholesterol synthesis in the lens leads to cataract
formation in man.
Smith-Limli-Opitz syndrome, me valonic aciduria and cerebrotendinous
xanthomatosis are inherited disorders of cholesterol metabolism and affected patients
may present with lens opacities. Triparanol, a hypolipidemic agent that inhibits
cholesterol biosynthesis was withdrawn from clinical use because of its propensity to
induce cataract formation in humans. The very widely used vastatin class of
hypolipidemic medicines is potent inhibitors of cholesterol biosynthesis and is able to
lower serum lipid concentration effectively. Although high ocular safety in older patients
over periods of up to 5 years, has been reported, it is still not clear whether these agents
Cataract Etiology
19
have the potential to be cataractogenic, particularly in younger patients and over longer
periods.
In order to assess the prevalence of lenticular opacities in patients with dyslipidemia
(raised serum cholesterol and triglycerides) a group of 80 dyslipidemic patients were
subjected to a general physical examination and an ophthalmic examination of the fully
dilated eye at the Tygerberg Academic Hospital, University of Stellenbosch, South Africa
(unpublished data).
Patients (n=80) of both genders and irrespective of age were enrolled in the trial if
they met the inclusion criteria for dyslipidemia. Patients were included if their fasting
serum cholesterol and triglyceride concentrations were >5.2 mmol/l and >2.3 mmol/l,
respectively when measured on three separate occasions over a one-month period (Fig.
1.6). Patients were excluded if they suffered from any condition known to cause or
predispose them to elevated lipid levels or lenticular opacification.
Results The study group was predominantly male Caucasian and smokers. Most
patients68.8 percent admitted regular alcohol consumption. The mean systolic and
diastolic blood pressure data, 13418 and 849 mm Hg, respectively, fell within the
normal range for age. The BMI of the group was significantly greater than the norm (i.e.
28.894.82 kg/m2).
The prevalence of lenticular opacities divided the study group into two cohorts, i.e.
those with normal lenses (62%) and those with opacities (39%) (Fig. 1.7).
FIGURE 1.6 The lipid profile of the

study group
The prevalence of lenticular opacity in dyslipidemic patients in the age group of 30 to 40
years was 33 percent. This age group was not studied in the Barbados Eye Study (BES)
or in The Beaver Dam Eye Study (BDES) and consequently data for comparison are not
available (Table 1.3). In the 40 to 50 year age group, the prevalence of lenticular opacity
in our patients was 50 percent compared to 4.7 percent in the BES and 8.3 percent in
BDES. Differences in the older age groups were not prominent (Fig. 1.8).
Modern medicine today aspires to early detection of disease processes with the aim of
early intervention in an attempt either to halt the progression or to reverse the process.
Phacoemulsification
18
Although the classic systemic signs of dyslipidemia are well appreciated, i.e.
xanthomata, xanthelasma, thickening of the Achilles tendon and corneal arcus, in our
study the prevalence of one or more of the ocular signs was far greater than that of the
systemic signs, 23.8 percent for the former as opposed to 47.3 percent for the latter.
The distribution of dyslipidemia-related signs in this study was:
Xanthelasma7.5 percent
Corneal arcus8.8 percent
Achilles tendon involvement16.3 percent
Cortical lenticular opacity31.0 percent.
TABLE 1.3 Age distribution of patients with

lenticular opacities compared to other population
based studies
Age group Study group Percentage of opacities BES BDES (years)
3040
33.33
4050
50.00
5060
18.51
6070
33.33
7080
66.67
80+
33.33
BES: Barbados Eye Study
BDES: Beaver Dam Eye Study N/A: Not available.
N/A
4.7
24.5
57.5
85.9
98.3
N/A
8.3
26.5
56.7
70.5
N/A
FIGURE 1.7 The prevalence of lens

opacities in the study group
Cataract Etiology
21
FIGURE 1.8 Prevalence of lenticular

opacities in two population-based
studies compared to the dyslipidemic
study group
FIGURE 1.9 Physical signs associated

with dyslipidemia
It is noteworthy that the most frequent ocular signcortical lenticular opacityoccurred
twice as frequently as the most frequent systemic signAchilles tendon thickening (Fig.
1.9).
This work leads the investigators to conclude that:
Dyslipidemic patients are more likely to develop cortical opacification than the normal
population.
Cortical lens opacification in dyslipidemics manifests at a younger age than does
nuclear opacification.
Phacoemulsification
20
Cortical lens opacification in the patient younger than 50 years of age should alert the
ophthalmologist to arrange for diagnostic serum lipid assessment.
Cortical lenticular opacification should be regarded as one of the most common, and
hence reliable, clinical signs of dyslipidemia.
Jahn et al attempted to determine the role of glucose and lipid metabolism in the
formation of cataract in elderly people undergoing cataract extraction. They found that
patients with posterior subcapsular cataract had higher concentrations of fasting serum
triglycerides and were significantly younger than patients with nuclear or cortical
cataract. Their results furthermore suggest that the association of hypertriglyceridemia,
hyperglycemia and obesity favors the formation of a specific morphologic type of lens
opacity, posterior subcapsular cataract, occurring at an early age. Because these factors
are potentially modifiable by lifestyle changes, these observations may prove important
as the modification of these parameters could constitute an effective mode of prevention
or retardation in a subgroup of patients developing cataract at an early age.
Acetylator Status
The human acetylation polymorphism has been known for more than three decades since
its discovery during the metabolic investigation of the antituberculous hydrazine drug,
isoniazid. The trait was originally known as the isoniazid acetylation polymorphism but
is now usually abbreviated as acetylation polymorphism because acetylation of
numerous hydrazine and arylamine drugs and other chemicals are subject to this trait.
Individuals phenotype as slow acetylators when homozygous for the slow acetylator
gene, rapid when homozygous for the rapid acetylator gene or intermediate when
heterozygous. The acetylator phenotype is a lifelong, relatively stable characteristic of the
individual that can phenotypically be determined by procedures using any of several test
agents (e.g. caffeine, isoniazid, sulfamethazine, sulfapyridine). Certain disease states such
as AIDS can change the phenotype expression in an individual. On the other hand,
acetylator genotype can be determined by specialized polymerase chain reaction (PCR)
methods.
Several diseases have been linked to acetylator pheno- and/or genotype. The best
documented are bladder cancer (slow), colorectal adenomas (rapid), Gilberts syndrome
(slow), allergic diseases Type I diabetes mellitus (fast), Type II diabetes mellitus (slow)
and familial Parkinsons disease (slow).
Recent work (PhD level, unpublished) at the departments of Ophthalmology and
Pharmacology at the University of Stellenbosch, South Africa have also established an
association between age-related cataract and acetylation status as determined both
phenotypically and genotypically. Sixty adult patients of both sexes with classic agerelated lens opacities presenting for cataract surgery were enrolled in a prospective
controlled study. Patients were included in the trial if they perceived themselves to be
colored and if this was verified by at least one independent observer. The South African
population of mixed ancestry (including Malay, Khoisan, Negroid and Caucasoid stock)
is referred to as colored and all patients were selected from this well studied subgroup
of the population. Care was taken to exclude all patients with well known etiological
factors for cataract formation such as diabetes mellitus, previous ocular trauma, other
Cataract Etiology
23
metabolic and/or inherited diseases. One hundred and twenty patients of the same race
group served as controls.
Figure 1.10 demonstrates that in the control group (representing the population at
large) the distribution of the phenotypic acetylation status was 20 percent rapid, 50
percent intermediate and 30 percent slow. In the cataract group the distribution was 5
percent rapid, 42 percent intermediate and 53 percent slow. This clearly seems to
suggest that cataract possibly occur more frequently in slow acetylators than in the rest of
the population. Could this finding perhaps suggest a possible etiologic role for chemical
substances possessing a primary aromatic amine or hydrazine group in human lenticular
opacification?
Lipid Peroxidation, Free Radicals and Nutritional Influences on
Cataract Formation
Oxygen and oxygen-derived free radicals and a failure of intracellular calcium
homeostatic mechanisms are recurring themes in a wide variety of cell injuries.
The addition of electrons to molecular oxygen leads to the formation of toxic free
oxygen radicals or reactive oxygen species (ROS), e.g.
O2 = superoxide (one electron)
H2O2 = hydrogen peroxide (two electrons)
OH = hydroxyl radical (three electrons)
FIGURE 1.10 Acetylator status of

cataract vs normal patients
Iron is very important in this process according to the Haber-Weiss reaction:
H2O2+O2Fe2+.OH+OH+O2
These free radical species cause lipid peroxidation and other deleterious effects on cell
structure. Recent studies have shown that lipid peroxidation, an event caused by
Phacoemulsification
22
imbalance between free radical production and antioxidant defense, may play a role in the
genesis of cataract. Higher levels of malondialdehyde (MDA), a final product of the lipid
peroxidation process, have been observed in diabetic and myopic cataract compared with
senile cataract. Protection of the cell against damage by these free radicals takes place
indirectly (enzymatically) by antioxidant enzymessuperoxide dismutase (SOD),
glutathione peroxidase (GPX) and catalase (CAT). Direct protection is offered by mainly
dietary antioxidantsascorbate (Vit C), tocopherol (Vit E), carotenoids (Vit A) and
glutathione (GSH).
Light and oxygen as risk factors for cataract Various epidemiological studies
demonstrate associations between elevated risk of various forms of cataract and exposure
to higher intensities of incident and/or reflected ultraviolet light (Table 1.4).
Elevated levels of oxygen exposure perhaps show the clearest causal relationship
between oxidative stress and cataract. Nuclear cataract was observed in patients treated
with hyperbaric oxygen therapy, and markedly elevated levels of mature cataract were
observed in mice that survived exposure to 100 percent oxygen twice weekly for 3 hours.
A higher incidence of cataract was noted in lenses exposed to hyperbaric oxygen in vitro.
Very early stages of cataract in guinea pigs exposed to hyperbaric oxygen was noted by
Giblin.
Role of cellular antioxidants against lens damage Protection of the organism against
photooxidative insult can be viewed as two interrelated processes. Primary defenses offer
protection of proteins and other lens constituents by lens antioxidants and antioxidant
enzymes whereas secondary defenses include proteolytic and repair processes. The
primary defenses shall form the focus of our attention.
The major aqueous antioxidants in the lens are ascorbate and GSH.
Ascorbate is probably the most effective, least toxic antioxidant identified in
mammalian systems. The following has been observed
The lens and aqueous concentrate ascorbate >10 times the level found in human plasma.
TABLE 1.4 Extent of light expoxure and the risk of

cataract
Study
Exposure
USA: NHANES Daily hours of sunlight

survey
in area; ages 6574
PR 95% CI
<6.6 h 1.0
7.17.7 h 1.7 1.22.7
>8.2 h 2.7 1.64.6
Australia
Daily hours of sunlight <8 h
1.0
in area
8.59 h 2.9 0.613.2
>9.5 h 4.2 0.918.9
Average mean erythemal 2000
1.0
dose of area
2500
1.3 0.82.3
3000
1.8 1.03.4
Nepal
Average hours of sunlight 79 h
1.0
1011 h 1.2 0.91.4
>12 h
2.5 2.13.0
PR=prevalence ratio
CI=confidence interval
Cataract Etiology
25
The concentration of ascorbate in the lens nucleus is only 25 percent that of the
surrounding cortex.
Ascorbate levels in normal lenses are higher than in cataractous lenses.
Ascorbate levels are higher in the older guinea pig lens than in younger animals despite
the same dietary intake of ascorbate.
Increasing lens ascorbate concentrations by two-fold is associated with protection
against cataract-like damage.
With this basic science knowledge several epidemiological, clinical and even
interventional studies have been undertaken. Vitamin C was considered in approximately
9 published studies and observed to be inversely associated with at least one type of
cataract in eight of these studies.
In the Nutrition and Vision Project, age-adjusted analyses bases on 165 women with
high vitamin C intake (mean=294 mg/day) and 136 women with low vitamin C intake
(mean=77 mg/day) indicated that the women who took vitamin C supplements for 10
years had >70 percent lower prevalence of early opacities (RR: 0.23; CI: 0.090.60) and
>80 percent lower risk of moderate opacities (RR: 0.17; CI: 0.030.87) at any site
compared with women who did not use vitamin C supplements.
In comparison to the above data, Mares-Perlman and et al report that past use of
supplements containing vitamin C was associated with a reduced prevalence of nuclear
cataract, but an increased prevalence of cortical cataract after controlling for age, sex,
smoking, and history of heavy alcohol consumption.
Glutathione (GSH) levels in the lens are several fold the levels found in whole blood
and plasma. GSH levels also diminish in the older and cataractous lenses.
Pharmacological opportunities could be suggested by observations that incorporating the
industrial 0.4 percent butylated hydroxytoluene in diets of galactose-fed (50% of diet)
rats diminished prevalence of cataract. Clinical studies however have not yet been
forthcoming.
Vitamin E, a natural lipid-soluble antioxidant, can inhibit lipid peroxidation and
appears to stabilize lens cell membranes. Consumption of Vit E supplements was
inversely correlated with cataract risk in two studies. Robertson et al found among ageand sex-matched cases and controls that the prevalence of advanced cataract was 56
percent lower (RR: 0.44; CI: 0.240.77) in persons who consumed vitamin E
supplements (>400 IU/ day) than in persons not consuming supplements. Jacques and
Chylack (unpublished) observed a 67 percent (RR: 0.33; CI: 0.120.96) reduction in
prevalence of cataract for vitamin E supplement users after adjusting for age, sex, race
and diabetes.
Two prospective studies demonstrated a reduced cataract progress among individuals
with higher plasma vitamin E. Rouhianen et al found a 73 percent reduction in risk for
cortical cataract progression (RR: 027; CI: 0.080.83), whereas Leske et al reported a 42
percent reduction in risk for nuclear cataract progression (RR: 0.58; CI: 0.360.94).
Vitamin E supplementation was related to a lower risk for progress of nuclear opacity
(RR: 0.43; CI: 0.190.99).
The carotenoids, like vitamine E, are also natural lipid-soluble antioxidants. Betacarotene is the best known carotenoid because of its importance as a vitamin A precursor.
However, it is only one of the 400 naturally occurring carotenoids, and other carotenoids
Phacoemulsification
24
may have similar or greater antioxidant potential. In addition to -carotene, -carotene,

lutein and lycopene are important carotenoid components of the human diet.
Jacques and Chylack were the first to observe that persons with carotene intakes above
18,700 IU/ day had the same prevalence of cataract as those with intakes below 5,677
IU/day (RR: 0.91; CI: 0.233.78). Hankinson et al followed this report with a study that
reported that the multivariate-adjusted rate of cataract surgery was about 30 percent lower
(RR: 0.73; CI: 0.550.97) for women with high carotene intakes (median=14,558 IU/day)
compared with women with low intakes of this nutrient (median=2,935 IU/day).
However, while cataract surgery was inversely associated with total carotene intake, it
was not strongly associated with consumption of carotene-rich foods, such as carrots.
Rather, cataract surgery was associated with lower intakes of foods such as spinach that
are rich in lutein and xanthin carotenoids, rather than -carotene. This would appear to be
consistent with the observation that the human lens contains lutein and zeaxanthin but no
-carotene.
This observation would appear to be consistent with the observation that lutein and
zeaxanthin are the most prevalent carotenoids in lens. However, Mares-Perlman did not
detect a significantly altered risk for cataract among consumers of these nutrients.
Intervention studies To date only one intervention trial designed to assess the effect of
vitamin supplements on cataract risk has been completed. Sperduto et al took advantage
of two ongoing, randomized, double-blinded vitamin and cancer trials to assess the
impact of vitamin supplements on cataract prevalence. The trials were conducted among
almost 4,000 participants aged 45 to 74 years from rural communities in Linxian, China.
Participants in one trial received either a multisupplement or placebo. In the second trial,
a more complex factorial design was used to evaluate the effects of four different
vitamin/mineral combinations:
Retinol (5000 IU) and zinc (22 mg)
Riboflavin (3 mg) and niacin (40 mg)
Vitamin C (120 mg) and molybdenum (30 mg)
Vitamin E (30 mg), -carotene (15 mg), and selenium (50 g).
At the end of the five to six year follow-up, the investigators conducted eye examinations
to determine the prevalence of cataract. In the first trial there was a significant 43 percent
reduction in the prevalence of nuclear cataract for persons aged 65 to 74 years receiving
the multisupplement (RR: 0.57; CI: 0.360.90). The second trial demonstrated a
significantly reduced prevalence of nuclear cataract in persons receiving the
riboflavin/niacin supplement relative to those persons not receiving the supplement (RR:
0.59; CI: 0.450.79). The effect was strongest in those aged 65 to 74 years (RR: 0.45; CI:
0.310.64). However, the riboflavin/niacin supplement appeared to increase the risk of
posterior subcapsular cataract (RR: 2.64; CI: 1.315.35). The results further suggested a
protective effect of the retinol/zinc supplement (RR: 0.77; CI: 0.581.02) and the vitamin
C/molybdenum supplement (RR: 0.78; CI: 0.501.04) on prevalence of nuclear cataract.
Conclusion Although light and oxygen are necessary for physiological function, when
present in excess they seem to be causally related to cataractogenesis. Aging might
diminish the bodies primary antioxidant reserves, antioxidant enzyme abilities, and
diminished secondary defenses such as proteases.
Cataract Etiology
27
The literature creates the strong impression that antioxidant intake might diminish the
risk for cataract formation.
Longitudinal studies and more intervention studies are essential in order to establish
the value of dietary antioxidants and to determine the extent to which cataract progress is
affected by nutritional supplements. This fact becomes significant when one appreciates
that poor education and lower socioeconomic status are directly related to poor nutrition.
It is therefore not irrational to contemplate the value of intervention for populations at
risk. The work available, albeit preliminary, indicates that nutrition may provide the least
costly and most practicable means to attempt the objectives of delaying cataract.
Ocular Disease
Many ocular diseases have been associated with cataract formation either as direct cause
and effect relationships or as common associations.
Myopia
Weale suggested that lenses of myopes are subject to excessive mechanical stress which
could lead to cataract. This hypothesis was tested by several investigators and Harding et
al during their Oxford case-control studies found that the risk of cataract after the age of
50 was doubled in myopes. Weale (1980) also suggested that there is a graded risk for
increasing degrees of myopia. This was eloquently confirmed two decades later by Lim et
al in the Blue Mountains Eye Study. Eyes with onset of myopia before age 20 had the
greatest posterior subcapsular (PSC) cataract risk (odds ratio [OR] 3.9; confidence
interval [CI] 2.07.9) Refraction-related increasing odds were found between PSC
cataract and myopia: low myopia (OR 2.1; CI: 1.43.5), moderate myopia (OR 3.1; CI:
1.65.7), and high myopia (OR 5.5; CI: 2.810.9). High myopia was associated with
PSC, cortical, and late nuclear cataract. Conversely PSC cataract was inversely associated
with hyperopia (OR 0.6; CI: 0.40.9). They finally concluded that early-onset myopia
(before 20 years of age) may be a strong and independent risk factor for PSC cataract,
that nuclear cataract was associated with presumed acquired myopia, whereas high
myopia was associated with all three types of cataract.
Wensor et al demonstrated that a myopic shift is associated with nuclear cataract. In
the population based study of 3,271 Australians an association between myopia of 1
diopter or more and both nuclear and cortical cataract was observed. Between posterior
subcapsular cataract and myopia such a relationship did not exist. It is not sure that a
causal relationship exists between cortical cataract and myopia or rather that a myopic
shift occurs after people develop cortical cataract. The temporality of this relationship
should still be explored in future prospective analyses.
Glaucoma
Glaucoma has been shown to be strongly associated with the pathogenesis of cataract in
many studies undertaken in many countries. The relative risk (odds ratio [OR]) of
cataract developing in a glaucoma patient can be as high as six times normal. This risk
more than doubles to an OR of 14.3 after glaucoma filtration surgery. This rise in risk is
Phacoemulsification
26
most probably due to the trauma of surgery for glaucoma. Vesti in Helsinki, Finland
investigated cataract progression after trabeculectomy in a study of 47 eyes with
exfoliative glaucoma (EXG) and in 20 eyes with primary open-angle glaucoma (POAG).
EXG, age, hypotony (IOP<or=5 mm Hg) lasting>or= 5 days and early postoperative IOP
rise>30 mm Hg were observed to be risk factors for cataract progression.
Besides formal filtering procedures like full thickness procedures, laser procedures for
the management of different types of glaucomas are frequently performed such as argon
laser trabeculoplasty, argon laser iridoplasty and Nd-YAG peripheral iridotomy. Each of
these procedures carries the risk of inducing a cataract especially of the focal type. Zadok
et al has described a previously unreported complication of a posterior chamber
intraocular lens (IOL) implanted in a phakic eye. The left eye of a 25-year old patient
with high myopia was treated prophylactically with Nd: YAG laser iridotomy prior to
phakic IOL implantation. Slit lamp examination of the same eye disclosed an opacity of
the anterior capsule of the crystalline lens under the iridotomy site.
Miotics, particularly long-acting cholinesterase inhibitors, if used for long term, may
cause tiny
FIGURE 1.11 Anterior subcapsular

flecks after acute closed angle
glaucoma
anterior subcapsular vacuoles and, occasionally, more advanced opacities. Cessation of
medication may stop, retard or occasionally reverse their progression.
Acute congestive angle-closure glaucoma is associated with the subsequent formation
of glaukomflecken consisting of small, gray-white, anterior, subcapsular or capsular
opacities in the pupillary zone (Fig. 1.11).
Ophthalmic Surgical Procedures
Many different ophthalmic procedures carry the risk of inducing cataract. Among others
are surgical iridectomy, filtration surgery, corneal transplants, retinal detachment surgery
with and without intraocular silicone oil as well as pars plana vitrectomy especially in
diabetics. Assessing the surgical outcome in a series of 63 consecutive patients treated for
rhegmatogenous retinal detachment by primary vitrectomy Oshima reported the
reattachment rate by final examination as 100 percent, but there was a high incidence
(53.8%) of cataract progression in phakic eyes.
Cataract Etiology
29
More recently with the advent of minus power phakic IOL implantation surgery,
several reports have appeared of cataract induction secondary to the implantation of these
lenses into the ciliary sulcus. These cataract have occurred both with silicone and
collamer materials. Some have taken as short a time as 6 months, whilst others took 7
years to form. In another series of 38 consecutive eyes with high myopia implanted with
a silicone posterior chamber plate-style intraocular lens (Chiron, Adatomed) over a
period of 21 months and followed for between 3 and 24 months not a single cataract
occurred. The lens style and design may play a significant role in the cataract
pathogenesis, because in a recent study Brauweiler et al attempted to assess the
effectiveness and safety of implantation of a silicone, posterior chamber IOL in the
ciliary sulcus of phakic, highly myopic eyes in a noncomparative consecutive
interventional series. Eighteen eyes of 10 patients underwent implantation of a Fyodorov
094M-1 IOL by the same surgeon and were evaluated for a 2-year postoperative period.
Cataract formation of the anterior subcapsular (8 eyes) or nuclear (only 1 eye) type was
observed in overall 9 (52.9%) of 17 eyes. When considering only the patients with a
follow-up of 2 years, the incidence of cataract formation was 81.9 percent (9 of 11 eyes).
Obviously this very high incidence of cataract formation should discourage the
implantation of the type of IOL used in this study.
Ocular Trauma
The development of cataract is a known complication following blunt or penetrating
ocular trauma. However traumatic cataract and zonular dehiscence is only one
complication of the injured ocular tissues. Other complications include glaucoma, retinal
detachment, optic nerve damage, extraocular muscle imbalance and injury to the bony
orbit.
Ocular trauma is a major cause of monocular blindness in both the developed and
developing world, but this is not seen as a significant cause of bilateral blindness. Trauma
can therefore be considered as a major cause of blind eyes but not of blind people.
Crystalline lens subluxation, total dislocation, or localized cortical or diffuse opacities
are often observed secondary to blunt ocular trauma. An unusual complication of blunt
trauma is rupture of the posterior capsule with subsequent lens fiber hydration leading to
rapidly progressive lens opacification (Fig. 1.12). Posterior capsular breaks have been
reported to develop thick, fibrous, opaque margins approximately 6 weeks after blunt
trauma.
Secondary Cataract
Uveitis A secondary cataract develops as a result of some other primary ocular disease.
The most common cause of secondary cataract is chronic anterior uveitis. The earliest
finding is a polychromatic luster at the posterior pole of the lens. If the uveitis is
controlled, the progression of cataract may be arrested. If the inflammation cannot be
controlled, anterior and posterior subcapsular opacities develop and the lens may become
completely opaque. The lens opacification seems to progress more rapidly in the presence
of posterior synechiae.
Phacoemulsification
28
FIGURE 1.12 Vossius ring after

blunt ocular trauma
Hereditary posterior segment disease Hereditary fundus dystrophies such as retinitis
pigmentosa, Lebers congenital amaurosis, gyrate atrophy, Wagners and Sticklers
syndromes may be associated with posterior subcapsular lens opacities. In a study of 384
eyes of 192 patients with a mean age of 39.1 years who presented with typical retinitis
pigmentosa, cataract was found in 46.4 percent of the eyes. Among these, 93.6 percent
showed posterior subcapsular opacification. The incidence of cataract increased with age.
Wagners vitreoretinal degeneration is characteristically associated with high myopia,
glaucoma, choroidal atrophy, retinal detachment and presenile cataract.
Persistent hyperplastic primary vitreous (PHPV) is a congenital disorder that manifests
a range of ocular anomalies including leukoria, microphthalmia, a retrolental
fibrovascular membrane and cataract. In general the prognosis for visual acuity with
PHPV is poor.
Iris color McCarty et al in their Australian population study of 3,271 adults aged 40 years
and older found an association between cortical cataract and brown or dark brown irides
for all ages that was not explained by country of birth or language spoken. In all age
categories, brown iris color was also associated with nuclear cataract. No such
association was found for posterior subcapsular cataract however.
In the Italian-American Cataract Study, there was an increased, although not
significant, risk of cortical cataract in people with brown irides. Dark iris color was not
associated with cortical cataract in the Lens Opacities Case-Control Study. In the
National Health and Nutrition Examination Survey, blacks, who have dark brown irides,
were found to have significantly increased risk of cortical cataract. In both the above
mentioned studies, dark iris color was also found to be a significant risk factor for nuclear
cataract.
The relationship of nuclear cataract and iris color could result from genetic
susceptibility associated with iris color or other factors not yet determined. This finding
may partially explain the variation in the prevalence of nuclear cataract observed in
different countries with different racial groups.
Cataract Etiology
31
Systemic Diseases
Hypertension
The association between hypertension and cataract was first noted in the Framingham
study where earlier detection of elevated blood pressure was more common in those later
found to have cataract. It was also noted in the same study that consumption of diuretics
which restores normal blood pressure in many patients does not protect against this risk.
There may however be a variety of interactions in these patients in that hypertension may
be associated with high blood glucose, diabetes and other conditions as well as with use
of diuretics. Diuretics have different effects on plasma urea levels, with frusemide and
acetazolamide associated with the highest levels, and parallel effects on cataract. Overall
diuretic use was associated with an odds ratio of 1:6 but cyclopenthiazide (Navidrex),
which had least effect on plasma urea, was reported by a greater proportion of controls
than cases. Loop diuretics were reported by more than twice the proportion of cases than
of controls. Hypertension and diuretic consumption did not appear as risk factors in
Oxford but the graded properties of different diuretics did emerge and with a similar
sequence to that found in Edinburgh. The only significant association of individual
diuretics was an apparent protective effect by cyclopenthiazide and a risk associated with
spironolactone which itself is a steroid. There was no significant association of particular
sites of opacity with diuretic use.
Dehydrational Crisis
Harding has proposed that frequent episodes of diarrhea may be related to
cataractogenesis and may account for the excess prevalence in some developing
countries. Four intermediate events have been suggested to explain the role of diarrhea in
the development of cataract
Malnutrition secondary to malabsorption of nutrients
Relative alkalosis from administration of rehydrating fluids with bicarbonate
Dehydration induced osmotic disturbance between the lens and the aqueous humor and
Increased levels of urea and ammonium cyanate which may denature lens proteins by
the process of carbamylation.
Six case-control studies have examined the relationship of severe diarrhea and increased
risk of cataract, with discordant results. Two case-control, clinic-based studies done in
Madhya Pradesh and Orissa, India have suggested a three-to four-fold increase in the risk
for cataract for those with remembered episodes of life-threatening dehydration crises,
severe enough to render the patient bedridden for at least three days. However, these
findings were not replicated in two other epidemiologic investigations done in India.
Using a less stringent definition of diarrhea (confinement to bed for one day), the IndiaUS Case-Control Study found no associations with cataract. Also, a village-based casecontrol study in Southern India showed no association between severe diarrhea and risk
of cataract. Furthermore, an observational study done in Matlab, Bangladesh, revealed
that diarrhea from all causes was not significantly associated with cataract, although it
Phacoemulsification
30
was difficult to determine how cataract was defined in the study. The case-control study
in Oxford found a marginally significant excess risk of cataract with reported severe
diarrhea, but a significant risk in the subgroup aged 70 and older. Adjustments for the
other possible confounding factors also found in the study were not done. Considering the
potential public health importance of diarrhea as a risk factor, as well as the biologically
plausible role of dehydration in cataractogenesis, further research to clarify this
association is needed. Prospective studies involving closer follow-up of groups of
patients who suffered from acute life-threatening diarrhea may provide more convincing
evidence. Moreover, studies that examine the cumulative effect of milder, chronic
dehydration episodes in cataractogenesis may also add to the current understanding of
this issue.
Renal Failure
Cataract has been reported in many cases of renal failure. Sometimes cataract, often
transient, was associated with hemodialysis and thought to be caused by the osmotic
shock that dialysis causes, but Laqua (1972) noted lens opacities before dialysis and
suggested they were caused by uremia. Increased blood urea could lead to cataract in a
similar way to that postulated in severe diarrhea. After renal transplantation patients are
treated with immunosuppressants usually including corticosteroids that may cause
cataract. Posterior subcapsular lens opacities were observed in 19 out of 22 renal
transplant recipients, aged 21 to 54 years in Hiroshima. Half of the patients suffered
visual loss, attributed to steroid-induced cataract. In a study of diabetic patients receiving
renal transplants in the USA only one patient developed a visually-impairing cataract but
lesser degrees of lens opacification were seen in 26 percent of eyes. Fourteen of 55 nondiabetic renal transplant patients were found to have cataract. The case-control study in
Edinburgh did not report on renal failure as such but did find that the mean urea level was
significantly higher in the plasma of cataract patients compared with controls. The level
was not high enough to indicate renal failure. The raised urea levels are still present when
subjects are subdivided by age and sex. Diuretics may raise urea levels and thus
contribute to these differences but when all diabetics and individuals receiving diuretics
were excluded, a relationship between high plasma urea and cataract remained.
Environmental Factors: Ultraviolet Radiation
There is considerable international interest in the association between solar ultraviolet B
(UVB) radiation and cataract. Much of this interest has resulted from concern about the
health effects of the increasing levels of UVB reaching the earths surface as a
consequence of depletion of the stratospheric ozone layer.
Young suggests that sunlight is the primary causal factor in cataractogenesis, and
strongly advocates the widespread distribution of sunglasses to prevent cataract. Harding
on the other hand suggests that sunlight is not a major etiological factor in human cataract
formation.
The lens is known to absorb UVB and UVA and change in lens clarity has been linked
in animal experiments with short-term, high intensity exposure and chronic exposure to
UVB.
Cataract Etiology
33
Epidemiologic studies have demonstrated cataract to be more prevalent in sunny

countries, such as Israel, than in cloudy countries, such as England. Moreover, in
Romania and the United States, cataract are more prevalent in dry hot areas with more
sun exposure within each country than in areas with prolonged cloud cover. The Beaver
Dam Eye Study, found an association between ultraviolet B radiation exposure and
cortical cataract in men only.
The Lens Opacity Case-Control Study did not find an association between sun
exposure and any type of cataract development. However, this study investigated only
urban populations, and this may explain why no association was found. In both the
Italian-American Cataract Study and India-US Case-Control Study, sunlight exposure
was associated with cataract formation. Taylor studied 797 watermen and went to great
lengths to calculate an ultraviolet radiation exposure index on the basis of field variables
such as outdoor hours worked, work location, and attenuation due to spectacle use and
hat cover. He found a significant association between ultraviolet B radiation index and
cortical cataract but found no association with other morphological cataract types.
Bochow et al studied the relationship between ultraviolet radiation exposure and
posterior subcapsular cataract. He not only discovered a significant association but also a
dose-response relationship.
Two unique studies, one prospective and one case-control, provide indirect evidence
that ultraviolet light plays a role in cataract formation. Schein et al studied the
distribution of cortical opacities by lens quadrant in a prospective study of Chesapeake
Bay watermen. The prevalence of cortical lens opacities increased with age, with a high
degree of concordance between eyes. The inferonasal lens quadrant was the most
common location involved both for new cataract development and for progression of
preexisting cataract. Cataract formation in this quadrant was presumed to be the most
consistent with ultraviolet radiation damage on the basis of greater exposure in this area
of the lens. Resnikoff et al studied the association of lens opacities with two other
presumed ultraviolet radiation-associated ocular diseases, climatic droplet keratopathy
and exfoliation syndrome. There was a strong correlation between the diseases in this
case-control study.
Based on the available epidemiological evidence, the following conclusions can be
drawn
There is sufficient experimental evidence that exposure to artificial sources of UVB can
cause lens opacities in laboratory animals.
There is limited evidence suggesting that exposure to solar UVB causes cortical
opacities in humans.
There is also limited evidence suggesting that exposure to solar UVB causes posterior
subcapsular cataract in humans.
The epidemiological evidence is consistent in suggesting that nuclear cataract are not
causally associated with exposure to solar UVB.
Drug Related Factors
A number of well-known and widely used drugs have been implicated in cataract
etiology with oral corticosteroids probably the widest recognized of all.
Phacoemulsification
32
Corticosteroids
In 1930, Hench postulated that a naturally occurring substance might be responsible for
the clinical improvement seen in women with rheumatoid arthritis when they became
pregnant. He called this substance compound E, but it was not until 1948 that this
substance (soon to be called cortisone) was synthesized and became available for clinical
use. In the 50 years since then, corticosteroids have had an enormous impact in medicine,
however it soon became clear that hydrocortisone has significant mineral corticoid as
well as antiinflammatory activity and that this could produce dose-related toxicity It is
now known that the principal naturally occurring corticosteroids secreted by the adrenal
cortex are hydrocortisone (cortisol), a glucocorticoid involved in the regulation of
carbohydrate, protein and lipid metabolism and aldosterone, a mineralocorticoid affecting
fluid and electrolyte balance. Because hydrocortisone also exerts some mineralocorticoid
(salt-retaining) effects, several structurally modified glucocorticoids with relatively
greater antiinflammatory and lower salt-retaining properties were synthesized once the
therapeutic potential of their antiinflammatory and immuno-suppressive properties
became apparent. Antiinflammatory and immunosuppressive effects occur at doses above
the normal physiological levels of daily glucocorticoid production, i.e. at
pharmacological doses. However since many physiological and pharmacological actions
are mediated by the same receptor, it is not surprising that prolonged use of
pharmacological doses can lead to adverse physiological effects.
It is estimated that between 10 to 60 percent of patients using systemic corticosteroids
develop cataract, especially of the posterior subcapsular (PSC) type. Glucocorticosteroids
are lipophilic and therefore diffuse easily across the cell membrane after which they bind
and activate a cytoplasmic glucocorticoid receptor. The resulting receptor steroid
complex enters the cell nucleus, binds to the glucocorticoid response elements on the
DNA and up- or downregulates the expression of corticosteroid-responsive genes with
resultant effects on protein synthesis in target tissues.
FIGURE 1.13 Progession of steroidinduced cataract
Cataract Etiology
35
FIGURE 1.14 Posterior subcapsular

cataract
Several ways have been identified in which corticosteroids may induce cataract formation
(Fig. 1.13) including:
Elevation of glucose level
Inhibition of Na, K-ATPase
Increased cation permeability
Inhibition of glucose-6-dehydrogenase
Inhibition of RNA-synthesis
Loss of ATP
Covalent bonding of steroids to lens proteins.
Posterior subcapsular cataract is the hallmark of steroid cataract (Fig. 1.14). It starts as
fine granular and vacuolated opacities at the posterior aspect of the lens. PSC opacities
occur frequently with high doses (more than 15 mg prednisone or equivalent per day) and
prolonged use (more than one year) of corticosteroids. Clinical trials have shown that
PSC opacities secondary to oral corticosteroids may develop within as short a time as 4
months.
Recent studies have suggested that the use of inhaled corticosteroids may be a
significant risk factor for the development of cataract, may be even more so than the use
of oral corticosteroids. These studies have again pointed out the importance of the firstorder effect. A drug absorbed through the nasal mucosa or conjunctiva drains to the
right atrium and ventricle. The drug is then pumped in part, to the head (i.e. the eye as a
target organ) before returning to the left atrium and ventricle. The second passage is then
to the liver and kidneys, where the drug is metabolized and detoxified. With oral
medicationthe first pass includes absorption from the gut via the liver where,
depending on the drug, more than 90 percent of the drug is detoxified before going to the
right atrium. Therefore, oral medications are metabolized even before the first pass, while
ocular or nasally administered drugs are not metabolized until the second pass. This, in
part, may be a reason why more potent steroid inhalants have greater ocular exposure and
some ocular medications cause significant systemic adverse effects.
Considering the widespread use of corticosteroids and their association with PSC
cataract, clinicians should be aware of a patients medication history and recognize the
distinguishing features of PSC cataract.
Phacoemulsification
34
Allopurinol
Allopurinol is an antihyperuricemic drug widely used for the treatment of hyperuricemia
and chronic gout. It inhibits the terminal step in uric acid synthesis, which results in a
reduction of uric acid concentrations in both serum and urine. In about 85 percent of
patients with gout, serum urate concentrations can be normalized by an allopurinol dose
of 300 mg/d, and in some patients a dose of 100 to 200 mg/d is sufficient. Treatment with
allopurinol is usually well tolerated, with hypersensitivity reactions constituting the most
common adverse effects.
In 1982, Fraunfelder et al reported 30 cases of cortical and subcapsular cataract
associated with long-term use of allopurinol reported to the National Registry of DrugInduced Ocular Side Effects (Oregon Health Sciences University, Portland). The
observed lens changes appeared to have the characteristics of early age-related cataract.
At about the same time, Lerman et al used phosphorescence spectroscopy to demonstrate
in vitro the probable presence of allopurinol in cataractous lenses that had been extracted
from patients treated with allopurinol. The phosphorescence peaks characteristic of
allopurinol could not be demonstrated in lenses from patients who had not ingested
allopurinol. Evidence from epidemiologic studies on the possible cataractogenic effects
of allopurinol is however inconclusive. Two separate epidemiologic studies did not show
an increased risk. Another study reported an unusual morphologic thinning of the anterior
clear zone of the lens in patients receiving long-term treatment with allopurinol. In the
Lens Opacities Case Control Study, wherein gout medications were found to be
associated with a 2.5-fold increased risk of mixed cataract, no distinction was made
between allopurinol and other medications for gout. In a case control study conducted by
Garbe et al using data from the Quebec universal health program for all elderly patients
they established that a clear relationship exists between the long-term administration of
allopurinol and an increased risk for cataract extraction.
Phenothiazines
In 1965, the occurrence of ocular pigmentation and lens opacity in patients on high dose
phenothiazine drugs, particularly chlorpromazine, was reported in several papers.
Phenothiazine has been thought to cause pigmentation by virtue of its ability to combine
with melanin and form a photosensitive product. It is also postulated that this process
might accelerate any predisposition to lens opacification from environmental insults such
as solar radiation. A study involving schizophrenic patients showed an association
between severity or grade of lenticular pigmentation and equivalent dose of
phenothiazine intake. Epidemiologic research on the role of phenothiazines in
cataractogenesis is limited. A case-control study done in North Carolina found a two-fold
increased risk of cataract in those with history of tranquilizer use, although the types of
tranquilizers and cataract were not characterized. A health maintenance organization
based, non-concurrent prospective study that controlled for steroid use and diabetes
documented at least three-fold increased risk for cataract extraction among current and
past (two to five years prior to extraction) users of two groups of tranquilizers:
antipsychotic phenothiazine drugs (chlorpromazine, thioridazine, trifluoperazine,
perphenazine, fluphenazine) and other phenothiazine drugs (chlorperazine,
prochlorperazine, promethazine, trimeprazine).
Cataract Etiology
37
Given the paucity and limitations of available epidemiologic data, more studies, such
as those characterizing the specific types of senile cataract and phenothiazines, are
needed to verify any association.
Diuretics and Antihypertensives
Harding and van Heyningen reported that thiazide diuretics were used less frequently by
patients who underwent cataract surgery than control subjects. More recently, the Beaver
Dam Eye Study found that use of thiazides was associated with lower prevalence of
nuclear cataract and increased prevalence of posterior subcapsular cataract. Several other
studies have found that use of diuretics was associated with increased risk of cataract.
The Beaver Dam Eye Study also found a raised overall risk (OR, 1.3) for potassiumsparing diuretics, but this was not statistically significant. A cataractogenic effect of
potassium-sparing diuretics is biologically plausible, as these diuretics disturb sodium
transport across the lens fiber membrane.
The calcium channel blocker nif edipine has been associated with increased risk of
cataract extraction and angiotensin-converting enzyme inhibitors with decreased risk of
nuclear cataract. Hypertension and other cardiovascular conditions is a potential
confounding problem in studies of cataract and antihypertensive medications, including
diuretics.
Antimalarial Drugs
Most drugs used in the treatment of malaria produce phototoxic side effects in both the
skin and the eye. Cutaneous and ocular effects that may be caused by light include:
cataract formation, changes in skin pigmentation, corneal opacity and other visual
disturbances including irreversible retinal damage (retinopathy) leading to blindness. The
mechanism for these reactions in humans is unknown. A number of studies have been
published that suggest a strong relationship between chloroquine use and cataract
formation. The basis of the relationship seems to lie in the phototoxicity of chloroquine
and related drugs.
Because malaria is a disease most prevalent in regions of high light intensity,
protective measures (clothing, sunblock, sunglasses or eye wraps) should be
recommended whilst taking antimalarial drugs.
Amiodarone
Amiodarone hydrochloride is a benzofurane derivative used for cardiac abnormalities. Its
use is commonly associated with an asymptomatic keratopathy. The antiarrhythmic drug
also produces anterior subcapsular lens opacities that are usually asymptomatic. Anterior
subcapsular lens opacities were observed in 7 of 14 patients treated with moderate to high
doses of amiodarone at the Veterans Administration Medical Center in San Francisco in
1982. In 1993, a report was published that summarized the status of these same 14
patients 10 years later. Anterior subcapsular lens opacities developed or progressed in all
patients continuing treatment with this antiarrhythmic agent during the ensuing 10-year
interval. Although Snellen visual acuities were not decreased, subtle visual impairment
Phacoemulsification
36
was present as measured by contrast sensitivity measurements with and without glare.
The authors of the report concluded that decrease in visual acuity should not be a
contraindication for therapy with this potentially life saving drug.
FIGURE 1.15 Tempo of lens

opacification with Vastatin therapy
Hypocholesterolemic Drugs
Cataract in animals and men are in some instances associated with genetic defects in
enzymes that regulate cholesterol metabolism and the use of drugs which inhibit lens
cholesterol biosynthesis. The basis of this relationship apparently lies in the need of the
lens to satisfy its sustained requirement for cholesterol by on-site synthesis, and
impairing this synthesis can lead to alteration of lens membrane structure. The lens
membrane contains the highest cholesterol content of any known membrane. The genetic
defects Smith-Lemli-Opitz syndrome, mevalonic aciduria, and cerebrotendinous
xanthomatosis all involve mutations in enzymes of cholesterol metabolism, and affected
patients can develop cataract. Questions about the ocular safety of drugs, which can
inhibit lens cholesterol biosynthesis, persist. Concern over potential damage to the lens
from the use of hypocholesterolemic drugs stems from the reports in 1962 by Kirby et al
and Laughlin et al that treatment of patients with Triparanol (Mer 29, Wm. S.Merrel Co.)
to lower blood cholesterol was associated with development of cataract. Drugs used to
lower blood cholesterol are among the most widely prescribed medicines. One drug in the
group, lovostatin (Mevacor, Merck), is alone the third most prescribed drug in the United
States. This drug can inhibit cholesterol synthesis in lens and produce cataract in dogs.
Whether these drugs inhibit cholesterol biosynthesis in human lenses at therapeutic doses
is unknown.
The clinical safety trials indicate that treatment with lovastatin for up to five years
does not significantly increase the development of cataract or grossly alter visual
function. The ocular safety in an older patient population (>50 years) appears high. This
seems also to apply to simvastin, except that one clinical trial showed a significant
increase in cortical opacities with the use of this drug (Fig. 1.15).
Cataract Etiology
39
An unpublished study conducted at the University of Stellenbosch Medical School

found that the rate at which opacification occurs in dyslipidemic patients on Cerivastatin
was 4.5 percent per year (Fig. 1.15). Although this rate of opacification is not statistically
noteworthy it would seem that if this data is projected over a period of 20 years and
compared the normal rate of opacification reported by Boccuzzi and Leino et al, an
alarming amount of opacities would be present in the group of patients on cerivistatin.
Hypolipidemic drugs are intended for life-long use and patients as young as 18 years
can receive these drugs. Although the human lens grows throughout life, the rate of
growth is slow after 10 years of age. About 40 years are required for the lens cortex to
double in width. The size of the nucleus remains essentially constant after 10 years of
age. Thus, the consequences of inhibiting lens growth due to block of cholesterol
biosynthesis may be difficult to assess in only a 1 to 5 year period. A considerable body
of evidence indicates that sustained alteration of lens sterol content and composition due
to genetic mutations or exposure to drugs can lead to altered lens clarity. Long-term
ocular safety of the vastatin drugs should perhaps be viewed in units of 10 to 20 years.
Certainly a 20-year-old person required to have cataract surgery at age 40 because of
some chronic treatment would constitute a medical crisis for this individual, particularly
if a less toxic treatment had been available. The question of whether the vastatin drugs
inhibit lens cholesterol biosynthesis in humans treated with standard therapeutic doses is
unanswered. Since very low concentrations of lovastatin and simvastatin are required to
inhibit cholesterol synthesis in animal lenses (322 nM), and only five times the
therapeutic dose of lovostatin decreased cholesterol accumulation by the rat lens, it at
least appears possible that therapeutic doses could inhibit lens cholesterol biosynthesis in
humans.
Conclusion
Human lenticular opacification leading to the clinical challenge of cataract formation is
etiologically multifactorial. It does seem however that evidence is slowly mounting to
encourage clinicians to consider cataract as belonging to the growing list of preventable
ocular diseases.
Further Reading
1. Adler NE, Boyce T, Chesney MA et al: Socioeconomic inequalities in health. No easy solution.
JAMA 269:314045, 1993.
2. Alden ER, Ralina RE, Hodson WA: Transient cataract in low-birth-weight infants. J Pediatr
82:31831, 1973.
3. Amaya LG, Speedwell L, Taylor D: Contact lenses for infant aphakia. Br J Ophthalmol 74:154
56, 1990.
4. Ames GM, Janes CR: Heavy and problem drinking in an American blue-collar population:
implications for prevention. Soc Sci Med 8:94960, 1987.
5. Ansari NH, Awasthi YG, Srivastava SK: Role of glycosylation in protein disulphide formation
and cataractogenesis. Exp Eye Res 31:919,1980.
Phacoemulsification
38
6. Armitage MM, Kivun JD, Farrell RE: A progressive early onset cataract gene maps to human
chromosome 17q24. Nature Facet 93740, 1995.
7. Assmann et al: Lipid Metabolism Disorders and Coronary Heart Disease. MMV-Medizin-Verl
(2nd ed), 1993.
8. Baghdassarian SA, Tabbara KF: Childhood blindness in Lebanon. Am J Ophthalmol 79:82730,
1975.
9. Bandmann O, Vaughan J, Holmans P et al: Association of slow acetylator genotype for NAcetyltransferase 2 with familial Parkinsons disease. Lancet 350:113639, 1997.
10. Barnes PJ: Anti-inflammatory mechanisms of glucocorticoids. Biochem Soc Trans 23:94045,
1995.
11. Behrens-Baumann W, Thiery J, Wieland E et al: 3-Hydroxy-3-methylglutaryl coenzymea
reductase inhibitor simvastatin and the human lens: clinical results of 3-year follow-up.
Arzneim-Forsch 42(11):102324, 1992.
12. Beigi B, OKeefe M, Bowell R et al: Ophthalmic findings in classical galactosaemia
prospective study. Br J Ophthalmol 77:162464, 1993.
13. Belpoliti M, Maraini G: Sugar alcohols in the lens epithelium of age-related cataract. Exp Eye
Res 56:36, 1993.
14. Benos DJ: Amiloride: a molecular probe of sodium transport in tissues and cells. Am J Physiol
242:C13145, 1982.
15. Benson WH, Farber ME, Caplan RJ: Increased mortality rates after cataract surgery: a
statistical analysis. Ophthalmology 95:128892, 1988.
16. Berger J, Shepard D, Morrow F et al: Relationship between dietary intake and tissue levels of
reduced and total vitamin C in the guinea pig. J Nutr 119:17, 1989.
17. Bernstein HN: Chloroquine ocular toxicity. Surv Ophthalmol 12(5):41547, 1967.
18. Bhatnagar R, West KP (Jr), Vitale S et al: Risk of cataract and history of severe diarrheal
disease in Southern India. Arch Ophthalmol 109:69699,1991.
19. Bhuyan KC, Bhuyan DK, Podos SM: Free radical enhancer xenobiotic is an inducer of cataract
in rabbit. Free Radical Res Comm 1213:60920,1991.
20. Bhuyan KC, Bhuyan DK, Podos SM: Lipid peroxidation in cataract of the human. Life Sci
38:146371, 1986.
21. Bialas MC, Routledge PA: Adverse effects of corticosteroids. Adverse Drug React Toxicol Rev
17(4):22735, 1998.
22. Bjrkhem, I Boberg KM: Inborn errors in bile biosynthesis and storage of sterols other than
cholesterol. Metabolic Basis of Inherited Disease; New York, McGraw-Hill 7: 207399, 1995.
23. Blondin J, Baragi VJ, Schwartz E et al: Delay of UV-induced eye lens protein damage in
guinea pigs by dietary ascorbate. Free Radic Biol Med 2:27581, 1986.
24. Boccuzzi SJ, Bocanegra TS, Walker JF et al: Long-term safety and efficiency profile of
simvastatin. Am J Cardiol 86:112731, 1991.
25. Bochow TW, West SK, Axar A et al: Ultraviolet light exposure and risk of posterior
subcapsular cataract. Arch Ophthalmol 107:36972, 1989.
26. Bonting SJ: NaK activated adenosine triphosphatase and active cation transport in the lens.
Invest Ophthalmol 4:723, 1965.
27. Brauweiler PH, Wehler T, Busin M. High incidence of cataract formation after implantation of
a silicone posterior chamber lens in phakic, highly myopic eyes. Ophthalmology 106(9):1651
55, 1999.
28. Brilliant LB, Grasset NC, Pokrel RP et al: Associations among cataract prevalence, sunlight
hours and altitude in the Himalayas. Am J Epidemiol 118:25064, 1983.
29. Brown CA, Burman D: Transient cataract in a diabetic child with hyperosmolar coma. Br J
Ophthalmol 57:42933, 1973.
30. Burke JP, OKeefe M, Bowell R et al: Ophthalmic findings in classical galactosemia: a
screened population. Pediatr Ophthal Strabismus 26:16568, 1989.
31. Caird Fl, Pirie A, Ramsell TG: Diabetes and the Eye. Blackwell Scientific: Oxford 1969.
Cataract Etiology
41
32. Caird Rl, Hutchinson M, Pirie A: Cataract and diabetes. BMJ 2:66568, 1964.
33. Cenedella RJ: Cholesterol and cataract. Surv Ophthalmol 40: 32037, 1996.
34. Chatterjee A, Milton RC, Thyle S: Prevalence and aetiology of cataract in Punjab. Br J
Ophthalmol 66:3542, 1982.
35. Chiba M, Masironi R: Toxic and trace elements in tobacco and tobacco smoke. Bull World
Health Organ 70:27076, 1992.
36. Christen WG, Manson JE, Seddon JM et al: A prospective study of cigaret smoking and risk of
cataract in men. JAMA 268:98993, 1992.
37. Chylack LT Jr, Henriques H, Tung W: Inhibition of sorbitol production in human lenses by an
aldose reductase inhibitor. Invest Ophthalmol Vis Sci 17: ARVO (Suppl): 300, 1978.
38. Cigala O, Pancallo MT, Della Valle M et al: La simvastatina nel trattamento delle
piercolesterolemie. La Clinica Terapeu 137:33337, 1991.
39. Clair WK, Chylack LTJ, Cook EF et al: Allopurinol use and the risk of cataract formation. Br J
Ophthalmol 73:17376, 1989.
40. Clayton RM, Cuthbert J, Duffy J et al: Some risk factors associated with cataract in SE
Scotland: a pilot study. Trans Ophthalmol Soc UK 102:33136, 1982.
41. Clayton RM, Cuthbert J, Philips CJ et al: Analysis of individual cataract patients and the
lenses: a progress report. Exp Eye Res 31:55366.
42. Clayton RM, Cuthbert J, Philips CJ et al: Epidemiological and other studies in the assessment
of factors contributing to cataractogenesis. Ciba Fdn Symp 106:2547, 1984.
43. Clayton RM, Cuthbert J, Philips CJ et al: Some risk factors associated with cataract in SE
Scotland: A pilot study. Trans Ophthalmol Soc UK, 102:33136, 1982.
44. Clayton RM, CuthbertJ, Phillios CI et al: Analysis of individual cataract patients and their
lenses: a progress report. Exp Eye Res 1980; 31:55356.
45. Cohen DL, Neil HA, Sparrow J et al: Lens opacity and mortality in diabetes. Diabetic Med
7:61517, 1990.
46. Collman GW, Shore DL, Shy CH et al: Sunlight and other risk factors for cataract: an
epidemiological study. Am J Public Health 78:145962, 1988.
47. Cooperative Study of Lipoproteins and Atherosclerosis. Evaluation of serum lipoprotein and
cholesterol measurements as predictors of clinical complications of atherosclerosis. Circulation
14.2:691741, 1956.
48. Cotlier E, Kwan B, Beatty C: The lens as an osmometer. Bioctfm Biophys Acta 150:705, 1968.
49. Cotlier E, Rice P: Cataract in the Smith-Lemli-Opitz syndrome. Am J Ophthalmol 72:95559,
1971.
50. Cotlier E: Congenital rubella cataract. In Cotlier E, Lambert SR, Taylor D (Eds): Congenital
Cataract. RG Landes/ CRC: Boca Raton, 6576, 1994.
51. Cotlier E: Congenital varicella cataract. Am Ophihalmol 86: 62729, 1978.
52. Cruickshanks KI, Klein BEK, Klein R: Ultraviolet light exposure and lens opacities: the Beaver
Dam Eye Study. Am J Public Health 82:165862, 1992.
53. Cuthbert J, Clayton RM, Philips: Cuneiform cataract: a special case? Colloq DINSERM,
147:38796.
54. Dawber TR: The Framingham Study: The Eipidemiology of Atherosclerotic Disease.
Cambridge Harvard University Press: London 1980.
55. de Vries ACJ, Cohen LH: Different effects of the hypolipidemic drugs pravastatin and
lovastatin on the cholesterol biosynthesis of the human ocular lens in organ culture and on the
cholesterol content of the rat lens in viva. Biochim Biophys Acta 1167:6369, 1993.
56. Dohi K, Fukuda K et al: Cataract in kidney transplant patients. Horishima J Med Sci 33:275
78, 1984.
57. Dolan BJ, Flach AJ, Peterson JS: Amiodarone keratopathy and lens opacities. J Am Optom
Assoc 56(6):46870, 1985.
58. Donahue RP, Bias WB, Renwickj H et al: Probable assignment of the Duffy blood group locus
to chromosome I in man. Proc Natl Acad Sci USA 61:94955, 1968.
Phacoemulsification
40
59. Dorlands Illustrated Medical Dictionary (28th edn) WB Saunders: Philadelphia 276.
60. Drack AV, Burke JP, Pulido JS et al: Transient punctate lenticular opacities as a complication
of argon laser photoablation in an infant with retinopathy of prematurity. Am J Ophthalmol
113:58384, 1992.
61. Drews RC: Alcohol and cataract. Arch Ophthalmol 111:1312, 1993.
62. Drews RC: Ethanol cataract. In Solanes M (Ed): XXI Concilium Ophthalmologicum Mexico
1970. Amsterdam: the Netherlands Exerpta Medica 75358, 1970.
63. Duncan G, Hightower KR, Gandolfi SA, Tomlinson J, Maraini G: Human lens membrane
cation permeability increases with age. Invest Ophthalmol Vis Sci 30:185559, 1989.
64. Dunn JP, Jabs DA, Wingard JC et al: Bone marrow transplantation and cataract development.
Arch Ophthalmol 11:136773, 1993.
65. Duthie GG, Arthur JR, James WP: Effects of smoking and vitamin E on blood antioxidant
status. Am J Clin Nutr 53(Suppl):1061S64S, 1991.
66. Ederer F, Hiller R, Taylor HR: Senile lens changes and diabetes in two population studies. Am J
Ophthalmol 91: 38195, 1981.
67. Eiberg H, Marner E, Rosenberg T et al: Marners cataract (AM) assigned to chromosome 16:
linkage to haptoglobin. Clin Cenet 34:27275, 1988.
68. Elsas U II, Fridovich-Keil JL, Leslie ND: Galactosemia: a molecular approach to the enigma.
Pediatr 8:10109, 1993.
69. Elsas U, Dembure PP, Langley S et al: A common mutation associated with the Duarte
galactosemia allele. Am J Hum Cenet 54:103036, 1994.
70. El-Yazigi A, Johansen K, Raines DA et al: N-Acetylation Polymorphism and diabetes mellitus
among SaudiArabians. J Clin Pharmacol 32(10):90510, 1992.
71. Emmelot P: The organization of the plasma membrane of mammalian cells: structure in relation
to function. In Jamieson GA, Robinson DM (Eds): Mammalian Cell Membranes, Butterworths:
Boston, 2:154, 1977.
72. Emmerson BT: The management of gout. N Engl J Med 446: 44551, 1996.
73. Epstein FH: Cardiovascular Disease Epidemiology; A Journey from the Past Into the Future.
Circulation 93:175564,1996.
74. Erdman J: The physiologic chemistry of carotenes in man. Am J Clin Nutr 7:101106,1988.
75. Fechner PU: Cataract formation with a phakic IOL. J Cataract Refract Surg 25(4):461
62,1999.
76. Fink AM, Gore C, Rosen E: Cataract development after implantation of the Staar Collamer
posterior chamber phakic lens. J Cataract Refract Surg 25(2):27882, 1999.
77. Finley SC, Finley WH, Monsky DM: Cataract in girl with features of Smith-Lemli-Opitz
syndrome. J Pediatr 75:70607, 1969.
78. Flach AJ, Dolan BJ, Sudduth B et al: Amiodarone-induced lens opacities. Arch-Ophthalmol
101(10):155456, 1983.
79. Flach AJ, Dolan BJ: Progression of amiodarone induced cataract. Doc Ophthalmol 83(4):323
29, 1993.
80. Flaye DE, Sullivan KN, Cullinan TR et al: Cataract and cigaret smoking: the City Eye Study.
Eye 3:37984, 1989.
81. Francois J: Congenital Cataract, Charles C Thomas (Ed): Springfield, 1963.
82. Francois J: Late results of congenital cataract surgery. Ophthalmol 86:158698, 1979.
83. Franfelder FT: Do inhaled corticosteroids significantly increase cataract surgery in elderly
patients? Arch Ophthalmol 116:1369, 1998.
84. Fraunfelder FT, Hanna C, Dreis MW et al: Cataract associated with allopurinol therapy. Am J
Ophthalmol 94: 13740, 1982.
85. Friend J, Chylack LT, Khu P et al: The MSDRL Study Group: Lack of human cataractogenic
potential of lovastatin: results of three year study. Invest Ophthalmol Vis Sci 33: 1301, 1992.
86. Garbe E, Suissa S, LeLorier J: Exposure to allopurinol and the risk of cataract extraction in
elderly patients. Arch Ophthalmol 116:165256, 1998.
Cataract Etiology
43
87. Garner MH, Spector A: ATP hydrolysis kinetics by Na, K-ATPase in cataract. Exp Eye Res
42:33948, 1986.
88. Gibbs ML, Jacobs M, Wilkie AOM et al: Posterior lens. Surv Ophthalmol 40(6):1996.
89. Giblin FJ, Padgaonkar VA, Leverenz VR et al: Nuclear light scattering, disulfide formation and
membrane damage in lenses of older guinea pigs treated with hyperbaric oxygen. Exp Eye Res
60:21935, 1995.
90. Giblin FJ, Schrimscher L, Chakrapani B et al: Exposure of rabbit lens to hyperbaric oxygen in
vitro: regional effects on GSH level. Invest Ophthalmol Vis Sci 29:131219, 1988.
91. Glynn RJ, Christen WG, Manson JE et al: Body Mass Indexan independent predictor of
cataract. Arch Ophthalmol 113:113137, 1995.
92. Gofman et al: The role of lipids and lipoproteins in atherosclerosis. Science 111:16671, 1950.
93. Gretton C: Like falling off a cliff. Med Ad News 325, 1994.
94. Grundy SM: HMG-KoA reductase inhibitors for treatment of hypercholesterolemia. N Engl J
Med 319:24:33, 1988.
95. Gumming RG, Mitchell P, Leeder SR: Use of inhaled corticosteroids and the risk of cataract. N
Engl J Med 337: 814, 1997.
96. Hankinson SE, Seddon JM, Colditz et al: A prospective study of aspirin use and cataract
extraction in women. Arch Ophthalmol 111:50308, 1989.
97. Hankinson SE, Stampfer MJ, Seddon JM et al: Intake and cataract extraction in women: a
prospective study. Br Med J 305:33539, 1992.
98. Hankinson SE, Willet WC, Colditz GA et al: A prospective study of cigaret smoking and risk
of cataract surgery in woman. JAMA 268:99498,1992.
99. Harding J: Cataract: Biochemistry, Epidemiology and Pharmacology. Chapman and Hall:
London, 12223, 1991.
100. Harding JJ, Crabe MJC: The lens: development, proteins, metabolism and cataract. In
Davidson H (Ed): The Eye, Academic Press: London, 207492.
101. Harding JJ, Egerton M, Harding RS: Protection against cataract by aspirin, paracetamol and
ibuprofen. Acta Ophthalmol 67:51824, 1989.
102. Harding JJ, Harding RS, Egerton M: Risk factors for cataract in Oxfordshire: diabetes,
peripheral neuropathy, myopia, glaucoma and diarrhoea. Acta Ophthalmol 67:51017, 1989.
103. Harding JJ, van Heyningen R: Beer, cigarets and military work as risk factors for cataract. Dev
Ophthalmol 17:1316.1989.
104. Harding JJ, van Heyningen R: Drugs including alcohol that act as risk factors for cataract and
possible protection against cataract by aspirin like drugs. Br J Ophthalmol 73: 57980, 1989.
105. Harding JJ, van Heyningen R: Drugs including alcohol, that act as risk factors for cataract, and
possible protection against cataract by aspirin-like analgesics and cyclopenthiazide. Br J
Ophthalmol 72:80914,1988.
106. Harding JJ: Cataract Biochemistry, Epidemiology and Pharmacology. Chapman and Hall
11618, 1991.
107. Harding JJ: Physiology, biochemistry, pathogenesis, and epidemiology of cataract. Curr
Opinion Ophthalmol 3:312, 1992.
108. Harding JJ: Possible causes of the unfolding of proteins in cataract and a new hypothesis to
explain the high prevalence of cataract in some countries. In Regnault F, Hockwin O, Courtois
Y (Eds): Ageing of the lens. Proceedings of the symposium on the aging of the lens held in
Paris, September 1979. Biomedical Press: Amsterdam, 7180, 1980.
109. Havel et al: Lovastatin (Mevolin) in the treatment of heterozygous familial
hypercholesterolemia. Ann Intern Med 107:60915, 1987.
110. Hayes RB, Bi W, Rothman N et al: N-Acetylation phenotype and genotype and risk of bladder
cancer in benzidine-exposed workers. Carcinogenesis (United States); 14(4): 67578, 1993.
111. Henkj M, Whitelocke RAF, Warrington A1P et al: Radiation dose to the lens and cataract
formation. Radiat Oncol Biol Phys 25:81520, 1993.
Phacoemulsification
42
112. Hesker H: Antioxidative vitamins and cataract in the elderly. Z Ernahrungswiss 34:16776,
1995.
113. Hiller R, Giacometti L, Yuen K: Sunlight and cataractan epidemiologic investigation. Am J
Epidemiol 105:1977.
114. Hiller R, Sperduto RD, Ederer F: Epidemiologic associations with cataract in the 19711972
National Health and Nutrition Examination Survey. Am J Epidemiol 118: 23949, 1983.
115. Hiller R, Sperduto RD, Ederer F: Epidemiologic associations with nuclear, cortical, and
posterior subcapsular cataract. Am J Epidemiol 124:91625, 1986.
116. Hiller R, Yuen K: Sunlight and cataract: an epidemiological investigation. Am J Epidemiol
105:45059, 1977.
117. Hing S, Speedwell L, Taylor D: Lens surgery in infancy and childhood. Br J Ophthalmol
74:7377, 1990.
118. Hockwin O, Koch H: Cataract of toxic etiology. In Bellows (Ed): Cataract and Abnormalities
of the Lens. Grune and Stratton 23445, 1975.
119. Hoffmann G, Gibson KM, Brandt IK et al: Mevalonic aciduria: an inborn error of cholesterol
and nonsterol isoprene biosynthesis. N Engl J Med 314:161014, 1986.
120. Holowich F, Boateng A, Kolck B: Toxic Cataract. In Bellows JG (Ed): Cataract and
Abnormalities of the Lens. Grune and Stratton: New York 23043, 1975.
121. Hunninghake et al: Lovastatinfollow up ophthalmological data. JAMA 259:35455, 1988.
122. Hyman L: Epidemiology of eye disease in the elderly. Eye 1:33041, 1987.
123. Jaafar MS, Robb RM: Congenital anterior polar cataract. Ophthalmology 91:24954, 1984.
124. Jackson RC: Temporary cataract in diabetes mellitus. Br J Ophthalmol 39:62931, 1955.
125. Jacques PF, Chylack LT (Jr): Epidemiologic evidence of a role for the antioxidant vitamins
and carotenoids in cataract prevention. Am J Clin Nutr 53:352S55S, 1991.
126. Jacques PF, Taylar A, Hankinson SE et al: Long-term vitamin C supplement use and
prevalence of early age-related lens opacities. Am J Clin Nutr 66:91116, 1997.
127. Jahn CE, Janke M, Winowski H et al: Identification of metabolic risk factors for posterior
subcapsular cataract. Ophthalmic Res 18:11216,1986.
128. Jay B, Black RE, Wells RS: Ocular manifestations of ichthyosis. Br J Ophthalmol 52:21726,
1968.
129. Jedziniak JA, Chylack LT Jr, Cheng HM et al: The sorbitol pathway in the human lens: aldose
reductase and polyol dehydrogenase. Invest Ophthalmol Vis Sci 20:31426, 1981.
130. Jick H, Brandt DE: Allopurinol and cataract. Am J Ophthalmol 98:35558, 1984.
131. Kahn HA, Leibowitz HM, Ganley JP et al: The Framingham Eye Study. IIAssociation of
ophthalmic pathology with single variables previously measured in the Framingham Heart
Study. Am J Epidemiolo 106:3341, 1977.
132. Kahn MU, Kahn MR, Sheikh AK: Dehydrating diarrhoea and cataract in rural Bungladesh.
Ind J Med Res 85:31115, 1987.
133. Kallner AB, Hartmann D, Horning DH: on the requirements of ascorbic acid in men: steadystate turnover and blood pool in smokers. Am J Clin Nutr 34:134755, 1981.
134. Kanski JJ: Clinical Ophthalmology (3rd edn). Butterworth-Heineman: Oxford. 289, 1994.
135. Kasai K, Nakamura T, Kase N et el: Increased glycosylation of proteins from cataractous
lenses in diabetes. Dia-betologia 25:3638, 1983.
136. Kench PS, Kendall EC, Slocumb CH, Polley HF: The effect of a hormone of the adrenal
cortex (17-hydroxy-11-dehydrocorticosterone; compound E) and of pituitary and
adrenocorticotrophic hormone on rheumatoid arthritis. Mayo Clin Prvc 4:18197, 1949.
137. Keys A: Atherosclerosis: a problem in newer public health. J Mt Sinai Hosp 20:11839, 1953.
138. Kirby TJ, Achor RWP, Perry HO et al: Cataract formation after triparanol therapy. Arch
Ophthalmol 68:48689,1962.
139. Klein BEK, Klein R, Jensen SC et al: Hypertension and lens opacities from the Beaver Dam
Eye Study. Am J Ophthalmol 119:64046, 1995.
Cataract Etiology
45
140. Klein BEK, Klein R, Lee KE: The incidence of age-related cataract, the Beaver Dam Eye
Study. Arch Ophthalmol 116: 219, 1998.
141. Klein BEK, Klein R, Linton KL et al: Cigaret smoking and lens opacities: the Beaver Dam
Eye Study. Am J Prev Med 9:2730, 1993.
142. Klein BEK, Klein R, Linton KL et al: The Beaver Dam Eye Study: the relation of age-related
maculopathy to smoking. Am J Epidemiol 137:190200, 1993.
143. Klein BEK, Klein R, Moss SE: Prevalence of cataract in a population-based study of persons
with diabetes mellitus. Ophthalmology 92:119196, 1985.
144. Klein BEK, Klein R, Ritter LL: Is there evidence of an estrogen effect on age-related lens
opacities? The Beaver Dam Eye Study. Arch Ophthalmol 112:8591, 1994.
145. Klein R, Klein BEK, Jenses SC et al: The relation of socioeconomic factors to age-related
cataract, maculopathy, and impaired vision. Ophthalmology 101(21):196979.
146. Klein R, Klein BEK, Moss SE: Visual impairment in diabetes. Ophthalmology 91:18,1984.
147. Klein R, Moss SE, Klein BE et al: Relation of ocular and systemic factors to survival in
diabetes. Arch Intern Med 149:26672, 1989.
148. Kleinman NJ, Spector A: The relationship between oxidative stress, lens epithelial cell DNA
and cataractogenesis. Exp Eye Res 55(Suppl):1 (abstract 807), 1992.
149. Koga T, Shimada Y, Kuroda M et al: Tissue-selective inhibition of cholesterol synthesis in
viva by pravastatin sodium, a 3-hydroxy-3-methylglutaryl coenzyme: a reductase inhibitor.
Biochim Biophys Acta 1045:11520, 1990.
150. Khler L, Stigmar G: Vision screening of four-year-old children. Acta Paediatr Scand 62:17
27, 1973.
151. Kreines K, Rowe KW: Cataract and adult diabetes. Ohio Med J 75:78286, 1979.
152. Kretzer FL, Hittner HM, Mehta RS: Ocular manifestations of the Smith-Lemli-Opitz
syndrome. Arch Ophthalmol 99: 200006,1981.
153. Kuchle M, Schonherr U, Dieckmann U: Risk factors for capsular rupture and vitreous loss in
extracapsular cataract extraction. The Erlangen Ophthalmology Group. Fortschr Ophthalmol
86:41721, 1989.
154. Kuriyama M, Fujiyama J, Yoshidome H et al: Cerebrotendinous xanthomatosis: clinical and
biochemical evaluation of eight patients and review of the literature. J Neurol Sci 102:22532,
1991.
155. Kuzma JW, Kissinger DG: Patterns of alcohol and cigarette use in pregnancy. Neurobehav
Toxicol Teratol 3:21121, 1981.
156. Lambert SR, Taylor D, Kriss A et al: Ocular manifestations of the congenital varicella
syndrome. Arch Ophthalmol 107: 5256, 1989.
157. Laqua H: Kataract bei chronisher Nierensuffinzeinz und Dialysebehanlung. Klin MB1
Augenheilk 160:34649, 1972.
158. Laties AM, Shear CL, Lippa EA et al: Expanded clinical evaluation of lovastatin (EXCEL)
study results II. Assessment of the human lens after 48 weeks of treatment with lovastatin. Am J
Cardiol 67:44753, 1991.
159. Laughlin RC, Carey TF: Cataract in patients treated with triparanol. JAMA 181:33940, 1962.
160. Laurent M, Kern P, Regnault F: Thickness and collagen metabolism of lens capsule from
genetically prediabetic mice. Ophthalmic Res 13:93, 1981.
161. Law MR, Wald NJ: An ecological study of serum cholesterol and ischeamic heart disease
between 1950 and 1990. Eur J Clin Nutr 48:30525, 1994.
162. Leino M, Pyorala K, Lehto S et al: Lens opacities in patients with hypercholesterolemia and
ischemic heart disease. Doc Ophthalmol 80:30915, 1992.
163. Lerman S, Megaw JM, Fraunfelder FT: Further studies on allopurinol therapy and human
cataractogenesis. Am J Ophthalmol 97:20509, 1984.
164. Lerman S, Megaw JM, Gardner K: Allopurinol therapy and cataractogenesis in humans. Am J
Ophthalmol. 94:14146, 1982.
Phacoemulsification
44
165. Lerman S, Moran M: Sorbitol generation and its inhibition by Sorbinil in the aging normal
human and rabbit lens and human diabetic cataract. Ophthalmic Res 20:34852, 1988.
166. Leske MC, Chylack LT (Jr), He Q et al: The LSC Group: Antioxidant vitamins and nuclear
opacitiesThe longitudial study of cataract. Ophthalmology 105:83136, 1998.
167. Leske MC, Chylack Lt (Jr), Wu S: The lens opacities case-control study: Risk factors for
cataract. Arch Ophthalmol 109:24451, 1991.
168. Leske MC, Connel AMS, Schadat A: Prevalence of lens opacities in the Barbados Eye Study.
Arch Ophthalmol 115: 105, 1997.
169. Lessel S, Forbes AP: Eye signs in Turners syndrome. Arch Ophthalmol 76:21113, 1966.
170. Letson RD, Desnick RJ: Punctate lenticular opacities in Type II mannosidosis. Am J
Ophthalmol 85:21824, 1978.
171. Leveille PJ, Weidruch R, Walford RL et al: Dietary restriction retards age-related loss of
gamma crystalline in the mouse lens. Science 224:124749, 1998.
172. Liang J, Chakrabarti B: Sugar-induced change in near ultraviolet circular dichroism of alphacrystallin. Biochem Biophys Res Commun 102:180,1981.
173. Libondi T, Menzione M, Auricchio G: In vitro effect of alpha-tocopherol on
lysophosatiphatidylcholine-induced lens damage. Exp Aye Res 40:66166, 1985.
174. Lim R, Mitchell P, Gumming RG: Refractive associations with cataract: the Blue Mountains
Eye Study. Invest Ophthalmol Vis Sci 40(12):302126, 1999.
175. Lin LR, Reddy VN, Giblin FJ et al: Polyol accumulation in cultured human lens epithelial
cells. Exp Eye Res 52:93100, 1991.
176. Liu CS, Brown NA, Leanard TJ et al: The prevalence and morphology of cataract in patients
on allopurinol treatment. Eye 2:60006,1988.
177. Lovastatin Study Group II: Therapeutic response to lovastatin (mevolin) in non-familial
hypercholesterolemia. JAMA 260:35966, 1988.
178. Lovastatin Study Group III: A multicenter comparison of lovastatin and cholestyramine
therapy for severe primary hypercholesterolemia. JAMA 260:35966, 1988.
179. Lovastatin Study group IV: A multicenter comparison of lovastatin and probucol for treatment
of severe primary hypercholesterolemia. Am J Cardiol 66:22B30B, 1990.
180. Lubkin VL: Steroid cataracta review and conclusion. J Asthma Res 14:5559, 1977.
181. Lubsen NH, Renwickjfl, Tsui LC et al: A locus for a human hereditary cataract is closely
linked to the gamma-crystallin gene family. Proc NatI Acad Sri USA 84:48992, 1987.
182. Machlin LJ, Bendich A: Free radical tissue damage: protective role of antioxidants. FASEB J
1:44145, 1987.
183. Marais JS: The Cape Coloured People 1652 to 1932 (1st edn) 131. Witwatersrand University
Press: Johannesburg, 1957.
184. Mares-Perlman JA, Brady WE, Klein BEK et al: Diet and nuclear lens opacities. Am J
Epidemiol 141:32234, 1995b.
185. Mares-Perlman JA, Klein BEK, Klein R et al: Relation between lens opacities and vitamin
and mineral supplement use. Ophthalmology 101:31525, 1994.
186. Marinho A, Neves MC, Pinto MC et al: Posterior chamber silicone phakic intraocular lens. J
Refract Surg 13(3):21922, 1997.
187. Marmot MG, Kogevinas M, Elston MA: Social/economic status and disease. Ann Rev Public
Health 8:11135, 1987.
188. Marmot MG, Smith GD, Stansfeld S et al: Health inequalities among British civil servants:
the Whitehall II study. Lancet 337:138793, 1991.
189. Matthews KA, Kelsy SF, Meilahn EN et al: Educational attainment and behavioral and
biologic risk factors for coronary heart disease in middle-aged women. Am J Epidemiol
129:113244, 1989.
190. McCarty CA, Mukesh BN, Fu CL et al: The epidemiology of cataract in Australia. Am J of
Ophthal 128(4):44665, 1999.
Cataract Etiology
47
191. McCornsick AQ: Transient cataract in prensature infants:a new clinical entity. Can J
Ophthalmol 3:30208, 1968.
192. Meltzer EO: Prevalence, economic, and medical impact of tobacco smoking. Ann Allergy
73:38191, 1994.
193. Merin S, Crawbird S: The etiology of congenital cataract. Can J Ophthalmol 6:178284,
1971.
194. Merits S, Craw S: Hypoglycemia and infantile cataract. Arch Ophthalmol 86:49598, 1993.
195. Micozzi MS, Beecher GR, Taylor HR et al: Carotenoid analyses of selected raw and cooked
foods associated with a lower risk for cancer. J Natl Cancer Inst 82:28285, 1990.
196. Minassian DC, Mehra V, Jones BR: Dehidrational crisis from severe diarrhoea or heatstroke
and risk factor for cataract. Lancet 1:75153, 1984.
197. Minassian DC, Mehra V, Jones BR: Dehidrational crisis: a major risk factor in the risk of
blinding cataract. Br J Ophthalmol 73:100105, 1989.
198. Minchin RF, Kadlubar FF, Ilett KF: Role of acetylation in colorectal cancer. Mutat Res
290(1):3542, 1993.
199. Mitchell RN, Cotran RS: In Kumar V, Cotran RS, Robinson SL (Eds): Basic Pathology (6th
edn): WB Saunders Company.
200. Mohan M, Sperduto RD, Angra SK et al: India US case control study of age-related cataract.
201. Molgaard J, Lundh B, van Schenck H et al: Long- term efficacy and safety of simvastatin
alone and in combination therapy in treatment of hypercholesterolemia. Atherosclerosis
91:S2124, 1991.
202. Mosley ST, Kalinowski SS, Schafer BL et al: Tissue-selective acute effects of inhibitors of 3hydroxy-3-methylglutaryl coenzyme: a reductase on cholesterol biosynthesis in lens. J Lipid
Res 50:141120, 1989.
203. Mostafa MSE, Teintamy S, EI-Gammal MY et al: Genetic studies of congenital cataract.
Metah Pediatr Ophthalmol 5: 23342, 1981.
204. Motten AG, Martinez LJ, Holt N et al: Photophysical studies on antimalarial drugs.
Photochem Photobiol 69(3): 282,1999.
205. Mune M, Meydani M, Jahngen-Hodge J et al. Effect of calorie restriction on liver and kidney
glutathione in aging emory mice. AGE 18:49, 1995.
206. Munoz B, Tajchman U, Bochow T et al: Alcohol use and risk of posterior subcapsular
opacities. Arch Ophthalmol 111: 11012, 1993
207. Nagata M, Hohmann TC, Nisihimura C et al: Polyol and vacuole formation in cultured canine
kens epithelial cells. Exp Eye Res 48:66777, 1989.
208. Nakamura B, Nakamura O, Ufer das vitamin C in der linse und dem Kammerwasser der
menschlichen katarakte. Graefes Arch Clin Exp Ophthalmol 134:197200, 1935.
209. Neilson NV, Vinding T: The prevalence of cataract in insulin-dependent and non-insulindependent diabetes mellitus: an epidemiological study of diabetics treated with insulin and oral
hypoglycaemic agents (OHA). Acta Ophthalmol 62:591602, 1984.
210. ONeil WM, Gilfix BM, DiGirolamo A et al: N-acetylation among HIV-positive patients and
patients with AIDS: when is fast, fast and slow, slow? Clin Pharmacol Ther 62(3): 26171,
1997.
211. Orzechowska-Juzwenko K, Milejski P, Patkowski J et al: Acetylator phenotype in patients
with allergic diseases and its clinical significance. Int J Clin Pharmacol Ther Toxicol
28(10):42025, 1990.
212. Oshima Y, Emi K, Motokura M et al: Survey of surgical indications and results of primary
pars plana vitrectomy for rhegmatogenous retinal detachments. Jpn J Ophthalmol 43(2):120
26,1999.
213. Oxman TE, Berkman LF, Kasl S et al: Social support and depressive symptoms in the elderly.
Am J Epidemiol 135: 35668, 1992.
Phacoemulsification
46
214. Pacurariu I, Mar in C: Changes in the incidence of ocular disease in children and old people.
Ofthalmologia (Buchuresti). 17:289308, 1973.
215. Palmquist BM, Phillipson B, Barr PO: Nuclear cataract and myopia during hyperbaric oxygen
therapy. Br J Ophthalmol 60:11317, 1984.
216. Pande A, Gamer WH, Spector A: Glucosylation of human lens protein and cataractogenesis.
Biochem Biophys Res Commun 89:126066, 1979.
217. Petrohelos MA: Chloroquine-induced ocular toxicity. Ann Ophthalmol 6(6):615, 1974.
218. Pirie A, van Heyningen R: The effect of diabetes on the content of sorbitol, glucose, fructose
and inositol in the human lens. Exp Eye Res 3:12431, 1964.
219. Probst-Hensch NM, Haile RW, Ingles SA et al: Acetylation polymorphism and prevalence of
colorectal adenomas. Cancer Res (US) 55(10):201720, 1995.
220. Pruett RC: Ritinitis pigmentosa: clinical observations and correlations. Trans Am Ophthalmol
Soc 81:69335, 1983.
221. Racz P, Erdohelyi A: Cadmium, lead and copper concentrations in normal and senile
cataractous human lenses. Ophthalmic Res 20:1013, 1988.
222. Rafferty iVS: Lens morphology. In Maisel H (Ed): The Ocular Lens: Structure, Function and
Pathology. Marcel Dekker: New York 160, 1985.
223. Ramsay RC, Barbosa JJ: The visual status of diabetic patients after renal transplantation. Am J
Ophthalmol 87: 30510, 1979.
224. Reddy VN: Glutathione and its function in the lensan overview. Exp Eye Res 150:77178,
1990.
225. Renwick JH, Lawler SD: Probably linkage between a congenital cataract locus and the Duffy
blood group locus. Ann Ham Genet 27:6784, 1963.
226. Resnikoff S, Filliard G, DellAquila B: Climatic droplet kera-topathy, exfoliation syndrome,
and cataract. Br J Ophthalmol 75:73436, 1991.
227. Risch A, Wallace DM, Bathers S et al: Slow N-Acetylation genotype is a susceptibility factor
in occupational and smoking related bladder cancer. Hum Mol Genet 4(2):23136 (Feb 1995).
228. Ritter LL, Klein EK, Klein R et al: Alcohol use and lens opacities in the Beaver Dam Eye
Study. Arch Ophthalmol 111:11317, 1993.
229. Robertson J McD, Donner AP, Trevithick JR. Vitamin E intake and risk for cataract in
humans. Ann NY Acad Sci 570:37282, 1989.
230. Rouhianen P, Rouhiainen H, Salonen TJ: Association between low plasma vitamin E
concentration and progression of early cortical lens opacities. Am J Epidemiol 144:496500,
1996.
231. Rubb RM: Cataract acquired following varicella infectims. Ault Ophthalmol 8732254, 1972.
232. Sabiston DW: Cataract, Dupuytrens contracture, and Alcohol Addiction. Am J Ophthalmol
76:100507, 1973.
233. Sacanove A: Pigmentation due to phenothiazines in high and prolonged dosage. JAMA
191:26368, 1965.
234. Salive ME, Guralnik J, Christen W et al: Functional blindness and viusal impairment in older
adults from three communities. Ophthalmology 99:184047, 1992.
235. Salmon JF, Wallis CE, Murray ADN: Variable expressivity of autosomal dominant
microcornea with cataract. Arch Ophthalmol 106:50510, 1988.
236. Scales DK: Immunomodulatory agents. In Mauger TF, Craig EL (Eds): Haveners Ocular
Pharmacology (Mosby-Yearbook: St Louis 40214,1994).
237. Schein OD, West S, Mlnoz B et al: Cortical lenticular opacification: distribution and location
in a longitudinal study. Invest Ophthalmol Vis Sci 35:36366, 1994.
238. Schocket SS, Esterson J, Bradford B et al: Induction of cataract in mice by exposure to
oxygen. Israel J Med 8:15961601, 1972.
239. Scott MR, Hejtmaucik F, Wozencraft LA et al: Autosomal dominant congenital cataract;
interocular phenotypic variability. Ophthalmol 101:86671, 1994.
Cataract Etiology
49
240. Shun Shin GA, Ratcliffe P, Bron AJ et al: The lens after renal transplantation. Br J
Ophthalmol 73:52227, 1990.
241. Siddall JR: The ocular toxic findings with prolonged and high dosage chlorpromazine intake.
242. Siegmund W, Fengler JD, Frane G et al: N-Acetylation and debrisoquine hydroxylation
polymorphisms in patients with Gilberts syndrome. Br J Clin Pharmacol 32(4):46772, 1991.
243. Simonelli F, Nesti A, Pensa M et al: Lipid peroxidation and human cataractogenesis in
diabetes and severe myopia. Exp Eye Res 49:18187, 1989.
244. Simons LA: Interrelations of lipids and lipoproteins with coronary artery disease mortality in
19 countries. Am J Cardiol 57:5G10G, 1985.
245. Sirtori CR: Tissue selectivity of hydroxymethylglutaryl co-enzyme A (HMG CoA) reductase
inhibitors. Pharmacol Ther 60:43159, 1993.
246. Solberg Y, Rosner M, Belkin M: The association between cigaret smoking and ocular
diseases. Surv Ophthalmol 42: 53557, 1998.
247. Spector A, Garner WH: Hydrogen peroxide and human cataract. Exp Eye Res 33:67381,
1981.
248. Sperduto RD, Hu T-S, Milton RC et al: The Linxian Cataract Studies: two nutrition
intervention trials. Arch Ophthalmol 111:124653, 1993.
249. Srivastava S, Ansari NH: Prevention of sugar induced cataractogenesis in rats by mutilated
hydroxytoluene. Diabetes 37:150508, 1988.
250. Stambolian D: Galactose and cataract. Surv Ophthalmol 32: 33349, 1988.
251. Stayte M, Reeves B, Wortham C: Ocular and vision defects in preschool children. Br J
Ophthalmol 77:22832, 1993.
252. Steele G, Peters R: Persistent hyperplastic primary vitreous with myopia: a case study. J Am
Optom Assoc 70(9):59397, 1999.
253. Stewart Brown SL, Raslum MN: Partial sight and blindness in children of the 1970 birth
cohort at 10 years of age. J Epidemiol Community Health 42:1723, 1988.
254. Stoll C, Alembik Y, Dott B, Roth MP: Epidemiology of congenital eye malformations in
131,760 consecutive births. Ophthalmic Pediatr Genet 39:43335, 1993.
255. Stryker WS, Kaplan LA, Stein EA et al: The relation of diet, cigaret smoking, and alcohol
consumption to plasma beta-carotene and alpha-tocopherol levels. Am J Epidemiol 127: 283
296, 1988.
256. Subar AF, Block G: Use of vitamin and mineral supplements: demographics and amounts of
nutrients consumedthe 1987 Health Interview Survey. Am J Epidemiol 132:10911101, 1990.
257. Summers CG, Letson RD: Is the phakic eye normal in monocular pediatric aphakia? J Pediatr
Ophthalmol Strabismus 29:32427, 1992.
258. Szmyd L Jr, Schwartz B: Association of systemic hypertension and diabetes mellitus with
cataract extraction: A case-control study. Ophthalmology 96:124852, 1989.
259. Takemoto L, Takehana M, Horwitz J: Covalent changes in MIP 26K during aging of the
human lens membrane. Invest Ophthalmol Vis Sci 27:44346, 1986.
260. Tavani A, Negri E, La Vecchia C: Selected diseases and risk of cataract in Women. A casecontrol study from northern Italy. Ann Epidemiol 5(3):23438, 1995.
261. Taylor A, Jacques P, Nadler D et al: Relationship in humans between ascorbic acid
consumption and levels of total and reduced ascorbic acid in lens, aqueous humor, and plasma.
Curr Eye Res 16:85764, 1997.
262. Taylor A, Jacques PF, Nadler D et al. Relationship in humans between ascorbic acid
consumption and levels of total and reduced ascorbic acid in lens, aqueous humor, and plasma.
Curr Eye Res 10:75159, 1991.
263. Taylor A, Jaques PF, Epstein EM: Relations among aging, antioxidant status, and cataract. Am
J Clin Nutr 62(Suppl): 1439S47S, 1995.
264. Taylor A: Nutritional and Environmental Influences on the Eye. CRC Press, London; 15,
1999.
Phacoemulsification
48
265. Taylor A: Nutritional and Environmental Influences on the Eye. CRC Press: London. 5681,
1999.
266. Taylor D, Rice NSC: Congenital cataract, a cause of preventable child blindness. Arch Dis
Child 57:16567, 1982.
267. Taylor HR, West S, Munoz B et al: The long-term effects of visible light on the eye. Arch
Ophthalmol 110:99104,1992.
268. Taylor HR: The environment and the lens. Br J Ophthalmol 64:30310, 1980.
269. Taylor HR: Ultraviolet radiation and the eye: an epidemiologic study. Trans Am Ophthalmol
Soc 87:80253, 1989.
270. Teramoto S, Fukuchi Y, Uejima Y: Influences of chronic tobacco smoke inhalation on ageing
and oxidant-antioxidant balance in the senescence-accelerated mouse (SAM)-P/2. Exp Gerontol
28:8795, 1993.
271. Thaler JS, Curinga R, Kiracofe G: Relation of graded ocular anterior chamber pigmentation to
phenothiazine intake in schizophrenics: quantification procedures. Am J Optom Physiol Optics
62:60004, 1985.
272. The Italian-American Cataract Study Group: Risk factors for age-related cortical, nuclear, and
posterior subcapsular cataract. Am J Epidemiol 133:54153, 1991.
273. Tielsch JM, Sommer A, Katz J et al: Socioeconomic status and visual impairment among
urban Americans. Arch Ophthalmol 109:63741, 1991.
274. Tint et al: Defective cholesterol biosynthesis associated with the Smith-Lemli-Opitz
syndrome. N Engl J Ed 330:10713, 1994.
275. Tobert JA: New developtments in lipid-lowering therapy: the role of inhibitors of
hydroxymethylglutaryl-coenzyme A reductase. Circulation 76:53438, 1987.
276. Traboulsi El, Weinberg RJ: Familial congenital cornea guttata with anterior polar cataract. Am
J Ophthalmol 108:12325, 1989.
277. Trindade F, Pereira F: Cataract formation after posterior chamber phakic intraocular lens
implantation. Cataract Refract Surg 24(12):166163, 1998.
278. Tsutomu Y, Mihori K, Yoshito H: Traumatic cataract with ruptured posterior capsule from a
nonpenetrating ocular injury.
279. Tuormaa TE: The adverse effects of tobacco smoking on reproductive and health: A review
from the literature. Nutr Health 10:105120, 1995.
280. Ughade SN, Zodpey SP, Khanolkar VA: Risk factors for cataract: a case control study.
281. Urban RC (Jr), Cotlier E: Corticosteroid-induced cataract. Surv Ophthalmol 31:102110,1986.
282. Vadot E, Guibal JP: Pathogenic de la cataracte diabetique. Bull Soc Ophthalmol Fr 82:1513
14, 1982.
283. Vajpayee RB, Angra SK, Honavar SG et al: Pre-existing posterior capsular breaks from
penetrating ocular injuries. J Cataract Refract Surg 20:99194,1994.
284. Van Heyningen R, Harding JJ: A case-control study of cataract in Oxford: some risk factors.
Br J Ophthalmol 72: 80408, 1988.
285. van Heyningen R, Harding JJ: Do aspirin-like analgesics protect against cataract? Lancet
i:111113, 1986.
286. van Heyningen R: The human lens. Ia comparison of cataracts extracted in Oxford
(England) and Shikarpur (W Pakistan). Exp Eye Res 13:13647, 1972.
287. Varma S, Schocket SS, Richards RD: Implications of aldose reductase in cataract in human
diabetes. Invest Ophthalmol Vis Sci 18:23741, 1979.
288. Vesti E. Development of cataract after trabeculectomy. Acta Ophthalmol 71(6):77781, 1993.
289. Vidal P, Fernandez-Vigo J, Cabezas-Cerrato J: Low glycation level and browning in human
cataract. Acta Ophthalmol 66:22022,1988.
290. Vitale S, West S, Hallfrisch J et al: Plasma antioxidants and risk of cortical and nuclear
cataract. Epidemiol 4:195203, 1994.
291. Waxman SL, Bergen RL: Wagners vitreoretinal degeneration. Ann Ophthalmol 12(10):1150
51, 1980.
Cataract Etiology
51
292. Weale R: A note on a possible relation between refraction and a disposition for senile nuclear
cataract. Br J Ophthalmol 64:31114, 1980.
293. Weber WW: Acetylation. Birth Defects Orig Artic Ser 26(1): 4365, 1990.
294. Wensor MD, McCarty CA, Taylor HR. The prevalence and risk factors of myopia in Victoria,
Australia. Arch Ophthalmol 117:65863, 1999.
295. West S, Munoz B, Emmett EA et al: Cigaret smoking and risk of nuclear cataract. Arch
Ophthalmol 107:116669, 1989.
296. West S, Munoz B, Schein OD et al: Cigaret smoking and risk for progression nuclear
opacities. Arch Ophthalmol 113: 137780, 1995.
297. Wiechens B, Winter M, Haigis W et al: Bilateral cataract after phakic posterior chamber top
hat-style silicone intraocular lens. J Refract Surg 13(4):39297, 1997.
298. Wilczek M, Zygulska-Machowa H: Zawartosc witaminy C W.roznych typackzaem. J Klin
Oczna 38:47780, 1968.
299. Winkleby MA, Fortmann SP, Barret DC: Social class disparities in risk factors for disease:
eight-year prevalence patterns by level of education. Prev Med 19:112,1990.
300. Wolff SM: The ocular manifestations of congenital rubella. Sri Am Ophthalmol Soc 70:577
14, 1972.
301. World Health Organization: Management of Cataract in Primary Health Care Services. WHO:
Geneva 1990.
302. Ye JJ, Zadunaisky JA: A Na+/H+ exchanger and its relation to oxidative effects in plasma
membrane vesicles from lens fibers. Exp Eye Res 55:25160, 1992.
303. Young RW. Optometry and the preservation of visual health. Optom Vis Sd 70:25562, 1993.
304. Zadok D, Chayet A: Lens opacity after neodymium: YAG iridectomy for phakic intraocular
lens implantation. J Cataract Refract Surg 25(4):59293, 1999.
305. Zelenka PS: Lens lipids. Curr Eye Res 3:133759, 1984.
2
Biochemistry of the Lens
Ashok Garg
Introduction
The crystalline lens which is positioned behind the iris is the chief refractive medium of
the eye having the maximum refractory power. It is a transparent, elastic and biconvex
lens enclosed in a capsule. It refracts the light entering the eye through the pupil and
focuses it on the retina.
Biochemistry of the Lens
The human lens is the least hydrated organ of the body. It contains 66 percent water,
and the 33 percent remaining bulk is composed mainly of protein. The lens cortex is more
hydrated than the lens nucleus. Lens dehydration is maintained by an active Na+ ion
water pump that resides within the membranes of cells in the lens epithelium and
each lens fiber.
The inside of the lens is electronegative. There is a 23 mV difference between
anterior and posterior surfaces of the lens. Thus, the flow of electrolytes into the lens is
directed by an electrical gradient.
Crystalline Lens as an Osmometer
The capsule of the lens acts as an intact cell and induces properties like swelling in
hypotonic media and dehydration in hypertonic media. The osmolarity of the human lens
is 302 mOsm and equals the osmolarity of aqueous. Cations like sodium and potassium
with concentration of 145 mEq/L and anions (chloride, bicarbonate, sulfate, ascorbate
and glutathione) with concentration of 50 to 60 mEq/L contribute to lens osmolarity. An
anionic deficit of 90 mEq/L is probably made by acidic groups of lens protein and
glycoproteins.
The water equilibrium between the lens and the surrounding fluids is disrupted if the
concentration of osmotically active compounds (Na+, K+, etc.) increases inside the lens.
Increase in Na+ and K+ levels also follows lens exposure to surface active detergents or
antibiotics. When retained inside the cell, abnormal products of sugar metabolism such as
sorbitol can exert osmotic effects and result in water influx and lens swelling.
Biochemistry of the lens
53
Lens Proteins
The human lens contains the highest concentration of proteins (33%) of any tissue in the
body. Proteins, are synthesized in the anterior epithelium and the equatorial region. The
perfect physiochemical arrangement of the lens protein living in an optimum
environment of water, electrolytes and sulfhydryl gives transparency to the lens. Amino
acids which are actively transported by the anterior lens epithelium are used by the lens
to synthesize lens proteins. Since lens protein is sequestered from the body immune
system during embryonic life, later exposure of the lens protein can result in an
autoimmune reaction. The separation of lens proteins is based initially on their
solubility of water. Fifteen percent of the lens proteins are insoluble in water. These form
the albuminoid fraction which is thought to include membrane bound protein and
aggregated crystallins. The remaining 85 percent are soluble in water and are classified as
alpha, beta and gamma crystallins on the basis of molecular weight, electrophoretic
mobility and presence or absence of subunits as shown in Figure 2.1. The soluble alpha
and gamma crystallins leak into the aqueous humor during cataract formation causing a
reduction in total lens protein.
The water soluble lens proteins are grouped as: (i) -crystallins (15%), (ii) crystallins (55%), and (iii) -cystallins (15%). On the basis of their electrophoretic
mobility towards the anode, -crystallin is fastest, -crystallin is intermediate and crystallins is slowest. The molecular weight of crystallins in daltons is -crystallin
1,000,000, -crystallin 50,000100,000 and -crystallin 20,000. and -crystallins are
made of subunits and aggregation or separation of these subunits determines the
physiochemical characteristics of each crystallin. The protein subunits are assembled by
the alignment of amino acids through ribonucleic acid (RNA) as specified by the genetic
code (Fig. 2.2). Lens proteins are degraded by proteases and amino peptidases. In the
normal lens the membrane of lens fibers and lens capsule do not allow the passage of
protein molecules from the lens to the aqueous humor. When a mature cataract
develops, the membranes of the lens fibers are
FIGURE 2.1 Human lens protein

composition
Phacoemulsification
52
FIGURE 2.2 Biochemistry of lens

protein synthesis
lysed, the capsule becomes more permeable and protein can leak out of the lens.
Lens proteins in the anterior chamber can act as an antigen which lead to
inflammation of the uveal tissues known as lens induced or phacogenic uveitis.
Sometimes degraded lens proteins leak through the capsule into the aqueous humor
and are engulfed by macrophages which plug up the trabecular meshwork thus blocking
aqueous humor outflow and producing increased intraocular pressure (IOP)phacolytic
glaucoma.
Active Transport Processes
Water and Electrolyte Transport
The electrolyte and water content of the lens resembles that of an intact cell as shown in
Figure 2.3. Whereas the Na+, Cl and K+ ion and water content of aqueous and vitreous is
similar to that in plasma or extracellular fluids. To maintain electrolyte and water
gradients against the surrounding fluids, the lens generates chemical and electrical
energy.
55
FIGURE 2.3 Chemical composition of

human lens. (All values in mmol/kg of
lens water), unless otherwise stated
Chemical energy extrudes Na+ ions and water is provided by ATP through glucose
metabolism.
Cation Transport
The energy dependent cation pump in the lens accumulates K+ intracellularly and
extrudes sodium (Na+). The influx of K+ and efflux of Na+ are thought to be linked and
mediated by the membrane bound enzyme, Na+-K+-ATPase which degrades ATP to
adenosine diphosphate (ADP) inorganic phosphate and energy with which to power this
cation pump. The action of Na+-K+-ATPase of lens can be inhibited by cardiac glycoside
such as digitalis thereby stopping the cation pump.
It is generally believed that the cation pump of the lens functions at the anterior
epithelial surface because the concentration of Na+-K+-ATPase is greater in this area than
elsewhere. When K+ is pumped into the lens and Na+ is pumped out at the anterior
surface, a chemical gradient is generated that stimulates a diffusion of Na+ into the lens
and K+ out of the primarily through the posterior surface. This process of active transport
(pump)
Phacoemulsification
54
FIGURE 2.4 Active transport process

of lens (pump-leak) mechanism
stimulating passive diffusion (leak) has been termed as pump and leak theory of cation
transport (Fig. 2.4). This cation transport system performs three important functions.
It regulates the water content of the lens, thereby allowing the lens to act as a perfect
osmometer. This prevents colloid osmotic swelling.
It produces and maintains an electrical potential difference (approximately 70 mV)
between the lens and the medium surrounding it.
It promotes the proper physiochemical environment within the lens to maintain
transparency and optimal enzymatic activity.
Surface active agents (antibiotics, detergents, lysophospholipids and fatty acids) disrupt
the physiochemical integrity of the membrane and Na+ extrusion pump with subsequent
gain of Na+ ions and water by the lens, lens swelling and eventually complete loss of lens
transparency follow.
Amino Acids
Amino acids and inositol are actively transported into the lens at the anterior epithelial
surface (Fig. 2.5). Once in the lens, free amino acids are incor-
57
FIGURE 2.5 Schematic diagram

showing amino acid active transport
into the lens (epithelial pump)
porated into RNA to form lens protein, can be metabolized with formation of CO2, or can
efflux from the lens. The turnover of free amino acids in the lens is very rapid, the
renewal rate for lysine being 16 percent of the total in the lens per hour. There are three
separate pumps for acidic, basic and neutral amino acids. Once in the lens these amino
acids are metabolized and used for energy.
Glutathione-Sulfhydryl Proteins
Glutathione, a polypeptide is actively synthesized in the lens. It is a tripeptide containing
glycine, cysteine and glutamic acid. The levels of glutathione in the lens are high and in
most of lens glutathione is in the reduced form (GSH). Only 6.8 percent of all lens
glutathione is in the oxidized form (GSSG). GSH and GSSG are in equilibrium.
GSH concentrations are 12.0 micromoles/gm in the human lens. GSH levels are much
higher in the cortex than in the nucleus of the lens. A reducing agent by virtue of its free
sulfhydryl group, glutathione maintains membrane stability in the lens by supporting the
protein complexes of the membrane. GSH levels decrease slightly with age. One of the
earliest changes noted in the lens in different types of cataracts is the loss of glutathione.
This allows the cross-linkage of proteins by the formation of disulfide bonds through
sulfhydryl oxidation.
Another polypeptide ophthalmic acid is also found in the lens in concentrations of
1/10 to 1/ 100 those of GSH.
The pentose shunt of glucose metabolism active in the lens generates NADPH
(reduced nicotinamide-adenine dinucleotide phosphate) that maintains glutathione in the
reduced state by the following reductase:
Phacoemulsification
56
Lens proteins contain reduced sulfhydryl groups (PSH) and oxidized disulfide groups
(PSSP) maintaining high levels of GSH as shown in the following reaction
2PSH+GSSG2GSH+PSSP
Thus, decreased GSH or increased GSSG will result in PSH oxidation and alterations in
protein linkages, their solubility and their transparency.
The main functions of lens GSH are:
To preserve the physiochemical equilibrium of lens proteins by maintaining high levels
of reduced sulfhydryl (SH) groups.
To maintain transport pumps and the molecular integrity of lens fiber membranes.
Synthesis of lens glutathione proceeds via -glutamylcysteine synthetase which is
markedly decreased in human senile cataracts. The enzyme glutathione peroxidase
removes H2O2 or toxic lipid peroxides but decreases rapidly with age and in senile
cataracts. Thus, the ability of lens to remove toxic oxygen appears impaired in early
senile cataracts.
Lipids
The lipids of human lens are unique and differ markedly from those of other species.
Lipids represent about 3 to 5 percent of the dry weight of lens. In human lens cholesterol
is about 50 percent of lipids followed by phospholipids (45%) and glycosphingolipids
and ceramides (5%). The lipids are major components of the lens fiber membranes and
either decrease in their synthesis or impaired degradation brings about lens membrane
damage and lens opacities. Cataracts develop in humans if treated with
anticholesterolemic agents such as triparanol. Esterification of cholesterol takes place in
human lens where 25 percent of total cholesterol is in the ester form. Among
phospholipids, the human lens is specially rich in sphingomyelin and its precursor
ceramides may increase in senile cataracts. Cer amide synthesis proceeds via fatty acids
and sphingosine. Its degradative enzyme ceramidase is present in the human lens.
Sphingomyelin is degraded by sphingomyelinase which is somewhat decreased in senile
cataract.
The cholesterol-phospholipid ratio of human lens fiber membranes is the highest
among cell or organelle membranes, thus conferring the lens resistance to deformation.
Lipids as structural components of lens fiber membranes are associated with the insoluble
lens proteins. The increased insolubility of the proteins with age or during cataract
formation may be due to derangements in the stereochemical arrangement between lipids
and proteins in the membrane and soluble proteins inside the fibers.
59
Ascorbic Acid
In human lens ascorbic acid values are higher in the lens than in the aqueous. The role of
ascorbic acid in the lens is not clear, but it could participate in oxidation-reduction
reactions alone or coupled to glutathione.
Glucose Metabolism
Lens is avascular and surrounded by aqueous and vitreous humors. Both of which are
rich in glucose and poor in oxygen. Glucose used by the lens is metabolized through
following four main pathways.
The glycolytic pathway
The Krebs (oxidative) cycle
The hexose monophosphate (pentose) shunt
The sorbitol pathway.
End products of glucose metabolism are lactic acid, carbon dioxide and water. Lactic acid
from the
FIGURE 2.6 Lens glucose

metabolism pathway (Krebs cycle)
lens diffuses to the aqueous and is eliminated via this circulating fluid.
About 80 percent of glucose used by the lens is metabolized anaerobically by the
glycolytic pathway to produce lactic acid and adenosine triphosphate (ATP). A small
proportion of lens glucose may be metabolized via oxidative Krebs citric acid cycle
which is 18 times more efficient in producing ATP than glycolysis (Fig. 2.6). About 15
percent of the glucose consumed by the lens is metabolized by the pentose or hexose
Phacoemulsification
58
monophosphate shunt. Although this pathway produces no energy in the form of ATP it
does provide five carbon sugars (pentoses) for the synthesis of RNA and NADPH to
maintain glutathione in a reduced state.
The sorbitol pathway in which glucose is converted to sorbitol by aldose reductase in
the normal lens is relatively insignificant, but it is extremely important in the production
of cataracts in diabetic and galactosemic patients (Fig. 2.7).
The lens uses the energy of metabolism for two principle processes, reproduction and
growth and active transport processes.
The synthesis of RNA, DNA, lens fiber membrane constituents, enzymes and other
lens proteins
FIGURE 2.7 Lens glucose

metabolism (sorbitol pathway)
occurs mainly at the anterior surface and equatorial region of the lens.
Glucose metabolism generates adenosine triphosphate. ATP breakdown is required for
active transport of ions and amino acids, maintenance of lens dehydration, lens
transparency and for continuous protein and GSH synthesis. The pentose shunt does not
generate ATP, but it forms pentoses required for RNA synthesis. NADPH generated from
the shunt is needed to maintain lens glutathione in the reduced state. The pentose shunt is
extremely active in the lens. In addition, an active mechanism for pyruvate
decarboxylation exists in the lens which results in formation of carbon dioxide and
acetaldehyde. The latter is metabolized through lens aldehyde dehydrogenase. The carbon
dioxide combination with water to form bicarbonate (HCO3) may be partially active in
the lens nucleus where the levels of carbonic anhydrase exceed those in lens cortex.
However, carbonic anhydrase inhibitors do not produce cataracts.
The enzymes hexokinase and phosphofructokinase regulate the rate of glucose
metabolism by the lens whereas oxygen is not essential for glucose metabolism.
Conversion of glucose to amino acids such as glutamic acid, aspartic acid, glycine and
others may account for 6 to 8 percent of glucose metabolism. Oxygen consumption by
the lens is minimal 0.5 mol/glens/hour. The Krebs cycle requires oxygen and it is very
inactive in the lens as there is paucity of mitochondria and oxidative enzymes. If the lens
is deprived of glucose, it will utilize its own endogenous energy reserves.
When deprived of glucose the lens will gain water and lose transparency. In infantile
hypoglycemia, cataract develops because of the low plasma glucose level are present.
The levels of glucose are higher in the aqueous (5.5 mol/ml) than in the lens (1
mol/ml) and glucose diffuses readily into the lens. Transport of glucose into the lens is
61
not affected by the absence of sodium or calcium ions. However other sugars or phloretin
can inhibit lens glucose transport.
Studies of intact lens metabolism or protein structure can be done by noninvasive
techniques. The 31P nuclear magnetic resonance (NMR) spectra of intact lens sugar
phosphates and dinucleoside phosphate are among the best resolved in biological tissues.
For lens protein analysis, laser spectroscopy techniques are available. The Raman laser
signals allow determination of the axial distribution of protein subgroups such as
tryptophan, sulfhydryl and disulfide which suffer modifications during cataract
formation.
Applied Physiology
Chemical Changes in Lens Proteins in Senile Cataractogenesis
Lens proteins glycosylation happens on exposure to high glucose levels. These high
glucose levels lead to protein conformational changes, near similar to those that occurs in
glycosylated hemoglobin. The amino acid terminals of lens - and -crystallins are
acetylated. Thus sugar attachment in lens proteins occurs primarily by binding to amino
groups of lysine and formation of covalent sugarlysine bonds. Glucosyl-lysine
combination results in conformational protein changes, protein formation of S-S bonds
through oxidation of adjacent sulfhydryl groups, protein aggregation and opacification.
These findings explain in part the protein aggregation in human cataracts. Levels of amino acids in diabetic senile cataracts are substantially reduced as compared to agerelated cataract. Another chemical modification of lens protein includes carbamylation,
i.e. addition of cyanate which occurs secondary to accumulation of urea cycle metabolites
in uremia or secondary to dehydration. Urea cycle enzymes are active in human lens and
cataracts.
Research studies have now clearly shown that formation of protein S-S bonds is the
major primary or secondary event associated in senile cataracts. Oxidation of lens protein
SH groups with H2O2 induces protein conformation changes leading to opacification.
Protection against oxidation of protein SH groups is vital. Cysteine and glutathione
have proven effective to prevent formation of S-S protein bonds. Protein unfolding due to
primary modification of exposed lysine amine groups can be prevented by lysine
acetylation. Lysine acetylation of protein prevents attachment of glycosyl, cyanate or
other reactive groups like keto groups of steroids.
Biochemistry of Cortical Cataracts
Cortical cataract is characterized by abnormalities in fiber permeability that causes
vacuoles or clefts in the lens cortex. Damage to the membranes of lens fibers represents
the initial insult due to X-rays, diabetes, galactosemia, arachidonic acid or other surface
active agents. The various chemical changes some of which develop prior to clinical
cortical changes include:
Loss of glutathione with compensatory increase in NADPH synthesis
Phacoemulsification
60
Increase K+ ion efflux

Loss of K+ ions, inositol and amino acids from lens
Gain in Na+ ions
Decrease lens protein synthesis with decrease in the proportional of soluble protein and
increase in insoluble protein
Increase in protein S-S groups and in Ca++ ions.
Decreased activity of most enzymes and increased activities of hydrolytic enzymes
Decreased ATP content.
The majority of cataractogenic agents damage the ability of the lens to maintain GSH
synthesis or increase its efflux through more permeable membranes. Thus a cycle of
increased exudation of K+ ions, amino acids and inositol is initiated. The lens epithelium
tries to maintain the concentration of these compounds by increased pumping. Depending
upon the magnitude of cataractogenic stimuli, the GSH leak out may continue or stop. To
maintain normal levels of NADPH is required which in turn stimulate the glucose
metabolism through the pentose shunt. If the epithelium or lens fibers are structurally
damaged and are unable to extrude Na+ ions water gain will occur. This is followed by a
decrease in protein synthesis which manifest itself by decreased levels of soluble lens
proteins. This is compounded by the retention of cations and formation of disulfide S-S
bonds with increased turbidity and protein insolubility. At this stage of cataractogenesis,
the increased activity of glycolysis and other enzymes is detected. The generalized
disarray of lens metabolism is accompanied by ATP loss. The end result is a total opaque
or cataractous lens.
Nuclear Sclerosis
The human lens normally undergoes changes with age. It slowly increases in size as new
lens fibers develop throughout life. Older lens fibers in the center of the lens become
dehydrated and compacted. The cross-linking of proteins in the nucleus increases its
optical density and decreases its transparency. Clinically this condition is known as
nuclear sclerosis which may cause refractive changes. Simultaneously splits in sutures or
clefts in the cortical fibers are visible causing damage to the permeability of the lens. The
nucleus of the lens becomes more compact and resists mechanical disruption with aging.
There is extensive cross-linkage of the lens protein. The cataract protein cross-linkage is
accompanied by increased pigmentation in certain cases. In senile cataracts, changes in
lens color to dark yellow, yellow brown or brown and hardening of the nucleus parallel
lead to decreased transparency. Three major types of cross-links are identified in senile
cataracts.
Disulfide cross-links (S-S)
Lysine modification
Dityrosine cross-links.
Protein SH groups are oxidized and noncovalent S-S protein cross-links are formed in
senile cataracts.
These S-S bonds are susceptible to dissociation by a variety of reducing agents. The
origin of oxidative insult is attributed to either the loss of lens glutathione, excessive
63
H2O2 or lipid peroxidase in aqueous humor, increased permeability to oxygen into the
aqueous or lack of oxygen detoxifying enzymes. S-S cross-links may explain the
conformational changes in protein causing opacity, the presence of covalent bonds is a
feature of senile cataracts.
Superoxide anion-free radicals (O2) or its derivative peroxide (H2O2), singlet, oxygen
1
( O2) and OH induce oxidative damage to a variety of cells. The lens is highly
susceptible to these radicals. Peroxide (H2O2) is catalyzed through catalase and
peroxidase and synthesized through superoxide dismutase. This oxidative damage as a
result of free radicals to human lens leads to cataract formation (Fig. 2.8).
FIGURE 2.8 Oxidative damage of

lens (by free radicals)
Diabetic Cataract
Snow flake cortical lens opacities also known as metabolic cataract is found in diabetic
patients.
Increased levels of glucose in the aqueous and lens are found in patients with diabetes
mellitus. In general glucose concentration in the aqueous is similar to concentrations in
the plasma. From the aqueous glucose diffuses rapidly into the lens. The lens metabolizes
glucose through the four main pathways as already mentioned in this chapter. In diabetes
excessive glucose in the lens (more than 200 mg/100 ml) saturates hexokinase. Excessive
glycosylation of lens proteins takes place and glucose is converted to sorbitol by autooxidation and protein binding (aldose reductase). These chemical changes are present in
human diabetic cataract. However, glucose oxidation to sorbitol plays a more important
role in the rapidly developing diabetic cataract. Whereas abnormal protein glycosylation
is of greater significance in the slowly developing senile cataracts in patients with
diabetes.
3
History of Phacoemulsification
Charles D Kelman
A resident in ophthalmology today, seeing his first cataract performed by a surgeon who
uses Kelman phacoemulsification, might wonder how it could be performed any other
way. Seated comfortably at the operating microscope, the surgeon makes a tiny incision,
neatly peels open the anterior capsule, emulsifies and aspirates the lens within the
remaining capsule, and then, through the same incision inserts a foldable lens. On the
first postoperative day, in most cases, it is difficult to tell with the naked eye, which eye
has been operated.
In contrast, in 1960, when I finished my residency at Wills Eye Hospital, general
anesthesia was common, no microscopes were used for any ophthalmic surgery anywhere
in the world (except for a surgeon in Chicago, Richard Peritz), a 180 degree incision was
made, a large sector iridectomy was performed, and then the lens was grasped by a
capsule forceps, and the entire lens was pulled from the eye. Eight or more sutures closed
the incision, and the patient remained hospitalized for 7 to 10 days. The eyes were red,
the lids swollen, and irritated for up to six weeks.
One might ask how the idea for phaco came to me. Did I one day think, Ill just
take an ultrasonic needle and remove the cataract that way? As brilliant as that
leap of thought would have been, I cannot pretend to claim credit for making it.
Actually, it is so far from the truth, that the real answer serves to illustrate a point
the final solution to a problem is usually far afield from the first attempts at its
solution.
First, the impetus for wanting to find a better way to remove cataracts:
I was in the process of writing a grant application to the John A Hartford Foundation
to investigate the effects of freezing on the eye, and after finishing the final draft, I went
to bed. But I couldnot sleep. The application seemed boring. And I knew that the
foundation looked to support breakthrough procedures, not boring scientific studies. I
knew in my heart that the application would be rejected. I needed something exciting but
I did not know what. Without knowing what I was doing, I put my subconscious mind to
work, and went to bed.
Sometime in the night I got out of bed, and wrote a phrase which would forever
change my life, and would forever change the practice of cataract surgery. That
phrase was, The author will also find a way to remove a cataract through a tiny
incision, eliminating the need for hospitalization, general anesthesia, and
dramatically shortening the recovery period. That statement looked well on paper. I
had no idea how I would accomplish this feat. I was however, confident that I could do so
easilythis confidence sprang from three factors: (i) I had quite easily discovered
cryoretinopexy, and had published the first paper on that subject,1 (ii) I had quite easily
codiscovered (Krwawicz, in Poland had also, independently discovered the same thing)
History of phacoemulsification
65
cryoextraction of cataracts,2 and (iii) I was blissfully and naively unaware of the
complexity of the task I had set out for myself. It is certainly possible, that had I known
the number of problems I would have to solve, I would have been intimidated, and might
have never started. It is for this reason that often people outside of a particular discipline
are able to make breakthroughs. Those more knowledgeable are too aware of the
difficulties.
The Hartford Foundation director, E Pierre Roy, called me a few days later to tell me
that he was not interested in the effects of freezing on the eye, but that he would give the
grant for the new cataract operation. I was ecstatic! This was going to be easy!
The first method for removing the lens through a small incision revolved around a
collapsible butterfly net (Fig. 3.1), the net portion being made out of condom thin latex.
The idea I had was to dilate the pupil, instill an enzyme to loosen the zonule, turn the
patient over on his or her face and vibrate his or her head with a manual vibrator, until the
lens fell into the anterior chamber, then instill acetylcholine to constrict the pupil. Once
the
FIGURE 3.1 Folding lens bags

cataract would be trapped in the anterior chamber, the collapsed latex net would be
introduced to trap the cataract, which would then be simply mushed up with a needle,
until the net and the squashed cataract could be pulled through the small incision. It is
important for the reader to note how far from the sophisticated phaco machines this
original, naive idea was. It would have been so easy to listen to those who said to me, I
told you you could not do it, and admit defeat, just as it may be easy for you the reader
to abandon your first idea on a subject, and never get to the second generation, the third,
the fourth, the fifth, the sixth, etc. until you come up with a solution totally unrelated to
your original idea.
This cat in the bag method could not be made to work (all attempts with this device
were made on animal and eye bank eyes). It was too traumatic to the cornea, the bag was
too thick and took too much volume in the anterior chamber, the bag kept breaking, etc. It
had taken six months to fabricate this butterfly net and to test it. I had used up one-sixth
of my three year grant, and I began to worry.
I then began investigating devices which would break up a cataract, so that it could be
irrigated and aspirated from the eye.
Phacoemulsification
64
Various drills, rotary devices, and various types of microblenders were constructed
and tried (Figs 3.2 to 3.4). Each failed for several reasons. If the iris was touched with a
rotating tip, it would immediately become completely ensnared and a total 360
iridodialysis would inadvertently be performed.
FIGURE 3.2 Various unsuccessful

devices
FIGURE 3.3 Rotating devices
FIGURE 3.4 Rotary cutters

Usually, uncontrollable hemorrhage would ensue. Furthermore, the iris did not even have
to be close
67
FIGURE 3.5 Microblenders

to the rotating tip. The eddy currents set up within the chamber were enough to draw the
iris to the rotating tip and instantaneously disinsert and remove it.
The second obstacle to fast rotating devices was that the eddy currents set up in
the anterior chamber would throw lens particles against the endothelium and
completely denude it in a few seconds, leading to permanent opacification and
vascularization. Thirdly, the lens itself when caught on the rotating tip would also spin
in the chamber with the consequent destruction of the endothelium. The microblender
(Fig. 3.5) with needles rotating in opposite directions was intended to prevent the lens
from spinning, but it was unsatisfactory. It also increased the chances of incarcerating the
iris in the two rotating tips. Slow turning drills (Fig. 3.6) were designed, but these, too,
were unable to prevent the lens from turning. Rocking vibrators still rubbed off
endothelium. These abandoned devices are similar to the rotorooter-type devices which
others are reevaluating at present. Steps were taken to fix the lens from the opposite side
with the use of the prongs. The sharp tips, however, endangered the posterior capsule.
Low-frequency vibrators were tried, but the lens merely vibrated with the tip. None of the
aforementioned devices were ever used clinically, as they were considered dangerous and
ineffective.
Two years, and most of the grant money, had now elapsed. The solution of this
problem had become more than a challengeit had become an obsession.
FIGURE 3.6 Worm gear feeder
Phacoemulsification
66
In analyzing the difficulties I had so far, it became clear that the main problem was
that the lens was moving, rotating, or vibrating inside of the anterior chamber and,
therefore, rubbing against the endothelium. This realization eventually led to the
solution only a few months before the expiration of the grant. At this time, it became
obvious that in order to let the lens remain stationary in the chamber, the acceleration of
the moving tip against it had to be high enough so that the standing inertia of the lens
would not be overcome, in other words, high enough acceleration was required so that the
lens could not back away, vibrate, or rotate with the tip. To demonstrate this principle,
imagine a sharp knife slowly punching against a punching bag. The punching bag will
move with the knife. If, however, the knife is quickly plunged against the bag, the knife
will enter and the bag will not move. In this analogy, the punching bag represents the
lens, and the knife represents the tool used to enter the lens. The high acceleration could
only be achieved with an ultrasonic frequency. Early experiments with a dental ultrasonic
unit using irrigation only and a nonlongitudinal motion were encouraging, but were
clinically unsuccessful because of the high energy radiated and the relative inefficiency
requiring many minutes of ultrasonic time in the anterior chamber. Substitution of a
longitudinal motion at the tip was introduced to prevent disinsertion of the iris and to
reduce radiation. This type of motion also significantly reduced flaking (originally
published in 1974, courtesy of the American Academy of Ophthalmology3).
Once I had discovered the method of breaking up the lens, I thought the rest would be
easy. It was not. There were three types of problems lurking ahead, which as they were
discovered, had to be overcome:
i. surgical problems,
ii. instrument problems, and
iii. political problems.
Surgical Problems
Pupil Constriction
In the first attempt to do phacoemulsification, the pupil constricted during the surgery
There had to be new drugs and methods to maintain dilatation.
In the early cases, the pupil constricted rapidly in the procedure, since we did not have
potent mydriatics at that time. At first, I performed large sector iridectomies so that I
could see behind the iris, but in many cases the iris became aspirated into the tip and
became badly frayed. Because of this problem, I began to bring the lens into the anterior
chamber before performing the phaco, and before the pupil constricted. For several years
I, then, taught anterior chamber phaco, which I believe is still a viable alternative to
posterior chamber phaco, for those less skilled. There is a slight increase in endothelial
cell loss over the posterior chamber phaco, but not enough to be significant.
After a few years, mydriatics were placed in the irrigating solution, and
antiinflammatory drops were used on the cornea in combination with more powerful
mydriatics. Once viscoelastics came into use, they too aided in pupillary dilation, and
posterior chamber phaco became much easier. For those pupils which are fibrotic, several
models of iris hooks are available.
69
Anterior Capsular Opening

A method of opening the anterior capsule had to be developed which would be
consistent, exposing the lens, but not extending to the zonules.
FIGURE 3.7 Christmas tree opening

My first attempts to incise the anterior capsule in several directions, with criss-crossing
lines taught me that these incisions in the capsule, if subjected to traction, could extend
around the anterior surface of the lens into the zonule, and perhaps even onto the
posterior capsule. One day, I observed on an animal eye, that if I used a dull cystotome
rather than a sharp one, instead of cutting the capsule, the cystotome tore it. And that tear
was always in the form of a triangle. I named this technique the Christmas Tree Opening
(Fig. 3.7). If I could rewrite history, I would call it a triangular capsulorhexis, a
more accurate description, and one which would place it in its proper historical
position, the forerunner of the continuous tear capsulorhexis. Once the triangular tear
was made, the pie-shaped flap would be grasped with a forceps, gently extracted, and
then cut at its base. This method was in general use until the can opener technique was
introduced, and then finally the continuous tear technique widely used today.
Magnification and Visualization
Using loups (the standard method of magnification at that time), the magnification was
not adequate. Using existing surgical microscopes gave no depth perception, since the
lighting was flat, and there was no red reflex.
This technique involved acute visualization of the intraocular structures never really
seen before. No surgeon had ever really seen at surgery, cortical material lying on top of
a capsule, or a tiny zonular dehiscence, or a minute opening in the capsule, and yet this
type of visualization was required if phaco was ever going to be successful.
The first microscopes I tried were table top dissecting microscopes, and they had
inadequate side illumination. In examining other types of microscopes, I came upon an
exciting discovery. Using an ENT microscope, the red reflex from the coaxial light gave
me an incredible depth perception intraocularly. From then on, only ENT microscopes
were used until Zeiss finally made one more suitable for ophthalmology.
Phacoemulsification
68
Protection of the Posterior Capsule

The posterior capsule is not a strong membrane. Techniques had to be developed which
would protect it during the lens removal.
It became evident to me very early on, that the big obstacle to phaco would be the
rupture of the posterior capsule. The early phaco machines did not have the power or the
suction that present models have, and the tip had to be pushed into a hard nucleus in order
to emulsify it. Like a dull knife must be pushed harder onto tissue than a sharp one. This
pushing often broke the capsule. One must remember that there were no viscoelastics at
that time. In order to make the procedure safer for me, and especially for others learning
it, I devised a technique for prolapsing the entire nucleus into the anterior chamber, where
it could be emulsified at some distance from the capsule. This method remained in vogue
until the equipment was improved, at which time phaco in the posterior chamber (where
phaco began) was reintroduced.
Protection of Iris and Cornea
A technique of surgery had to be developed which would allow the surgeon to safely
emulsify the nucleus without damaging the endothelium, or the iris.
In the early cases, the cornea collapsed many times against the vibrating needle, and
the corneas had severe striate for sometimes up to one month. There was no method at
this time of counting endothelial cells, but later studies showed up to 50 percent cell loss
in these first cases. It is interesting to note that these corneas eventually cleared, giving
the patients good vision.
Cortical Clean-up
A technique would be needed to safely pull the cortex out of the fornices of the capsule,
and then to aspirate it.
In the early cases, the same phaco tip and sleeve were used to remove cortex, but it
became obvious that this terminal opening endangered the capsule. I modified the tip, so
that it had a closed terminal end, with the lumen on the side, so that it could be directed
away from the capsule.
Instrument Problems
An instrument powerful enough to emulsify all types of cataracts, without damaging
adjacent structures would have to be developed.
The first phacoemulsifier used on animals and patients consisted of a table with
various parts and devices connected to each other. One of the parts was a dental apparatus
used to remove tartar from the teeth. This was modified, so as to add suction and
irrigation. The ultrasonic stroke was not only too small to act on hard cataracts, but it got
dampened even further when a load (the cataract) was put on. I found that with
piezoelectric crystals, rather than magnetostrictive stacks, a greater stroke could be
achieved, and that dampening could be prevented. Today there is no cataract too hard to
be emulsified.
71
Heat Build-up
Ultrasonic frequencies build up sufficient heat to denature tissue. Cooling would have to
be guaranteed.
After actually cooking and denaturing the protein of the lens in some animal eyes, it
became clear to me that constant irrigation of the vibrating tip had to be assured. My
original idea of having a water tight, close fitting incision was not going to work, since
when the tip was occluded, the outflow through the tip was blocked, and since the
incision was tight around the tip, no fluid could escape. It then became necessary to have
the incision slightly larger than the tip so that fluid could always escape from the eye, and
also to insure that the amount of fluid flowing into the eye always exceeded the amount
being aspirated. Once these concepts were put into effect, heat build-up ceased to be a
problem.
Anterior Chamber Collapse
Considerable suction was necessary to hold lens material onto the vibrating tip. Once this
material was aspirated, in a few milliseconds, there was enough suction build up to
collapse the chamber. The result of this collapse was to see the cornea touching the
vibrating tip, with the endothelium being emulsified. A method had to be found to
prevent this.
In order for the lens material (especially if it is hard nucleus) to remain fixed to the tip
while that tip is vibrating, a fairly high level of vacuum must be achieved. If we started
with a high level of vacuum, copious amounts of fluid would always be entering and
leaving the eye. Also, if the capsule or iris were inadvertently engaged, these tissues
would be more susceptible to damage, than if the suction were lower. It became obvious
that a peristaltic type pump could apply minimum suction until such a time as the tip
became occluded, at that time the suction would rise, holding the lens material onto the
tip while it was being emulsified. The problem created with this system was that as soon
as the lens material became suddenly aspirated, the high level of suction in the system
would collapse the chamber. For the first 50 or so cases, I had no other solution to this
problem, than that of trying to anticipate the collapse, and just before the morcel would
be aspirated, I would take my foot off the foot pedal. This was very ineffective, and many
times during the first cases, the cornea would collapse onto the vibrating tip. Although I
am sure that the endothelium was damaged, to my good fortune, these eyes always
cleared after a few days, permitting me to continue developing the instrument and
technique.
After much searching, I finally found a fluid control system which monitored
flow in arteries by creation of an electrical current from the ions as they rushed
through the arteries. I adapted this system so that the fluid flow through the
aspiration line was monitored. When it stopped (tip occlusion), a valve was put into
the alert position. Within a few milliseconds after flow started up again (aspiration
of the morcel), this valve would open to the atmosphere, killing the suction. This was
a very satisfactory system, and was used for several generations of phacoemulsifiers.
After having suffered through hundreds of actual collapses on my first cases, I still
remember the joy of seeing the tiny beat of the cornea, instead of a collapse, once the
system was working.
Phacoemulsification
70
Handpiece Design
The early handpieces were extremely heavy and cumbersome. The original procedures
took up to four hours, with over one hour of ultrasonic time. A special three-dimensional
parallelogram had to be invented and constructed to hold the handpiece.
Ophthalmic surgeons are used to tiny instruments which fit into the fingers. The
original phaco handpiece was about the size of a large flashlight, and weighed almost a
pound. I was willing to use it while I was developing the techniques, but I knew no one
else would be willing. While looking for ways to make the handpiece lighter and smaller,
I developed the three-dimensional parallelogram to hold the handpiece, with all axes of
rotation around the incision (Fig. 3.8).
The original handpiece was magnetostrictive, and had a frequency of 25,000 cycles.
By substituting piezo electric crystals for the heavy magnetostrictive plates, the size and
weight were greatly reduced, and the frequency was raised to 40,000 cycles. I now had a
handpiece that others might be willing to try.
Handpiece Heat Build-up
The original handpiece was magnetostrictive, and had to be water cooled. This cooling
water had to be isolated from the sterile end of the handpiece.
The original handpiece was water cooled. Non-sterile water flowed in, around and out
of the magnetostrictive plates. The first handpiece had a set of O-rings to isolate this
nonsterile water from the sterile irrigation fluid, but in one instance the O-rings failed,
causing an infection. The interim
FIGURE 3.8 Three-dimensional

parallelogram support for handpiece
73
solution was to add a second set of O-rings, but finally, when the piezoelectric crystal
replaced the magnetostrictive, air cooling was sufficient, and no O-rings were needed.
Flaking of the Tips
The original tips were steel, and flaking was a problem, with the possibility of leaving
iron shavings inside the eye.
Titanium is a completely inert metal, and is silent in tissue. It is also less friable than
steel, and therefore the steel tips were replaced with this metal, and in millions of cases
now, there has not been any report of adverse effects from this material. It is extremely
rare to see any particle in any operated eye.
Insulating the Vibrating Tip
The vibrating tip had to be insulated from the corneo-scleral wound to prevent heating.
Various materials were tried and the two best found were silicon and Teflon. Since
silicon was softer, it was the final choice.
Irrigating Solution
Since a fair amount of solution would be washing over the cornea during the procedure, it
was important to find the best possible irrigating solution. Rather than embark on a
scientific quest as to which solution would be the safest, I had observed in Barcelona, that
Jouquim Barraquer employed a solution, made in Spain, which closely approximated the
fluid in the anterior chamber. I began importing and using this solution.
Political Problems
It is difficult enough for a serious scientist to introduce a dramatic change in a procedure
which everyone thinks is already ideal. But when this new technique involves
considerable training, using an operating microscope when one has never used one
before, when those who are unable to perform the new technique announce that you have
to lose a bucketful of eyes before you are adept at it, and when that technique is
developed by a saxophone player who is still appearing in Carnegie Hall, and doing
stand-up comedy in the casinos of Atlantic city, it sounds like getting this procedure
accepted would be a hopeless proposition.
At this point, I must say again, that if I had known in advance how many
problems there were, I might well never have started the project. The Chinese
proverb is appropriate here, The longest journey in the world begins with the first
step.
Although the surgical and instrument problems outlined above were difficult to solve,
they were a constant challenge and their solution brought a great deal of satisfaction. Not
so for the political problems! When I first introduced phacoemulsification and aspiration,
it was met with more than scientific reserve. It was met with scorn. How dare I, a young
nobody presume to change what the University professors were proclaiming the safest
Phacoemulsification
72
and most sophisticated surgical procedure ever devised (intracapsular surgery)? At

meetings where I presented the concept, there was considerable derision, mockery and
hostility in the questions from the floor.
At Manhattan Eye and Ear Hospital where I was assistant attending surgeon, the
hospital voted to allow only one case per week, for every year an attending was on the
staff. This vote cut down on the number of cataract cases I could do. Since that edict only
affected me, I was, after a great battle, able to get this ruling considered restraint of
trade, and the hospital had to withdraw that ruling. When I began doing
phacoemulsification, the Surgeon Directors advised me that I would have to stop
immediately if I had even one case of serious complications. When you put that sword of
Damocles together with the problems outlined above with the technique and instrument,
one can imagine the pressure involved in every procedure.
Once the technique had been taken up by several others in various parts of the country,
each investigator was met with the same hostility that I had encountered. Once it began to
be accepted by several dozen surgeons, the political forces against it had the operation
declared experimental by Medicare, meaning that there would be no reimbursement for
the procedure. It took several months, and letters from a thousand patients from all over
the country to get this ruling by the government reversed.
The American Academy of Ophthalmology then commissioned one of the most
vociferous antagonists to the procedure to do an unbiased study comparing the results
of phaco to intracapsular surgery. I was put on the panel, but was never allowed to see
any of the results of this study until they were ready to be submitted. It came as no
surprise to find that intracapsular surgery was found to be infinitely superior to
phacoemulsification. Since the justification of this conclusion was rather suspect, I was
able to engage the professor of statistics at Columbia Presbyterian University to examine
the methods and conclusions drawn. His report was so scathing, that the original report
was discarded, and the final verdict submitted to the Academy was that phaco was at least
as safe and effective as intracapsular surgery.
The increase in the percentage of cases done with phaco slowly increased over the
years, until foldable lenses were introduced. At that time, Phaco cases increased
dramatically, until today, more than 85 percent of cataracts removed use
phacoemulsification and aspiration.
I am grateful to the early pioneers who stood with me, and grateful to all those who
even today are improving this technique.
References
1. Kelman CD, Cooper IS: Cryosurgery of retinal detachment and other ocular conditions. The Eye,
Ear, Nose and Throat Monthly 42:4246, 1963.
2. Cryogenic surgery: N Engl J Med 268:1963.
3. Kelman CD: Symposium; phacoemulsification. History of emulsification and aspiration of senile
cataracts. Transactions American Academy of Ophthalmology and Otolaryngology 78:OP7
OP9, 1974.
4
Biometry
Sunita Agarwal
Introduction
It is necessary for every ophthalmologist who is working with intraocular lenses to know
how to calculate the power of the IOL.
Axial Length Measurement
For IOL implantation, the ultrasonic method affords the best way to calculate the axial
length and achieves the desired postoperative refraction. The instruments available to
make these measurements are of two basic types:
i. instruments with rigid probe tips, and
ii. instruments with distensible tips or with water baths.
Those instruments with distensible membranes on the front of the probe are
approximately 5 percent more accurate in making measurements than those with the rigid
tip. The reasons why the distensible tip are better are as follows.
1. The distensible tip prevents indenting the cornea when the measurement is made, and
does not cause the eye to appear artificially shortened. A rigid tip can cause corneal
indentation between 0.1 and 0.3 mm, resulting in error from 0.3 to 1.0 diopters (Fig.
4.1). In other words if one is buying an A-scan, one should get one with a distensible
tip.
FIGURE 4.1 Disadvantage of hard tip

transducernote indentation on the
cornea
Phacoemulsification
74
2. The distensible tip helps to separate the corneal reflection from the signal sent out from
the front surface of the transducer, i.e. it makes it more accurate to determine exactly
where the front surface of the cornea is, and when it is not in direct contact with the
transducer.
Keratometric Measurements
The keratometric measurements can be done through a keratometer or through an
autokeratometer. Many biometers (Fig. 4.2) have provision for connecting the
autokeratometer to their computer so that once the keratometer reading is taken
automatically, the value is entered into the biometer, and one does not have to feed it in
again.
IOL Formula
There are two major categories of IOL formulae.
FIGURE 4.2 Biometer

Theoretical Formula
Introduction
This formula is based on an optical model of the eye. An optics equation is solved to
determine the IOL power needed to focus light from a distant object onto the retina. In
the different formulae, different assumptions are made about the refractive index of the
cornea, the distance of the cornea to the IOL, the distance of the IOL to the retina as well
as other factors. These are called theoretical formulae because they are based on a
theoretical optical model of the eye. All of these theoretical equations make simplifying
assumptions about the optics of the eye, and hence, provide a good (but not perfect)
prediction of IOL power.
Biometry
77
The most popular formula in this group is the Binkhorst formula. This is based on
sound theory. All the theoretical formulae can be algebrically transformed into the
following
P=[N/(LC)][NK/(NKC)]
where,
P = Dioptric power of the lens for emmetropia,
N = Aqueous and vitreous refractive index,
L = Axial length (mm)
C = Estimated postoperative anterior chamber depth (mm), and
K = Corneal curvature [D].
Binkhorst Formula
Binkhorst has made a correction in his formula for surgically induced flattening of the
cornea, using a corneal index of refraction of 1.333. Binkhorst also corrects for the
thickness of the lens implant by subtracting approximately 0.05 mm from the measured
axial length. Thus with the Binkhorst formula, 0.25 mm is added to the measured axial
length to account for the distance between the vitreoretinal interface and the
photoreceptor layer, and 0.05 mm is subtracted for lens thickness, resulting in a net
addition of 0.20 mm to the measured axial length. The Binkhorsts formula is:
D=1336 (4ra)/(ad) (4rd)
where,
D = Dioptric power of IOL in aqueous humor,
1336 = Index of refraction of vitreous and aqueous,
r = Radius of curvature of the anterior surface of the cornea,
a = Axial length of the globe (mm), and
d = Distance between the anterior cornea and the IOL.
Disadvantages
The problem in the theoretical formula is in the axial length measurement. The reason
why it is difficult to measure the axial length accurately is that one must know the exact
velocities of the ultrasound as it travels through the various structures of the eye. Because
of the variation of the acoustic density of a cataract, these velocities cannot be known
exactly. As a result, when cataractous lenses are much more acoustically dense than the
average lens, the sound wave will move more rapidly through the lens and return to the
transducer much more quickly than would have been expected for a given axial length.
As a result of the velocity error, the eyes appear to be shorter. The formula consequently
calculates an IOL power for an axial length which is too short. The patient then becomes
overminused (too myopic). Theoretical formulae help the surgeon to anticipate what
should result, not what will result from implantation.
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76
Regression Formula (Empirical formula)

Introduction
The regression formulae or empirical formulae are derived from empirical data and are
based on retrospective analysis of postoperative refraction after IOL implantation. The
results of a large number of IOL implantations are plotted with respect to the corneal
power, axial length of the eye, and emmetropic IOL power. The best-fit equation is then
determined by the statistical procedure of regression analysis of the data. Unlike the
theoretical formulae, no assumptions are made about the optics of the eye. These
regression equations are only as good as the accuracy of the data used to derive them.
Advantages
Implant power calculations can be made much more accurately through the use of
regression formulae that are based on the analysis of the actual results of many
uncomplicated IOL implantations in previous cataract surgeries. Since regression analysis
is based on the results of actual operations, it includes the vagaries of the eye and
measuring devices, vagaries that theoretical formulae attempt to address with correction
factors.
Sanders-Retzlaff-Kraff (SRK) Formula
The most popular regression formula is the SRK formula which was developed by
Sanders, Retzlaff and Kraff in 1980. This is
P=A2.5 L0.9 K
where,
P = Implant power to produce emmetropia,
L = Axial length (mm),
K = Average keratometer reading, and
A = Specific constant for each lens type and manufacture.
The SRK formula calculates the IOL power by linearly regressing the results of previous
implants. As this is a linear formula, it will underestimate the power of high-powered
lenses and it will overestimate the power of the low-powered lenses compared to the
theoretical calculation. For example, if the Binkhorst formula predicts that a 28-diopter
lens should be used, the SRK formula will predict that a 26-diopter lens should be used.
In lenses with low power, if the Binkhorst formula predicts that a 10-diopter lens is
necessary, the SRK will predict that a 12-diopter lens should be used.
Biometry
79
Relation of Equipment to Specific Formulae

Most of the instruments calculate the desired power for the IOL at least by three different
methods including a regression formula and a theoretical formula. It is the responsibility
of the doctor to select which of the formulae he or she wants to use. Rarely, between 18
and 22 diopters, is there a significant difference between the calculated lens powers. But
outside this range, there will be a progressive increase in difference between that
determined by the theoretical formula and the one calculated by the regression formula.
Since the regression formula has turned out to be statistically more accurate, 5 percent at
these extremes, it is presently more reliable than the theoretical formulae. The
manufacturers vary as to which programs they provide. One should anyway make sure
that both the regression and theoretical formulae are included so that one has the
opportunity to personally select the most reliable technique for ones surgery.
Targeting IOL Postoperative Refraction
The question that comes to ones mind next is How to predetermine what postoperative
refraction the patient should have? This is the one parameter which the doctor has to
decide upon and feed into the computer. The other parameters like axial length, etc. we
have no control over. The answer depends on whether we are doing a monocular or
binocular correction.
Monocular Correction
If we are considering only one eye (i.e. if the other eye has cataract or is amblyopic),
targeting the postoperative refraction for approximately 1.00 diopter is probably the best
choice. This is usually best because most people have visual needs for both distance and
near. This means that the patient wants to be able to drive and to read without wearing
glasses. If we target the postoperative refraction to 1.00D, it will allow the patient to
perform most tasks with no glasses. At times, when they need finer acuity, they can wear
regular bifocals, which will correct them for distance and near.
The second reason for targeting the postoperative refraction to 1.00D is that
statistically, between 70 percent and 90 percent of the patients will fall within +1.00D
error of the desired postoperative refraction. The errors, as mentioned earlier are due to
our inexact measurements. Therefore, the patient will fall between piano and 2.00D 90
percent of the time. This will assure most patients of useful vision without glasses.
Hence, the error of the ultrasound is best handled by choosing the postoperative
refraction to 1.00D. If we would target for piano, then 90 percent of the patients will be
between 1.00 and +1.00D. When the patients refraction is on the +1 side he or she has
no useful vision at any distance because he or she is hyperopic and does not have the
ability to accommodate. Consequently, because it is very undesirable to have a hyperopic
correction, targeting for 1.00D not only optimizes the best vision at all distances, but
Phacoemulsification
78
also minimizes the chance for hyperopia that can result from inaccurate ultrasonic
measurements.
Binocular Correction
When the vision in the other eye is good, its refraction must be considered for binocular
vision. One overriding rule when prescribing glasses is that one should never prescribe
spectacles which gives the patient a difference in the power between the right and left
lens greater than 3D. The reason for this is that even though the patient may have 6/6
vision in primary gaze, when the patient looks up or down, the induced vertical prism
difference in the two eyes is so great that it will create double vision. In a patient who
has good vision in the nonoperative eye, one must target the IOL power for a
refraction within 2D of his or her present prescription in the nonoperative eye. Two
dipoters, not three, due to our 1D A-scan variability. For example, if we have a patient
who is hyperopic and has +5D correction in each eye, we cannot target the IOL for a
postoperative refraction of 1.00D because this would produce a 6D difference between
the two lenses resulting in double vision. We must therefore select the IOL power to
obtain a refraction which is approximately 2D less than the nonoperative eye.
Consequently, on our patient who is +5D in both eyes, we should target the postoperative
refraction in the eye with the cataract for +3D, so that there is a 90 percent probability
that there will be less than a 3D difference.
In contrast, if the patient were highly myopic in each eye, for example, 10D in both
eyes, we should target the IOL power to produce refraction of approximately 8D. Again,
we have limited the difference in the spectacles lenses to a 2D difference in the final
prescription. Again, target, for a 2D difference not a 3D, because there is approximately a
1D tolerance in the accuracy of the ultrasonic measurement.
If the operation on the second eye is to be done shortly after the first, the preoperative
spectacles refraction can be ignored, and the patient is treated as if he or she were
monocular.
Factors Affecting Accuracy of IOL Power Calculation
Many factors can affect the accuracy of the power of the IOL calculated.
Keratometry
Keratometers only measure the radius of curvature of the anterior corneal surface. This
measurement must be converted to an estimate of the refracting power of the cornea in
diopters, using a fictitious index (the true corneal refractive index of 1.376 could be used
only if both the anterior and posterior corneal radii of curvature were known). The
variability can alter calculated corneal dioptric power by 0.7D.
Biometry
81
Axial Length Measurement

As explained earlier, indentation of the cornea by the A-scan instrument tip can alter the
axial length affecting the accuracy of the power of the IOL.
Axial Length Correction Factor
The distance from the vitreoretinal interface to the photoreceptor layer has been estimated
to be about 0.15 to 0.5 mm. This distance can affect the accuracy of the IOL power
calculated.
Site of Loop Implantation
Posterior chamber IOLs may be implanted with both loops in the ciliary sulcus or in the
capsular bag, or with one loop in the sulcus and one loop in the capsular bag. Positioning
the implants within the capsular bag places the implant further back in the eye and
decreases the effective power of the lens. There is usually a 0.5 to 1.5D loss of effectivity
by placing the implant in the capsular bag as opposed to the ciliary sulcus. A higher
power lens should therefore be used when the implant is placed in the capsular bag.
Orientation of Planoconvex Implants
Some surgeons implant planoconvex posterior chamber lenses with the piano surface
forward.
FIGURE 4.3 Ultrasonic reading in

dense cataract
Such flipping of the implant decreases the effective power of the lens by 0.75D even if
the position of the lens is unchanged. An additional 0.5D loss of effectivity occurs
because the principal plane of the lens is usually displaced further back into the eye.
Thus, a total loss in effectivity of 1.25D is expected by turning the lens around.
Phacoemulsification
80
Postoperative Change in Corneal Curvature

Suturing of a cataract incision has a tendency to steepen the vertical meridian. These
changes affect the postoperative refraction of the patient.
Density of the Cataract
The density of the cataract also makes a difference. In a dense cataract (Fig. 4.3), the
ultrasonic waves travel faster whereas in an early cataract (Fig. 4.4) the ultrasonic waves
travel slower.
IOL Tilt and Decentration
When a lens is tilted, its effective power increases and plus cylinder astigmatism is
induced about the axis of the lens tilt. The tilting of the lens occurs if one loop is in the
capsular bag and the other in the sulcus (Fig. 4.5). Alternatively, residual cortex being left
behind can cause an inflammatory response which causes contraction and pulling
unequally on parts of the loops and the optic.
FIGURE 4.4 Ultrasonic reading in

early cataract
Biometry
83
FIGURE 4.5 Captive iris syndrome

Pseudophakic Lasik
If a patient has had a wrong biometry then the solution can be to remove the IOL and
replace it with a correct powered IOL. Another alternative is to perform LASIK and
correct the problem. Figure 4.6
Phacoemulsification
82
FIGURE 4.6 Topograph of a patient

in whom a wrong power IOL was
implanted
FIGURE 4.7 Topograph of the same

patient as in Figure 4.6 after LASIK
is the topograph before LASIK of a patient who had a power of 10.0 dioptres after IOL
implantation. The patient was referred to us and we did a LASIK as the patient was
operated a year back, We felt that the IOL might be fixed firmly in the bag. Figure 4.7 is
the topograph after LASIK.
5
IOL Power Calculation After Corneal
Refractive Surgery
Jairo E Hoyos
Melania Cigales
J Hoyos-Chacn
Corneal refractive surgery corrects refractive errors by modifying the anterior surface of
the cornea. The problem appears years later when, as a result of the normal aging process,
these patients develop cataracts and require lens extraction surgery and intraocular lens
(IOL) implantation. Figure 5.1 shows one eye with cataract surgery after corneal
refractive surgery. The question arises about which should be the basis for calculating
this lens implant. Being able to determine the accurate power of the IOL to be implanted
in a patient undergoing cataract surgery is a big challenge, even more so when the patient
has had prior refractive surgery. A patient with prior refractive surgery is very special
both medically and psychologically because he or she will not want to use glasses
permanently after having spent time without them.
FIGURE 5.1 (Hoyos). High myope

patient operated on with in situ
queratomileusis and radial keratotomy
for the residual error, who developed
cataract 10 years later. A
phacoemulsification technique was
Phacoemulsification
84
performed and an IOL foldable was

implanted
Formulas for calculating the IOL power include multiple variables, but with the current
standardized cataract surgery techniques, these are reduced to only three: lens constant,
corneal diopter power and axial length of the eye. The lens constant is standard for each
lens model; refractive corneal surgery does not change axial length; however,
postrefractive surgery produces a significant change in corneal curvature. At present, the
best system for measuring corneal curvature is computerized corneal topography,
although this method overestimates the central diopter power of a flattened cornea
resulting from corneal refractive surgery. Consequently, the IOL power calculation will
depend primarily on how accurately the corneas central refractive power is calculated.
In this chapter we will analyze the information from the patients refractive surgery
history, the current systems for measuring corneal power and the proposed methods for
patients with previous corneal refractive surgery. In addition to this, the scan
measurement of axial length and the IOL power calculation formulas we also be
reviewed.
Ocular History
The refractive success of cataract surgery in eyes with prior refractive corneal surgery
will depend mainly on the ability to calculate the current keratometric power of the
cornea accurately. This requires knowledge of the patients ocular history before and
after refractive surgery, as well as of the current ocular status.
a. The history prior to refractive surgery will provide information about refraction,
corneal power and axial length before refractive surgery.
b. The postrefractive surgery history will provide information about stable refraction
obtained following the procedure.
c. The current ocular history must include biometry and computerized corneal
topography besides the complete ophthalmological examination.
Keratometric Readings
The refractive change of the anterior surface of the cornea as measured by topographic
and keratometric readings has been and continues to be the basis for a large number of
surgical techniques designed to correct refractive errors. Everything started with the early
observations by Christopher Scheiner in 1619, based on the reflection of the grid of
windowpanes on the cornea, which later led to the use of simple versatile keratoscopy
and keratometry. Until the development of the modern computerized equipment for
corneal topography, ophthalmologists used different instruments for studying the anterior
corneal surface whose sensitivity and specificity have improved with time and as a result
of technological breakthroughs.13
IOL Power calulation after corneal
87
The old devices such as Javal were, for many years, of great help in keratometric
study. However, it was not until the late 1980s when computerized devices were
implemented and marketed that we were able to obtain a much more reliable assessment
of the central power of the cornea in patients with prior refractive surgery. The
keratometer is capable of measuring a regular spherocylindrical surface with accuracy
greater than 0.25 diopters. However, the major limitations of the keratometer are that it
assumes that the cornea is an spherocylindrical surface. It provides no information
regarding the topography central or peripheral to the points of measurement, and mild
corneal surface irregularity causes distortion, precluding meaningful measurement.
Despite these slight drawbacks, the Javal keratometer was of great help to us when we
began performing keratomileusis in the late 1980s.
Topographic parameters are studied in computerized corneal topography using the
absolute and normalized scale and topographic maps:
a. Sim K (Simulated keratoscope reading) is derived from maximum K readings for rings
6, 7 and 8.
b. Min K (Minimum keratoscope reading) corresponds to the minimum keratometric
power of rings 6, 7 and 8.
c. Central K (Central keratoscope reading) corresponds to the central topographic area
within the central 3 mm of the cornea which coincides with the visual axis and whose
value may be obtained from the center of the topographic map and the color code bar
in diopters (Fig. 5.2).
It is very important to bear in mind that rings 6, 7 and 8 are on the outer limit of the three
central millimeters of the corneal fixation center and, therefore, outside the area of
refractive treatment in many high myopic patients.
FIGURE 5.2 The central K

corresponds to the central topographic
area within the central 3 mm of the
cornea coinciding with the visual axis
Phacoemulsification
86
Corneal Power Calculation Methods

The next challenge for the surgeon is to determine the keratometry to be used for
calculating the intraocular lens power. The main methods which are normally used to
calculate corneal power after refractive surgery are: the calculation method or refractive
history method;4 the hard contact lens method5; and corneal topography.
A. Calculation method or refractive history method: This is the most accurate method
and requires knowing three parameters: K-readings and refraction before the
keratorefractive procedure, and stabilized postoperative refraction (before any myopic
shifts from nuclear cataract occur). The main concept is to subtract the refractive
change on the corneal plane due to the keratorefractive procedure, from the original Kreadings before the procedure, to arrive at a calculated postoperative K-reading.
Step I: Calculate the spheroequivalent refraction for refraction on the
corneal plane (SEQc) on the basis of the spheroequivalent refraction on
the spectacle plane (SEQs) at a given vertex.
Step II: Calculate the change in refraction on the corneal plane, where
refraction change is equal to preoperative SEQc minus postoperative
SEQc.
Step III: Determine the calculated postoperative corneal refractive
power, where mean postoperative K is equal to the mean preoperative K
minus the change in refraction on the corneal plane. The value obtained is
the calculated central power of the cornea following the keratorefractive
procedure.
Once the pre- and postrefractive surgery refraction (spherical equivalent) is known, the
refractive change induced on the corneal plane is determined and subtracted from the Kreading present before the corneal refractive surgery. Refraction must be measured on the
corneal plane. For this purpose, distance-to-vertex conversion tables or the following
formula may be used: Rc=Rg/[1(dRg)], where Rc is the refraction on the corneal
plane, Rg is the refraction on the spectacle plane and d is the distance to the vertex in
meters (0,012).
It is important to determine the stable residual refraction in patients who have
undergone prior refractive surgery since it may change with time as a result of cataractinduced myopization of the index or due to an increased axial length in some cases.
B. Trial hard contact lens method: This method requires a piano hard contact lens with a
known base curve and a patient with a cataract, which allows us to see the retinoscopy,
shadows during the refraction.
Step I: The patients spherical equivalent refraction is determined by
normal refraction.
Step II: The refraction is repeated with a hard contact lens in place. If
the spheroequivalent refraction does not change with the contact lens, the
89
patients cornea must have the same power as the base curve of the piano
contact lens (Fig. 5.3A). If there is a hyperopic shift in the refraction, then
the base curve of the contact lens is weaker than the cornea by the shift
amount (Fig. 5.3B). If the patient has a myopic shift, then the base curve
of the contact lens is stronger than the cornea by the shift amount (Fig.
5.3C).
Step III: The appropriate algebraic formula for each case is then made,
taking into account that spheroequivalent values greater than 4.00 D
must be converted to corneal plane. This method is limited by the
accuracy of the
FIGURE 5.3 Trial hard contact lens

method: A If the spheroequivalent
refraction does not change with the
contact lens, the power of the patients
cornea must be the same as the base
curve of the planocontact lens. B When
there is a hyperopic shift in the
refraction, then the base curve of the
contact lens is weaker than the cornea
by the amount of the shift. C If the
patient exhibits a myopic shift, then
the base curve of the contact lens is
stronger than the cornea by the amount
of the shift
refraction, which is in turn limited by the amount and type of the
cataract, and it requires good visual acuity of 20/80 or better.
C. Corneal topography method: Corneal topography allows for an accurate determination
of the anterior surface of the cornea. For this method, the central corneal power
following keratorefractive surgery must be known. This one, like the keratometry
Phacoemulsification
88
method, is very inaccurate. Current topographers do not allow us to determine an

objective central K-reading and only provide Sim K and Min K values which are
always overestimated in patients with prior surgery for myopia and underestimated in
cases of hyperopic surgery. If those keratometric values were used for calculating the
intraocular lens, postoperative results would be very far from ametropia (Fig. 5.4).
Biometry
A-mode ultrasound biometry enables us to measure the eyes visual axis through echo
generation representing the reflection of the ultrasound beams on the different interfaces
of the ocular tissues. Corneal ablation used for correcting the refractive
FIGURE 5.4 IOL power calculation

using different corneal powers: Sim K,
Min K, Calculated K and Central K
error is minimal (less than 150 m) and has negligible effects in terms of modifying the
axial length after refractive surgery.6 Care must be taken when performing biometry in
order to avoid errors caused by the loss of alignment with the optic axis, and excessive
pressure of the transducer on the cornea which leads to short readings of the axial length
(especially in eyes with a thinned-out cornea). It is also important to ensure that a
standard deviation of less than 0.1 is obtained for several measurements. In high myopia,
the presence of a posterior staphyloma may give rise to inconsistent recordings, but this
may be avoided by asking the patient to fix on the transducer light.7,8
During biometry, it is important to ensure that the transducer is applied without
indenting the cornea, which may be significantly thinner in high myopes as a result of the
refractive technique. A 1 mm error in the axial length determination results in a 3-diopter
error, while a 1 mm error in the preoperative determination of the anterior chamber depth
will induce a refractive error of 1.4 diopters. Consequently, we recommend using the
biometer in automatic mode with five measurements and a standard deviation of less than
0.1. Also, whenever possible, the patient must be made to fix on the transducer light.
In our patients, whenever we find variations between the current axial length and the
one existing before refractive surgery, we always use the higher value because of the
91
possibility of a post-operative increase of the axial length with increased myopia, or

because of the possibility of introducing a biometric error as a result of indenting a thin
cornea.
IOL Power Calculation Formulas
A number of theoretical and regression formulas are used. It is generally accepted that
both theoretical and regression-derived formulas perform well for eyes of average axial
lengths between 22 mm and 24.5 mm. Even in extremely long eyes of more than 28.4
mm in length, excellent accuracy can be achieved with the Holladay and the SRK-T
formulas. Regression formulas such as the SRK II, which perform very well in eyes of
usual length, should not be used in these extremely long eyes.9 Hoffer10 recommends
using his own formula for eyes with axial lengths of less than 22 mm, and the SRK-T and
Holladay for axial lengths greater than 24.5 mm.
Koch11 discovered that the modern theoretical formulas were far better than regression
formulas when evaluating IOL power for radial keratotomy eyes. Therefore, the first
thing to do to improve accuracy is to refrain from using a regression formula (SRK, SRK
II, etc) to calculate the IOL power for these eyes. A modern third-generation theoretical
formula such as the Holladay, the Hoffer Q or the SRK-T should be used; their accuracy
is further improved when they are individualized.
It is very important to use third-generation formulas, which take into consideration
axial length and anterior chamber depth (e.g. Holladay, SRK-T, or Hoffer-Q) since the
old ones like SRK I, SRK II and Binkhorst may give rise to significant errors. Accurate
power calculation constants are absolutely essential for the effective implant power
calculation; the SRK II formula utilizes A-constants, the SRK-T theoretical formula
utilizes either A constants or ACD constants, the Holladay formula utilizes the Surgeon
Factor (SF) constant, which is an offset of the ACD constant. Manufacturer published
constants are first determined for specific IOLs by the manufacturer through closed
studies or are estimated by comparison with existing IOLs. Each surgeon should become
familiar with, and use the same type of lens as long as the operative conditions allow it,
because that would allow the surgeon to determine personal variations and establish a
personal constant (A, ACD or SF).12,13
For calculating the power of the intraocular lens in high myopia, it is better to aim for
0.75D, because we have noticed that these patients benefit significantly from their near
vision. In many of our patients, despite using an intraocular lens calculated to induce a
myopia of 0.75 to 1.00, we have found that there is a minor residual defect or a
tendency to emetropization; this observation should be taken into account because the
tendency to hyperopia is undesirable in these patients who, aside from having been
myopes, have no accommodation.
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Case Report
Ocular History
A 43-year old male with refraction in the left eye of [16/4170], with a 20/25
corrected visual acuity, 31.9 mm axial length and the following topographic values: Sim
K [46.3D82/42.4D172] and Min K [42.3D176] (Fig. 5.5A). LASIK was
performed to correct myopia and astigmatism, and six months later, refraction was
0.50D spherical, and topographic parameters were: Sim K [32.1D45/ 31.6D135]
and Min K [31.4D172] (Fig. 5.5B). Three years later the patient developed a cataract
and refraction was 4.50D spherical, uncorrected visual acuity was 20/200, corrected
visual acuity was 20/30, axial length was 31.06 mm and
FIGURE 5.5A Clinical case: PreLASIK data
FIGURE 5.5B Clinical case: Data 6

months after LASIK surgery
93
FIGURE 5.5C Clinical case: Data 3

years after LASIK surgery when the
eye shows cataract
topographic values were: Sim K [32.7D55/32.3 D145] (mean 32.50), Min K
[32.1D173] and Central K [30.30D] (Fig. 5.5C).
Corneal Power Calculation
We used the refractive history method to calculate the corneal power.
1. Pre-LASIK refraction was 16/4170. The spherical equivalent (SE) was 18 D and
the same value towards the cornea was 14.75D.
2. Post-LASIK refraction was 0.50D.
3. Refractive change was the pre-LASIK SE (14.75) minus the post-LASIK SE (0.50),
that means 14.25D.
4. Preoperative keratometry average was 44.35D (Sim K [46.3D82/42.4D172]).
5. Calculated corneal power was the preoperative keratometry average (44.35D) minus
the refractive change induced by LASIK (14.25), that equals 30.1D.
Axial Length
There are two axial length values for this patient: 31.9 mm before LASIK and 31.06 mm
before cataract surgery the difference being 0.84 mm. The reduction in axial length is
attributed to corneal indentation, which may occur during measurement despite every
precaution, especially in very high myopes with thin corneas resulting from refractive
surgery. As mentioned previously, axial length does not change statistically Therefore,
the axial length selected in this patient was the preoperative axial length of 31.9 mm.
IOL Power Calculation
The IOL power calculation, using the SRK-T formula, for an IOL with A constant of
118.8 and a 0.75D of desired refraction, was +16.50D.
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92
Result
Uncorrected visual acuity three months after cataract surgery was 20/25 and pianorefraction. (Fig. 5.5D).
Summary
Refractive corneal surgery induces changes on the corneal surface and, consequently, in
topographic
FIGURE 5.5D Clinical case:

Postcataract surgery data
readings. After refractive corneal surgery, corneal power may be calculated using the data
of the patients refractive history.
Comparisons between the keratometric values obtained with the refractive history
method (calculated K) and the topographic data, allow us to conclude that the central
keratometric value shown by topography (central K) is the closest to the calculated
value. Sim K and Min K values correspond to rings 6, 7 and 8 on the outer limit of the
three central millimeters of the corneal fixation center. For this reason, they cannot reflect
the true value of the central cornea or, in other words, the keratometric value of the center
of the cornea. Therefore, in calculating the IOL, these topographic values would lead to
an undercorrected power calculation, thus inducing a final hyperopic refractive error.
Although the calculation method will continue to be used until the computerized
system of modern videokeratoscopes allows us to obtain objective central keratometric
values, topographic central K may be useful when the refractive history is not
available.
We recommend recording refraction values pre-and postrefractive surgery, corneal
topography values and axial length measurements in all patients who will be subjected to
corneal refractive surgery, in order to facilitate calculation of intraocular lens power in
the future, when the patient requires cataract surgery.
As discussed previously, third-generation formulas (SRK-T, Holladay and Hoffer Q)
are much more accurate than previous formulas for the more unusual eyes. Old formulas
such as SRK, SRK-II and Binkhorst should not be used in these patients (Fig. 5.6). None
95
of these formulas provide the desired result if the central corneal power is measured
incorrectly.
We generally use phacoemulsif ication bi-manual technique with foldable intraocular
lens implantation through a 3.5 mm clear cornea incision. On the first day following
cataract surgery, patients usually exhibit a hyperopic shift primarily due to transient
postoperative corneal edema and intraocular pressure changes. These patients also exhibit
FIGURE 5.6 IOL power calculation

using different formulas: SRK, SRKII, SRK-T, Holladay, Binkhorst
the same daily fluctuation during the early postoperative period after cataract surgery.
Because refractive changes are expected and vary significantly among patients, no lens
exchange should be considered until after the first postoperative week or until after the
refraction has stabilized, whichever is longer.
References
1. Rabinowitz YS, Wilson SE, Klyce SD: Color atlas of corneal topography: Interpreting
Videokeratography (1st ed). New York: Igaku-Shoin Medical Publishers Inc, 115, 1993.
2. Sanders DR, Koch DD et al: Atlas of Corneal Topography. (1st ed). Thorofare, NJ: Slack
Incorporated, 209, 1993.
3. Klyce SD, Dingeldein SA: The topography of normal corneas. Arch Ophthalmol 107:51218,
1989.
4. Holladay JT: IOL calculations following radial keratotomy surgery. Refractive & Corneal Surg
(Question & Answer) 5(3): 36A, 1989.
5. Hoffer KJ: Intraocular lens power calculation for eyes after refractive keratotomy. J Refract Surg
11:4903, 1995.
6. Hoffer K: Accuracy of intraocular ultrasound lens calculation. Arch Ophthalmol 99:181923,
1981.
7. Olsen, Thim, Cory don: Accuracy of the newer generation IOL power calculation formulas in
long and short eyes. J Cataract Refract Surg 17:18793, 1991.
8. Steele CE, Crabb DP, Edgar DF: Effects of different ocular fixation conditions on A-Scan
ultrasound biometry measurements. Ophthal Physiol Opt 12:4915, 1992.
Phacoemulsification
94
9. Retzlaff J, Sanders DR, Kraff MC: Development of the SRK/T intraocular lens implant power
calculation formula. J Cataract Refractive Surg 16(3):33340, 1990.
10. Hoffer KJ: The Hoffer Q formula: a comparison of theoretical and regression formulas. J
Cataract Refract Surg 19:70012, 1993.
11. Koch DD, Liu JF, Hyde LL et al: Refractive complications of cataract surgery after radial
keratotomy. Am J Ophthalmol, 108:67682, 1989.
12. Holladay JT, Praeger TC, Chandler TY, Musgrove KH: A three-part system for refining
intraocular lens power calculations. J Cataract Refract Surg 14:1724, 1988.
13. Retzaff J, Sanders DR, Kraff MC: A manual of implant Power Calculation: Medfort, Oregon.
Retzlaff, Sanders and Kraff, 1982, 1985, 1988.
6
IOL Master for Determining the IOL Power
at the Time of Surgery
Hampton Roy
Warren E Hill
Introduction
The Zeiss IOLMaster is a noncontact optical device that measures axial length of the eye
by partial coherence interferometry, with a consistent accuracy of 0.02 mm (less than
0.10 diopter), or better. It also does automated keratometry, measures anterior chamber
depth, the horizontal corneal diameter, and calculates intraocular lens powers, all in a
single sitting.16
The IOLMaster employs a modified Michelson interferometer to divide, and phase
delay, a 780 nm partially coherent beam of light. One beam is reflected from the corneal
surface, while the other is reflected from the retinal pigment epithelium. A photodetector
and on-board computer translate the interference pattern produced by the two beams into
a highly accurate measurement of axial length. Calibrated against the ultra-high
resolution 40-MHz Greishaber Biometric System, an internal algorithm then
approximates the distance to the vitreo-retinal interface, for the equivalent of the
ultrasonic axial length. Considering the fact that axial length measurements by A-scan
ultrasonography (using a standard 10-MHz transducer) have a typical resolution of 0.10
mm to 0.12 mm, axial length measurements by the IOLMaster represent a fivefold
increase in accuracy.
Using the instrument is straightforward. The patient is placed in the chin rest and looks
straight ahead at a small red fixation target. The eye is viewed on a video screen by the
technician during all phases of measurement, allowing for proper alignment.
Modes
The following modes are useful:
Overview mode
This allows the technician to grossly align the instrument.
Axial length mode
The axial length can be determined in most eyes with a high degree of precision,
including high myopes with posterior staphyloma, aphakia, pseudophakia and even for
eyes filled with silicon oil. The machine displays a signal-to-noise ratio for each
Phacoemulsification
96
measurement, as one indication of reliability, and also compares multiple measurements.

If the measurements are all within 0.1 mm, the machine displays an average axial length.
If the measurements fall outside this range, the technician is instructed to evaluate the
series of measurements before concluding the examination.
The characteristics of a proper axial length display are the following:
Signal-to-noise ratio greater than 2.0.
Tall, narrow primary maxima, with a thin, well-centered termination.
At least one set of secondary maxima. However, if the ocular media is poor, secondary
maxima may not be displayed.
At least four of the 20 measurements taken should be within 0.02 mm of one another
and show the characteristics of a good axial length display.
Automated keratometry mode
IOLMaster uses an integrated autokeratometer to determine the corneal curvature of the
principal meridians with corresponding axes, displayed in diopters, or in millimeters. The
instruments take five measurements within 0.5 seconds and averages them. The latest
software revision (version 3.01) has an improved keratometry algorithm and will alert the
operator if a keratometry measurement is questionable.
Anterior chamber depth mode
The distance between the optical section of the cornea, and the crystalline lens, is
measured using a lateral slit illumination at approximately 30 degrees to the optical axis.
This measurement is helpful for intraocular lens power calculation formulas, such as
Haigis and Holladay 2, which require a measured anterior chamber depth.
Intraocular lens power calculation mode
The collected data can be transferred to the intraocular lens power calculation area. Five
intraocular lens power calculation formulas (Haigis, Hoffer Q, Holladay 1, SRK II,
SRK/T) are included with the IOLMaster software. The surgeons selects the calculation
formula that he wishes to use, the target refraction, and the IOLMaster will calculate the
power of upto four intraocular lenses in the physician database.
The IOLMaster can accommodate as many as 20 surgeons, each with upto 20
preferred intraocular lenses, and corresponding personalized lens constants.
The IOLMaster is easy to use, accurate and has excellent reproducibility.
New Intraocular Lens Constants
Some lenses, like the Alcon SA60AT, show very little difference when compared to
immersion A-scan ultrasonography, while others, like the Bausch and Lomb U940A
show a larger difference. In order to determine the best initial IOLMaster constant, Dr.
Wolfgang Haigis, at the University of Wrzburg in Germany has recommended the
following approach for calculating the initial A-constant.
AIOLMaster = A Ultrasound+3 * (AL IOLMasterAL Ultrasound)
AIOLMaster = Optimized Aconstant for IOL Master
IOL Master for determining the IOL
99
AUltrasound = Optimized Aconstant for ultrasonography

ALIOLMaster = Average IOLMaster axial length
ALUltrasound = Average ultrasound axial length
Advantages of Using the IOL Master

No topical anesthetic is needed.
Multiple measurements, at different instrument stations, are not necessary.
Patients sit upright.
Using the IOLMaster is quick, accurate, and requires minimal training, although some
Interpretation by the operator is necessary.
Noncontact technique precludes the occurrence of corneal epithelial injuries, and the
transmission of infections.
Disadvantages
Unable to use for dense nuclear cataracts, posterior subcapsular plaques, corneal scars
and vitreous hemorrhages. In any case in which the axial opacity interferes with the
partially coherent light beams, IOL master cannot be used.
Unable to use on patients that cannot fully cooperate because of physical or
psychological reasons.
Approximately 95 percent of patients can be measured successfully using the IOL
Master.
Results of the IOL Master
The accuracy of intraocular lens power predictions from the IOLMaster measurements
have been found to be as good, or better, than immersion A-scan ultrasonography. With a
combination of the IOLMaster, and the Holladay 2 formula, Warren E. Hill, M.D. has
been able to consistently achieve refractive outcomes with a mean absolute prediction
error of better than 0.25 diopters. This approaches the theoretic limit of the exercise,
given the fact that intraocular lens implants come in 0.50 diopter steps.
Summary
Think of the IOL Master (Fig. 6.1) as a form of ultra high-resolution immersion A-scan
ultrasonography, giving the refractive axial length, rather than the anatomic axial length.
Because the IOLMaster is an optical device, measurements may not be possible in the
presence of significant axial opacities, such as a corneal scar, mature cataract, vitreous
hemorrhage, or dense PSC plaque, etc.
IOL constants for the IOLMaster will often be slightly higher than the manufacturers
suggested numbers and are very close to those used for
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98
FIGURE 6.1 IOL master

immersion A-scans. It is suggested that IOLMaster-specific intraocular lens constants be
used with the various popular intraocular lens power calculation formulas.
The IOLMaster is a highly reliable tool for determining the intraocular lens power
prior to surgery.
References
1. Vogel A, Dick B, Krummenauer F: Reproducibility of optical biometry using partial coherence
interferometry. Intraobserver and interobserver reliability. J Cataract Refract Surg 27:196168,
2001.
2. Schachar RA, Levy NS, Bonney RC: Accuracy of intraocular lens powers calculated from Ascan biometry with the Echo-Oculometer. Ophthalmic Surg 11:85658, 1980.
3. Drexler, W, Findl O, Menapace R et al: Partial Coherence Inferometry: A Novel Approach to
Biometry in Cataract Surgery. Am J Ophthalmol 126:52434, 1998.
4. Holladay JT, Musgrove KH, Praeger TC et al: A three-part system for refining intraocular lens
power calculations. J Cataract Refractive Surgery 14:1724, 1988.
5. Wallace RB: IOLMaster Optical Coherence Biometry: Accurate Axial Length Measurement for
Cataract Surgery and Refractive Lensectomy. Refractive Eyecare for Ophthalmologists 4:17
20, 2000.
6. Retzlaff J, Sanders DR, Kraff MC: Development of the SRK/T intraocular lens implant power
calculation formula. J Cataract Refractive Surgery 16:33340, 1990.
7
Corneal Topography in Cataract Surgery
Athiya Agarwal, Sunita Agarwal
Amar Agarwal, Nilesh Kanjani
Introduction
Topography is defined as the science of describing or representing the features of a
particular place in detail. In corneal topography, the place is the cornea, i.e. we describe
the features of the cornea in detail.
The word Topography is derived1,2 from two Greek words:
TOPOS- meaning place and
GRAPHIEN- meaning to write
Cornea
There are basically three refractive elements of the eye- namely; axial length, lens and
cornea. The cornea is the most important plane or tissue for refraction. This is because it
has the highest refractive power (which is about+45 D) and it is easily accessible to the
surgeon without going inside the eye.
To understand the cornea, one should realize that the cornea is a parabolic curveits
radius of curvature differs from center to periphery. It is steepest in the center and flatter
in the periphery. For all practical purposes the central cornea, that is the optical zone is
taken into consideration, when you are doing a refractive surgery. A flatter cornea has
less refraction power and a steeper cornea has a higher refraction power. If we want to
change the refraction we must make the steeper diameter flatter and the flatter diameter
steeper.
Keratometry
The keratometer was invented by Hermann Von Helmholtz and modified by Javal,
Schiotz etc. If we place an object in front of a convex mirror we get a virtual, erect and
minified image (Fig. 7.1). A keratometer in relation to the cornea is just like an object in
front of a convex reflecting mirror. Like in a convex reflecting surface, the image is
located posterior to the cornea. The cornea behaves as a convex reflecting mirror and the
mires of the keratometer are the objects. The radius of curvature of the corneas anterior
surface determines the size of the image.
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FIGURE 7.1 Physics of a convex

mirror. Note the image is virtual, erect
and minified. The cornea acts like the
convex mirror and the mire of the
keratometer is the object
The keratometer projects a single mire on the cornea and the separation of the two
points on the mire is used to determine corneal curvature. The zone measured depends
upon corneal curvaturethe steeper the cornea, the smaller the zone. For example, for a
36-D cornea, the keratometer measures a 4-mm zone and for a 50-D cornea, the size of
the cone is 2.88 mm.
Keratometers are accurate only when the corneal surface is a sphere or a
spherocylinder. Actually, the shape of the anterior surface of the cornea is more than a
sphere or a spherocylinder. But keratometers measure the central 3-mm of the cornea,
which behaves like a sphere or a spherocylinder. This is the reason why Helmholtz could
manage with the keratometer (Fig. 7.2). This is also the reason why most
ophthalmologists can manage management of cataract surgery with the keratometer. But
today, with refractive surgery, the ball game has changed. This is because when the
cornea has complex central curves like in keratoconus or after refractive surgery, the
keratometer cannot give good results and becomes inaccurate. Thus, the advantages of
the keratometer like speed, ease of use, low cost and minimum maintenance is obscured.
FIGURE 7.2 Keratometers measure

the central 3-mm of the cornea, which
Corneal topography in cataract surgery
103
generally behaves like a sphere or a

spherocylinder. This is the reason why
keratometers are generally accurate.
But in complex situations like in
keratoconus or refractive surgery they
become inaccurate
The objects used in the keratometer are referred to as mires. Separation of two points on
the mire are used to determine corneal curvature. The object in the keratometer can be
rotated with respect to the axis. The disadvantages of the keratometer are that they
measure only a small region of the cornea. The peripheral regions are ignored. They also
lose accuracy when measuring very steep or flat corneas. As the keratometer assumes the
cornea to be symmetrical it becomes at a disadvantage if the cornea is asymmetrical as
after refractive surgery.
Keratoscopy
To solve the problem of keratometers, scientists worked on a system called Keratoscopy.
In this, they projected a beam of concentric rings and observed them over a wide expanse
of the corneal surface. But this was not enough and the next step was to move into
computerized videokeratography.
Computerized Videokeratography
In this, some form of light like a placido disk is projected onto the cornea. The cornea
modifies this
FIGURE 7.3 Placido type corneal

topography machine
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light and this modification is captured by a video camera. This information is analyzed by
computer software and the data is then displayed in a variety of formats. To simplify the
results to an ophthalmologist, Klyce in 1988 started the corneal color maps. The corneal
color maps display the estimate of corneal shape in a fashion that is understandable to the
ophthalmologist. Each color on the map is assigned a defined range of measurement. The
placido type topographic machines (Fig. 7.3) do not assess the posterior surface of the
cornea. The details of the corneal assessment can be done only with the Orbscan (Bausch
and Lomb) as both anterior and posterior surface of the cornea are assessed.
Orbscan
The ORBSCAN (BAUSCH and LOMB) corneal topography system (Fig. 7.4) uses a
scanning optical slit scan that is fundamentally different than the corneal topography that
analyses the reflected images from the anterior corneal surface. The high-resolution video
camera captures 40 light slits at 45 degrees angle projected through the cornea similarly
as seen during slit lamp examination. The slits are projected on to the anterior segment of
the eye: the anterior cornea, the posterior cornea, the anterior iris and anterior lens. The
data collected from these four surfaces are used to create a topographic map.
FIGURE 7.4 Orbscan

Normal Cornea
In a normal cornea (Fig. 7.5), the nasal cornea is flatter than the temporal cornea. This is
similar to the curvature of the long end of an ellipse. If we see figure 5 then we will
notice the values written on the right end of the pictures. These indicate the astigmatic
values. In that is written Max K is 45 @ 84 degrees and Min K is 44 @ 174 degrees. This
means the astigmatism is +1.0D at 84 degrees. This is with the rule astigmatism as the
astigmatism is plus at 90 degrees axis. If the astigmatism was plus at 180 degrees then it
is against the rule astigmatim. The normal corneal topography can be round, oval,
irregular, symmetric bow tie or asymmetric bow tie in appearance. If we see Figure 7.6
we will see a case of astigmatism in which the astigmatism is +4.9D at 146 degrees.
These figures show the curvature of the anterior surface of the cornea. It is important to
105
remember that these are not the keratometric maps. So the blue/green color denote
steepening and the red color denote flattening. If we want the red to denote steepening
then we can invert the colors.
Cataract Surgery
Corneal topography is extremely important in cataract surgery. The smaller the size of the
incision lesser the astigmatism and earlier stability of the astigmatism will occur. One
FIGURE 7.5 Topography of a normal

cornea
FIGURE 7.6 Topography showing an

astigmatic cornea
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104
FIGURE 7.7 Topography after

extracapsular cataract extraction
(ecce).The figure on the left shows
astigmatism of +1.1 d at 12 degrees
preoperatively. The astigmatism has
increased to +4.8 d as seen in the
figure on the right
can reduce the astigmatism or increase the astigmatism of a patient after cataract surgery.
The simple rule to follow is that wherever you make an incision that area will flatten and
wherever you apply sutures that area will steepen.
Extracapsular Cataract Extraction
One of the problems in extracapsular cataract extraction is the astigmatism which is
created as the incision size is about 10 to 12 mm. In Figure 7.7, you can see the
topographic picture of a patient after extracapsular cataract extraction (ECCE). You can
see the picture on the left is the preoperative photo and the picture on the right is a
postoperative day 1 photo. Preoperatively one will notice the astigmatism is +1.0D at 12
degrees and postoperatively it is +4.8D at 93 degrees. This is the problem in ECCE. In
the immediate postoperative period the astigmatism is high which would reduce with
time. But the predictability of astigmatism is not there which is why smaller incision
cataract surgery is more successful.
107
Nonfoldable IOL
Some surgeons perform phaco and implant a non-foldable IOL in which the incision is
increased to 5.5 to 6 mm. In such cases the astigmatism is better than in an ECCE. In
Figure 7.8, the pictures are of a patient who has had a nonfoldable IOL. Notice in this the
preoperative astigmatism is +0.8D @ 166 degrees. This is the left eye of the patient. If
we had done a phaco with a foldable IOL the astigmatism would have been nearly the
same or reduced as our incision would have come in the area of the astigmatism. But in
this case after a phaco a non-foldable IOL was implanted. The postoperative astigmatism
one week postoperative is +1.8D @ 115 degrees. You can notice from the two pictures
the astigmatism has increased.
Foldable IOL
In phaco with a foldable IOL the amount of astigmatism created is much less than in a
nonfoldable IOL. Let us look now at Figure 7.9. The patient as
FIGURE 7.8 Topography of a

nonfoldable IOL implantation
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106
FIGURE 7.9 Topography of phaco

cataract surgery with a foldable IOL
implantation
you can see has negligible astigmatism in the left eye. The picture on the left shows a
preoperative astigmatism of +0.8D at 166 degrees axis. Now, we operate generally with a
temporal clear corneal approach, so in the left eye, the incision will be generally at the
area of the steepend axis. This will reduce the astigmatism. If we see the postoperative
photo of day one we will see the astigmatism is only +0.6D @ 126 degrees. This means
that after a day, the astigmatism has not changed much and this shows a good result. This
patient had a foldable IOL implanted under the no anesthesia cataract surgical technique
after a phaco cataract surgery with the size of the incision being 2.8 mm.
Astigmatism Increased
If we are not careful in selecting the incision depending upon the corneal topography we
can burn our hands. Figure 7.10, illustrates a case in which astigmatism has increased due
to the incision being made in the wrong meridian. The patient had a 2.8-mm incision with
a foldable IOL implanted after a phaco cataract surgery under the no anesthesia cataract
surgical technique. Both the pictures are of the right eye. In Figure 7.10, look at the
picture on the left. In the picture on the left, you can see the patient has an astigmatism of
+1.1D at axis 107 degrees. As this is the right eye with this astigmatism we should have
made a superior incision to reduce the preoperative astigmatism. But by mistake we made
a temporal clear corneal incision. This has increased the astigmatism. Now, if we wanted
to flatten this case, we should have made the incision where the steeper meridian was.
That was at the 105 degrees axis. But because we were doing routinely temporal clear
corneal incisions, we made the incision in the opposite axis. Now, look at the picture on
the right. The astigmatism has increased from +1.1D to +1.7D. This shows a bad result. If
109
we had made the incision superiorly at the 107 degrees axis, we would have flattened that
axis and the astigmatism would have been reduced.
Basic Rule
The basic rule to follow is to look at the number written in red. The red numbers indicate
the plus axis. If the difference in astigmatism is say 3D at
FIGURE 7.10 Increase in astigmatism

after cataract surgery due to incision
being made in the wrong meridian.
Topography of a phaco with foldable
IOL implantation
Phacoemulsification
108
FIGURE 7.11 Unique casetopographic changes after suture

removal
180 degrees, it means the patient has +3D astigmatism at axis 180 degrees. This is against
the rule astigmatism. In such cases, make your clear corneal incision at 180 degrees so
that you can flatten this steepness. This will reduce the astigmatism.
Unique Case
In Figure 7.11, the patient had a temporal clear corneal incision for phaco cataract
surgery under no anesthesia with a nonfoldable IOL. Both the pictures are of the left eye.
The figure on the left shows the postoperative topographic picture. The postoperative
astigmatism was +1.8D at axis 115 degrees. This patient had three sutures in the site of
the incision. These sutures were put as a nonfoldable IOL had been implanted in the eye
with a clear corneal incision. When this patient came for a follow-up we removed the
sutures. The next day the patient came to us with loss of vision. On examination, we
found the astigmatism had increased. We then took another topography. The picture on
the right is of the topography after removing the sutures. The astigmatism increased to
+5.7D. So, one should be very careful in analyzing the corneal topography when one
does suture removal also. To solve this problem one can do an astigmatic keratotomy.
Phakonit
Phakonit is a technique devised by Dr Amar Agarwal in which the cataract is removed
through a sub 1.4-mm incision. The advantage of this is obvious. The astigmatism created
is very little compared to a 2.6-mm phaco incision. Today with the reliable IOL and the
111
acritec IOLs which are ultrasmall incision IOLs one can pass IOLs through sub 1.4
mm incisions. This is seen clearly in Figures 7.12 and 7.13. Figure 7.12 shows the
comparison after phakonit with a reliable IOL and Figure 7.13 with an acritec IOL. If you
will see the preoperative and the postoperative photographs in comparison you will see
there is not much difference between the two. In this case a reliable IOL was implanted.
The point which we will notice in this picture is that the difference between the
preoperative photo and the one day postoperative photo is not much.

phakonit with a reliable IOL

phakonit with an acritec IOL
Phacoemulsification
110
Summary
Corneal topography is an extremely important tool for the ophthalmologist. It is not only
the refractive surgeon who should utilize this instrument but also the cataract surgeon.
The most important refractive surgery done in the world is cataract surgery and not Lasik
(Laser-in situ keratomileusis) or PRK (Photorefractive keratectomy). With more
advancements in corneal topography, Topographic-Assisted Lasik will become available
to everyone with an Excimer Laser. One might also have the corneal topographic
machine fixed onto the operating microscope so that one can easily reduce the
astigmatism of the patient.
References
1. Gills JP et al: Corneal Topography: The State-of-the Art; New Delhi; Jaypee Brothers, 1996
2. Sunita Agarwal, Athiya Agarwal, Mahipal S Sachdev et al: Phacoemulsification, Laser Cataract
Surgery and Foldable IOLs; New Delhi; Second edition; Jaypee Brothers, 2000.
Section II
Instrumentation and
Medication
8. The Phaco Machine: How It Acts and Reacts
9. The Fluidics and Physics of Phaco
10. Air Pump to Prevent Surge
11. Microseal and Other Phaco Tips
12. Sterilization
13. Local Anesthetic Agents
14. Anesthesia in Cataract Surgery
15. Mydriatics and Cycloplegics
16. Update on Ophthalmic Viscosurgical Devices
8
The Phaco Machine: How It Acts and Reacts
William J Fishkind
Introduction
All phaco machines consist of a computer to generate ultrasonic waveform, and a
transducer, piezoelectric crystals, to turn these electronic signals into mechanical energy.
The energy thus created is then harnessed, within the eye, to overcome the inertia of the
lens and emulsify it. Once turned into emulsate, the fluidic systems remove the emulsate
replacing it with balanced salt solution (BSS). There is a delicate balance between phaco
power, which tends to push lens material away from the phaco tip, and flow and vacuum
which tends to attract and hold lens material on the phaco tip. Many of the principles
outlined below will vary dependent upon the individual machine. Therefore the
information in this chapter is based on general principles and the reader is encouraged to
investigate the function and suggested parameters for the machine that they are using.
Power Generation
Power is created by the interaction of frequency and stroke length.
Frequency is defined as the speed of the needle movement. It is determined by the
manufacturer of the machine. Presently, most machines operate at a frequency of between
35,000 cycles per second (Hz) and 45,000 cycles per second, although there are some
machines that operate at lower frequencies (Table 8.1). The frequency range which
appears to be most efficient for nuclear emulsification is from 30 to 45,000 cycles/sec
(Hz). Lower frequencies are less efficient and higher frequencies create excess heat.
Frequency is maintained constant by tuning circuitry designed into the machine
computer.
TABLE 8.1 Machine technology

Company Model
Phaco Machines
Freq Pump type Pump comment
KHZ
Alcon
40
Turbostatic High vacuum pack 0500 060

Peristaltic
40
Peristaltic
Allergan
Legacy
Series
20,000
Diplomax
Microprocessor
Control of Pump
Vac Flow Comments

range range
mm cc/min
Hg
0500 044
Flared ABS Tip

New Software:
Burst/ Pulse Mode
Pulse and Burst
Mode
The phaco machine
Allergan
Prestige
47.5 Peristaltic
Allergan
Sovereign
38
Bausch
Millennium 28
and Lomb
Mentor
SIStem
40
Staar
The Wave
42
Peristaltic
117
Microprocessor
Control of Pump
Microprocessor
Control of Pump
Shield-Fluid
Coupled Pressure
Sensor
0500 040
0500 040
0550 060
Venturi or Venturi Hybrid:
Concentrix Programmable to
Emulate venturi or
Peristaltic
Peristaltic Microprocessor
0500 050
Control of Pump
Variable Rise Time
(VRT)
Peristaltic Fluid Coupled
0500 050
Aspiration System
Pulse and Burst

Mode
Prosync-onboard
Computer Control.
Power Matrix and
Digital Control
allows power
down to 5%
Dual Linear Foot
Pedal Modular
Upgrades
Automatic Surge
Suppression
Surge Suppression
System CDRom
Printout of Events
Tuning is vital for the reason that the phaco tip is required to operate in different media.
The resistance of the aqueous is less than the resistance of the cortex, which in turn is less
than the resistance of the nucleus. As the resistance to the phaco tip varies, to maintain
maximum efficiency, small alterations in frequency and/or stroke length, are created by
the tuning circuitry in the machine CPU. The surgeon will be conscious of good tuning
circuitry by a subjective sense of smoothness and power.
Stroke length is defined as the length of the needle movement. This length is generally
2 to 6 mils (thousandths of an inch). Most machines operate in the 2 to 4 mil range.
Longer stroke lengths are prone to generate excess heat. The longer the stroke length the
greater will be the physical impact on the nucleus. In addition, the greater the generation
of cavitation forces. Stroke length is determined by foot pedal excursion in position three
during linear control of phaco.
Energy at the Phaco Tip
The actual tangible forces that emulsify the nucleus are a blend of the jackhammer
effect and cavitation.
The jackhammer effect is the physical striking of the needle against the nucleus.
The cavitation effect is more convoluted. The phaco needle, moving through the liquid
medium of the aqueous at ultrasonic speeds, creates intense zones of high and low
pressure. Low pressure, created with backward movement of the tip, literally pulls
dissolved gases out of solution. The gas bubble forms around dissolved particulate matter
in the aqueous. This gives rise to microbubbles. Forward tip movement then creates an
equally intense zone of high pressure. This produces compression of the microbubbles
until they implode. At the moment of implosion, the bubbles create a temperature of
13,000 degrees F, and a shock wave of 75,000 PSI. 75 percent of the microbubbles thus
Phacoemulsification
116
created, implode, amassing to create a powerful shock wave, radiating from the phaco tip
in the direction of the bevel. 25 percent of the bubbles, however, are too large to implode.
These microbubbles are swept up in the shock wave and radiate with it. The shock wave
and microbubbles diverge with annular spread (Fig. 8.1).
FIGURE 8.1 Microbubbles generated

at the phaco tip
The cavitation energy thus created can be directed in any desired direction as the angle of
the bevel of the phaco needle governs the direction of the generation of the shock wave
and microbubbles.
A method of visualization of these forces, called enhanced cavitation, has been
developed. Using this process it can be seen that with a 45 tip, the cavitation wave is
generated at 45 from the tip and 30 tip generates cavitation at a 30 angle from the
comes to a focus 1 mm from it (Fig. 8.1). Similarly a bevel, (Fig. 8.2) and a 15 tip 15
from the bevel. A 0 tip creates the cavitation wave directly in front of the tip and the
focal point is mm from the tip (Fig. 8.3). The Kelman tip has a broad band of powerful
cavitation that radiates from the area of the angle in the shaft. A weak area of cavitation is
developed from the bevel but is inconsequential (Fig. 8.4).
From analysis of enhanced cavitation, it can be concluded that emulsification is most
efficient when both the jackhammer effect and cavitation energy are coupled. To
accomplish this, the bevel of the
FIGURE 8.2 30 Tip. Enhanced

cavitation shows ultrasonic wave
focused 1 mm from the tip, spreading
at an angle of 45
The phaco machine
119
FIGURE 8.3 30 Tip. Enhanced

cavitation shows ultrasonic wave
focused 1/2 mm in front of the tip
spreading directly in front of it
FIGURE 8.4 Kelman tip. Enhanced

cavitation shows broad band of
enhanced cavitation spreading
inferiorly from the angled of the tip. A
weak band of cavitation spreads from
the tip
needle should be turned toward the nucleus, or nuclear fragment. This simple maneuver
will cause the broad bevel of the needle to strike the nucleus. This will enhance the
physical force of the needle striking the nucleus. In addition, the cavitation force is then
concentrated into the nucleus rather than away from it (Fig. 8.5). This causes the energy
to emulsify the nucleus. When the bevel is turned away from the nucleus the cavitational
energy is directed up and away from the nucleus toward the iris and endothelium (Fig.
8.6). The energy thus misdirected will damage the iris and the blood-aqueous barrier
leading to prolonged postoperative inflammatory change in the anterior segment. Addi-
Phacoemulsification
118
FIGURE 8.5 Turning the bevel of the

phaco tip toward the nucleus focuses
cavitation and jackhammer energy into
the nucleus
FIGURE 8.6 The bevel is turned away

from the nucleus. Cavitation energy is
wasted and may damage iris and
endothelium
tionally the powerful shock wave and microbubbles will severely damage endothelial
cells leading to endothelial cell loss. Finally, in this configuration, the vacuum force
(discussed below) can be maximally made use of as occlusion is encouraged. A 0 tip, by
design, directs both the jackhammer force and cavitational energy directly ahead and into
the nucleus. The occlusive properties are also enhanced by a cross-sectional area of
occlusion which is smaller than a 30 or 45 tip. Therefore the 0 tip is an excellent
choice for controlled low power phacoemulsification (Fig. 8.7).
Modification of Phaco Power Intensity
Application of the minimal amount of phaco power intensity necessary for emulsification
of the nucleus is desirable. Unnecessary power intensity is a cause
The phaco machine
121
FIGURE 8.7 The 0 tip, by its design,

focuses both jackhammer and
cavitation forces directly ahead, and
into the nucleus
of heat with subsequent wound damage, endothelial cell damage, and iris damage with
alteration of the blood-aqueous barrier. Phaco power intensity can be modified by: (i)
alteration in stroke length, (ii) alteration of duration, and (iii) alteration of emission.
Alteration of Stroke Length
Stroke length is determined by foot pedal regulation. When the machine is set for linear
phaco, depression of the foot pedal in position 3, will increase stroke length and
consequently power. New foot pedals, such as those found in the Allergan Sovereign and
the Alcon Legacy, permit surgeon adjustment of the throw length of the pedal in position
3. This can refine power application. The B&L Millennium dual linear foot pedal permits
the separation of the fluidic aspects of the foot pedal from the power elements.
Alteration of Duration
The duration of application of phaco power has a dramatic effect on overall power
delivered. Usage of pulse or burst mode phaco will considerably decrease overall power
delivery. New machines, for example, allow for a power pulse of 50 milliseconds
duration alternating with a period of aspiration only (Fig. 8.8). Burst mode (parameter is
machine dependent) is characterized by 150 milliseconds of power combined with
variable periods of aspiration only (Fig. 8.9). Phaco techniques such as choo-choo-chop
and phaco chop utilize minimal intervals of power in pulse mode to reduce total power
delivery to the anterior chamber. In addition, the use of pulse mode to remove the
epinucleus and cortex provides for an added margin of safety. When the epinucleus is
emulsified, the posterior capsule is exposed to the phaco tip and may move forward
toward it due to surge. Activation of pulse phaco will create a deeper anterior chamber to
work within. This occurs because each period of phaco energy is followed by an interval
of no energy. During the interval of absence of energy, the epinucleus is drawn toward
the phaco tip, producing occlusion, interrupting outflow. This allows irrigation bottle
inflow to deepen the anterior chamber immediately prior to onset of another pulse of
Phacoemulsification
120
phaco energy. The surgeon will recognize the outcome of this approach as operating in a
deeper, more stable anterior chamber.
Alteration of Emission
The emission of phaco energy is modified by tip selection. Phaco tips can be modified to
accentuate: (i) power, (ii) flow, or (iii) a combination of both.
Power intensity is modified by altering bevel tip angle. Noted previously, the bevel of
the phaco tip will focus power in the direction of the bevel. The Kelman tip will
produce broad powerful cavitation directed away from the angle in the shaft. This tip
is excellent for the hardest of nuclei. New flare and cobra tips direct cavitation into the
opening of the bevel of the tip. Thus random emission of phaco energy is minimized.
Designer tips such as the flathead designed by Dr. Barry Seibel and power wedges
designed by Douglas Mastel modify the direction and focus delivery of phaco energy
intensity.
Power intensity and flow are modified by utilizing a 0 tip. This tip will focus power
directly ahead of the tip and enhance occlusion due to the smaller surface area of its
orifice.
Small diameter tips, such as 21ga. tips, change fluid flow rates. Although they do
not actually change power intensity, they appear to have this effect, as the nucleus
must be emulsified into smaller pieces for removal through the smaller diameter
tip.
FIGURE 8.8 Graphic representation

of pulse mode in the Allergan
Sovereign Machine
The phaco machine
123
FIGURE 8.9 Graphic representation

of burst mode in the Allergan
Sovereign Machine (Photo Courtesy of
Allergan)
FIGURE 8.10 Flare tip. Widened tip

focuses power close to the tip. Narrow
neck acts as a flow restriction
decreasing postocclusion surge (Photo
Courtesy of Microsurgical
Technology)
Phacoemulsification
122
FIGURE 8.11 A 0.175 mm hole

drilled in the shaft of the ABS tip
provides an alternate path for fluid to
flow into the needle when there is an
occlusion at the phaco tip (Photo
Courtesy of Alcon)
The Alcon ABS (aspiration bypass system) tip modification is now available with
a 0 tip, a Kelman tip, or a flare tip. The flare is a modification of power intensity
due to its ability to focus power near the needle opening, and a flow modification
as the narrowed area proximal to the tip acts to decrease flow and thus dampen
surge (Fig. 8.10). The ABS tip is a flow modification. In the ABS system a 0.175
mm hole in the needle shaft permits a variable flow of fluid into the needle during
occlusion. This flow adjustment serves to prevent total occlusion and
consequently minimize surge (Fig. 8.11).
Finally flow can be modified by utilizing one of the microseal tips. These tips have a
flexible outer sleeve to seal the phaco incision. They also have a rigid inner sleeve or a
ribbed shaft configuration to protect cooling irrigant inflow. Thus a tight seal allows
low flow phaco without danger of wound burns.
Phaco power intensity is the energy that emulsifies the lens nucleus. The phaco
tip must operate in a cool environment and with adequate space to isolate its
actions from delicate intraocular structures. This portion of the action of the
machine is dependent upon its fluidics.
Fluidics
The fluidics of all machines are fundamentally a balance of fluid inflow and fluid
outflow.
Inflow is determined by bottle height above the eye of the patient. It is important to
recognize that with recent acceptance of temporal surgical approaches, the eye of the
patient may be physically higher than in the past. This then requires that the irrigation
bottle be adequately elevated. A shallow, unstable anterior chamber will otherwise result.
The phaco machine
125
Outflow is determined by the sleeve-incision relationship, as well as the aspiration rate

and vacuum level commanded. The incision length selected should create a snug fit with
the phaco tip selected. This will result in minimal uncontrolled wound outflow with
resultant increased anterior chamber stability.
Aspiration rate, or flow, is defined as the flow of fluid in cc/min through the tubing.
With a peristaltic pump it is determined by the speed of the pump. Flow determines how
well particulate mater is attracted to the phaco tip.
Aspiration level or vacuum is a level and measured in mm Hg. It is defined as the
magnitude of negative pressure created in the tubing, and ultimately, the anterior
chamber. Vacuum is the determinant of how well, once occluded on the phaco tip,
particulate material will be held to the tip.
Vacuum Sources
There are three categories of vacuum sources or pumps. These are flow pumps, vacuum
pumps, and hybrid pumps.
FIGURE 8.12 The peristaltic pump.

Rotating cams compress tubing. The
speed of the rotation is determined by
the surgeon and governs the flow rate
in cc/min
The primary example of the flow pump type is the peristaltic pump. These pumps allow
for independent control of both aspiration rate and aspiration level (Fig. 8.12).
The primary example of the vacuum pump is the venturi pump. This pump type allows
direct control of only vacuum level. Flow is dependent upon vacuum level setting.
Additional examples are the rotary vane and diaphragmatic pumps.
The primary example of the hybrid pump is the Allergan Sovereign peristaltic pump
(Fig. 8.13) or the B & L Concentrix pump (Fig. 8.14). These pumps are interesting as
they are able to act like either a vacuum or flow pump dependent upon programming.
Phacoemulsification
124
They are the most recent supplement to pump types. They are generally controlled by
digital inputs creating incredible flexibility and responsiveness.
The challenge to the surgeon is to balance the effect of phaco intensity, which tends to
push nuclear fragments off the phaco tip, with the effect of flow, which attracts fragments
toward the phaco tip, and vacuum, which holds the fragments on the phaco tip. Generally
low flow slows down intraocular events, and high vacuum speeds them up. Low or zero
vacuum is helpful during sculpting of hard
FIGURE 8.13 Hybrid pump. The

Allergan Digital Pump. A peristaltic
pump with digital controls allows
forward, backward, or to and fro
movement to precisely control flow.
This pump is capable of performing
like a venturi or peristaltic pump
(Photo Courtesy of Allergan)
The phaco machine
127
FIGURE 8.14 Hybrid pump. The

B&L Concentrix pump. Inside two
cam-shaped disks rotate to generate a
vacuum which is regulated to emulate
either a peristaltic or venturi pump
FIGURE 8.15 Occlusion. The nucleus

has occluded the phaco tip. There is no
flow. The vacuum increases to preset.
Tubing collapses (Original art by Tony
Pazos)
Phacoemulsification
126
or a large nucleus, where the high power intensity of the tip may be applied near the iris
or anterior capsule. Zero vacuum will prevent inadvertent aspiration of the iris or capsule
preventing significant morbidity.
Surge
A principal limiting factor in the selection of high levels of vacuum or flow is the
development of surge. When the phaco tip is occluded, flow is interrupted and vacuum
builds to its preset level. Additionally, the aspiration tubing may collapse in the presence
of high vacuum levels (Fig. 8.15). Emulsification of the occluding fragment then clears
the occlusion. Flow instantaneously begins reaching the preset level immediately. In
addition, if the aspiration line tubing is not reinforced to prevent collapse (tubing
compliance) the tubing, constricted during occlusion, then expands on occlusion break.
The expansion is an additional source of vacuum production. These factors cause a rush
of fluid from the anterior segment into the phaco tip. The fluid in the AC may not be
replaced rapidly enough by infusion to prevent shallowing of the anterior chamber.
Therefore there is subsequent rapid anterior movement of the posterior capsule and
collapse of the cornea (Fig. 8.15). This abrupt forceful snapping of the posterior
capsule as well as the stretching of
FIGURE 8.16 Postocclusion surge.

The fragment has been emulsified.
Vacuum drops to 0 and flow
instantaneously will increase to preset.
Fluid will rush into the phaco tip more
rapidly than it can be replenished by
irrigation inflow. The posterior capsule
snaps up and the cornea will collapse.
A small tear in the posterior capsule
begins (Original art by Tony Pazos)
The phaco machine
129
the bag around nuclear fragments may be a cause of capsular tears. In addition the
posterior capsule can be literally sucked into the phaco tip, tearing it (Fig. 8.16). The
magnitude of the surge is contingent on the presurge settings of flow and vacuum.
If the surge is considered an event, then the entire sequence can be divided into
phases. Thus there is a preocclusive, occlusive, and postocclusive phase. Surge can
therefore be modified in each phase.
Preocclusion Modification
To decrease surge in preocclusion, the vacuum preset, or flow maximum preset should be
decreased. Decreased flow will result in slower generation of vacuum. Decreased vacuum
will result in less absolute vacuum level during occlusion. The net effect of both is the
decrease of postocclusion surge.
Attention to wound size and construction, as well as selection of a phaco tip with a
soft sleeve of adequate size to adequately seal and prevent excess fluid outflow, will
augment anterior chamber stability. Finally, elevating the infusion bottle will increase
fluid inflow.
Occlusion Modification
The Alcon Legacy employs an Aspiration Bypass System (ABS). This consists of high
vacuum tubing and the aspiration bypass tip. The tubing is reinforced to prevent
collapse during periods of high vacuum. The tips have 0.175 mm holes drilled in the shaft
of the needle. During occlusion the hole provides for a continuous alternate fluid flow.
The higher the vacuum the greater will be the flow through the bypass hole. Thus,
complete occlusion never occurs. This will cause dampening of the surge on occlusion
break.
The dual linear foot pedal of the B&L Millennium is another device to control surge in
the occlusive phase. It can be programmed to separate both the flow and vacuum, from
power. In this way flow or vacuum can be lowered before beginning the emulsification of
an occluding fragment. The emulsification therefore occurs in the presence of a lower
vacuum or flow. This will dramatically decrease surge.
Postocclusion
Presently there are four machines that will decrease surge in the postocclusive phase.
This type of surge dampening requires instantaneous sensing of resumption of flow after
occlusion. Therefore all machines making use of this form of surge control employ
sophisticated microprocessors. The microprocessors sense resumption of flow and
immediately slow the pump lowering vacuum, the engine for surge.
These machines are
The Allergan Diplomax.
The Allergan Sovereign Microprocessors sample vacuum and flow parameters 50 times
a second creating a virtual model of the events in the anterior chamber. At the
moment of surge, the machine computer senses the increase in flow and
Phacoemulsification
128
instantaneously slows or even reverses the pump. This allows inflow to establish a
new equilibrium and will cut short surge production.
The Staar Wave This machine has patented microprocessors that act in a similar fashion
to the Allergan Sovereign to dampen surge.
The Mentor SIStem (Paradigm) This machine has microprocessor controlled variable
rise time. Adjustments in rise time slow the generation of vacuum and decrease surge.
Phaco Technique and Machine Technology

The patient will have the best visual result when total phaco energy delivered to the
anterior segment is minimized. Additionally, phaco energy should be focused into the
nucleus. This will prevent damage to iris blood vessels and endothelium. Finally,
proficient emulsification will lead to shorter overall surgical time. Therefore a lesser
amount of irrigation fluid will pass through the anterior segment.
The general principles of power management are to focus phaco energy into the
nucleus, vary fluid parameters for efficient sculpting and fragment removal, and
minimize surge.
Divide and Conquer Phaco
Sculpting
To focus cavitation energy into the nucleus a zero degree tip or a 15, or 30 tip turned
bevel down should be utilized. Zero or low vacuum (dependent upon the manufacturers
recommendation) is mandatory for bevel down phaco. This will prevent occlusion.
Occlusion, at best, will cause excessive movement of the nucleus during sculpting. At
worst, occlusion occurring near the equator is the cause of tears in the equatorial bag
early in the phaco procedure, and occlusion at the bottom of a groove will cause phaco
through the posterior capsule. Once the groove is judged to be adequately deep, the bevel
of the tip should be rotated to the bevel up position to improve visibility and prevent the
possibility of phaco through the posterior nucleus and posterior capsule.
Quadrant and Fragment Removal
The tip selected, as noted above, is retained. Vacuum and flow are increased to
reasonable limits subject to the machine being used. The limiting factor to these levels is
the development of surge. The bevel of the tip is turned toward the quadrant or fragment.
Low pulsed or burst power is applied at a level high enough to emulsify the fragment
without driving it from the phaco tip. Chatter is defined as a fragment bouncing from the
phaco tip due to aggressive application of phaco energy.
The phaco machine
131
Epinucleus and Cortex Removal

For removal of epinucleus and cortex the vacuum is decreased while flow is maintained.
This will allow for grasping of the epinucleus just deep to the anterior capsule. The low
vacuum will help the tip hold the epinucleus on the phaco tip, preventing the fracturing of
chunks and poor followability created by undesirable high vacuum. The epinucleus is
emulsified for three quadrants and the attached cortex is aspirated around the epinucleus
as documented by Dr Howard Fine. The epinucleus and attached cortex is then mobilized
so that it scrolls around the equator and can be pulled to the level of the iris. There, low
power pulsed phaco is employed for emulsification. If cortical cleaving hydrodissection
has been performed, the remainder of the cortex will be removed concurrently.
Stop and Chop Phaco
Sculpting
Groove creation is performed as noted above under divide and conquer sculpting
techniques.
Heminucleus Creation
When the initial trough is considered adequately deep (three phaco tips or 3.0 mm) the
initial crack is created using the phaco tip and chopper. If the nucleus will not crack the
initial groove is not deep enough and must therefore, be deepened. The nucleus is then
rotated 90.
Quadrant and Fragment Removal
Once the nucleus is cracked, creating into two halves, vacuum and flow are increased to
improve the holding ability of the phaco tip. The tip is then burrowed into the mass of the
distal heminucleus using pulsed linear phaco. The sleeve should be 1 mm from the base
of the bevel of the phaco tip to create adequate exposed needle length for sufficient
holding power. Excessive phaco energy application is to be avoided, as this will cause
nucleus immediately adjacent to the tip to be emulsified. The space thus created in the
vicinity of the tip is responsible for interfering with the seal around the tip and therefore
the capability of vacuum to hold the nucleus. The nucleus will then pop off the phaco tip
making chopping more difficult. With a good seal the heminucleus can be drawn toward
the incision and the chopper can be inserted at the endonucleus-epinucleus junction. After
the first chop, the pie-shaped piece of nucleus thus created is elevated to the plane of the
pupil and removed with low power pulsed phaco as discussed in the divide and conquer
section.
Epinucleus and cortex removal is also performed as noted above.
Phacoemulsification
130
Phaco Chop
Phaco chop requires no sculpting. Therefore the procedure is initiated with high vacuum
and flow and linear pulsed phaco power. For a 0 tip, when emulsifying a hard nucleus, a
small trough may be required to create adequate room for the phaco tip to burrow deep
into the nucleus. For a 15 or a 30 tip, the tip should be rotated bevel down to engage the
nucleus. A few bursts or pulses of phaco energy are necessary to allow the phaco tip to be
buried within the nucleus. It then can be drawn toward the incision to allow the chopper
access to the epiendo nuclear junction. If the nucleus comes off the phaco tip, so that it
cannot be pulled toward the incision, excessive power has produced a space around the
tip impeding vacuum holding power as noted above. The first chop is then produced. The
first quadrant is then emulsified with low power pulsed phaco. If a beveled tip is used it is
turned toward the nuclear material to enhance the occlusive properties of the tip. Then
rotation of the nucleus will allow for creation of the second chop. The nuclear fragments
are then emulsified in turn.
Irrigation and Aspiration
Similar to phaco, anterior chamber stability during I and A is due to the balance of inflow
and outflow. Fluid outflow can be minimized by employing a soft sleeve around the I and
A tip. Combined with a small incision (2.8 to 3 mm), a deep and stable anterior chamber
will result. Generally a 0.3 mm I and A tip is used. With this orifice a vacuum of 500 mm
Hg and flow of 20 cc/min is excellent to tease cortex from the fornices. Linear vacuum
allows the cortex to be grasped under the anterior capsule and drawn into the center of the
pupil at the iris plane. There, in the safety of a deep anterior chamber, vacuum can be
increased and the cortex aspirated. In an effort to provide an additional margin of safety,
the I and A can be performed after insertion of the IOL. The IOL acts as a barrier
between I and A tip and the posterior capsule. Thus, the I and A can be performed with
less chance of posterior capsular capture and tear.
Vitrectomy
Most phaco machines are equipped with a vitreous cutter which is activated by
compressed air or by electric motor. As noted previously, preservation of a deep anterior
chamber is dependent upon a balance of inflow and outflow. For vitrectomy, a 23 gauge
cannula, or chamber maintainer, inserted through a paracentesis, provides inflow. Bottle
height should be adequate to prevent chamber collapse. The vitrector should be inserted
through another paracentesis. If equipped with a Charles sleeve, this should be removed
and discarded. Utilizing a flow of 20 cc/min, vacuum of 250 mm Hg, and a cutting rate of
250 to 350 cuts/min the vitrector should be placed through the tear in the posterior
capsule, orifice facing upward, pulling vitreous out of the anterior chamber. The vitreous
should be removed to the level of the posterior capsule (Fig. 8.17).
The phaco machine
133
Conclusion
It has been said that the phaco procedure is blend of technology and technique.
Awareness of the
FIGURE 8.17 The vitrector, with the

Charles sleeve removed is placed
through a paracentesis into the
vitreous. Irrigation is provided by a 23
gauge cannula placed through another
paracentesis (Original art by Tony
Pazos)
principles, which influences phaco machine settings, is requisite for the performance of a
proficient and safe operation. Additionally, often during the procedure, there is a demand
for changes from the initial parameters. A thorough understanding of fundamental
principles will enrich the capability of the surgeon for appropriate response to this
requirement.
Further Reading
1. Cimino WW, Bond LJ: Physics of ultrasonic surgery using tissue fragmentation Part II,
Ultrasound in Medicine and Biology 22(1):10117, 1996.
2. Doulah MS: Mechanism of disintegration of biological cells in ultrasonic cavitation in
biotechnology and bioengineering, John Wiley & Sons Inc., 19:64960.
3. Fishkind WJ: Pop Goes the Microbubbles ESCRS Film Festival Grand Prize Winner, 1998.
4. Krey HF: Ultrasonic turbulences at the phacoemulsification tip. J Cataract Refract Surg 15:343
44, 1989.
5. Neuhann TF, Steinert RF: Instrumentation. Cataract Surgery, Technique Complications and
Management. WB Saunders: Philadelphia 6:5767, 1995.
9
The Fluidics and Physics of Phaco
Barry S Seibel
Introduction
Phacoemulsification is comprised of two basic elements: (i) ultrasound energy is used to
emulsify the nucleus, and (ii) a fluidic circuit is employed to remove the emulsate
through a small incision while maintaining the anterior chamber (Fig. 9.1). This circuit is
supplied by an elevated irrigating bottle which supplies both the fluid volume and
pressure to maintain the chamber hydrodynamically and hydrostatically, respectively;
anterior chamber pressure is directly proportional to the height of the bottle. The fluid
circuit is regulated by a pump which not only clears the chamber of the emulsate, but also
FIGURE 9.1
provides significant clinical utility. When the phaco tip is unoccluded, the pump produces
currents in the anterior chamber, measured in cc per minute, which attract nuclear
fragments. When a fragment completely occludes the tip, the pump provides holding
power, measured in mm Hg vacuum, which grips the fragment. In order to fully exploit
the potential of a phaco machine the surgeon must understand the logic behind setting the
parameters of ultrasound power, vacuum, and flow.
The fluidics and physics of phaco
135
Categorization of Pumps
A discussion of flow and vacuum in phaco surgery must begin with a categorization of
the various pumps which are utilized. There are two basic types of pumps in phaco: (i)
the flow pump, and (ii) the vacuum pump.
Flow Pump
The flow pump also known as a positive displacement pump, physically regulates the
fluid in the aspiration line via direct contact between the fluid and the pump mechanism.
Although the scroll pump is the newest example of a flow pump, the peristaltic pump is
the most commonly employed in current phaco machines and serves as a good schematic
example of the flow pumps principles (Fig. 9.2).
One important characteristic of a flow pump is its ability to independently control flow
and vacuum. Flow rate, also known as aspiration flow rate, is measured in cc per minute
and is directly proportional to the rotational speed of the pump head, measured in
revolutions per minute (rpm). Note that because the pump head physically interdigitates
with the fluidic circuit via the aspiration line tubing, it regulates the flow rate
independently of the amount of pressure in the line via the elevated irrigating bottle.
Therefore, flow rate is independent of bottle height when using flow pumps.
However, actual fluid flow rate is very dependent on the degree of phaco tip
occlusion. Flow rate decreases with increasing tip occlusion (i.e. decreased effective
aspiration port surface area)
FIGURE 9.2
Phacoemulsification
134
FIGURE 9.3
until flow ceases completely with complete tip occlusion. Note that in Figure 9.3 the
irrigation bottles drip chamber mirrors the activity in the
FIGURE 9.4
anterior chamber. Aspiration flow control on the phaco machine is still important with
complete tip occlusion in that it controls the rotational speed of the pump head, and even
though no actual flow exists with complete occlusion, the surgeon can control the speed
of vacuum build-up via pump speed control; the amount of time required to reach a given
vacuum preset, assuming complete tip occlusion, is defined as rise time.
137
Rise time is inversely proportional to the rotational speed of the pump head (Fig. 9.4).
All graphs represent the same machine, but note that when the flow rate is cut in half
(from 40 to 20 cc per minute), the rise time is doubled (from 1 second to two seconds).
Rise time is doubled again to four seconds when flow rate is halved again to 10 cc per
minute. A longer rise time gives the surgeon more time to react in cases of inadvertent
incarceration of iris, capsule, or other unwanted material, although a useful setting for
training residents, even experienced surgeons appreciate the enhanced safety margin
afforded by a longer rise time.
Several points should be made about the preceding discussion on rise time. First, rise
time was adjusted via manipulation of the machines flow rate control. However, as
discussed previously, no actual flow exists with complete occlusion, which is necessary
to efficiently build vacuum at the phaco tip. Adjusting the machines flow parameter,
measured in cc per minute, actually directly affects the rotational speed of the pump head.
Vacuum builds more quickly as the rollers more rapidly traverse the aspiration line
tubing in the pump head, even though no additional fluid is removed from the anterior
chamber through the occluded phaco tip.
The second point regarding the rise time discussion concerns the fact that although no
fluid flows from the eye with tip occlusion, a minute amount of fluid is pumped from the
aspiration line tubing as vacuum is built up, thus, accounting for the relation of pump
speed to rise time. Because fluid is noncompressible and nonexpansile, theoretically no
change in aspiration line fluid volume would occur as the pump head exerted pressure on
the fluid. However, two factors account for this not being true with peristaltic pumps: (i)
the use of the aspiration line tubing as a conduit for transmitting the pump rollers force
results in some inefficiency in the form of slippage both between the pump rollers and the
tubing as well as in between the opposed internal surfaces of the aspiration line tubing,
and (ii) the mechanism of action of a peristaltic pump requires enough aspiration line
tubing compliance to allow for collapse by the pump rollers. This compliance must be
overcome during rise time in the form of some tubing constriction as some fluid is
removed from the line (not the eye) by the pump even with complete tip occlusion (Fig.
9.5). The most modern peristaltic pumps minimize the systems compliance to the
minimum level compatible with the functioning of the pump, thereby, attaining fairly
rapid potential rise times. By placing the pump element directly into aspiration fluid path,
a scroll pump further reduces the need for aspiration line compliance to the minimum
amount required for ergonomic handpiece control. This type of pump can therefore
achieve the tightest potential control of rise time with the most rapid vacuum build-up
attainable.
The final point concerning rise time and flow pumps is the fact that a maximum
attainable vacuum can be preset on the machine. In order to prevent vacuum build-up
past this level, a variety of methods are employed. For example, the pump head can be
stopped when the preset value is reached. Alternatively, vacuum can be regulated with a
moving pump head by venting air or fluid into the aspiration line if the preset value is
exceeded. Venting is also employed if the surgeon wishes to release material which is
held to the phaco tip with vacuum. Air venting has the disadvantage of increasing the
fluidic circuits compliance relative to fluid venting. Higher compliance increases rise
time and decreases the machines responsiveness to foot-pedal vacuum control. Figure
9.6 illustrates this principle, whereby an air-bubble which was vented into the circuit to
Phacoemulsification
FIGURE 9.5
FIGURE 9.6
136
139
decrease vacuum must be first stretched out by the pump before vacuum can begin to
build in the aspiration line again. By employing either air or fluid venting to regulate
vacuum build-up, a flow pump therefore not only directly controls flow but also allows
indirect control of vacuum.
Vacuum Pump
In contrast, a vacuum pump directly controls vacuum although it can indirectly control
flow. Vacuum pumps represent the second main category of phaco pump, with examples
being the rotary vane pump, the diaphragm pump, and the Venturi pump. Vacuum pumps
have in common a rigid drainage cassette attached to the aspiration line tubing. The
various pumps are linked to the cassette and produce vacuum in it which in turn
proportionately produces flow when the aspiration port is unoccluded (Fig. 9.7). When
the tip is occluded, flow ceases and vacuum is transferred
FIGURE 9.7
from the cassette down the aspiration line to the occluded tip (Fig. 9.8). Because no
rollers are required to collapse the tubing as with peristaltic pumps, vacuum pumps can
employ more rigid tubing with less compliance. This lower compliance coupled with the
short times needed for vacuum transfer from the cassette to the phaco (or IA) tip result in
low rise times with vacuum pumps.
Low rise times can be a potential liability when using high vacuum techniques, if
unwanted material is inadvertently incarcerated in the aspiration port, the surgeon has
Phacoemulsification
138
little time to react before potentially permanent damage occurs. Recall that when using a
flow pump with a high vacuum preset, low flow rate can be set to produce longer rise
times which give the surgeon more time to react to unwanted occlusions. Most vacuum
pumps donot allow attenuation of rapid rise times, although the Storz Millennium and
Premiere
FIGURE 9.8
machines are exceptions. These pumps allow the surgeon to set at time delay for full
commanded vacuum build-up which starts when the surgeon enters pedal position 2.
However, once this delay has elapsed, any subsequent engagement of material will be
exposed to a typically rapid vacuum pump rise time. An even better, if not elegant,
solution to this issue is the dual linear foot control on the millennium (Fig. 9.9), this
separates simultaneous linear control of vacuum and ultrasound in two planes of pedal
movement (pitch and yaw). With linear control of vacuum in phaco mode, the surgeon
can approach material with safer lower vacuum levels and increase it only after desired
material is positively engaged.
Direct linear control of vacuum has another advantage with vacuum pumps in that it
allows subsequently indirect linear control of aspiration flow rate when the tips
aspiration port is unocclu-
141
FIGURE 9.9
ded (Fig. 9.7). However, because flow is thus indirectly controlled by these pumps, it is
more sensitive to resistive variances in the fluidic circuit. For example (Fig. 9.10), a
vacuum pump will
FIGURE 9.10
produce a certain flow rate at a particular vacuum when using a phaco tip; this same flow
rate could also be produced on a flow pump. However, changing to an IA tip (with its
smaller surface are aspiration port and subsequently higher fluidic resistance) will
decrease actual flow in both systems, but to a greater degree in the vacuum pump. This
indirect control of flow by a vacuum pump has another important clinical corollary with
regard to bottle height. Unlike a flow pump, a vacuum pumps flow rate is affected by
bottle height as a result of a higher pressure head from a higher bottle height pushing
Phacoemulsification
140
fluid through the open circuit more rapidly (compare the fluidic schematics in Figures 9.2
and 9.7, noting again the interdigitation of the flow pump in its fluidic circuit).
Application of Ultrasound Power
Besides setting fluidic parameters, the surgeon must also decide on the application of
ultrasound power, which is produced most often by a piezoelectric crystal oscillating
between approximately 20,000 and 60,000 times a second for most machines. This
frequency is fixed on a given machine. Ultrasound power is varied by changing the
amplification voltage of the handpiece. Increased voltage translates to increased stroke
length at the phaco needle tip, up to a maximum of about five microns on most machines
(Fig. 9.11). Usually, a maximum ultrasound limit is preset on the machines front panel,
and the surgeon then titrates with linear pedal control the percentage of this preset maxi-
FIGURE 9.11
mum which is appropriate to a given intraoperative instant.
The actual mechanism of action of ultrasonic phacoemulsification is somewhat
controversial. One school of thought centers around the acoustic breakdown of lenticular
material as a result of sonic wave propagation through the fluid medium. Another theory
concerns the microcavitation bubbles produced at the distal phaco tip, the implosion of
these bubbles produces brief instances of intense heat and pressure which is thought to
emulsify adjacent lens material. Yet another potential mechanism of action is via the tips
axial oscillations through its stroke length, this resultant jackhammer affect is thought to
mechanically break down lens material. This last mechanism also explains the clinical
phenomenon of repulsion of free floating lens material with high ultrasound power levels,
these levels need appropriate fluidic titration of the attractive parameters of flow and
vacuum to counteract this repulsion.
Ultrasonic phaco needles are available in a variety of configurations. One basic design
parameter is the distal bevel angle, which is most commonly 0, 15, 30, or 45 as
shown in Figure 9.12. The sharper 45 angle is thought to carve dense
143
FIGURE 9.12
FIGURE 9.13
nuclei more efficiently to the extent that the jack-hammer mechanism of action is valid,
whereas the 0 tip would be more efficient to the extent that the microcavitation theory is
valid (the 0 tip has more frontal surface area perpendicular to the axis of oscillation,
thereby, producing more cavitation bubbles). In practice, it is difficult to quantitatively
compare these efficiencies on a standard density nucleus. Another traditional teaching
regarding tip angulation is that a 0 tip occludes more readily than 45 tip, this
Phacoemulsification
142
observation is correct only in that the smaller surface area and perimeter of the 0 tip does
seal more readily than does the tip with a larger bevel. However, this axiom is less
relevant intraoperatively. A tip occludes readily when the surface to be occluded is
parallel to the needle bevel, the surface can and should be manipulated as necessary to
achieve this configuration (Fig. 9.13, which illustrates the attempted gripping of a heminucleus during a stop and chop maneuver).
FIGURE 9.14
When titrating ultrasound power, the surgeon must be aware of interrelated clinical
variables affecting the resistance to emulsification, especially sculpting. This resistance is
directly proportional to both the linear speed of sculpting as well as the amount of the tip
engaged. In Figure 9.14, it can be noted that for the increased resistive load caused by the
increased tip engagement, the surgeon must compensate by either increasing phaco power
or decreasing in linear speed of sculpting. Either solution is satisfactory, as long as the
interrelationship among the above variables is respected, so as to facilitate the needle
carving through the nucleus instead of pushing it and stressing the zonules or capsule.
Adjustment of Machine Parameters
In order to appropriately adjust the machine parameters for various stages of surgery, it is
necessary to analyze the function of those parameters for a given stage. For example,
sculpting requires titration of ultrasound power as described in the previous paragraph.
Furthermore, it requires enough flow to clear the anterior chamber of the emulsate
produced by ultrasound as well as sufficient flow to cool the phaco tip, a modest flow of
18 cc/min is usually adequate for these functions. There is little need for vacuum during
sculpting, as there are not yet any fragments which need to be occluded and gripped.
Furthermore, vacuum is not needed to counteract the repulsive action of ultrasound since
the nucleus is held stationary by the capsule, zonules, and its intact structure at this point.
145
Therefore, a low vacuum is adequate for sculpting. Although 0 mm Hg is advocated by

some surgeons, a slightly higher level of 15 to 30 mmHg still provides significant safety
(in case of contraincisional peripheral epinuclear or capsule incarceration) while
decreasing the likelihood of a clogged aspiration line.
Once the nucleus is debulked or grooved, it then needs manipulation such as rotation
or cracking. These maneuvers should be performed in pedal position 1 so that the
chamber will be pressurized without any pump action which might inadvertently aspirate
unwanted material. Once the nucleus is debulked or cracked into fragments, machine
parameters need to adapt to the needs to emulsifying these fragments. Ultrasound power
requirements are lower at this stage relative to sculpting because of the increased
efficiency of phacoaspiration with complete or almost complete tip occlusion. Even with
only moderate ultrasound levels, though, flow rate and vacuum usually must be increased
from their sculpting levels in order to overcome the repulsive action of ultrasound at the
axially vibrating needle tip. Although 26 cc/min flow rate and 120 mmHg vacuum are
reasonable baseline values at this stage, these parameters should ideally be linearly
titrated intraoperatively to a given ultrasound level and nuclear density. This level of
control has only recently been available to the surgeon with the advent of the dual linear
pedal as previously described.
Chopping maneuvers often require further manipulation of parameters. The actual
chop may require only moderate vacuum because the nucleus is mechanically fixated
between the phaco tip and the chopper. However, higher vacuum levels of 200 to 250
mmHg can be used advantageously to grip
FIGURE 9.15
and manipulate the nucleus. For example, the gripped nucleus can be displaced so that the
chopper is more centrally located when engaging the nuclear periphery. This maneuver is
especially effective if the nucleus was previously grooved and hemisected as has been
described by Drs. Paul Koch and Ron Stasiuk (Fig. 9.15). If a flow pump is used, 26
cc/min is a useful compromise between a reasonably rapid rise time and a reasonable
safety margin against surge. If a vacuum pump is used at 200 to 250 mmHg, the surge
potential is especially high. When the chop is completed and the occlusion breaks, the
subsequent induced flow with a standard needle would be over 60 cc/min. A Microflow
or similar needle with a reduced inner diameter (therefore increased fluidic resistance)
Phacoemulsification
144
reduces this flow by about 40 percent to a safer level. The safest technique, though,
would be to use the high vacuum level during the actual manipulation and chop when
gripping the nucleus and then to dynamically decrease the vacuum with pedal control just
as the chop is completed to minimize the surge potential.
Surge, as has been discussed, occurs when an occluded fragment is held by high
vacuum and is then abruptly aspirated (i.e. with a burst of ultrasound), fluid tends to rush
into the tip to equilibrate the built-up vacuum in the aspiration line with potentially
consequent shallowing or collapse of the anterior chamber (Fig. 9.16). In addition to the
preventive measures mentioned in
FIGURE 9.16
the previous paragraph, phaco machines employ a variety of methods to combat surge.
Fluidic circuits are engineered with minimal compliance which will still allow adequate
ergonomic manipulation of the tubing as well as functioning of the pump mechanism, the
latter being primarily important for peristaltic pumps. Small bore aspiration line tubing,
utilized by Allergan and Alcon, provide increased fluidic resistance which obtunds surges
in a manner similar to that of the Microflow needle previously discussed. The Surgical
Designs machine incorporates a second, higher irrigating bottle whose fluidic circuit is
engaged upon detection of a surge. While all of these designs are helpful, it is ultimately
up to the surgeon to set parameters which optimize a given machine for a given patient
with regard to surge prevention.
The parameter of bottle height has a constant function during all phases of surgeryto
keep the chamber safely formed without overpressurization which might stress zonules,
misdirect aqueous into the vitreous, or cause excessive incisional leakage.
Approximately, 10 mm Hg hydrostatic pressure is produced intraocularly for every 15 cm
bottle height above the eye.
However, it is vital that the appropriate bottle height be set hydrodynamically with the
pump operating (pedal position 2 or 3) and the tip unoccluded so that an adequate
pressure head will be established to keep up with the induced aspiration outflow from the
eye.
147
This chapter has stressed the importance of appropriate machine parameter settings. It
should also be stressed, of course, that surgical technique is not only just as important,
but is moreover integrally related. For example, if a surgeon wishes to grip and pull a
heminucleus in preparation for chopping yet finds that the tip instead pulls away from the
lens material, the tendency would be to increase the vacuum parameter to give a stronger
grip. However, it is critical to remember that the full preset vacuum can be produced at
the phaco tip only with complete tip occlusion. Therefore, if an adequate vacuum seal is
not obtained, the preset value will not be reached. Increasing the vacuum preset will not
affect the clinical performance in the absence of a good vacuum seal, which is obtained
by embedding the phaco tip at least 1 to 1.5 mm with light ultrasound energy so as to
avoid excessive cavitation (Fig. 9.17). The tip is also embedded in the central densest
FIGURE 9.17
FIGURE 9.18
Phacoemulsification
146
nucleus as opposed to more peripheral, softer material which might irregularly aspirate,
again causing a loss of the vacuum seal (Fig. 9.18). This subtle attention to technique
pays off with the machine being used to its most effective potential.
Summary
Modern phaco machines offer unprecedented levels of control and safety. In order to
fully exploit these values, a thorough understanding of the principles by which the
machines operate is essential. In particular, the surgeon must appropriately adjust flow
rate, vacuum, ultrasound power, and bottle height as necessary for a given patient and for
a given stage in the operation. This vigilance and attention, coupled with meticulous
technique designed to optimize the machines performance, will result in the safest, most
efficient phacoemulsification surgery.
10
Air Pump to Prevent Surge
Sunita Agarwal
Amar Agarwal
Athiya Agarwal
Introduction
One of the main bugbears of phacoemulsification is surge.1 The problem is that as the
nuclear piece gets occluded in the phaco tip and we emulsify it, surge occurs. Many
people have tried various methods to solve this problem. Some phaco machines like the
Sovereign have been devised with the help of I Howard Fine, Barry Seibel and William
Fishkind to solve this problem. Others have tried to use an anterior chamber maintainer to
get more fluid into the eye. The problem with the anterior chamber maintainer is that
another port has to be made. In other words, now we have three ports and if you are doing
the case under topical or no anesthesia (as we do in our hospital) it becomes quite
cumbersome. Another method to solve surge is to use more of phacoaspiration and chop
the nuclear pieces with the left hand (non-dominant hand). The problem by this is the
surgical time decreases and if the case is of a hard brown cataract, phacoaspiration will
not suffice.
Surge
Surge1 occurs when an occluded fragment is held by high vacuum and is then abruptly
aspirated with a burst of ultrasound. What happens is that fluid from the anterior chamber
rushes into the phaco tip and this leads to collapse of the anterior chamber.
New Technique
One of us (Sunita Agarwal), then thought of a method to solve surge using an air pump.
We got this idea as when we were operating cases with Phakonit (a new technique in
which cataract is removed through a sub 1.4 mm opening), we wanted more fluid
entering the eye. Now we, routinely use the air pump to solve the problem of surge.
Phacoemulsification
148
Method
First of all (Fig. 10.1), we use two balanced salt solution (BSS) bottles and not one.
These are put in the IV stand.
Instead of using an IV set for the fluid to move from the bottle to the phaco handpiece,
we use a TUR set. This is a transurethral tubing set, which is used by urologists. The
advantage of this is that, the bore of the tubing is quite large and so more fluid passes
from the infusion bottle to the phaco handpiece. The TUR set has two tubes, which go
into each infusion bottle, and then the TUR set becomes one, which then passes into
the phaco handpiece.
Now we take an air pump. This air pump is the same air pump, which is used in fish
tanks to
FIGURE 10.1 Diagrammatic

representation of the air pump and
infusion bottle. Note two infusion
bottles connected to a TUR set. Also
note the air pump connects to one of
the infusion bottles
Air pump to prevent surge
151
FIGURE 10.2 Air pump connected to

the infusion bottle. Note two infusion
bottles. The black box on the left over
the phaco machine is the air pump. On
the right is the phaco handpiece lying
in a tray
give oxygen to the fishes. The air pump is plugged on to the electrical connection.
An IV set now connects the air pump to the infusion bottle. The tubing passes from the
air pump and the end of the tubing is passed into one of the infusion bottles (Fig.
10.2).
What happens now is that when the air pump is switched on, it pumps air into the
infusion bottle. This air goes to the top of the bottle and because of the pressure, it
pumps the fluid down with greater force. With this, the TUR set also is in place and so
the fluid now flows from the infusion bottle into the TUR set to reach the phaco
handpiece. The amount of fluid now coming out of the handpiece is much more than
what would normally come out and with more force.
One can use an air filter between the air pump and the infusion bottle so that the air
which is being pumped into the bottle is sterile.
This extra amount of fluid coming out compensates for the surge which would occur.
Phacoemulsification
150
Continuous Infusion
Before we enter the eye, we fill the eye with visco-elastic. Then once the tip of the phaco
handpiece is inside the anterior chamber we shift to continuous irrigation. This is very
helpful especially for surgeons who are starting phaco. This way, the surgeon, never
comes to position zero and the anterior chamber never collapses. Even for excellent
surgeons this helps a lot.
Advantages
With the air pump, the posterior capsule is pushed back and there is a deep anterior
chamber.
The phenomenon of surge is neutralized. This prevents the unnecessary posterior
capsular rupture.
Striate keratitis postoperatively is reduced, as there is a deep anterior chamber.
One can operate hard cataracts also quite comfortably, as striate keratitis does not occur
postoperatively.
The surgical time is shorter as we can go quite fast in removing the nuclear pieces, as
surge does not occur.
One can easily operate cases with the Phakonit technique as quite a lot of fluid now
passes into the eye. Thus, the cataract can be removed through a 0.9 mm opening.
It is quite comfortable to do cases under topical or no anesthesia.
Topical or No Anesthesia Cataract Surgery

When one operates under topical or no anesthesia, the main problem is sometimes the
pressure is high especially if the patient squeezes the eye. In such cases, the posterior
capsule comes up anteriorly and one can produce a posterior capsular rupture. To solve
this problem, surgeons tend to work more anteriorly, performing supracapsular
phacoemulsification. The disadvantage of this is that striate keratitis tends to occur.
With the air pump, this problem does not occur. When we use the air pump, the
posterior capsule is quite back, as if we are operating a patient under a block. In other
words, there is a lot of space between the posterior capsule and the cornea, preventing
striate keratitis.
Disadvantages
As we tend to use two bottles instead of one, the cost is a bit more expensive.
The TUR set is slightly more expensive than a normal IV set.
Summary
Air pump to prevent surge
153
The air pump is a new device, which helps to prevent surge. This helps to prevent
posterior capsular rupture, helps deepen the anterior chamber and one can work
comfortably even in hard cataracts. The air pump pumps air into the infusion bottle thus
tending to push more of fluid into the eye and with greater force. Now, we routinely use
the air pump in all our cases.
Reference
1. Agarwal S, Agarwal A et al: Phacoemulsification, Laser Cataract Surgery and Foldable IOLs.
New Delhi: Jaypee Brothers, 1998.
11
Microseal and Other Phaco Tips
Hampton Roy
Introduction
The cutting part of the phacoemulsification instrument is the phaco tip. This chapter will
discuss the various types of phaco tips that are currently in the market. There are several
more in a developmental stage that are not discussed in this chapter. Some of the
efficiency of the phaco tip is related to the type of handpiece. For example, the cobra tip
is especially designed for the magnetorestrictive handpiece because this generally heats
up faster than the piezoelectric handpiece.
Another interesting feature of the tips has to do with the sleeve surrounding the tip.
With the higher efficiency tips, there is more danger of getting a burn of the cornea.
Thus, several tips are designed to reduce the burn. For example, the microflow has
grooves in the outer shaft to allow the fluid to keep the shaft cooler. The microseal has an
insulated sleeve that is thicker and cuts down on the possibility of heat transfer through
the sleeve with a corneal wound burn.
Characteristics of Phaco Tips
The phacoemulsification tips are attached to a handpiece, and it is important that you
understand the dynamic range. The dynamic range is the relationship between the
balanced application of fluidics [vacuum, aspiration flow rate (AFR), and irrigation] and
ultrasonic power. The relationship between fluidics and ultrasonics should be one of
balance. The preset maximums of each of these parameters will vary depending on the
dominant parameter employed.
Type of Phaco Tips
Standard Tip
The standard tip has a straight shaft of 19 gauge and requires a 3.0 to 3.2 mm incision.
With the traditional divide and conquer surgery, this is the tip of choice (Fig. 11.1).
FIGURE 11.1 Standard tip
Microseal and other phaco tips
155
0-degree tip The 0-degree phaco tip was designed by Kunihiro Nagahara and James
Little. It does not have any angle at the tip end. There is no bevel at the tip, but there is an
internal 60 degree bevel that provides a cutting surface. The 0 degree tip has the
enhanced ability to gain occlusion and vacuum rise. Dr. Roger Steinert performs a phaco
chop through a 2.8 mm sutureless wound with topical anesthesia. His preferred vacuum
sets are 200 mm Hg for 2+ cataracts, 300 mm Hg for 3+ cataracts, and 400 mm Hg for 4+
cataracts. He generally uses linear flow 26 cc per minute flow and 70 percent linear
phaco power. His bottle height varies. He enters initially with a low height because of the
clear cornea topical anesthesis technique. The height then varies depending on the
maximum vacuum settings. At the 300 mm Hg and above set-tings, height will be at its
maximum allowable pole setting.
15-degree tip It is becoming much more common with the high vacuum capabilities for
phacoemulsification.
30-degree tip The most common tip that is used. A 30-degree tip of the same diameter
presents 15 percent more cross-sectional area to the cataract than the 0-degree tip.
45-degree tip The 45-degree tip is generally considered more effective in cutting hard
cataracts over a 30 degree tip. However, it is more difficult to occlude because the 45
degree bevel has a larger cross-sectional area. In fact, a 45-degree tip presents 40 percent
more area than a 0 degree tip.
KelmanTip
Kelman tip is a 19 gauge needle that has the advantage of increased cutting ability. It has
a disadvantage that it has 180 degree cutting edge that can be dangerous because it can
cut toward the periphery of the lens. It provides circular cutting. It has a higher stroke
length, thus, the increased frequency leads to more energy (joules) that is used during the
procedure. This tip has a higher incidence of wound burn. It can be very efficient if it is
used in combination with a thermal protective sleeve in the hands of an excellent surgeon
(Fig. 11.2).
FIGURE 11.2 Kelman tip

Microflow
The microflow needle is a 19 gauge needle and has grooves in the outer shaft. It has an
advantage that the grooves in the outer shaft help to cool down the phaco tip. It is
generally used with a 2.85 to 3.2 mm incision size (Fig. 11.3).
FIGURE 11.3 Microflow tip
Phacoemulsification
154
Cobra Tip
The cobra tip is a 19 gauge needle that has an increased size on the end of the needle
shaft. It is used for magnetorestrictive handpieces that have a tendency to heat up faster
than the piezoelectric handpieces. It is used very rarely (Fig. 11.4).
FIGURE 11.4 Cobra tip

Microseal
The microseal is a 19 gauge needle. It is similar to the Mackool with its insulated sleeve.
It has the advantage of having a thicker sleeve that closes down the fluid outflow for a
totally enclosed system, and so you maintain the chamber better than if you use another
system (Fig. 11.5).
FIGURE 11.5 Microseal

Masket Ergo Tip
The Masket Ergo tip is a 19 gauge needle. It is bent at the hub for more control. It is safer
than the Kelman system because it cuts with a longer stroke length. It is not used much
because it is not very well known. Particularly with an insulated sleeve, it would be an
excellent choice. The manufacturer gives the following benefits.
Ergonomics design for a more comfortable hand position reducing fatigue
Greater efficiency during phaco requiring less ultrasound being delivered to the eye
Tip maintains a more parallel position to the iris and posterior capsule, reducing the risk
of breaking the capsule
Easier access into the deep set eye (Fig. 11.6).
FIGURE 11.6 Masket Ergo tip

Mackool Tip
The Mackool tip is a 21 gauge needle. It has an insulated sleeve with thermal protection.
It requires a 2.75 mm incision size scleral tunnel or a 2.85 mm clear corneal incision. It
Microseal and other phaco tips
157
has the advantage that if the doctor spends much time in the position 3 of phaco
ultrasound, there is less chance of wound burn (Fig. 11.7).
FIGURE 11.7 Mackool tip

Mackool-Kelman Tip
The Mackool-Kelman tip is a 21 gauge needle. It has the advantage of having a smaller
gauge with precise cutting control. It has a bent tip with greater cutting space and an
oscillating stroke length. The insulated sleeve reduces the thermal heating. It has the
disadvantage of cutting all the way around the tip, and it takes a skillful surgeon to reduce
cutting unwanted tissue. There can be a reduction in the outflow particularly if the
incision size is in the range of 2.65 mm. It has an increase in the high vacuum
capabilities, but the tip is generally a 45 degree tip such that the holding capabilities are
not as good as a lesser angle tip (Fig. 11.8).
FIGURE 11.8 Mackool-Kelman tip

Summary
Eight major types of phacoemulsification tips that are used to remove the cataract are
discussed in this chapter. Each has advantages and disadvantages, and it is important for
the surgeon to realize the various types that are on the market and what is best suited for
the characteristics of the surgeon, the type of handpiece available, and other factors.
The authors personal preference is the use of the Mackool-Kelman tip.
12
Sterilization
Sunita Agarwal
Introduction
When viewed upon from the broader angle however good a surgery may have been
performed should it be complicated with infection, the result is fraught with peril. The
patient suffers ultimately and the surgeon goes through hell. We have all had our share of
infection and its disastrous effects.
Should a surgeon say they have never had infection spoiling their case, either they
have never done surgery or the truth lies hidden elsewhere.
Be that as it may we need to understand microorganisms in a much better manner. We
need to give this topic full attention in our hospitals and conti-nue to give it the
importance it requires by continuing quality checks at every interval regularly every day
and in every case.
Some basic facts of postsurgical infection in human eyes whether cataract surgery or
any intraocular surgery is concerned, are that we need to regard all infections to arise
from the operation theatre unless proved otherwise. The operating room is certainly the
most guilty in providing the microorganism for postsurgical infection.
It may be very easy to complain about patient compliance and dirtiness to be the cause
of infection, and sometimes that may be true, however in our hearts it is safer and better
for us to accept that this infection has come from the operating room and then work
ourselves backwards in removing the source of the disease.
We may be able to shift blame to a tooth infection or septic foci in the sinus, however,
should we be able to first accept the operating room to be at fault, our energies would be
directed in improving our facilities, thus averting further mishaps from occurring.
The first rule in sterilization at least where developing countries are concerned is not
to believe any manufacturer when they claim to have sterilized their wares. To be taken
as guilty of infection unless proved otherwise. This is true of not only suture material,
disposable needles and syringes but also of intravenous and intraocular fluids. Many
cases have been reported in India where bacteria have grown from the Ringer lactate
used. A startling study was carried out in the early 90s where several eyes were lost due
to balanced salt solution (BSS) not being of pH 7.4, because the last rinse did not wash of
the remnant soap from the glass bottle.
What we all need to remember is that when everything is going fine nobody
complains, but as soon as there is a complication the surgeon is the first and often the last
person to be held totally responsible for all misdemeanors on anybodys part. Thus, as
captain of the ship the surgeon has to sink with his or her ship. However, all this can be
avoided by taking precautions before entering the operating room.
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History
Dating back to the time that Sushruta from 500 BC explained the importance of washing
hands and draping wounds with clean cloth, as well as having a clean environment for
surgical procedures, Indian medicine has always kept this part of medical practice in
good stead. Practicing principles of Dhanvantri medicine a Hindu physician-oculist wrote
that surgeons should clean their nails prior to operating, wear fresh clothing, and spray
sweet smelling vapors around the operating room. Little did he know the importance of
these instructions. However, these were carried down through the ages by the Vaidyas
(Hindu physicians), now with better knowledge there is more understanding of the topic
on infection and sterilization control.
The middle ages saw European medicine catching ground however, sterilization
tactics were still very rudimentary. Most surgeons thought it to be fashionable not to
wash hands, mayhap due to the cold climate of the temperate zones. Thus, centuries of
unknown prevailed with thousands being lost to infection and disease even inside the
operating room. It was considered hazardous to lay a surgeons hand in the fear of losing
the patient to fever as it was called then.
However, Hieronymus Fracastorus in 1546 published a landmark book that may have
led to the discovery of bacteria. His theory of contagious diseases and their treatment
sparked off the original microbe hunter, to identify bacteria with his own saliva in 1675,
using his microscope screwed together with some lenses, Antoni van Leeuwenhoek had
set about 2 centuries of hot debate amongst the European scientists.
In 1840, Jakob Henle postulated the theory of the contagion. This was further
specified by Robert Koch in 1876 where he showed that by isolating the anthrax bacillus
and was able to infect a normal animal with the same that the theory of contagion was
true. This work won him the Nobel Prize for medicine and physiology in 1905.
It took Louis Pasteur to bring out the emphasis of the little beings as those
responsible for disease. His paper on the importance of washing hands before starting a
obstetrical delivery shows the utmost significance of this one act towards a sterile
atmosphere.
Throughout the 1800s pioneering technologies of Pasteur, Nizer, Klebs, Escherich,
Cohn and Ehrlich played major roles in the evolution of discovery of pathological germs.
Today the science of microbiology and medicine are occupied by their names forming
important landmarks in the discovery of the importance of sterilization techniques.
Where hospital wards are concerned, making surgery safe and banishing sepsis from
hospital wards, an era of pre-Lister and post-Lister can be demarcated. This was the
importance of Joseph Lister on surgical outcome. He based a lot of his studies however
on Ignaz Semmelweiss (18181865)who was cruelly maligned for his theory of the
origins of child-bed fever that led him to be institutionalized and die an unhappy man.
The irony of the situation was his studies brought about a revolution in hospital wards
and the prevention of infection by antiseptics and cleanliness reiterated by Joseph Lister.
By the time Daimler brought out his first motor cycle in 1884, scientists round the
globe had devised the autoclave deriving from the fact that boiling did away with
microbes. This revolutionized hospital wards and operation theatre sepsis to a great
extent. So much so that till date some contraption of the autoclave is still used in every
operation theatre in existence in the modem world.
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158
By 1899 a century was going by and scientists believed this was the ultimate and that
internal sepsis was not going to be much more advanced beyond theory and that the field
was not likely to advance further. Today with much more information and knowledge we
think contrary, that we still know only a drop in this ocean of knowledge against disease
and infection.
Change is the spice of life and just as today changes to another day, of more discovery
and more scientific achievements so to these pioneers were to discover much more.
Sulfanilamide first discovered by Paul Gelmo in 1908 was found to be effective on
surgical wounds, by Gerhard Domagk who first used the drug on humans in 1935. This
won Domagk the Nobel Prize for Medicine and Physiology in 1939.
Paul Ehrlich and Toju Hata discovered Salvarsan, the arsenic derivative for the
treatment of syphilis, it heralded yet another era, that of the antibiotic.
In 1929, Alexander Fleming published his classical work on Penicillin from London
and history followed his every achievement. Through the World Wars his medicine was
of immense use in the control of infection and weeding out of disease. He showed first
through in-vitro studies that a contaminant of Staphylococcus medium, Penicillium
notatum had a destructive effect on the Staphylococcus bacteria that was growing on the
agar plate. In further experiments he showed that this mold also had strong antibacterial
activity against other pathogenic gram-positive bacteria as well as gram-negative cocci
and bacilli but was not effective against organisms such as Escherichia coli.
While the world raged with War, yet another kind of war was being fought for
mankind inside the laboratories of HW Florey at Oxford University. By 1940 Ernst Chain
showed the curative effects of penicillin in vivo. In 1945, by the end of the World War II,
these three men were awarded the Nobel Prize for Medicine and Physiology. SelmanWaksman discovered spates of antibiotics in succession with streptomycin in 1944 for
tuberculosis and neomycin in 1949.
Much of todays discoveries have been dependent on the way we see these small
animalcules of Leeuwenhoek, in 1933. Our eyes could see the destruction of the world
with Hitler as the Chancellor of Germany, and could see even greater destruction by
microbes since the invention of the first transmission electron microscope by Ruska.
Further developed to a phase contrast microscope by 1953, by which time the World War
had ended and humanity was once again allowed to prosper. So much so that the
scanning tunneling microscope could be developed by 1980 and its fast developing
clones that are in use today.
However, very soon the side effects of antibiotics were noted with the classic example
of chloramphenicol the first broad-spectrum antibiotic, discovered in 1949, effective
against rickettsial infection, typhoid. A link was established between severe bone marrow
depression and aplastic anemia with its use. This curtailed the use of these eyedrops and
oral regime in USA.
We owe a lot to these forefathers of modern medicine and surgery, and todays
technological advancements have made us more wary of the microbe. It seems to be the
more we advance the more microbes we find the cause of disease. Stress and other
dietary factors were believed to be the cause for peptic ulcers, though now we know
bacteria to be the root. In a similar manner, there are many more diseases that still retain
their shroud of mystery.
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Let us not rest on previous laurels and with the close of this century believe that we
have reached the ultimate. In reality, we have only skimmed the surface there is much
more to be unraveled in this body beautiful of the Homo sapiens.
Tempting to say in the words of Louis Pasteur, Science knows no country,
because knowledge belongs to humanity, and is a torch which illuminates the
world.
Areas of Sterilization
Once we enter the operating room we expect that everything must be in order, and
somebody else is in charge, not me. However, much to our utter astonishment seldom
does anything go wrong, though when it does, the blame is once again pushed on to
somebody else, not me. This is where the first principle of surgery has to be changed and
restructured. The first and only person responsible for the whole team at work inside
an operating room is the main surgeon. This is the person who everybody in the
operation theatre must report to. This is the person who before entering the theatre has to
ensure that everything inside this pious area is under strict control of the surgeon. This is
the person who must take responsibility if an infection should arise in the patients eye
within one week of surgery.
After carrying out so many tests and sterilization techniques I would rather believe for
the benefit of all future patients that infection in a postsurgical eye arises from the
operation theatre facilities. It is very difficult to put infection inside a closed eyeball,
though it is easy enough while the eye coats are still open. More often than not infection
is carried into the eye by instruments themselves.
There is however a small possibility that this may not be the case and there may be a
septic foci residing in some corner of the human body like a tooth abscess or such. Still
these occurrences are very rare and far between. Moreover, it is far more beneficial to all
concerned to garner our resources and give a thorough job of the operating room than to
be witch hunting on the patients habits and dirtiness. It is my belief that even a dirty
patient cannot infect the inside of his or her eye, if he or she has a postsurgical infection
for sure it has been carried in through the workings of the operation theatre.
Going in a methodical manner from without to within anything entering the theatre has
to be sterile. First the operating room itself has to be sterile.
The Operating Room Air
The air we breathe can be filled with pollutants, viruses, bacteria and irritants such as
pollen, chemical gases, odors and smog. In critical situationsmilitary command centers
and public arenasthere is also a threat of chemical and biological agents being released
into the air. All these air borne pollutants can be treated by using various technologies.
We forget about the air coming into the operating room, though however we should
understand that if this itself is clean it is much easier to retain the cleanliness within.
There are many ways of filtering clean air into the operating room. One of the easiest and
best is to first make sure the rooms pertaining to the operation theatre complex are sealed
Phacoemulsification
160
shut, with only one entry into the complex. Now, we need to bring in clean air into the
operating rooms.
Air Conditioning
Ideally the whole operating area complex must be air-conditioned with the units stationed
well outside the complex and only ducts bringing in fresh temperature-controlled air into
the complex. The air conditioning units could be in the form of towers or split units
stationed on the terrace or window firmaments outside.
Filtration of air The ducts bringing in the clean oxygenated air need to have the air
passing through filters that can ward off bacteria which means they should be 0.2 micron
filters. More often these filters need to be changed and or cleansed on a daily pattern.
Ultraviolet radiation Ultraviolet light bulbs could be placed in the path of the filtered air
to make sure the air is disinfected as it enters the operating rooms. Alternately these bulbs
could be left in the operating area and kept on throughout the night, this would also
ensure clean areas the next morning after 12 hours of exposure to the ultraviolet light.
Ozone treatment Another technology gaining ground for clean air is the ozone treatment
plants that generate ozone into the air. This breaks up the microorganisms and clean,
disinfected air is ensured. One unit for 5000 cubic feet of air space is recommended.
Ozone is a reactive molecule comprising three atoms of oxygen. Because ozone is a
reactive molecule it acts as a powerful oxidizing agent against all microbial
contaminants, organic toxins and most volatile organic compounds (VOCs) and because
of its short half-life it rapidly reverts to water and oxygen.
When a combination of UV, moisture and ozone are used a synergistic effect is seen.
The absorption of UV by the ozone-producing highly reactive substances that effectively
kill microorganisms including hard to kill spore forming bacteria.
Positive pressure A positive pressure pump is maintained to make sure the air entering
the operating rooms are kept at a pressure above the rest of the area. These pumps can be
installed in the ducting and positive pressure inside the operating areas would ensure that
the air comes only from this area and not through leaks from windows or doors. The main
door of the operating room must function for only air escaping the operating area and not
for entering it.
Air curtain Entry points in the operating area would do well to have automatic door
closers so that the door does not remain open unnecessarily. Also the door can be fitted
with an air curtain so that the outside air is curtailed off from entering.
Quality Check
Quality check is ensured by every day/regularly carrying out the PLATE TEST. This
means leaving a bowl of clean sterile water in the room to be tested for 20 minutes.
Microorganisms present in the air would settle down on the surface of the water, a small
sample is taken from this and grown on a culture plate. If the sterilization techniques have
been effective the culture should be sterile in 24 to 48 hours. If the culture grows positive
growth remedial means have to be taken to ensure sterile cultures.
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163
The Operating Room Water

The water coming into the operating room needs to be free of microorganisms. After all
the water with which we are cleaning the most important area of the hospital needs to be
totally clean. If microorganisms are present in water then they would remain on the items
cleansed and the cleaning would be bad. The water coming into the operating room must
also contain adequate amounts of minerals.
Filtration
This still finds the safest use in bringing in clean water into the operating area. It could be
done by many methods, ceramic is one of them. However, today membrane filters seem
to have replaced all else as here they bring out the fluid bereft of bacteria. Sometimes a
suction pump is attached to the water jet so that the filtration can take place at a faster
pace.
Reverse Osmosis
A high pressure is set about in the clean water and a system of reverse osmosis sends
back the mineral content of the water while a filtration process blocks out the microbial
content. In this way water is able to reach the operating room withless minerals and is
absolutely sterile with no bacteria. This is also one of the techniques used in the
manufacture of bottled mineral water and can be used very effectively in operating area
complexes. This water is now used for cleaning the operating rooms, machines, and for
surgeons while scrubbing. The water coming from such a plant is placed in a storage
drum, preferrably made of stainless steel.
Electronic Control
Water can be made to contain low mineral counts and no bacteria through another
technique of manufacturing mineral water. This is by producing cathode and anode
electrodes on two ends of the water channel. The anions and cations would respectively
move to their corresponding electrodes and this would clear the fluid of mineral content.
A filter present below would clear the water of microorganisms. This is another method
of producing sterile bottled mineral water.
The Operating Room Walls, Floor, Ceiling and Fixtures
All elements of the operating room need to be first cleansed, then disinfected and last but
not the least totally sterile. The three steps in this process can be done by three different
fluids and chemicals.
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162
Cleansing
This is best done with a soap and water wash. Every surface, every table, every chair and
every fixture needs to be cleansed with a direct application of soap and water on the
surface. After cleaning with this it needs to be cleaned with plain water.
Disinfection
Benzalkonium chloride solution 4.5 percent could be used as a disinfectant and as a
general cleaning agent for floors.
One of the best solutions used worldwide towards the disinfection of operation
theatres and consultation suites is the Bacillocid made by Bode from Germany. This
contains 1,6 dihydroxy 2,5 dioxyhexane (chemically bound formaldehyde) with
glutaraldehyde, benzalkonium chloride and alkyl urea derivative. A 2 percent solution is
used for the operation theatre and a 0.5 percent solution for the consultation areas. With
this solution all areas mopped and cleansed of vegetative organisms, fungus and viruses
(Figs 12.1 to 12.3).
Formaldehyde in the form of liquid, tablets or gas has been used extensively in the
past, however, today its use is put to question since culture tests have proved positive
with growth even after formaldehyde sterilization.
FIGURE 12.1 Cleaning of the

operation table and chair, external
surfaces of the microscope, instrument
table, IV poles with Bacillocid
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165

operation theatre walls with Bacillocid

operation theatre floor with Bacillocid
The Operating Room Macroinstruments
All fixtures including fans, lights, air conditioning have to be first cleansed carefully with
a dry cloth and then mopped with Bacillocid so that they can be disinfected.
Chairs, stools, operating tables, trays have to be first cleansed with soap water and
then mopped with Bacillocid (Fig. 12.1) and left alone for over four hours to ensure
disinfection.
Care needs to be taken on operating theatre instruments like Boyles apparatus,
microscopes, phaco machines, diathermy machines, suction machines, laser machines.
Though delicate these instruments need to be thoroughly cleansed everyday. Many a time
infection is found to be harboring in these areas and they are difficult to clean. More
sophisticated the machine more care need to be taken in its cleanliness. This task cannot
be given to an untrained personnel and even then ideally there should be a doctor
supervising their cleaning.
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164
Microscope
The rest of the microscope can be cleansed with soap water as well as Bacillocid however
the optics need special care and need to cleaned only with a clean cloth preferrably
silicon paper. Antifog chemical coating could be given to the optics. After cleaning and
before closing for the day the optics should be ideally wrapped in its original cloth or
plastic casing and drying agents placed inside like silicon oxide. This allows the moisture
inside to be absorbed by the chemical and with less moisture, formation of fungus and
other microorganisms on the optics is rare.
Phaco Machines
As eye surgeons we need to be well aware of the pressure maintained inside the eye
during phacoemulsification procedures for cataract surgery, but little do we realize the
importance of the machinery involved in giving us this information. When the phaco
probe is inside the eye of the patient there is a continuous flow of fluid. The fluid arises
from the bottle suspended 65 cm above the head of the patient and this produces a certain
pressure inside the eye. The fluid then goes through the irrigation line to the phaco tip
which enters the eye and leaves the eye through the suction tubing entering the phaco
machine. From the phaco machine another set of tubings takes the excess fluid away into
a drainage bag. What we have overlooked is between the tubing entering the phaco
machine and exiting into the drainage bag, it goes through a channel inside the
phaco machine. This part of the tubing is never sterilized in the proper manner that
is required before a cataract surgery. In fact, it cannot be sterilized as well. This part
of the tubing is attached to two manometers that gauge the pressure in the tubing and give
us a reading on the panel in front. A vent exists that can release the pressure in the tubing
to atmospheric levels as soon as our footswitch transfers from position 3 to 2 to 1. In so
doing the air from the operating room directly enters the tubings thus if there should be
bacteria in the air they would now have an easy access to the most sterile line that we
have been trying to maintain.
These facts were not known to us for a long time, and we had a spate of infections
as Pseudomonas had managed entry into the tubings present inside the phaco
machine. None of the companies representatives ever let us know of this tubing and its
existence and we never racked our brains hard enough to trace the tubings, until this
major catastrophy occurred. Over a spate of 12 months we had taken out 4 intraocular
lenses (IOLs) from eyes with infection. We were able to save the eyes from blindness
however rendering them aphakic.
We first accepted that the infection came from the operating room and now with a
technology of omission went about in a scientific manner trying to decipher where the
infection came from.
First the microsurgical instruments and tubings were taken through the 10-step
procedure as you will read later on. Now, they were tested for sterility by flowing fluids
through them and taking this fluid on a culture plate. They were sterile, after fixing the
tubings and probe onto the phaco machine the fluids were collected from the drainage
bag and sent for culture. The second one was positive. This told us that our sterilization
techniques were good however something was amiss.
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167
We opened the phaco machine and found this tubing running through it and found the
vent as well. This vent ideally should have an air filter attached to it. We sent the tubing
for culture and replaced it with a fresh sterile piece. The culture proved to us where the
culprit lay, the Pseudomonas was grown from this tubing.
The internal tubing cannot be changed with every case, though this would be ideal. So,
we have devised a better structure for its disinfection. That is to keep the air totally sterile
and make sure no infection goes into the tubing through the vent. This is ensured with the
ozone generator for the total operating room areas.
What we did realize through this study was that not all cases turned up with infection
even though the bacteria must have been residing in the tubing for many a day. The cases
turned up with infection had something to do with being the last few of the day. The
cases which turned up with infection had low immune status, either diabetes or
hypertension or such. The cases which turned up with infection had a complication most
often a posterior capsular rupture on table thus resorting to vitrectomy This shows us
some characters of infection that we may already have known but not given them their
due acknowledgement.
FIGURE 12.4 Collection of Ringer

lactate solution from the aspiration
tube before the operation

lactate solution from the aspiration
tube after the operation
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166
However, what we have realized is that the phaco machine has to be cleansed very
well and air filters placed on the vent. The tubing changed every week. And culture tests
done for every case before and after surgery (Figs 12.4 and 12.5). What this means is
when the tubings and probe are attached to the machine before starting the case first few
drops of fluid entering the drainage bag is taken for culture (Fig. 12.6). Once again at the
end of the case this is repeated. If and when at anytime a culture should turn positive we
would know the problem immediately. After these stringent measures have been installed
at our hospitals we have neither had even one infection coming from

lactate solution from the front end of
the internal tubing
the operating room nor had to remove any more IOls lenses from infected eyes.
Boyles Apparatus
Regular cleaning of all parts of the machine is necessary with spirit as this evaporates and
does not leave a residue on it. However, the parts of the tubings that enter the human
system or are connected to them need to be thoroughly cleansed, disinfected and then
sterilized. The method of choice for sterilization here is the ethylene oxide gas chambers
(Fig. 12.7). As most of the tubings are plastic temperature of below 60C are comfortably
taken by them. Needless to say that oxygen, nitrogen dioxide, halogen levels should be
monitored on a daily basis with every case in particular.
The Operating Room Microinstruments
Every case must be treated separately and all instruments must be cleansed thoroughly
before the next case. Once a day a 10-step cleansing routine must be established. This 10step routine includes
1. Soap water wash with toothbrush
2. Ultrasonic cleansing with Lysol
3. Cidex cleansing and soaking for half an hour
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169
4. Isopropyl alcohol cleansing

5. Plain sterile water cleansing
FIGURE 12.7 Ethylene oxide

sterilizer
8. Boiling in sterile water
9. Ethylene oxide sterilization overnight
10. Flash autoclave sterilization three times.
Four trays are kept aside on a long side table (Fig. 12.8). Water used in this sterilization
must be mineral sterile water, as this water is totally sterile, prove it by growing the water
on a culture plate and making sure it is sterile. The trays are filled with the respective
fluids. Each tray is numbered and labeled so that mixing does not occur.
FIGURE 12.8 Four trays arranged in

sequence containing carbonic soap
with mineral water, 2 percent
glutaraldehyde, 70 percent isopropyl
alcohol and mineral water
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168
FIGURE 12.9 Wash all instruments in

a tray of carbonic soap and water with
toothbrush
In each tray a toothbrush and 50 ml syringe with a yellow tubing taken off from an IV set
is kept. All microsurgical instruments are dipped in each tray periodically. Every
instrument is cleansed delicately with gloved hands and toothbrush. When and where
required every lumen of every instrument is injected with 50 ml of the liquid that it is
dipped in. Thus, the cleansing action is from the outside as well as from the inside of
every instrument. This is specially true of probes and tubings.
Tray I with Liquid Soap and Sterile Water
The first step in sterilization of instruments is its proper cleansing as whenever the
microbial load will be less on the sterilization technique used the better would be the
results that can be achieved.
This is best done with the old soap and water wash (Fig. 12.9). Liquid soap is used in
a tray with clean sterile mineral water. First a plain cleansing with gloved hands is
completed and then using a toothbrush into the small crevices of instruments. This is of
special importance to instruments filled with blood and tissue. In ophthalmic matters
special reference has to be given to machines like the automated flapper in LASIK (laserassisted in situ keratomileusis) cases, as it is known that corneal tissue gets clogged into
the tracks and other areas of the flapper. This can be removed much better using
palmolive liquid soap as it contains some of the safest and yet cleanest ways to get grid
out of the system.
Ultrasonic Cleansing
The mainstay of cleansing into cervices where the toothbrush cannot reach and this gets
into the fulcrum of forceps and scissors to clean the instruments. A chemical solution like
Lysol (Cresol and soap solution) could be used as an adjuvant to remove the debris from
clogged surfaces. This breaks up the protein and organic matter so that it can come clean
Sterilization
171
from instrument surfaces. Most of the fluids used in the ultrasonic cleanser need to be
antiseptics as well so they can be used as disinfectants on the instruments cleaned.
Cidex or Glutaraldehyde 2%
Once activated Cidex solution manufactured by Johnsons and Johnsons must be used
within 14 days. Some facts like these go unnoticed in hospital environments and the use
of substandard procedures and drugs come into play. Reiterating the fact that the doctor
has to be on top of all these activities.
Instruments are left immersed in this solution (Fig. 12.10) for 30 minutes, which is
sufficient time for disinfection however for sterilization 10 hours would be needed.
Within 10 minutes at room
FIGURE 12.10 Wash all instruments

in a tray of 2 percent glutaraldehyde

in a tray of 70 percent isopropyl
alcohol
Phacoemulsification
170
temperature most vegetative organisms would be destroyed, including Pseudomonas,

fungi, and viruses. The solution is very toxic to the eye and great care has to be taken to
get the solution out of the instruments before using on humans.
Isopropyl Alcohol 70%
This is still one of the best ways of killing the microorganisms (Fig. 12.11). Instruments
are soaked in the solution for over 15 minutes and then cleansed using a toothbrush and
syringe to wash the internal elements of probes and tubings.
Sterile Water
Care must be taken to wash of the deleterious effects of the above mentioned solutions.
This is done effectively by first soaking and then washing all the instruments through
three trays of sterile water (Fig. 12.12). The lumen of the tubings must be clean with
sterile water each time 50 ml of the fluid passing through the probes and tubings.
Sterile Water
Once again cleansed with sterile water.
Sterile Water
Once again cleansed with sterile water.

in a tray of mineral water
Boiling
After going through a number of tests and methods of sterilization we still find one of the
best methods remains the age-old custom of boiling. This brings about total death of the
microorganisms. Most rudimentary of operation theatres would still contain means and
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173
methods of performing this essential act of sterilization. However, what needs to be

detailed is whether the particular article can withstand temperatures of over 100C.
After having a spate of infections and removing IOLs from infected eyes to save the
eyes, my hospital and staff got spurned to find the cause of the infection. Towards this a
whole new regimen was set-up on cleansing, disinfection and sterilization of
microsurgical instruments. After each methodology culture tests would be taken to prove
its efficacy. We did understand that the silicon tubings had gram-positive cocci growing
in them. In a process of eliminating them we found that the cocci inside the silicon tubing
withstood many sterilization techniques like ethylene oxide and autoclave. However,
when subjected to boiling for 20 minutes the tubings would be sterile. This once again
reiterated our belief in this age-old custom of boiling (Figs 12.13 to 12.15).
Ethylene Oxide Sterilization
This is not a preferred technology of sterilization for microsurgical instruments because
of the time duration taken is over 16 hours. However, we have started using this as one
more step towards the end of the day. By the time we finish all the cases of the day we
take our instruments through this 10-step procedure ending it with a bout of ethylene
oxide where the instruments rest for the night. However, the only aspect of this
technology is that the instruments must be cleansed of the ethylene glycol residues that
may be found over them. This is effectively done by steam autoclave and washing
intraocular instruments with ringer lactate meant for intravenous use.
FIGURE 12.13 Diamond blades are

cleaned using steam
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172
FIGURE 12.14 The external tubings,

internal tubings, I/A probe and metal
knobs are boiled for 30 minutes
FIGURE 12.15 The instruments are

separately boiled for 30 minutes
Autoclave
As the last step in the sterilization cycle of instruments, they are passed through the flash
autoclave for 134C for 5 minutes and this cycle is repeated three times in the Statim
autoclave from Canada (Fig. 12.16). It has a built-in computer that tells us of the
efficiency of the cycle. However, color indicators would also tell us of the physical
measurements reaching the desired levels.
Sterilization
175
FIGURE 12.16 Statim autoclave

cassette containing the tubings and
instruments is kept in the ethylene
oxide sterilizer for a period of six
hours
After doing this, the instruments are laid on the operating table and each instrument that
enters the eye is dipped in Ringers lactate before entering the eye.
The Operating Room Linen and Accessories
All operation theatre linen and accessories must be cleansed before entering the complex.
Particular slots should be kept ready and clean for them everyday. Otherwise the
operation theatre should be totally bereft of any other article. Anything that is not used
everyday need not be found in the operating room. This is not the place to keep stocks
and inventory of medicines. They could be kept in the prefunction area of the operating
room but not in the operating room itself.
Linen
Sterile operation theatre gowns, towels, gloves could be of disposable variety, this is
internationally accepted to be the best. However, it is not practical in all kinds of
atmospheres. In India we still recycle our operating clothes which are usually made of
cloth. The methodology approached towards their care is explained in the same 3-step
procedure.
Cleaning This is done by taking all the sullied clothes and first taking away all clothes
coming from an infected patient being operated or from the septic operation theatre are
treated separately than that coming from a clean operating room. These clothes are
preferrably disposed off in an incinerator. If they cannot then they are soaked in Dettol
solution, before the cleaning process begins.
The clothes are cleansed preferrably in a washing machine with adequate soap being
used. Then the clothes are passed into a drying machine. Try not to leave these clothes on
the drying rope for nature to dry, because with this outside bacteria and fungus can settle
Phacoemulsification
174
on these clothes. Inadvertently they may fly off the clothes line and this would also create
much increase of the microbial load for sterilization.
However, if machinary is not available these clothes are first soaked for half an hour
in hot water with soap solution inside a large tub. A rod is taken and rotated round and
round for five minutes. This will shake off the dirt and grind from the clothes.
After this each cloth is taken separately and washed with hand and the clothes thrown
into another tub of hot water with a few drops of Dettol solution in it. The clothes are left
for another half an hour in this solution and then rinsed off with plain water.
A separate enclosure should be made for the drying of these clothes. When the clothes
are placed on the clothesline they should be pinned there as they may fly and hit the floor
picking up germs. This could be avoided. Once dry they are picked up, folded and sealed
for sterilization.
Sterilization Clothes could be sterilized by two methods, whichever method is used what
is important is that they be folded away keeping each procedure in mind. That is to say if
for one cataract procedure we need three operating gowns, ten towels and six shoulder
bags, then they should be folded in such a way that these are all kept together. One does
not have to search for the small items by opening up every item sterilized.
Autoclave: This still finds the pride of place in being the most accepted form of
sterilization. However, one needs to be aware that the clothes must not come out damp.
The steam in the autoclave must be saturated but dry. This means all the water vapor
present in the air should be gas and no droplets of water in the steam. If an autoclave is
giving out damp clothes that means it is not working efficiently. The drums kept in
the autoclave must be closed immediately on removal from the autoclave, ensuring that
outside air does not enter the drum. Once autoclaved the items can be considered sterile
for only 24 hours which means to say they need to be reautoclaved to improve efficiency
in sterilization techniques.
Ethylene oxide sterilization: With todays emphasis on better sterilization techniques and
total dependence on them, a move has come into using the gas industrial sterilization for
hospital purposes. As there is more surety on its efficacy this is even a preferred
technology over the autoclave. However, it does have its drawbacks which are that the
hospital needs to keep a bigger inventory. This is due to the fact that these clothing need
to be aired out for over 48 hours before they can come into contact with human skin.
Easily achieved by having four times the number of gowns and towels one would
ordinarily keep.
The advantage of ethylene oxide sterilization for linen over autoclave is that we never
get damp clothing which should be regarded as not sterile. Moreover, the personnel are
always sure of ready stocks for operating at anytime. We do not have to start the
autoclave and wait for sterilization, we always have sterile clothing ready.
Sealing and packing In ethylene oxide sterilization the methodology employed
towards its packaging is very important. High-grade thick plastic bags could be used,
alternately custom-designed bags are available for ethylene oxide sterilization. However,
these custom-designed bags are more expensive than plain plastic bags used
commercially.
Sealing of these bags has to be immaculate as any porthole left gaping will now allow
the atmospheric air containing microbes into the bag and once the seal is broken the
Sterilization
177
contents are not any more registered as sterile. Sealing machines are available in the
market and their use is much better than burning the bags with a candle and sealing them.
Ethylene oxide chamber The ethylene oxide (ETO) gas comes compressed in gas
cylinders that are attached to the machine. These machines which use the gas cylinder
have a vacuum pump attached which first empties the air in the ETO chamber, then we
let in the compressed ethylene oxide gas and leave it at about 50C for over 6 to 12 hours.
Now, when the chamber has to be opened, once again the vacuum pump empties the gas
out. The outlet from the machine needs to be placed 6 ft above and outside into the
atmosphere. This gas is toxic and its inadvertent entry inside the hospital premises is a
health hazard for personnel. Care must be taken that the outlet tubing is placed well
outside the hospital premises, onto the terrace if possible.
Once the ETO has escaped out the atmospheric air is let in and the chamber pressure
maintained at atmospheric pressure before it is opened. The materials can now be kept on
a shelf for airing. The shelf should be just racks with ample room on either side for the
gas to escape from its whereabouts. The linen can be now used as sterile after 48 hours of
airing.
Alternately gas ampules are present which can be placed inside the chamber, these
ETO gas ampules need neither the vacuum pump nor the temperature maintenance and
can be easily placed inside a big plastic bag also prescribed by the company that
manufactures the ETO gas ampules. All the clothing is stacked after sealing inside the big
plastic bag that occupies the whole of the gas chamber. The ampule is broken and this
allows the ETO gas to permeate through the whole closed plastic bag inside the chamber.
This is left so for 12 hours and for another 14 hours when the gas escapes the chamber.
After which the contents can be taken out and placed on airing shelves.
Medication
Parenteral
IV fluids and intraocular fluids: Fluids used inside the eye should be regarded as not
sterile unless proved otherwise. Towards this exercise we sterilize all our fluids, like
Ringer lactate, saline and even 2 percent methylcellulose. Many a surgeon in developing
countries has suffered immense loss by placing Ringer lactate into the eye without prior
sterilization. E. coli has been known to be grown from these fluids. At the moment of an
infection occurring not just one eye will be lost, but the whole batch of Ringer lactate
would and will be used on several eyes at a time and many losses have been reported.
From the Ringer lactate one surgeon lost over 12 eyes to infection from the fluid. This
cannot be really taken as a mistake as we understand that fluids meant for IV therapy
must be totally sterile, however this is not always the case.
So to protect our patients from such a malady occurring we resterilize these bottles in
the autoclave. It is preferrable to use glass bottles. Studies have shown the plastic
polymers react with the fluids and can have drastic effects on the cornea of patients.
Thus, world over glass is a preferred carrier for use of fluids inside the eye. Moreover,
plastic bottles cannot be autoclaved as they would melt with the over 100C needed for
autoclave sterilization.
Even when we are sterilizing these glass bottles care has to be taken in their placement
in the autoclave bins. Autoclave indicator stickers are used on every bottle. The bottles
Phacoemulsification
176
are placed head up, and kept in the bin with space all around. Preferrably wrapped in
some cloth towel so that should they inadvertently break and blow up, they would do so
inside the wrapping. Care has to be taken to let the fluids reach a level of below 80C
temperature before opening the autoclave chamber as they may blow up on exposure to
room temperature.
All fluids used inside the eye are kept at 4C for better trauma control on the eye. As
we know cold itself is an anesthetic and controls blood vessels by constricting them we
prefer to use cold fluids inside the eye. This would also ensure better control on the
delicate tissues of the eye and less trauma as well.
Methylcellulose 2% (VISCON): Much the same technology is used in autoclaving
methylcellulose. Glass containers are once again preferred as plastic would react with the
fluids inside. The vials are kept wrapped in cloth and placed inside the autoclave bins.
Once sterile these are shifted into a refrigerator to keep them at 4C, the preferred
temperature for methylcellulose as we know at this temperature the viscosity is the
greatest and best for intraocular use.
All other medication: These too need our undivided attention as to their expiry. Most
drugs are not resterilized since the methodologies used might just denature the
medication. However, place has to be kept in the operating area complex for essential
medication necessary during the course of a surgery. These medicines should not be
stocked inside the main operating room but in prefunction area.
Care needs to be taken regularly to keep dusting and keeping the area where medicines
are kept to be clean and free from germs. Thus, to do so every day this area must be
cleaned, drawers, shelves all cleaned with plain cloth and at least once a week with soap
water and/or Bacillocid.
Probes and Tubings
All probes and tubings are usually of disposable variety, and they could be kept in clean
shelves or drawers with names written on the outside.
Alternately today we could recycle probes and tubings by first cleaning them well and
then passing them through ethylene oxide sterilization. However, these tubings and
probes are usually made of plastic and for the gas sterilization to be totally safe and nontoxic they need to be kept on the shelf for airing for over 15 days. So the date and time of
ETO sterilization needs to be marked on the color indicators when sterilizing these items.
A preferred methodology for sharp instruments to be sterilized is also the ETO
chamber, some of these sharp instruments like disposable knives are also made of plastic
handles, which can withstand ETO temperatures but not the autoclave. These too need to
be kept on a shelf for 15 days before use on human tissues.
The I/A probes, the internal tubing, external tubing, rectal knibs are all cleaned with
various disinfectants (Figs 12.17 to 12.26).
The Operating Room Personnel
Most often surgeons like to operate in the morning, sometimes they need to operate
through the whole day, however, it is a good exercise to see that all operating area
personnel have a regular bath first thing in the morning before entering the operating
Sterilization
179
area. All street clothing and footwear should be removed before entering the operating
area. Thus, most hospitals would keep the changing rooms as the first area of the
operating area complex.
FIGURE 12.17 Flushing of I/A probe

with 70 percent isoproppyl alcohol
passing 200 ml of alcohol into every
lumen
FIGURE 12.18 Flushing of the lumen

of the internal tubing and the metal
knobs with carbonic soap and mineral
water passing 200 ml of the same into
the lumen
Phacoemulsification
178

knobs with 2 percent glutaraldehyde
passing 200 ml of the same into the
lumen
Footwear
Separate areas should be demarcated to keep footwear. This should be kept outside the
operating area complex. However, sometimes they could be kept just inside the door as
we have seen many a surgeon goes in taking out his or her shoes and when he or she
comes back his or her shoes are gone. This is

knobs with 70 percent isoproppyl
alcohol passing 200 ml of alcohol into
the lumen
Sterilization
181

knobs with mineral water passing 200
ml of the same into the lumen
specially true if he or she wears lovely expensive new shoes.
The personnel take off their shoes and are given alternate operating area clogs,
slippers or sandals. The operating area footwear should also undergo vigorous cleaning
procedures everyday. At the end of the day, all the footwear is taken in and washed with
soap water and cleansed with plain water and left for drying.

of the external tubing with carbonic
soap and mineral water passing 200 ml
of the same into the lumen
Phacoemulsification
180

of the external tubing with 2 percent
glutaraldehyde passing 200 ml of the
same into the lumen
Clothing
After changing the footwear all clothing needs to be changed. A changing room has to be
kept clean and with lockers so that operating room personnel can keep their clothes and
valuables safely. The most often used personnel clothing are pant with elasticated waist
and shirts with loose necks so that they could be slided into. It is preferrable not to keep
buttons and other such accessories on these

of the external tubings with 70 percent
isoproppyl alcohol passing 200 ml of
alcohol into the lumen
Sterilization
183

of the external tubings with mineral
water passing 200 ml of same into the
lumen
clothing as they would get damaged in the vigorous routine that these clothing should go
through.
After the operation theatre has finished for the day clothes from the personnel lockers
are taken ideally into a washing machine and then through the dryer and sent for sealing
and packing through ethylene oxide sterilization ready for use four days from the day of
sterilization. Towards this rigmarole the hospital would need to keep six times the
number of clothes actually required.
FIGURE 12.26 100 ml of Ringer

lactate solution is passed through the
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182
lumen of the internal tubings, external

tubings, I/A probe and metal knobs
However, if this is not possible the clothes could be washed by hand dried and then sent
into the autoclave for sterilization. In these clothes one is not really looking for sterility
but for disinfection and thus it is better to go a step further and make them sterile before
use.
Cap and Mask
The cap and mask need not be sterile, however they should be clean and disinfected.
Ideally the cap and mask used can be of disposable variety since their cleaning will then
not become necessary. However, if they are not and the hospital needs to use cloth cap
and mask, they can go through the same cycle of events like the other clothing.
The Patient
The patient should also be made to go through a process to make him or her clean and
disinfected. Ideally all patients should be told to have a bath before they go in for elective
planned surgery. This simple process does give large benefits. Shaving where men are
concerned is essential and removal of make-up is necessary where women are concerned.
Change of Clothes
The patient should change into operating room clothes and take out all street clothes.
Footwear has to be removed before entering the operating room. Ideally patients are
requested to remove all their clothing including undergarments and a patient gown given
to them. This is done in the benefit of the patient so that at any particular time should an
emergency procedure be called for it can be applied without interference from essential
clothing. Moreover, all patients need to be monitored for their heart and blood oxygen
these electrodes are usually placed close to the heart.
However, in ophthalmic practice it is customary in a day care surgical center that the
clothes need not come off the patient. Simple removal of shoes and shirt or dress is
sufficient. Patients are then given sterile disposable gowns that can be worn over their
undergarments. This process is found to be satisfactory for ophthalmic patients.
All patients are also given a disposable cap so that all hair can be placed inside the cap
and not interfere in surgical procedures.
Skin and Incision Site Disinfection
Many solutions are available for wound disinfection some of the best used worldwide are
povidone-iodine and chlorhexidine gluconate 1.5 percent with cetrimide 7.5 percent. All
these antiseptics will be put to better use if they are used in conjunction with simple
cleaning procedures first.
The patients face could be washed with soap and water and all jewellery and
accessories removed. Once the patient lies down on the operating table and is ready for
Sterilization
185
surgery, a scrubbed nurse paints povidone-iodine or any other antiseptic on the skin. This
is removed with plain gauze.
If anesthesia is necessary it can be given now after preliminary cleaning of the site.
After injections are given the site to be operated is once again cleansed by a scrubbed
personnel with antiseptic solution.
Sterile Disposable Surgical Drape
Where the eye is concerned, in todays world the lashes do not have to be cut for
intraocular surgery. However, whenever this is not done, then a plastic surgical
disposable sterile drape is used over the eyes. This has a gummy on the undersurface,
keeping the eyes open the surgeon places the gummy directly on the cornea and keeps the
lashes turned out so that they could stick to the gummy surface and keep out of the
surgical field.
The drape used in the ophthalmic field manufactured by Dr. Agarwals Pharma
is also equipped with a drainage bag. So, once the drape is stuck to the patients eye,
the central plastic over the palpebral fissure is cut open with sterile scissors after the
surgeon has scrubbed and changed.
A whole 20 cc of sterile refrigerated 4C Ringer lactate fluid is squirted over the eye,
to carryout a thorough cleaning procedure as well as to produce cryoanalgesia. The
surgery can now be started. This cleaning process is found to be very necessary for a
clean fornix and conjunctival sac.
Sterilizers
Methods of Sterilization
For a very long-time we had no idea that sterilization is the basis of surgical correction,
after all performing the best of surgery though introducing harmful microbes could mar
the effects of surgery irreparably. With the advent of the autoclave in 1884 we got to
know a lot of details. However, most surgical ward history can be detailed as that before
Lister and the era after Lister as this one person was responsible in explaining antiseptic
surgery as we understand it today.
Terminology
To better understand this vast and varied aspect of surgery, first let us understand the
terms and conditions often used.
Sterilization: is a process used to achieve sterilityan absolute term meaning the absence
of all viable micro-organisms.
Disinfection: is a process which reduces the number of contaminating microorganisms,
particularly those liable to cause infection, to a level which is deemed no longer harmful
to health.
Antisepsis: is used to describe disinfection applied to living tissue such as a wound.
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184
Cleaning: is a soil-removing process which removes many microorganisms. The

reduction in contamination by cleaning processes is difficult to quantify other than
visually.
Decontamination: is a general term for the treatment used to make equipment safe to
handle and includes microbiological, chemical, radioactive and other contamination.
Sterilization
An article may be regarded as sterile if it can be demonstrated that there is a probability
of less than I in a million of there being viable microorganisms on it.
Methods Five main methods are used for sterilization.
Head: A widely used method needs to reach temperatures above 100C to ensure
bacterial spores are killed.
Moist heat is more effective than dry as it coagulates and denatures the protein, where
water participates in the reaction. This requires 121C for 15 minutes with moist heat.
Temperatures above that of boiling water can be attained more easily by raising the
pressure in a vessel, this is the principle of the autoclave. At sea level water would boil
and produce steam at 100C, increasing the pressure to 2.4 bar would produce steam at
125C and increasing to 3 bar at 134C. However, at subatmospheric pressures this
temperature would fall, thus at higher altitudes water will boil at lower temperatures.
1. Quality of steam for sterilization: Steam is non-toxic and non-corrosive, though for
sterilization it should also be saturated, which means it should hold all the water it can
hold. It must also be dry, so it should not contain water droplets. This has a greater lethal
action and is quicker in heating up the article to be sterilized.
When dry saturated steam meets a cooler surface it condenses into a small amount of
water and liberates latent heat of vaporization. The energy available from this latent heat
is considerable. For example, 6 liters of steam at a temperature of 134C will condense
into 10 ml of water and liberate 2162 J of heat energy. By comparison less than 100 J of
heat energy is released by the sensible heat from air at 134C to an article in contact with
dry heat.
Steam at a higher temperature than the corresponding pressure would allow is referred
to as superheated steam and behaves like hot air. Steam with water droplets is called wet
steam and is less efficient.
2. Types of steam sterilizers
A. Sterilizers for porous loads: For linen, and wrapped instruments, so air could get
trapped in the textiles used. Thus, this type of sterilizer should have a vacuum-assisted
air removal stage to ensure that adequate air is removed from the load before
admission of steam. The vacuum pulsing of air also ensures that the load is dry on
completion of cycle.
B. Sterilizers for fluids in sealed containers: Must have a safety feature to ensure that the
door cannot be opened till the temperature in the glass containers has fallen below
80C. Otherwise the thermal stress of cold air on opening the door may cause the
bottles to explode under pressure.
C. Sterilizers for unwrapped instruments and utensils: These should not be used for
wrapped articles, recommended for dental clinics and LASIK stations.
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187
D. Laboratory sterilizers: Culture media in containers, laboratory glassware and

equipment may be contaminated, thus proper cleansing is necessary before
sterilization.
3. Monitoring of steam sterilizers: Every load everyday every time needs monitoring of
some important physical measurements.
Temperature
Pressure
Time with thermometers.
Detailed tests are undertaken with temperature-sensitive probes (thermocouples) inserted
into standard test packs. Though most indicators show color change on reaching
particular temperatures.
Biological indicators comprising dried spore suspensions of a reference heat-resistant
bacterium Bacillus stearothermopiles, are not used for routine testing. Although spore
indicators are essential for low-temperature gaseous processes in which the physical
measurements are very little to kill spores or not reliable. Most often used for ethylene
oxide sterilization.
Bowie-Dick test monitors penetration of steam into wrapped pack and detects uneven
steam penetration by a bubble of residual air in the pack.
Dry heat causes a destructive oxidation of the essential cell constituents. Thus, killing
spores here requires 160C for 2 hours. This may also cause charring of paper, cotton,
organic material.
4. Types of sterilization by dry heat
A. Incineration: Most cities around the world have made it mandatory for most hospitals
to have incinerators in their campus for efficient waste disposal where contaminated
materials like dressings, sharp needles and other clinical wastes. The high temperature
reached kills all organisms and disposes by charring and burning the material.
B. Red heat: Diathermy in ophthalmic hospitals would be done by burning a loop over a
flame, this would sterilize as well as cauterize the bleeding vessel. However, this is
still used to sterile loops, wires, points of forceps. It is a still very much used in
emergency situations.
C. Flaming: Inoculating loops and needles are sometimes treated by immersing them in
methylated spirit and burning off the alcohol, though this does not produce a
sufficiently high temperature for sterilization. This is also done for sterilizing drums
and trays over which sterile linen is placed. Once again this is not totally sterile as
spores may persist over the short-term flame that is produced with alcohol.
D. Hot and sterilizer: Oil, powders, carbon steel instruments, and empty glassware and
laboratory dishes are sterilized with hot air sterilizers, though the over-all heating up
and cooling may take several hours.
E. Microwave sterilizer: This is the latest in roads into sterilizers and can offer better
results than hot air sterilizers with shorter time spans. Within 10 minutes the material
can be sterilized. However, because of the high temperatures reached it is not very
good for organic material or plastics. Very good for microwave transparent material
like glass.
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186
5. Factors influencing sterilization by heat would include:

A. Temperature and time: They are inversely related, i.e. shorter time higher
temperatures, holding time is important loading and cooling time would make the total
time much longer (Table 12.1).
TABLE 12.1 Relationship between temperature

and time
Process Temp (inC) Hold time (min)
Dry heat 160
170
180
Moist heat 121
126
134
120
60
30
15
10
3
B. Microbial load: The number of organisms and spores affects the rapidity of
sterilization. Thus, it is better to go through vigorous cleaning procedures before
sterilization of products.
Ionizing radiation: Both beta (electrons) and gamma (photons) irradiation are employed
industrially for the sterilization of single use disposables.
All accelerated electrons are lethal to living cells, that includes, -rays, -rays, X-rays.
Bacterial spores are the most resistant. Sterilization is achieved by the use of high-speed
electrons from a machine such as a linear accelerator or by an isotope source such as
cobalt-60, a dose of 255 kGy is generally adequate, making this an industrial process. It is
used for single use prepackaged items like plastic syringes and catheters.
Filtration: Filters are used to remove bacteria and other larger organisms from liquids
that are liable to be spoiled by heating. Though virus can crossover they are felt to be
unimportant.
Filters using pore size of less than 0.45 microns can render fluids free of bacteria. It is
used in the preparation of toxins and thermolabile parenteral fluids such as antibiotic
solutions, radiopharmaceuticals, and blood products. Viruses and some bacteria like
mycoplasmas can pass through pore size of less than 0.22 microns.
Filter materials could be unglazed ceramic Chamberland filters, asbestos Seitz filters
and sintered glass filters. Though now membrane filters are usually used made of
cellulose esters or other polymers.
Sterilant gases: Ethylene oxide is used for sterilization of plastics and other thermolabile
material. Formaldehyde in combination with subatmospheric steam is more commonly
used in hospitals for reprocessing thermolabile equipment. Both processes are toxic and
carry hazards to user and patient.
1. Ethylene oxide: Highly penetrative, non-corrosive and microcidal gas which is used
to in industry for single use, heat-sensitive medical devices such as prosthetic heart
valves and plastic catheters. Ethylene oxide sterilization is usually carried out at
temperatures below 60C in conditions of high relative humidity. To ensure sterility,
material should be exposed to a gas concentration of 700 to 1000 mg/1 at 45 to 60C and
a relative humidity above 70 percent for about 2 hours. Care must be taken because of
Sterilization
189
toxicity to personnel, flammability and explosion risk. The sterilized product must be
aerated to remove residual ethylene oxide before it can be safely used on the patient, and
turn round time is consequently slow.
Some recommendations for boosting infection control as well as cut costs on EO
sterilization:
Cleaning is a necessary and important activity before sterilization. I feel that you need
to adopt standardized and effective cleaning method.
Further the items cleaned have to be dried as any wet item will react with ethylene
oxide and the efficacy may be reduced.
The items have to be packed in one of the three materials: linen, paper or plastic. Each
has its advantage but the limitation is the period that you can store these sterilized
items. You can use plastic bags which are of a proper grade and store the product upto
one year after sterilization.
The sealer used for sealing packs is inappropriate if the heating is too weak for the
packaging material used. This results in small holes in pack after sealing. An impulse
heat sealer capable of sealing at higher temperatures.
A safe EO machine which can complete the process of aeration within all items can be
used directly without any further handling.
Aeration is a natural process which can be hastened by installing an aerator.
2. Low temperature steam and formaldehyde: A combination process of steam generated
at subatmospheric pressure 70 to 80C and formaldehyde gives an effective sporicidal
process. It is appropriate for heat-sensitive articles that can resist temperatures of 80C
3. Propylene oxide: One of the latest and new techniques is the use of propylene oxide
which is a microcidal gas. It has a similar use and toxic effect like propylene oxide.
Sterilant liquids: Glutaraldehyde is generally the least effective and most unreliable
method.
Disinfection
Disinfection is applied in circumstances where sterility is unnecessary or impractical, like
bed-pans, eating utensils, bed linen and other such items. Similarly, the skin around the
site for an invasive procedure should be cleansed to reduce chances of wound infection.
Cleaning
Thorough cleaning is a prerequisite for successful disinfection and is a process of
disinfection by itself. This can be enhanced by ultrasonic baths given to the instruments
to remove dried debris.
Methods
Heat: Steam or water could be used.
1. Moist heat is the first method of choice, can be precisely controlled, leaves no toxic
residues and does not promote the development of resistant strains. Washing or rinsing
laundry or eating utensils in water at 70 to 80C for a few minutes will kill most non-
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188
sporing microorganisms present. Similarly, steam maintained at subatmospheric

pressure at 73C is used in low temperature steam disinfectors in hospitals to disinfect
thermolabile reusable equipment.
2. Boiling: Exposure to boiling water for 20 minutes achieves highly effective
disinfection, although this is not a sterilization process it can be useful in emergencies
if no sterilizer is available.
Ultraviolet radiation: It has limited application for disinfection of surfaces, some piped
water supplies but lacks penetrative power, however newer modifications in use with
ozone treatment plants is very effective in disinfection.
This is a low-energy, non-iodising radiation with poor penetrating power that is lethal
to microorganisms under optimum conditions. The shorter UV rays that reach the earths
surface in quantity have a wavelength of about 290 nm, but even more effective radiation
of 240 to 280 nm is produced by mercury lamps. It is used in the treatment of water, air,
thin films and surfaces such as laboratory safety cabinets.
Gases: Formaldehyde is used as a fumigant though it does not have an all pervasive
effect. Traditionally formaldehyde gas was used to disinfect rooms previously occupied
by patients with contagious diseases such as smallpox. It is still used for disinfection of
heat-sensitive equipment, however its efficacy is questionable with better products like
Bacillocid available.
Filtration: Air and water supplied to operation theatres and other critical environments
are filtered to remove hazardous microorganisms, though viruses cannot remain out
altogether. However, they are considered harmless in these environments.
A properly installed high efficiency particulate air (HEPA) filter achieves 99.9 percent
or better resistance to particles of 0.5 microns and can produce sterile air at the filter face.
Chemical: Several chemicals with antimicrobial properties are used as disinfectants.
Antiseptic can be regarded as a special kind of disinfectant which is sufficiently free
from injurious effects to be applied on the surface of the body, though not suitable for
systemic or oral administration.
Some would restrict the use of antiseptic preparations applied to open wounds or
abraded tissue and would use the word skin disinfection for removal of organisms from
hands and intact skin surfaces.
1. Factors influencing the performance of chemical disinfectants:
A. The concentration of the disinfectant: The optimum concentration required to produce
a standardized microbial effect in practice is described as the in-use concentration.
Care must be taken in preparing accurate in-use concentrations while diluting product.
Accidental or arbitrary over dilution may result in failure of disinfection.
B. The number, type and location of microorganism: The velocity of the reaction depends
upon the number and type of organisms present. In general gram-positive bacteria are
more sensitive to disinfection than gram-negative bacteria. Mycobacteria and fungus
are resistant while spores are highly resistant, while viruses are susceptible.
Glutaraldehyde is highly active against bacteria, viruses and spores. Other
disinfectants such as hexachlorophene have a relatively narrow range of activity,
predominantly against gram-positive cocci.
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191
C. The temperature and pH: Some disinfectants are more active or stable at a particular
pH. Though glutaraldehyde is more stable under acidic conditions its microbial effect
is seen better when the pH is 8.0
D. The presence of organic or other interfering substances: Disinfectants can be
inactivated by hard tapwater, cork, plastics, blood, urine, soaps and detergents, or
other disinfectants. Information should be sought from the manufacturer or from
reference authorities to confirm that the disinfectant will remain active in these
circumstances.
2. Common chemicals in use:
A. Alcohols: Isopropanol, ethanol, and industrial methylated spirit have optimal
bactericidal activity in aqueous solution at concentrations of 70 to 90 percent and have
little bactericidal effect outside this range. They have limited activity against
mycobacteria and are not sporicidal. Action against viruses is generally good. Because
they are volatile, alchohols are recommended as rapidly drying disinfectants for skin
and surfaces. However, they may not achieve adequate penetration and kill,
particularly if organic matter such as blood or other protein-based contamination is
present. Alcohols are suitable for physically clean surfaces such as washed
thermometers or trolley tops but not for dirty surfaces. Care must be taken when used
on the skin in conjunction with diathermy and other instances of flammable risk.
Alcohols with chlorhexidine or povidone-iodine are good choices for hand
disinfection, they are applied to the dry skin often with added emollient to counteract
the drying effect.
B. Aldehydes: Most aldehyde disinfectants are based on glutaraldehyde or formaldehyde
formulations, alone or in combination. Glutaraldehyde has a broad spectrum action
against vegetative bacteria, fungi, viruses, but acts more slowly against spores. It is
often for equipment such as endoscopes that cannot be sterilized or disinfected by
heat. It is an irritant to the eyes, skin and respiratory mucosa, and must be used with
adequate protection of staff and ventilation of the working environment. It must be
thoroughly rinsed after treated equipment with sterile water to avoid carry-over of
toxic residues and recontamination. The alkaline buffered solution is claimed to
remain active for several days, but this will vary depending on the in-use situation,
including the amount of organic material.
C. Biguanides (chlorhexidine): This is commonly used for disinfection of skin and
mucous membranes. It is less active against gram-negative bacteria such as
Pseudomonas and Proteus sp and in aqueous solution has limited virucidal,
tuberculocidal and negligible sporicidal activity. It is often combined with a
compatible detergent for handwashing or with alcohol as a handrub. Chlorhexidine has
low irritancy and toxicity and is effective even on exposed healing surfaces. It is
inactivated by organic matter, soap, anionic detergents, hard water and some natural
materials such as cork liners or bottle closures.
D. Halogens (hypochlorites): These broad-spectrum inexpensive chlorine-releasing
disinfectants are that of choice against viruses. For heavy spillage such as blood, a
concentration of 10,000 ppm of available chlorine is recommended.
These are inactivated by organic matter and corrode metals, so that contact with
metallic instruments and equipment should be avoided. The bleaching action of
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190
hypochlorites may have a detrimental effect on fabrics and should not be used on
carpets.
Chlorine-releasing disinfectants are relatively stable in concentrated form as
liquid bleach of as tablets (sodium dichloroisocyanurates) but should be stored in
well-sealed containers in a cool dark place. On dilution to the required
concentration for use, activity is rapidly lost.
Hypochlorites have widespread application as laboratory disinfectants on bench
surfaces and in discard pots. Care should be taken to remove all chlorinereleasing agents from laboratory areas before the use of formaldehyde fumigation
to avoid the production of carcinogenic reaction products.
Iodine: Like chlorine, iodine is inactivated by organic matter and has the additional
disadvantage of staining and hypersensitivity. The iodophors which contain iodine
complexed with an anionic detergent of povidone-iodine a water-soluble complex of
iodine, polyvinyl and pyrrolidone are less irritant and cause less staining. Aqueous and
alcohol-based povidone-iodine preparations are used widely for skin and ocular
disinfection as well as other mucous membrane disinfection.
E. Phenolics: These have been widely used as general purpose environmental
disinfectants in hospital and laboratory practice. They exhibit broad-spectrum activity
and are relatively cheap. Clear soluble phenolics have been used to disinfect
environmental surfaces and spillages if organic soil and transmissible pathogens may
have been present. As hospital disinfection policies are rationalized, phenolics are
being replaced by detergents for cleaning and by hypochlorites for disinfection. Most
phenolics are stable and not readily inactivated by organic matter, with the exception
of the chloroxylenos (Dettol) which are also inactivated by hard water and not
recommended for hospital use. Phenolics are incompatible with cationic detergents.
Contact should be avoided with rubber and plastics, such as mattress covers, since
they are absorbed and may increase the permeability of the material to body fluids.
The slow release of phenol fumes in closed environments and the need to avoid skin
contact are other reasons for care in use of phenolics.
The bis-phenol hexachlorophane has particular activity against gram-positive
cocci, and has been used in powder or emulsion formulations as a skin
disinfectant, notably for prophylaxis against staphylococcal infection in nurseries.
There has been some concern about the possible toxic effect of absorption across
the neonatal skin barrier on repeated exposure. An alternative, which has been
used in the control of methicillin-resistant Staphylococcus aureus outbreaks is
triclosan.
F. Oxidizing agents and hydrogen peroxide: Various agents, including chlorine dioxide,
peracetic acid and hydrogen peroxide, have good antimicrobial properties but are
corrosive to skin and metals. Hydrogen peroxide is highly reactive and has limited
application for the treatment of wounds.
G. Surface active agents: Anionic, cationic, non-ionic and amphoteric detergents are
generally used as cleaning agents. The cationic (quaternary ammonium compounds)
and amphoteric agents have limited antimicrobial activity against vegetative bacteria
and some viruses but not mycobacteria or bacterial spores. Quaternary ammonium
compounds disrupt the membrane of microorganisms, leading to cell lysis. Care must
be taken to avoid overgrowth by gram-negative contaminants and inactivation by
Sterilization
193
mixing cationic and anionic agents. Disinfection may be enhanced by appropriate

combination of a surface active agent with disinfectant to improve contact spread and
cleansing properties.
Quality Control
Every method used must be validated to demonstrate microbial kill. With heat and
irradiation a biological test may not be required if the physical conditions can be proved
to have reached their ultimate design.
D value The D value or the decimal reduction value is the dose that is required to
inactivate 90 percent of the initial population. When the time required or the dose
required to reduce the population from 1000000 to 100000 is the same as the time or dose
required to reduce the population from 100000 to 10000 the D value remains constant
over the full range of the survivor curve. Extending treatment beyond the point where
there is one surviving cell does not give rise to fractions of a surviving cell but rather to a
statement of the probability of finding one survivor. Thus, by extrapolation from the
experimental date it is possible to determine the lethal dose required to give a probability
of less than 1 in 1000000 which is required to meet the pharmacopoeial definition of
sterile.
Factors Influencing Resistance
Many factors affect the ability of the microorganism to withstand lethal procedures of
sterilization. This in fact is the reason why we need to keep updating ourselves as to the
methods of sterilization and their efficacies. This also happens to be the reason why
living creatures are able to withstand high amounts of torture only to make sure their
breed lives on. Bacteria are not that much different from us in this intrinsic need to
propagate, grow and leave their legacy behind. Still we need to be on top of them to
allow them to grow where we need them and the operating room is definitely not a place
we need any of them at all. Here are some of the reasons why these bacteria do withstand
our torture.
Species or strain of microorganism As usual the spores are more resistant than vegetative
bacteria or viruses. Though some strains of species have wide variations.
Enterobacteriaceae D values at 60C range from a few minutes (E. coli) to 1 hour
(Salmonella senftenberg). The typical D value for Staphylococcus aureus at 70C is less
than I min compared with 3 min for Staph. epidermidis. However, an unusual strain of
Staph. aureus has been isolated with a D value of 14 min at 70C. Such variable could be
attributed to the morphological and physiological changes such as alterations in cell
proteins or specific targets in the cell envelope affecting permeability.
Thus, we should not understand the inactivation data for one disease forming organism
would withstand by another. Creutzfeldt-Jakob disease is a highly resistant agent
requiring six times the normal heat sterilization cycle (134C for 18 minutes).
Physiological stage Organisms grown under nutrient-limiting conditions are typically
more resistant than those grown under nutrient-rich conditions. Resistance usually
increases through the late logarithmic phase of growth of vegetative cells and declines
erratically during the stationery phase.
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192
Ability to form spores Bacterial endospores are more resistant than fungal spores, some of
them are used as bacterial indicators especially for ethylene oxide sterilizers to monitor
their efficacy. Disinfection has no efficacy where spores are concerned.
Suspending menstrum Microorganisms occluded in salt have greatly enhanced resistance
to ethylene oxide, the presence of blood or other organic material will reduce the
effectiveness of hypochlorite solution. Thus, suspended particles will alter efficacy of
various techniques.
Number of microorganisms Quite obviously the initial bio-burden the more extensive
must the process of sterilization be to achieve the same assurance of sterility.
Sterilization and Disinfection Policy
All hospitals should go through a rigmarole of infection control and agree on a particular
policy to be followed uniformly by all concerned in this infection control team. This
should be headed by the chief surgeon and each one must report to the leader of the team
everyday.
It has been noticed over centuries of medical practice when a surgical team gets to do
routine surgeries everyday for many days and years, a kind of apathy sets into the system
and somewhere someone lapses. These instances have been the most common cause for
infection. To avoid such lapses the infection control team should meet each week to
update themselves on the latest happenings in their hospital and to bring to the notice
such lapses so that a tightening of procedures can be applied. At each lapse the chief
surgeon must be held responsible for the actions of his or her team.
All members of the team must familiarize themselves with the items to be sterilized
and the chemicals necessary to do so. A microbiologist should be included in this team as
they alone can monitor the efficacy of the said processes. Along with should also be a
pharmaceutical person who has full knowledge of the various chemicals used, their action
and the efficiency in said matters. It is very instrumental to include these persons on the
infection control team of a hospital.
The hospital policy should be common and should include:
The sources to be sterilized (equipment, skin, environment, air, water, personnel) for
which a choice of process is required to be commonly accepted by the team for
infection control.
The processes and products available for sterilization and disinfection must be made
available for all to see and inspect. An effective policy may include a limited number
of process options, restrictions on the range of chemical disinfectants eliminate
unnecessary costs, confusion and chemical hazards.
The category of process required for each item, sterilization for surgical instruments and
needles, heat disinfection for laundry, crockery, bed-pans, cleaning of floors, walls,
furniture and fixtures.
The specific products and method to be used for each item of equipment, the site of use
and the staff responsible for the procedure. These should all be earmarked in a record
so that one can get back to the lapse when it happens.
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195
Effective implementation of the policy requires liaison and training of staff and updating
the policy. Safety considerations for staff and patients require a careful assessment of
specific procedures to minimize risks.
The staff for implementation of these processes must wear protective gear where
necessary. Gloves, aprons, caps and masks must be included in the policy. Where
dangerous gases are used eye goggles similar to swim goggles can be used to protect the
eyes from the noxious gases.
For proper sterilization control, it is important to go back into every case that gets
infected to try and pry and find out what was the reason for the infection. This can
effectively be done by the weekly meeting of the infection control team where everyone
tries to pitch in their inputs.
Staff should not be penalized for accepting their wrong-doings, because if they are
penalized they will not accept the cause of the infection next time it occurs. The staff
should be goaded into performing better by putting the patients best interests in view and
not for witch hunting and blaming.
Culture Rate
The most important mechanism for the proper functioning of an operation theatre is the
fact that no organism should grow from this area. To find out whether an organism is
growing or not we need to make sure it is present or not, that can effectively be done by
growing it on a culture media. Some of the most common culture media used in hospitals
is discussed here.
MacConkeys Agar
To make this culture plate (Fig. 12.27) is simple enough. According to directions 51.5 gm
of the powder made available through Himedia Laboratories is dissolved in 1000 ml of
distilled water. This is allowed to boil till the powder is completely dissolved and the
fluid has boiled for over 15 minutes, thus sterilizing the fluid further. It could be still
sterilized by autoclaving though most hospitals find 15 minutes of boiling to suffice in its
sterilization.
This culture medium contains:
Peptic digest of animal tissue 17 gm/lit
Peptone
3
Lactose
10
Bile salts
1.5
Sodium chloride
5
Neutral red
0.03
Agar
15
At a final pH at 25C of 7.1
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194
FIGURE 12.27 MacConkeys blood

agar culture plates
Alternately if the readymade powder is not available then the following procedure can be
applied to the above-mentioned ingredients.
Base solution Dissolve agar in 500 ml of distilled water by autoclaving at 121C for 20
minutes. Dissolve the peptone, bile salts and sodium chloride in the remaining 500 ml of
distilled water, and bring the solution to boil. Combine the two solutions mixing
thoroughly. Dissolve the lactose and adjust the pH to 7.2. Distribute in screw-capped
bottles and sterilize with autoclaving at 121C for 15 minutes.
Dissolve 1 gm of neutral red in distilled water and make-up the volume to 100 ml.
Heat the solution in steam at 100C for 30 minutes.
Dissolve 0.1 gm of crystal violet in distilled water and make-up the volume to 100 ml.
Heat the solution in steam at 100C for 30 minutes.
To 200 ml of the base solution, melted and cooled to about 60C add aseptically 0.6
ml of the neutral red solution and 0.2 ml of solution with crystal violet. Mix well and
distribute into sterile Petri dishes.
FIGURE 12.28 Culture specimen

taken using sterile swab stick from the
instrument table
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197
Incubate the plates at 37C for 24 hours (Figs 12.28 to 12.30) and examine for
contamination. Inoculate four plates from the following stock culture Salmonella typhi,
Escherichia coli, a mixture of Salmonella typhi and E. coli and Shigella flexneri.

taken using sterile swab stick from the
operation table head rest
This will prove the efficacy of the culture media prepared and now it can be poured into
petri dishes and refrigerated to be used on need for culture plates. It is advisable to keep
them for 24 to 48 hours and to keep making fresh batches very often.
Nutrient Agar
A general purpose medium for the cultication of microorganisms and a base for enriched
or special purpose media. It can be made very simply by the

taken using sterile swab stick being
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196
streaked on the MacConkeys blood

agar culture plate
powder available from Himedia laboratories by dissolving 28 gm of powder in 1000 ml
of distilled water and boiling for 15 minutes. This would also sterilize the medium and it
is ready for use after cooling. The powder contains:
Peptic digest of animal tissue 5 gms/lit
Sodium chloride
5
Beef extract
1.5
Yeast extract
1.5
Agar
15
At 25C the pH is 7.4.
Alternately if the powder is not available the separate entities can be taken, mixed and
steamed for 2 hours. The pH should be adjusted first to 6.8 then clear the fluid with egg
albumin. Filter and bottle. Autoclave at 15 lbs pressure for 20 minutes or steaming for 30
minutes each day on three successive days.
Blood Agar
An enriched medium for general use in routine cultivation of the more delicate
microorganisms like Neisseria meningitidis, N. gonorrhoeae and Diplococcus
pneumoniae. The medium also serves as an indicator of hemolysin production by
bacteria.
It is very simple to make. Add 6 to 10 percent defibrinated blood to melted nutrient
agar and cool to 45 to 60C. Pour plate or slant, incubate 24 hours to prove sterility.
Sterilization Control
The infection control team which consists of a microbiologist must take regular samples
from the different areas sterilized or disinfected. Some of the quality checks necessary to
be carried out are:
Plate Test
One of the easiest to perform and tells us quite a bit about the cleaning tactics used for the
particular room. This test would not be so effective in open areas but is quite reliable for
closed areas like operating rooms.
For closed rooms Where operating rooms are concerned once we have assured ourselves
there is no contaminated air coming in, with door closers, air curtains and filtered airconditioned ducting, cleaning the room with detergents and disinfectants should clear the
air of all bacteria. However, this does not remain so through out the day, and it is noticed
that after a few surgeries due to human beings inside the operating rooms bacteria do
escape to contaminate the air. This can be effectively controlled by keeping a watch on
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199
the cleaning procedures and making sure a disinfectant mop is used after every procedure
and on every item of the operating room.
However, testing for the efficacy of the cleaning procedures is devised by the PLATE
TEST. Here a sterile bowl is used with sterile water and kept in the concerned room for
20 minutes. Should there be bacteria in the room they would settle down on the surface of
the bowl of water. Thus, skimming the surface a few drops are taken and placed on a
Petri dish with culture media on it. This is incubated at 38C for 48 hours and if this
grows bacteria then we know our disinfectant procedures were not enough and we need
to plough ourselves further. If it is negative then we can proceed with the same policy.
This test should be ideally carried out everyday, before every procedure in every room of
the operating area.
For open areas Lounges where patients wait or the outside arenas are to be cleansed as
well, if we would like to have a tight infection control in the operating area. After all
these areas lead to the operating areathe most pious sanctum sanctorum of the hospital
edifice.
The plate test is carried out everyday every few hours, and an optimum time interval
given to the hospital authorities where it can be stated that every four hours the hospital
lounges should be cleaned with disinfectant to maintain a clean bacteria-free atmosphere.
This can now be controlled by taking plate test samples every four hours before cleaning
procedures are done and making sure the tests remain negative for growth in all the tests
taken. If not the program needs to be revised and the hours shortened.
This test should also be carried out in the consultation areas and optimum time
intervals for cleaning prescribed by the microbiologist on the infection control team.
Culture Test from Walls, Floor, Fixtures and Furnitures
Everyday the different areas should be taken for culture, it is advised to take eight
different areas for culture from every room everyday. Methodology for taking culture is
to take a moist swab, by dipping a cotton tip applicator in sterile water and rubbing it in a
streak fashion on the culture plate.
The culture plates are made in Petri dishes about 3 inches in diameter. The back
surface of the Petri dish can be stroked with a marker pen and each culture plate divided
into eight parts.
One culture plate can be ear marked for each room, and 8 objects from the room can
be cultured. It is preferrable to always include the floor, of the room however different
parts of the floor can be taken each day to ensure proper cleaning and disinfectant use.
Other objects that can and should be cultured for are the fans, air conditioners, lights,
walls, tables, chairs, stools and all the equipment present in that particular room. Like
Boyles apparatus, phaco machines, etc.
All Fluids to be Cultured
All fluids used in the operating room must be sent for culture tests, sometimes this
becomes less possible as the fluid is too little and necessary for parenteral application.
However, every batch of fluids used can be sent for culture tests. This may not grow
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198
positive however its not growing positive itself is an indication of the efficacy of the
program. This sets aside any debate that the fluid may have contained bacteria.
Of special importance is fluids used for intraocular use, or for intravenous use. As
soon as each IV bottle is opened the first few drops from the IV set can be placed on a
culture plate for incubation.
Many eye surgeons from our subcontinent have grown E. coli from the Ringer lactate
used intraocularly. However, most often this has happened after a tragedy of multiple
eyes have succumbed to post-cataract surgery infection. Thus, by performing this simple
step we may be able to thwart further mishaps.
Should any one batch of fluids be found to be positive it is a good idea to report the
matter so that others can be forewarned and to take every bottle from that batch.
All Fluids used Parenterally to be Checked for pH Value
Great importance should be given to the pH of fluids inside the body especially where the
eye is concerned. We presume that all fluids marked for parenteral or intraocular use
come at the pH close to 7.4, however, it is alarming to note the amount of times I have
personally seen surgery go wary only due to the fact that the pH was either 5.6 or above
8. This can produce havock on the patients cornea.
In 1992, over 300 cases were reported lost due to hazy opaque corneas following
extracapsular cataract surgery in some states of India. This was followed by a widespread
search for the culprit. What was found was alarming to all concerned, a balanced salt
solution (BSS) was sold in small bottles. It was learned that this solution carried an
alkaline pH, because while cleaning the glass bottles the last rinse of soap solution (BSS)
was not totally washed out and the remaining soap solution left behind an alkaline pH
which recked havoc on the cornea producing total blindness.
It took the investigating authorities over six months to procure this data and cause by
which time multiple surgeries had been carried out with much devastation.
A simple technology to avoid such future catastrophies is to check out the pH on table
before the surgery. A few drops of the fluid can be dropped on a simple litmus strip and
one minute later the color change noted with a rough estimate of the pH value noted.
This should be ideally carried out for all cases.
Specialized Equipment Cultures
Special tests are performed for special machines, like the one available for the ethylene
oxide sterilizer.
Biological chemical indicator One or more biological chemical indicator can be placed in
the steam or ethylene oxide test packs and the process passed through the sterilization
cycles. If used to monitor a 270F steam flash cycle, place a wire mesh bottom
instrument tray and then proceed.
After sterilization processing has been completed, allow the biological chemical
indicator to cool until safe to handle and open. Remove the indicators and allow to cool
an additional 10 to 15 minutes. Observe chemical process exposure indicator on vial label
to verify color change corresponding to sterilization cycle, i.e. ethylene oxide turns gas
process indicator to gold and steam turns the steam process indicator to brown.
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201
If chemical process indicator is unchanged, exposure to the sterilization process may

not have occurred. Check the sterilization process.
If the chemical process exposure indicator on the vial label did change to the proper
color and the indicator has cooled to touch, firmly seal the biological indicator by
pushing the cap to close till the cap reaches second blue bar on the vial label.
Crush the inner ampule from the outside wall of the plastic vial to ensure that the
growth medium is released from the crushed ampoule and is in contact with the spore
disk.
Place the activated indicators in an incubator and incubate it at 37C for EO
sterilization and 55C for steam sterilization.
If there is a color change in the medium from deep blue to bright yellow and turbidity
is evident, it means there is a positive growth. Indicators positive for growth will often be
evident prior to maximum recommended incubation time, but indicators not evidencing
growth mtiust be allowed to incubate for at least 24 hours (steam) and 48 hours (ethylene
oxide) to assure confidence in the negative reading.
When, where and why to use biologicals
When?
Once a day in every sterilizer
Once a week in steam sterilizer cycle used
Every steam load with implants
Every EO load.
Three consecutive times before using new sterilizer and after repairs.
Where?
All sterilization processes.
why?
To challenge your sterilizers effectiveness
To assure load sterilization parameters were up to standard.
Surgeons Hands Cultured
Right after scrubbing and ready for operation a surgeons hands should be regularly
swabbed and taken for culture so that a close check can be carried out to the efficacy of
the cleaning and scrubbing solutions.
There are many surgeons who believe in different technologies of scrubbing. While
some would swear with the pounding away of epithelial tissue by a brush others would
want to keep the epithelium intact at all times. While some would swear with a last dip
into alcohol, others would keep alcohol well out of the way of surgeons hands.
However, it has been seen that three times to lather with soap and wash hands is a
uniform tendency of most surgeons.
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200
Linen and Textiles Cultured

Efficacy of sterilization on the different linens and textiles used in surgery should be
tested by taking culture tests from these items just after surgery.
13
Local Anesthetic Agents
Ashok Garg
Introduction
In modern ophthalmology with the preponderance of elderly patients (due to increased
life expectancy) and the move towards high-tech outpatient surgical care, there is a
growing emphasis and need of local anesthesia
Local anesthesia is the lifeline of modern ophthalmic surgery and is safer and should
always be used unless there are specific indications for general anesthesia. Local
anesthesia in the eye may be achieved by topical application of anesthetic drops or by
infiltration of the sensory nerves with anesthetic solution (injectables).
Local Anesthetics (Injectables)
Local anesthetics prevent the generation and conduction of nerve impulses by reducing
sodium permeability increasing the electrical excitation threshold, slowing the nerve
impulses propagation, and reducing the rate of rise of the action potential.
Indications
Local injectable anesthetics are indicated for infiltration anesthesia in any kind of
intraocular surgery.
Contraindications
Hypersensitivity to local anesthetics, para-amino benzoic acid or parabens. Do not use
large doses of local anesthetics in patients with heart block.
Precautions during Local Injectable Anesthesia
Use local anesthetic with caution when there is inflammation or sepsis in the region of
proposed injection.
Monitor cardiovascular respiratory vital signs and state of consciousness after each
injection.
Local anesthetic should be injected with great care in debilitated or elderly patients,
acutely ill patients, children and patients with increased intraabdominal pressure or
patients with severe shock or heart block.
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202
Many drugs used during local anesthesia are considered potential triggering agents for
familial malignant hyperthermia, hence the arrangement for supplemental general
anesthesia should be there.
Use solutions containing a vasoconstrictor with great caution in patients with history of
hypertension, peripheral vascular disease, arteriosclerotic heart disease, cerebral
vascular insufficiency, heart block, thyrotoxicosis, diabetes. These patients may
exhibit exaggerated vasoconstrictor response.
Watch for hypersensitivity reactions including anaphylaxis to any component of local
anesthetics.
Administer ester type local anesthetics cautiously to patients with abnormal or reduced
levels of plasma esterases.
Some of these anesthetic products contain sulfites which may cause allergic type
reactions in certain susceptible patients. Although prevalence of sulfite sensitivity is
low.
Use amide type local anesthetics with care in patients with impaired hepatic function.
Use local anesthetics with caution in patients with renal disease.
Exercise caution regarding toxic equivalence when mixtures of local anesthetics are
employed.
Do not use disinfecting agents containing heavy metals for skin (periorbital area)
disinfection.
Do not use local anesthetics in any condition in which a sulfonamide drug is employed.
Patients should be asked to avoid touching or rubbing the eye until the anesthesia is
worn off.
Adverse Reactions of Local Injectable Anesthetics
The most common acute adverse reactions are related to the CNS and cardiovascular
systems. These are generally dose related and may result from rapid absorption from the
injection site, from diminished tolerance or from unintentional intravascular injections.
CNS Adverse Reactions
Restlessness, anxiety, dizziness, tinnitus, blurred vision, tremors, convulsions, nausea,
vomiting, chills, pupil constriction, excitement may be transient or absent.
Depressive effects These may or may not be preceded by the excitatory symptoms. These
are: drowsiness, sedation, generalized CNS depression, unconsciousness, coma, apnea
and respiratory depression and even death from respiratory arrest.
Cardiovascular Symptoms of Toxicity
Peripheral vasodilation
Hypertension and tachycardia
Decreased cardiac output
Hypotension
Bradycardia
Methemoglobinemia
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205
Heart block, ventricular arrhythmias

Circulatory collapse.
Allergic Adverse Reactions
Cutaneous lesions of late onset
Erythema, angioneurotic edema
Sneezing, syncope
Excessive sweating
Elevated temperature and anaphylactoid symptoms.
Overdosage
Acute emergencies from local injectable anesthetics are generally related to high plasma
levels encountered during therapeutic use or to unintended injection overdosage can lead
to
Convulsions, apnea and under ventilation
Circulatory depression.
If not treated promptly, convulsions and cardiovascular depression can result in hypoxia,
acidosis, bradycardia, arrhythmias and cardiac arrest. Various local injectable anesthetics
used in ophthalmology are classified as follows.
Esters
Procaine
Chloroprocaine
Tetracaine
Amides
Lidocaine
Prilocaine
Mepivacaine
Bupivacaine
Etidocaine
Centbucridine
Individual drug monographs are described as follows.
Esters
Procaine
Procaine is paraaminobenzoic acid ester of diethylaminoethanol. It was first prepared in
1905. The chemical structure is depicted in Figure 13.1
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204
FIGURE 13.1 Chemical structure of

procaine
Indication Procaine is used for infiltration anesthesia prior to any intraocular surgery. It is
not used topically.
Dosage Procaine is available as 1 percent (2 ml) ampoules. It has rapid onset of action
(25 minutes) with an average duration of action one hour.
Concentration of 0.5 to 2 percent are used with a maximum dose of 14 mg/kg body
weight.
Detoxification occurs by hydrolysis to para-amino benoic acid and
diethylaminoethanol through the enzyme pseudocholinesterase in the plasma.
Solution for infiltration anesthesia is freshly prepared. To prepare 60 ml of 0.5 percent
solution (5 mg/ml) dilute 30 ml of 1 percent solution with 30 ml sterile distilled water.
Add 0.5 to 1 ml of epinephrine (1:1000 per 100 ml) anesthetic solution for
vasoconstrictive effect (1:200000 to 1:100000).
Precautions and adverse reactions have already been described in general monograph
section of local injectable anesthetics.
Chloroprocaine
Chloroprocaine is a 2 chloro4 aminobenzoate ester of B-diethylaminoethanol. It was
introduced in 1952 as an analog of procaine. The chemical structure is depicted in Figure
13.2.

Chloroprocaine
207
Chloroprocaine is used for infiltration anesthesia in concentrations of 0.5 to 2 percent.

Onset of anesthesia is very rapid (25 minutes) and the average duration of action lasts
for 1 hours. It is twice as potent as procaine and has similar

tetracaine
pharmacological properties. Metabolism is largely through hydrolysis by pseudocholinesterase in the plasma.
Tetracaine (Amethocaine)
Tetracaine is a parabutylaminobenzoic acid ester of dimethylaminoethanol. It was first
prepared in 1933. The chemical structure is depicted in Figure 13.3.
Tetracaine is used for infiltration as well as topical anesthesia.
Dosage Tetracaine is available in concentration of 0.25 to 2 percent solutions. Tetracaine
is a potent and toxic local anesthetic and dangerous overdosage may occur if it is given in
doses higher than 1.5 mg/ kg body weight.
It should be given with caution for infiltration anesthesia purpose.
Amides
Lidocaine
Lidocaine is one of the most common local injectable anesthetic agent used in ophthalmic
surgery worldwide.
Lidocaine is 2-diethylamino-2-6-acetoxylidine. It was first prepared in 1948. The
chemical structure is depicted in Figure 13.4.
Indication Lidocaine 2 percent is used for infiltration anesthesia prior to any type of
intraocular surgery.
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lidocaine
Dosage Lidocaine is available in concentration of 0.5 to 4 percent as lidocaine
hydrochloride (2, 5 ml ampoules and 30 ml and 50 ml vials). For infiltration anesthesia
generally 1 percent and 2 percent solutions are used (In 2 ml, 5 ml and 10 ml ampoules;
30 and 50 ml vials). It has rapid onset of action (0.52 minute) and average duration of
action lasts for 1 to 2 hours.
Lidocaine is metabolized in the liver to xylidine and diethylaminoacetic acid or is
directly excreted into the urine and bile.
For infiltration anesthesia it is generally given with mixture of adrenaline and
hyaluronidase to prolong the anesthetic effect and better diffusion to the ocular tissue.
Hyaluronidase is an enzyme capable of depolymerizing hyaluronic acid found in
interstitial spaces and when it gets depolymerized, fluid passes more easily between the
tissues. Preferable 1:100,000 solution of adrenaline concentration is used and it causes
sufficient vasospasm to reduce significantly the rate of removal of local anesthetic agent.
A correctly placed retrobulbar or peribulbar injection of this solution causes complete
akinesia and anesthesia of the globe. Hyaluronidase is also mixed with 2 percent
lidocaine and adrenaline injection for better diffusion of solution into the tissues. It
increases the effective area of anesthesia by 40 percent though inevitably of shorter
duration.
Various Lidocaine combinations available commercially are
Lidocaine HCl 0.52 percent with 1:100000 to 1:200000 epinephrine (in 5 ml and 10 ml
ampoules, 20, 30 and 50 ml vials).
Lidocaine HCl 1.55 percent with 7.5 percent Dextrose (in 2 ml ampoules).
Safe dose for lidocaine HCl is7 mg/kg body weight with vasoconstrictors and 2.9
mg/kg body weight without vasoconstrictors. Recently preservative free 1 percent
lidocaine hydrochloride (0.5 ml) ampoules have been available commercially for
intracameral use during intraocular surgery.
Usual dosage is to inject 0.25 cc of 1 percent preservative free lidocaine into the
anterior chamber through the cannula though 1 mm stab incision made in the peripheral
cornea, 5 seconds later eye is anesthetized.
Advantages of intracameral injection of lidocaine
It relieves all discomfort and apprehension of the patient.
It decreases the need of sedation.
209
Surgery is quicker and less tense and patient responds faster with no complications or
adverse effects.
Has an excellent deeper depth of anesthesis.
Eliminates blocks and their potential complications.
Has good effect in conjunction with topical anesthesia.
Prilocaine
Prilocaine is -propylamino 2 methylproprionanilide. It was first prepared in 1960. The
chemical structure is depicted in Figure 13.5.
Its pharmacological properties are similar to those of lidocaine and its onset of action
takes 5 to 15 minutes and duration of action lasts for 1 to 3 hours.
Prilocaine is used for infiltration and regional nerve block anesthesia. It is available in
concentration of 0.5 to 3 percent. The suggested maximum dose is 10 mg/kg body
weight.

prilocaine
Unusual toxic effect seen after administration of large doses (more than 800 mg) is
cyanosis due to methemoglobinemia.
Mepivacaine
Mepivacaine is N-methyl pipecolic acid 2,6 dimethyl anilide. It was first prepared in
1956. The chemical structure is depicted in Figure 13.6. Mepivacaine has
pharmacological properties similar to those of lidocaine. Notable exception is its effect
on blood vessels. It is shown to have mild vasoconstrictor effect which reduces its
absorption. The effect of mepivacaine on the peripheral circulation is a potentiation of the
action of norepinephrine on nerve endings. The onset of action starts within 3 to 5
minutes and duration of action is from 2 to 2 hours (with epinephrine). The suggested
maximum dose is 7.0 mg/kg body weight.
It is used for infiltration and nerve block anesthesia.
Phacoemulsification
208

mepivacaine
Dosage Mepivacaine is commercially available as mepivacaine HCl 1 to 2 percent
injectable solutions (in 20, 30 and 50 ml vials). For infiltration anesthesia, 1 percent
concentration is used.
Bupivacaine
Bupivacaine is structurally similar to mepivacaine and is one of the common anesthetic
agents used in the ophthalmology for infiltration anesthesia. It was first prepared in 1963.
The chemical structure is depicted in Figure 13.7.
Bupivacaine is 3 to 4 times more potent than lidocaine. Its onset of action starts within
5 to 10

bupivacaine
minutes and duration of action lasts for 3 to 5 hours (with epinephrine).
Dosage Bupivacaine is available as bupivacaine HCl injectable solution in concentration
of 0.25 to 0.75 percent (in 2 ml ampoules and 10, 30 and 50 ml vials). For retrobulbar or
peribulbar injection 0.75 percent strength solution is used.
Bupivacaine is also available in combination with epinephrine commercially.
Bupivacaine HCl 0.25 to 0.75 percent (in 2 ml ampoules, 10 ml, 30 ml and 50 ml
vials).
The maximum safe dose is 2.0 mg/kg body weight.
Practically for infiltration anesthesia prior to intraocular surgery it is used in
combination of 2 percent lidocaine to produce complete akinesia and anesthesia of globe
for more than 2 hours. Usually 50:50 percent of both solutions (0.5% bupivacaine HCl
and 2% lidocaine HCl in addition to adrenaline and hylase) are used to produce
anesthesia for major ocular surgeries.
211
Etidocaine
Etidocaine is used for infiltration anesthesia in ophthalmic surgery. It is available as 0.5
to 1 percent injectable solutions (in 30 ml vials and 20 ml ampoules). Its onset of action
start in 5 to 15 minutes and duration of action lasts for 3 to 5 hours. It is also available
commercially with epinephrine. Etidocaine HCl 1.0 to 1.5 percent with 1:20000
epinephrine (30 ml vials).
Centbucridine
Centbucridine is 4-N-butylamino-1, 2, 3, 4, tetrahydroacridine hydrochloride. It is
recently introduced anesthetic agent. It has been shown 5 to 8 times more potent than
lidocaine.
It is used for infiltration anesthesia and topical anesthesia.
Dosage Centbucridine is available as 0.5 percent Centbucridine injectable solution (in 10
ml and 30 ml vials). Its onset of action starts in 2 to 5 minutes and duration of action lasts
for 1 to 1 hours.
Local Anesthetics (Topical)
Topical anesthesia is the mainstay of modern ophthalmic surgery. Topical anesthesia is
now widely used from superficial minor surgery of conjunctiva and cornea to high-tech
phacoemulsification, excimer laser PRK and LASIK surgery. Topical anesthetic agents
produce their effect by blocking nerve conduction in the superficial cornea and
conjunctiva. The physiological effect of all topical anesthetic agents occur in a similar
fashion. They work at the level of cell membrane by preventing the sodium flux by
closing the pores through which the ions migrate in the lipid layer of nerve cell
membrane. The anesthetic agents block conduction of afferent nerve impulses thereby
abolishing sensation and producing local anesthetic action.
Indications
Corneal anesthesia of short duration for any diagnostic and surgical procedure on the eye.
Contraindications
Known hypersensitivity to the drug or to any other ingredient in these preparations.
Prolonged used specially for self-medication is not recommended.
Precautions
These anesthetic agents are for topical ophthalmic use only. Prolonged use is not
recommended as it may diminish duration of anesthesia, retard would healing and cause
epithelial erosions. It may produce permanent corneal opacification with accompanying
Phacoemulsification
210
visual loss, severe keratitis, scarring or corneal perforation, if signs of sensitivity

develops discontinue the use.
Tolerance varies with the status of the patient. Give debilitated, elderly or acutely ill
patients reduced doses commensurate with their weight, age and physical status.
Use with caution in patients with abnormal or reduced levels of plasma esterases.
Use with caution in patients with known allergies, cardiac disease or hyperthyroidism.
Protection of the eye from irritating chemicals, foreign bodies and rubbing during the
period of anesthesia is important.
Adverse Reactions
On topical use these anesthetic agents may cause
Mild stinging and burning sensation, vasodilation
Shortening of tear break-up time
Decreased blinking
Corneal edema
Decreased epithelial mitosis and migration
Slow epithelial healing
Punctate epithelial keratitis
Epithelial desquamation
Allergic reactions of lid and conjunctiva
Iritis
Various anesthetic agents used in ophthalmology as topical agents are
Benoxinate
Proparacaine
Tetracaine
Lidocaine
Centbucridine
Cocaine
Phenacaine
Dimethocaine
Piperocaine
Dibucaine
Naepaine
Butacaine
In today ophthalmic surgery and in diagnostic procedures, proparacaine, benoxinate and
tetracaine are commonly used. Their action starts within 15 to 20 seconds and effects last
for 15 to 20 minutes.
Other topically applied anesthetic agent is 4 percent Xylocaine, its use is becoming
lesser and lesser due to problems with irritation, allergy, etc.
Individual drug monograph of topical anesthetic agent is as follows.
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Benoxinate HCl (Oxybuprocaine)

Benoxinate HCI is a paraaminobenzoic acid ester. The chemical structure is depicted in
Figure 13.8.
It is available as 0.4 percent topical solution. Its action starts within 10 seconds of
topical instillation and effect lasts for 15 minutes. 1 to 2 drops of 0.4 percent solution is
sufficient to anesthetize the cornea. For deep anesthesia 3 instillations at 90 second
interval is sufficient. Because of high degree of safety it is most suitable for topical use.
It is also available as 0.4 percent benoxinate HCI solution with 0.25 percent
fluorescein sodium (in 5 ml pack). It is associated with less irritation on instillation.
Another topical anesthetic agent having properties and uses similar to benoxinate is
proxymetacaine (0.5%).
Proparacaine
Proparacaine is one of the most common topical anesthetic agents for topical anesthesia
in intra-ocular surgery (phacoemulsification, cataract surgery, excimer laser PRK and
LASIK surgery)
It is a benzoic acid ester. The chemical structure is depicted in Figure 13.9.

benoxinate

proparacaine
It is available as 0.5 percent and 0.75 percent topical solution. It is used 2 to 5 minutes
prior to intraocular surgery.
Its effect starts within 15 to 20 seconds and lasts for 15 minutes. Potency is similar to
that of tetracaine. Maximum dose is 10 mg (about 20 crops of 0.5 percent solution on
topical instillation).
Due to higher degree of potency and safety it is most appropriate choice for topical
ocular anesthesia. It is available as 0.5 percent proparacaine HCl solution and 0.25
percent fluorescein sodium.
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212
Tetracaine
Tetracaine is para-butylaminobenzoic acid ester of dimethylaminoethanol. It is one of the
most popular topical anesthetic agents currently used in ophthalmology.
It is available as 0.25 to 1 percent topical solution usually 0.5 percent strength is used
for topical anesthesia.
Tetracaine HCl penetrates tissue more deeply than proparacaine and benoxinate.
Its action starts in 20 seconds and lasts for 10 to 12 minutes after topical instillation. It
is instilled 2 to 5 minutes prior to the surgery. 1 to 2 drops are instilled topically 2 to 3
times at 60 second duration. Maximum dose is 5 mg (10 drops to each eye of 0.5%
solution).
On topical instillation however it produces stinging sensation for 30 seconds.
Lidocaine HCl
Lidocaine is 2-diethyl amino, 2,6 aceto xylidine.
Prior to introduction of topical benoxinate, proparacaine and tetracaine anesthetic
agents, 4 percent lidocaine HCl was commonly used for topical anesthesia.
One drop of 4 percent lidocaine solution renders the cornea anesthetized within 30 to
60 seconds and effect lasts for 10 minutes.
It is rapidly acting and does not cause dilation of pupil.
On topical instillation however it causes marked stinging sensation for 30 seconds.
Due to its stinging sensation problem, it is now less commonly used for topical
anesthesia purpose.
Centbucridine
Centbucridine is recently introduced topical anesthetic agent. It is available as 1 percent
topical solution and effect lasts for 15 minutes. It causes very less stinging than 4 percent
lidocaine and is safe on topical use. Usual dosage is one drop to be instilled topically and
sufficient to produce topical anesthesia.
Cocaine
Cocaine is an alkaloid of erythoxylon coca. It was first introduced in 1884. The chemical
structure is given in Figure 13.10.

cocaine
215
Cocaine was quite extensively used in late fifties of last century. It is available as topical
solution in concentration of 1 to 10 percent as cocaine HCl. One drop of 2 percent
solution renders the cornea anesthetized within 30 seconds and effect lasts for 12
minutes.
Maximum dose is 20 mg (about 10 drops to each eye of 2% solution). It is however
toxic directly to corneal epithelium. It may be used to aid penetration of the other drugs
(like cycloplegics) into the cornea and anterior chamber. Cocaine causes mydriasis and
when absorbed systemically it may be associated with dangerous drug interactions and
hypertensive crisis and CNS stimulation. Toxic doses of cocaine cause fatal circulatory
and respiratory collapse. It is now not commonly used for topical purpose as better
topical agents are available.
Phenocaine
Phenocaine is derivative of phenetidine. It is N, N, Bis (p-ethoxy-phenyl) acetamidine.
The chemical structure is depicted in Figure 13.11.

phenocaine
As it is not an ester, it can be considered as an alternative agent for use in patient
sensitive to ester group.
It is used as 1 percent topical solution for instillation. Phenocaine is no longer used
because it causes excessive irritation and highly toxic.
Dimethocaine
Dimethocaine was first prepared in 1932. It is 3-diethylamino, 2,2 dimethyl propyl pamino benzoate. The chemical structure is depicted in Figure 13.12. It has been used in
ophthalmology as topical agent in concentration of 2 to 5 percent. It is derivative of
paraaminobenzoic acid.
Phacoemulsification
214

dimethocaine

piperocaine
Piperocaine
Piperocaine is benzoic acid ester of methyl piperidinopropanol. The chemical structure is
depicted in Figure 13.13. It is used as topical 2 percent solution for topical anesthesia. It
has effect of regeneration of corneal epithelium.
Piperocaine alongwith lidocaine are the only agents associated with normal healing of
the cornea.
Dibucaine
Dibucaine is 2 butoxy-N (2-diethyl aminoethyl) cinchoninamide. It is quinolone
derivative and is not an ester. The chemical structure is depicted in Figure 13.14.
Dibucaine is probably the most potent local anesthetic agent but its use has declined
because
217

dibucaine
of toxicity. It is used as 0.1 percent topical solution for instillation.
Naepaine
Naepaine is mono-n-amylamino ethyl-p-amino benzoate. Its chemical structure is
depicted in Figure 13.15.
One topical use, it does not cause mydriasis of alteration in intraocular pressure. It is
not associated with local irritation. It is derivative of paraaminobenzoic acid and is used 2
to 4 percent topical ophthalmic solution.
Butacaine
Butacaine is paraminobenzoic acid ester of dibutylaminopropanol. The chemical structure
is depicted in Figure 13.16.
It is used topically as 2 percent solution.

naepaine
Phacoemulsification
216

butacaine
14
Anesthesia in Cataract Surgery
Ashok Garg
Introduction
Anesthesia for Cataract Surgery has undergone tremendous changes and advancements in
last century. In 1846 general anesthesia techniques were developed which were not found
suitable and satisfactory for ophthalmic surgery. In 1884 Koller discovered surface
anesthesia techniques using topical cocaine for cataract surgeries which found favor with
the ophthalmologists. However, due to significant complications and side effects of
cocaine Herman Knopp in 1884 described retrobulbar injection as local anesthetic
technique for ocular surgery. He used 4 percent cocaine solution injected into the orbital
tissue close to posterior part of the globe to achieve adequate anesthesia but in the
subsequent injections patients experienced pain. In 1914 Van Lint introduced orbicularis
akinesia by local injection to supplement subconjunctival and topical anesthesia.
However, this technique found favor only after 1930 when procaine (Novocaine) a safer
injectable agent made it feasible.
With the development of hyaluronidase as an additive to the local anesthetic solution
Atkinson (1948) reported that large volumes could be injected with less orbital pressure
and improved safety injections into the cone (Retrobulbar) were recommended and
gained rapid favor becoming anesthetic route of choice among ophthalmologists.
In mid 1970s, Kellman introduced an alternative technique of local anesthesia for
ocular surgery known as peribulbar injection. However, till 1985 this new technique was
not published in ophthalmic literature. In 1985 Davis and Mandel reported local
anesthetic injection outside the cone into the posterior peribulbar space (periocular).
Further modifications of both retrobulbar and periocular injection techniques were made
by Bloomberg, Weiss and Deichaman, Hamilton and colleagues, Whitsett, Murdoch
Shriver and coworkers. These modifications consisted of more anterior deposition of
anesthetic solution with shorter needles and smaller dosages.
With the introduction of small incision cataract surgery, Phaco emulsification and
other microsurgical procedures in ophthalmology, use of shorter needles with smaller
dosages became more common. Fukasawa and Furata et al reintroduced subconjunctival
anesthetic techniques. Fichman in 1992 first reported the use of topical tetracaine
anesthesia for phacoemulsification and intraocular lens implantation starting an era of
topical anesthesia in ocular surgery.
With the advent of many ocular anesthetic techniques in past two decades indicates the
need for the development of an ideal anesthetic and technique for ocular surgery. Every
existing technique has its own advantages and disadvantages. General anesthesia for
cataract surgery is virtually out of favor with ophthalmologists. Retrobulbar anesthesia,
periocular (peribulbar, subconjunctival, orbital and epidural) and topical anesthesia or a
Phacoemulsification
218
combination of peribulbar and topical are being used in present day ocular surgery Now
with the advent of below 1 mm incision technique, foldable and reliable intraocular
lenses, no anesthesia cataract surgery is becoming popular with increased frequency.
Anesthesia for Cataract Surgery
Cataract extraction may be performed under general anesthesia, local anesthesia or
topical anesthesia, depending upon condition of patient cataract status and surgeon
choice.
General Anesthesia
Usually for cataract surgery general anesthesia is not given. It is advisable only in highly
anxious/ nervous patient or when cataract surgery requires a long time for completion.
Patients who are extremely apprehensive, deaf, mentally retarded, unstable or cannot
communicate well with the surgeon are more suitable for general anesthesia. General
anesthetic facilities with expert anesthetist are mandatory.
General Anesthesia Procedure
Preoperative Preparation
A patient who is to be given a general anesthetic needs proper preoperative assessment
and examination, preferably on the day before the anesthetic is to be administered,
although preparation earlier on the day of surgery may be acceptable in many cases.
Patients with cataracts are often elderly and not infrequently have other medical problems
that must be considered before anesthesia is induced. These are:
Chronic (Obstructive) Respiratory Disease
These patients require more careful assessment. Their condition in severe cases can be
adversely affected by anesthetic drugs and muscle relaxants. On the other hand, the
inability to control obstructed respiration can lead to hazardous cataract surgery and a
high incidence of failure. Preoperative preparation with antibiotics, bronchodilators, and
physiotherapy often enable a sick patient to undergo a safe procedure with the benefit of
a general anesthetic.
Cardiovascular Disease
Because many patients with cardiovascular disease will already be on diuretic treatment,
preoperative assessment to detect and treat cardiac failure or hypokalemia is most
important. The adequate control of hypertension is also an essential safety requirement,
especially for the middle aged.
Anesthesia in cataract surgery
221
Diabetes Mellitus
Diabetes mellitus is commonly found in those for whom cataract surgery is indicated.
Preadmission stabilization is necessary, and when this is in doubt, a longer period of
preoperative inpatient assessment and management is required to eliminate any ketonuria
or gross hyperglycemia. Oral diabetic medication should be omitted on the day of surgery
because the effects may persist for up to 24 hours. During surgery and throughout the
early postoperative period, control is effected by using 5 percent glucose intravenously
and insulin as required, as shown by the blood glucose levels. When the patient resumes
normal oral intake postoperatively, the normal regimen is rapidly resumed.
Dystrophia Myotonica
These patients frequently require cataract surgery while they are quite young. They are
particularly sensitive to anesthetic drugs and subject to prolonged respiratory depression.
Suxamethonium is contraindicated; minimal doses of other drugs such as atracurium
should be used.
Premedication
The aim of premedication is to allow a smooth induction of anesthesia. Most patients
appreciate some sedation to alleviate the natural anxiety associated with any eye surgery.
Opiates, however, are to be avoided because of their association with respiratory
depression and postoperative vomiting. For the aged and anxious, oral premedication
with diazepam, 5 to 10 mg, according to fitness and size or Lorazepam, 1 to 2 mg, works
well. An antiemetic can then be administered during surgery.
For the younger and more robust, one can use a combination of pethidine,
promethazine hydrochloride, and atropine. This is also a helpful combination for those
with established respiratory disease.
Children over 1 year of age required sedation with trimeprazine tartrate syrup (3 to 4
mg per kg) 2 hours preoperatively. Younger babies should not require sedation. Atropine
may be given either intramuscularly (0.2 to 0.6 mg 30 minutes preoperatively) or
intravenously (0.015 to 0.02 mg with induction).
Method of Anesthesia
Induction
A smooth induction avoids the problems of increased central nervous pressure with its
consequent adverse effect on the intraocular pressure.
The drug most commonly used is thiopentone, which produces a rapid loss of
consciousness. When it is used in doses of 3 to 4 mg per kg, the onset is relatively slow in
the elderly, who frequently have a slower circulation time. For the very frail,
methohexitone is useful, producing less change in blood pressure. More recently
disoprofol (Diprivan) has been found to be useful; it also has a rapid onset of action and
induces little nausea and vomiting.
Phacoemulsification
220
Intubation of the trachea with a non-kinking endotracheal tube is achieved with

suxamethonium. Its use is associated with a transient rise in the intraocular pressure due
to choroidal expansion. Ventilation with nitrous oxide and oxygen with 0.5 to 1 percent
halothane is continued until the effects of the suxamethonium have subsided.
More recently techniques have been described for rapid sequence induction with
vecuronium. These methods do not seem to be associated with a significant rise in the
intraocular pressure and they avoid the problems of suxamethonium.
Maintenance
A nondepolarizing muscle relaxant is used throughout the surgical procedure, dosages
depending on the size, age, and health of the patient. Available drugs include
tubocurarine, which is inclined to produce hypotension (occasionally severe),
pancuronium, and more recently vecuronium and atracurium. Vecuronium has been
demonstrated to lower intraocular pressure. Because both atracurium and vecuronium act
and subside rapidly, their effectiveness must be monitored regularly by a peripheral nerve
stimulator.
Intermittent positive pressure ventilation is maintained by nitrous oxide, oxygen, and
an anesthetic drug. One-half percent halothane has long been considered effective and
also lowers the intraocular pressure. Other anesthetic drugs include enflurane (associated
with more postoperative vomiting and restlessness, though less hypotension) and
isoflurane. The latter does not appear to adversely affect the stability of the
cardiovascular system. Its effect on intraocular pressure has not been reported.
Throughout the procedure the pulse, blood pressure, electrocardiographic record, and
arterial oxygen saturation must be regularly monitored, along with the nerve stimulation
needed for the nondepolarizing muscle relaxant being used. All ventilators should be
fitted with an alarm to warn of malfunction.
Completion
Recovery from anesthesia after cataract surgery must be as smooth as the induction, care
being taken to avoid gagging, coughing, and of course vomiting. Modern ophthalmic
sutures are good but not foolproof! The neuromuscular blockade is reversed with atropine
and prostigmine. Gentle extubation is associated with careful pharyngeal suction. Patients
are encouraged to resume normal activity as soon as the effects of the anesthetic drugs
have worn off.
Anesthesia for Children
Adequate premedication and careful handling should insure a calm and quiet child and
allow a smooth induction. Because the cataract is dealt with by using a closed system, the
surgical risks of a rise in intraocular pressure are not so severe. Inhalational anesthesia
using nitrous oxide and oxygen with halothane is usually sufficient.
223
Complications of General Anesthesia

The complications associated with a general anesthetic range from death to the less
serious but irritating nuisances of protracted nausea and vomiting or sore throats. This
chapter covers only those complications producing serious morbidity or mortality and
those peculiar to the patient with eye disease.
1. Hypoxemia (insufficient oxygen in the arterial blood to sustain life) is the most
common cause of disaster, and failure to ventilate is the most common cause of
hypoxemia. Unrecognized esophageal intubation, ventilator disconnection, and, most
distressing of all, inability to ventilate after unconsciousness and paralysis have been
obtained are all possible causes of failure to ventilate. Delivery of an inadequate
oxygen concentration is a less common cause of hypoxemia. Most but not all of the
foregoing are preventable with the monitoring and fail-safe devices available today,
provided a competent anesthetist is monitoring the devices.
2. Aspiration of gastric contents remains a common complication despite such preventive
measures as overnight fasting, the use of metoclopramide to enhance gastric emptying,
and rapid sequence induction with cricoid pressure in emergency procedures. The two
life-threatening results of aspiration are airway obstruction from large food particles
and chemical pneumonitis from acidic gastric contents.
3. The two most serious cardiovascular complications, aside from cardiovascular collapse
secondary to hypoxemia and acute anaphylaxis, are myocardial infarction and
cerebrovascular accident. Surgery performed under general anesthesia within 3
months after a myocardial infarction carries a 40 percent incidence of repeat
infraction. This figure decreases to about 10 percent at 6 months, after which the
incidence is approximately the same as in the general population. All elective surgery
is delayed until after 3 months, and a 6-month wait is encouraged unless poor visual
acuity seriously limits activities.
4. Renal and hepatic toxic effects from anesthetic drugs are seldom seen in our practice.
Careful preanesthetic screening identifies all patients with renal and hepatic disease.
Halothane, which gained notoriety because of its hepatotoxicity, especially when
administered repeatedly, is not used in adults and is usually used for induction only in
children. The metabolic byproducts of methoxyflurane and enflurane are inorganic
fluorides, which can produce nephrogenic diabetes insipidus. We no longer use these
drugs because so many of our patients have diabetes and severe renal disease in our
population.
5. Failure to resume respiration at the end of the surgery occurs often enough to merit
mention. The most common causes are simple respiratory depression from the
anesthetic drugs or narcotics, electrolyte disturbance (i.e. hypokalemia), hypothermia
(particularly in infants), and the use of the combination of mycin antibiotics and
nondepolarizing muscle relaxants. It also may occur after the administration of
succinyl choline when there is a pseudocholinesterase deficiency. Respirations are
maintained until the cause is found and remedied.
Cardiovascular complications are the most commonly seen events in our practice. If
diagnosed and treated properly, they need not result in a disaster. Hypertension is the
most prevalent problem. The usual causes are apprehension, Neosynephrine eyedrops,
Phacoemulsification
222
pain, distended bladder if mannitol was given, and autonomic nervous system imbalance
secondary to the general anesthetic. Apprehension can be allayed with intravenous
injections of 1 to 3 mg of Valium or 0.5 to 2 mg Zolpidem. Nitropaste applied to the skin
and sublingual doses of nifedipine have proved invaluable, but an intravenous line should
be in place before their use. Hypotension must be treated immediately and vigorously
because it is tolerated less well than hypertension. Arrhythmias are the most frequent
cause of cancellation on the day of surgery in the elderly patient with eye disease. The
sudden onset of atrial fibrillation is the most common arrhythmia. An
electrocardiographic monitor is mandatory for eye surgery.
Extrusion of ocular contents during administration of a geneal anesthetic is a serious
complication in eye surgery. The entire anesthetic process is geared to minimize this
possibility. Once the eye is opened, patients are kept deeply anesthetized or paralyzed
with non-depolarizing relaxants to insure immobility.
Local Anesthesia
Local ocular anesthesia is the mainstay of cataract surgery. Local anesthesia minimizes
the risk of wound rupture a complication frequently associated with coughing during
extubation and postoperative nausea and vomiting (in general anesthesia) (Fig. 14.1).
Generally the use of 1:1 mixture of 2 percent Xylocaine and 0.50 percent Bupivacaine
alongwith Adrenaline and Hyaluronidase in Facial, Retrobulbar and Peribulbar blocks
achieve rapid anesthesia, akinesia and post-operative analgesia for several hours.
Care should be taken to avoid intravascular injections of anesthetic agents because
refractory cardiopulmonary arrest may result from an inadvertent intravenous or intraarterial injections.
FIGURE 14.1 Diagrammatic surface

distribution of sensory nerves. Note
branches derived from ophthalmic
nerve (V1) and maxillary nerve (V2) a
division of the trigeminal nerve
Many patients express pain of facial and retrobulbar injections so proper preoperative
sedation and good rapport with the surgeon make them quite comfortable.
225
Following techniques are used for giving local anesthesia. These include:
Orbicularis Oculi Akinesia
Temporary paralysis of the orbicularis oculi muscle is essential before making section for
the cataract surgery to prevent potential damage from squeezing of the lids. Following
methods are used, for getting orbicularis oculi akinesia.
a. OBriens technique Usually 10 ml of mixture of 2 percent Lidocaine solution (5 ml)
and 0.5 percent bupivacaine solution (5 ml) with 1:100,000 epinephrine and 150 units
of Hyaluronidase are infiltrated for local anesthesia.
OBriens method is the injection of above mentioned local anesthetic solution
down to the periosteum covering the neck of the mandible where the
temporofacial division of facial nerve passes forwards and upwards (Fig. 14.2). A
10 ml syringe with preferably No. 17 or 18 needle and 2.5 cm in length is used.
The patient is asked to open his mouth and the position of the condyle and
temporomandibular joint is located by the forefinger of the operatorss left hand.

presentation of OBrien technique of
local anesthesia
FIGURE 14.3 Needle position for Van

Lint akinesia (Courtesy: Ciba Geigy
Clinical Symposia)
Phacoemulsification
224
After closing the jaw, the injection is given on a horizontal line through the
junction of the upper and middle third of the distance between the zygoma and
angle of the mandible. The needle should pass straight down the periosteum. 23
ml of local anesthetic solution is injected and after withdrawing the needle firm
pressure and massage are applied. Paralysis of orbicularis oculi should occur
normally within 7 minutes. The injection is unlikely to injure the external carotid
artery which lies posterior and at a deeper level. However, damage may be done
to posterior facial vein and the transverse facial artery. Movement of jaws is
sometime painful for few days after this injection.
b. Van Lints akinesia Van Lints method is a better alternative. The injection of local
anesthetic solution is made across the course of branches of the seventh nerve as they
pass over the zygomatic bone (Fig. 14.3).
In this technique a 5 cm in length and 25 gauge needle is passed through the
wheal down to the periosteum of the zygomatic bone. The needle is then passed
upward towards the temporal fossa without touching the periosteum (as it may be
painful) and 4 ml of solution is injected and then forwards medially and
downwards towards the infraorbital foramen to inject 2 ml and downwards and
backwards along the lower margin of the zygoma for 2.5 cm where 3 ml of
solution is injected. It is essential to massage the infiltrated area with a gauze
FIGURE 14.4 Atkinson akinesia

(intercepting the facial nerve fibers as
they cross the zygomatic arch)
swab. Motor nerves are less susceptible than sensory nerves to a block with local
anesthetic agents.
The advantage of Van Lints method is that it provides regional anesthesia as well
as paralysis of the orbicularis muscle. After waiting for 57 minutes akinesia is
tested by holding the eyelids open with a small swab on to a holder and asking the
patient to close his eyelids. If slightest action is observed then injection may be
repeated to obtain adequate akinesia.
227
c. Atkinson block The needle enters through a skin wheal at the inferior border of the
zygoma just inferior to the lateral orbital rim. The path of the needle is along the
inferior edge of the zygomatic bone and then superiorly across the zygomatic arch,
ending at the top of the ear. 3 to 4 ml of the anesthetic is injected as the needle is
advanced (Figs 14.4 and 14.5).
d. Spaeth block The Spaeth block avoids the inconsistencies of the OBrien block as well
as the postoperative discomfort caused by going through the parotid gland and
entering the temporomandibular joint. An injection is made into the back of the
mandibulbar condyle just below the ear, catching the facial nerve before it divides
(Fig. 14.6). To locate the landmarks, the

presentation of OBrien and Atkinson
techniques. (A) Classic OBrien
technique (B) Modified OBrien
technique (C) Atkinson technique
fingers are placed along the posterior border of the mandible as superiorly as
possible. The needle is placed just anterior to the most superior finger. Bone
should be reached shortly. If not, the needle is withdrawn and the position
rechecked before a second attempt is made. After the bone is reached, the needle
is pulled back slightly and suction is placed on the syringe to make sure that a
vessel has not been punctured; 5 ml of anesthetic is then injected. Although rarely
required,
Phacoemulsification
226
FIGURE 14.6 Spaeth block (facial

nerve is blocked where it crosses the
posterior edge of the mandible)
FIGURE 14.7 Needle positions for

OBrien and Nadbath ocular akinesia
(Courtesy: Ciba Geigy Clinical
Symposia)
the needle can be redirected superiorly towards the outer canthus for 1.5 inches
and an additional 5 ml is injected. After 30 seconds, nearly complete facial palsy
should be evident.
e. Nadbath block An injection is made into the cavity between the mastoid process and
the posterior border of the mandibular ramus. The skin is pierced, and a skin wheal is
made 1 or 2 mm anterior to the mastoid process and inferior to the external auditory
canal. A 12 mm, 26 gauge needle is used, with the injection of anesthetic extending
from the skin wheal, passing through a taut membrane midway, to the full depth of the
needle; 3 ml is injected (Fig. 14.7).
The Nadbath block insures ease of performance, and there are few complaints
relating to the original injection or subsequent pain in the jaw area. The most
229
common side effect is a bitter taste as the parotid gland secretes the anesthetic.
Other problems reported are dysphonia, swallowing difficulty, and respiratory
distress. Judging from the fact that these complications are seen predominantly in
very thin patients and most certainly are secondary to the diffusion of anesthetic
to the jugular foramen, 1 cm deeper than the stylomastoid foramen, the length of
the needlei.e. the depth of injectionis critical.
Preexisting unilateral oropharyngeal or vocal cord dysfunction is a definite
contraindication, for bilateral vocal cord paralysis could result. The nadbath block
should never be done bilaterally. If, after a unilateral Nadbath block, dysphonia or
difficulty with swallowing or respiration occurs, lateral positioning will allow the
paralyzed vocal cord to fall out of the way, clearing the airway.
Proper administration of local anesthesia requires knowledge of orbital anatomy,
various anesthetic techniques, and the properties of the drugs used. Prompt
recognition of side effects and complications following injection results in the
best possible patient care.
f. Retro-ocular (retrobulbar) injection Anesthesia and akinesia of the eye are achieved by
injecting a local anesthetic solution into the retrobulbar space within the muscle cone
(Fig. 14.8).
FIGURE 14.8 Local anesthesia

techniques (A) Van Lint akinesia
(dotted arrows) (B) Nadbath facial
nerve block (C) Retrobulbar needle
position
Phacoemulsification
228

retrobulbar and peribulbar anesthesia
(frontal view) (Courtesy: Ciba Geigy
Clinical Symposia)
In this method patient is asked to look upwards and to the opposite side. A 3.5 cm length
23 gauge sharp edge round tipped needle is inserted in the quadrant between the inferior
and the lateral rectus muscles and directed posteriorly until the resistance of orbital
septum is encountered. After it has penetrated the orbit the needle is directed towards the
apex of the orbit and advanced until it meets the resistance of the intermuscular septum.
When this structure is penetrated, the needle tip is in the retrobulbar space. About 34 ml
of local anesthetic mixture solution is injected taking care, to minimize the needle
movement to prevent possible vessels lacerations. Following the injection the globe
should be intermittently compressed for several minutes for distributing the anesthetic
solution and to ensure hemostasis. A properly placed retrobulbar injection is effective
within seconds. It blocks all extraocular muscles except superior oblique muscle, affects
the ciliary ganglion and anesthetize the entire globe (Fig. 14.9).
Gills-Loyd Modified Retrobulbar Block
Before the anesthetic is administered, the patients vision is checked and the A scan
examined. Then, prior to the first injection, 2 drops of proparacaine 0.5 percent are given
topically. The eyes are either fixed in primary gaze or directed slightly superiorly,
avoiding the superonasal position. With sharp 27 gauge needle, enter is effected at LE
4:00, RE 8:00, 5 mm medial to the lateral canthus. The needle is inserted parallel to the
optic nerve. A preretrobulbar injection of 1.5 ml of pH adjusted Xylocaine is
administered subconjunctivally. After 30 seconds, a 5 ml retrobulbar injection of pH
adjusted bupivacaine and hyaluronidase is injected with a 25 gauge, 1 inch needle.
After 8 to 9 minutes, the eye is checked for akinesia. A 1 to 3 ml supplemental injection
of full strength anesthetic is given as needed to complete the block. 1.0 ml bolus is
231
administered subdermally into the inferolateral lid to anesthetize the distal branches of
the seventh cranial nerve; this technique does not require a total seventh nerve block.
Next 0.5 ml of cefazole is injected subconjunctivally, and gentle eye compression is
administered for 30 to 60 minutes with a Super Pinky Decompressor prior to surgery.
Complications of Retrobulbar Injection
A number of complications can occur as a result of retrobulbar injection, among them
retrobulbar hemorrhage, perforation of the globe, retinal vascular obstruction, and
subarachnoid injection.
Retrobulbar Hemorrhage
Retrobulbar hemorrhage probably occurs in 1 to 5 percent of the cases. It seems to occur
less frequently if a blunt tipped needle is used, but this has not been demonstrated in any
controlled study.
Retrobulbar bleeding may occur at a number of sites. The four vortex veins leave the
globe approximately 4 mm posterior to the equator and could well be subjected to the
shearing forces of an inserted needle, as could the central retinal or ophthalmic vein. An
arterial source of bleeding must be postulated to explain severe hemorrhages that produce
the rapid onset of proptosis, hemorrhage, chemosis, and immobility of the globe. The
posterior ciliary arteries supplying the choroid, the central retinal artery, and other
ophthalmic artery branches are all subject to damage. Even the ophthalmic artery can be
reached in the area of the optic foramen with a 1 inch needle.
Most instances of retrobulbar hemorrhage resolve without complication, but should a
complication arise, particularly during elective surgery, it is prudent to postpone the
operation for at least 3 to 4 weeks and then consider general anesthesia if the patient can
tolerate it.
Even when general anesthesia is employed, severe positive pressure can develop in an
open eye if the operation is performed within several days after the hemorrhage.
Vision may be permanently decreased following a retrobular hemorrhage. This
probably occurs as a result of closure of the central retinal artery or damage to the smaller
vessels that supply the retrobulbar optic nerve.
If examination reveals that the central retinal artery has closed because of increased
intraorbital and intraocular pressures, a lateral canthotomy should be performed. Other
possible therapeutic modalities include anterior chamber paracentesis and orbital
decompression. Prior of decompression of the orbit, computed tomographic scanning of
the region should be undertaken to help localize the blood and rule out the possibility of
bleeding within the optic nerve sheath, which also might have to be decompressed.
Perforation of the Globe
This is another sight-threatening complications of ophthalmic surgery with retrobular
anesthesia. Highly myopic eyes are particularly suscepticle to this complication because
Phacoemulsification
230
of their long axial lengths. General anesthesia should be considered as an alternative in

such eyes.
The scleral perforation should be repaired as soon as possible. Cryopexy or laser
treatment of the break(s) may suffice, although vitreous traction that develops along the
needle tract through the vitreous gel is better negated by a scleral buckling procedure. If
the fundus view is obscured by vitreous hemorrhage, a pars plana vitrectomy is warranted
to visualize the break(s). Although double scleral perforations probably have a worse
prognosis than the single variant, the latter also can be devastating. I have seen one case
in which the retina in the posterior pole was partially aspirated through the needle
following a scleral perforation anterior to the equator.
Inadvertent injection of lidocaine into the vitreous cavity appears to be tolerated by the
globe. However, it can cause an extreme elevation of the intraocular pressure and rapid
opacification of the cornea.
Retinal Vascular Obstruction
Retinal vascular obstruction has been reported after retrobular anesthesia. The most
common types are central retinal artery obstruction and combined central retinal arterycentral retinal vein obstructions. Central retinal artery obstruction seems to occur more
commonly in conjunction with diseases that affect the retinal vasculature, such as
diabetes mellitus and sickling hemoglobinopathies. Nevertheless, it also can be seen in
people with good health. Fortunately, the condition more often than not reverses
spontaneously and the central retinal artery reperfuses within several hours. The causes
are uncertain, but spasm of the artery, direct trauma to the vessel from the needle, and
external compression by blood or an injected solution are possible mechanisms that could
cause obstruction. Ophthalmic artery obstruction also can be induced, possibly by
injection and subsequent compression within the optic foramen.
Therapy is directed towards relieving the obstruction and keeping the retina viable.
Anterior chamber paracentesis may help, the aim being to lower the intraocular pressure
and decrease the resistance to blood through the central retinal artery. Although
paracentesis widens vessels narrowed by artery obstruction, fluorescein angiography
shows that the filling occurs in a retrograde fashion, via the retinal veins. Hence its value
is questionable.
Combined obstruction of the central retinal artery central retinal vein is a much more
serious complication. Ophthalmoscopically a cheery-red spot is seen, as well as
numerous intraretinal hemorrhages and dilated retinal veins. The mechanisms of
obstruction include direct trauma to the central retinal vessels from the needle or
compression from blood or fluid injected into the nerve sheath. Blood within a dilated
optic nerve sheath has been demonstrated in these cases.
The visual prognosis of these eyes is generally grim. Computed tomography of the
retrobulbar optic nerve may be used to determine whether a nerve sheath hemorrhage is
present. If an optic nerve sheath hematoma is discovered, decompression of the nerve
sheath may be of limited benefit.
Neovascularization of the iris may develop after combined central retinal arterycentral retinal vein obstruction. If the anterior chamber angle is not yet closed by a
233
fibrovascular membrane, aggressive, full scatter panretinal photocoagulation treatment

should be administered in an attempt to prevent neovascular glaucoma.
Injecting with the eye in the primary position may help prevent this complication. In
contrast, injecting with the eye looking up and in, places the optic nerve and central
retinal vessels more in the pathway of the needle and thus probably should be avoided.
Multiple emboli with the retinal arterial system have caused vascular obstruction
following retrobulbar corticosteroid injection. No therapy is available for this visually
devastating complication which likely results from injection into the central retinal or
ophthalmic artery. In theory, the use of a needle shorter than 1 inches may help to
prevent the complication, as can having the patient gaze in the primary position during
the injection.
Subarachnoid Injection
Among the most recently recognized complications of retrobulbar, anesthesia,
inadvertent injection into the subarachnoid space may be the most serious. The
subarachnoid space extends around the retrobulbar optic nerve up to the globe and can be
violated with a retrobulbar needle at any point along its course.
Optic atrophy and blindness have also been reported following retrobulbar blocks but
they are fortunately rare. Due to these potential complications retroocular injection is out
of favor with eye surgeon worldwide.
Peribulbar (Periocular) Technique
Since the exit of retrobulbar akinesia, Peribulbar akinesia is considered a safe and
effective technique of local anesthesia for cataract surgery. It is method of choice with
eye surgeons for giving local anesthesia to cataract. As the name indicates, peribulbar
anesthesia is a technique in which a local anesthetic is injected into peribulbar space and
is not aimed at blocking a perticular nerve.
Technique
Periocular anesthesia is administered at two sites lower temporal quadrant and nasal to
caruncle (Fig. 14.10).
The required local anesthetics are Lidocaine 1 percent and Bupivacaine 0.75 percent
with hyaluronidase. Bupivacaine is preferred as it is a longer acting anesthetic agent
which can provide prolonged anesthesia and analgesia.
In the first stage, injection of 0.5 cc of 1 percent lidocaine with a 26 G needle is done
under the skin at about I cm away from the lateral canthus in the lower lid, along the
orbital rim. The same needle is passed deeper to inject 0.5 cc of lidocaine into the
orbicularis muscle and 1.0 cc into the muscle sheath. A second injection is done in the
similar fashion in the upper eyelid just below the supraorbital notch. Pressure is applied
at both for a minute using gauze pieces.
Phacoemulsification
232
In the second stage, combination of 6.0 ml of 0.75 percent bupivacaine, 3 ml of 1

percent lidocaine and 0.25 cc of hyaluronidase is filled into a 10 ml Disposable syringe
fitted with a, 11/4 inch 23 G, hypodermic needle. The needle is first introduced deep
into the orbit through the anesthetized site in the lower eyelid. One ml is injected just
beneath the orbicularis muscle and then the needle is advanced up to the equator of the
globe to inject 2 to 3 ml of the solution. The same procedure is followed in the upper
nasal quadrant through the preanesthetized site to inject 1 ml and another 1 ml may be
injected around superior orbital fissure, by deeper penetration.
At the end of the procedure, fullness of the lids is noted due to the volume of the
injected. Firm

peribulbar and retrobulbar akinesia
(Courtesy: Ciba Geigy Clinical
Symposia)
pressure with the flat of the hand is applied over the globe and is maintained for a minute.
Then, before surgery, any pressure device as per the surgeons choice like Honans
balloon, super pinky ball, balance weight or simple pad-bandage is applied for 20 to 30
minutes, to achieve the desire response of hypotony.
The efficacy of the anesthesia is evaluated after about 10 minutes of injection and if
inadequate, 2 to 4 ml more can be injected. In case of persistent inferior or lateral
movement injection lower temporal quadrant and in case of persistent movements
upwards of nasally, the upper quadrant could be infiltrated in the same fashion.
Hyaluronidase is essential as it helps in the spread of the drug. Otherwise, there are
chances of the eye being proptosed due to high orbital pressure induced by the large
quantity of the fluid injected.
Single injection of 5 to 6 ml of anesthetic mixture injected from any site posterior to
equator of the globe also achieves same results. For convenience, however, it may be
done through lower lid the junction of lateral and middle one-third, along the floor of the
orbit.
235
Adequacy of akinesia is determined by the absence of ocular movements in all

directions.
This technique is certainly better than retroocular technique and has least
complications.
Advantages
The advantages reported are:
1. The injection is done outside the muscle cone and so, the inherent complications of
passing the needle into the muscle cone is completely eliminated.
2. It does not enter the retrobulbar space and thereby avoids retrobulbar hemorrhage,
injury to optic nerve and entry of anesthetic agents into subarachnoid space and other
complications like respiratory arrest.
3. Since the needle is constantly kept parallel to the bony orbit, it avoids injury to globe
and entry of anesthetic agents into the eyeball.
4. It causes less pain on injection.
5. The procedure is easier and can be performed without causing damage to vital
structures.
6. It does not reduce vision on table.
7. No facial block is required.
Drawback
The possible drawbacks of this procedure are:
1. Chemosis of conjunctiva.
2. Delayed onset of anesthetic effect, and
3. Potential risk of orbital hemorrhage. Though it occurs rarely, the magnitude of the
problem is comparable to retrobulbar hemorrhage and necessitates postponement of
surgery.
Mechanism
The exact mechanism is not known but this procedure may best be described as
infiltration anesthesia where nerve endings in all tissues in the area of injection get
anesthetized.
Peribulbar anesthesia is a safe and reliable technique for achieving akinesia and
anesthesia of the globe. In case of inadequate anesthesia, repeat injections in the similar
manner can be safely used to achieve the purpose.
Superior Rectus Injection
The induction of temporary paralysis of the superior rectus muscle is essential for any
intra ocular operation where the surgical field is upper half of the eye. This injection also
affects the action of levator palpebrae superioris.
Phacoemulsification
234
In this injection patient is asked to look down. The upper lid is retracted and 2.5 cm
long needle is passed into Tenons capsule at the temporal edge of the superior rectus
muscle. The needle is directed posteromedially and about 1 ml of anesthetic mixture of 2
percent Xylocaine is injected around the muscle belly behind the equator. This injection
can also be made through the skin of the upper orbital sulcus.
Tenons Capsule Injection
The injection of anesthetic mixture can be given into Tenons capsule around the upper
half of the eyeball and into the belly of superior rectus muscle. It is considered safer than
the retroocular injection across the postganglionic fibers of the ciliary body and may be
effective in inducing extraocular muscle akinesia.
FIGURE 14.11 Parabulbar (flush)

local anesthesia (cross-section view)
237
FIGURE 14.12 Parabulbar (flush)

local anesthesia (surgeon view)
Parabulbar (Flush) Akinesia
Parabulbar (flush) administration is a new route for local anesthesia which is highly
useful, safe, effective and technically easier (Figs 14.11 and 14.12). This method consists
of a limbal sub-tenon administration of retrobulbar anesthesia using a blunt irrigating
cannula. This technique can be used for anterior and posterior segment surgery.
Topical Anesthesia
Since the advent of retrobulbar and peribulbar techniques in the early part of this century,
both procedures are mainstay of local anesthesia for intraocular surgery till today. They
do carry the risk of perforation of globe, optic nerve and the inadvertent injection of
anesthetic at wrong places.
These accidents are mainly due to:
Carelessness on the part of ophthalmologist who considers the procedures lightly and
occurs more often with senior eye surgeons.
Using long needles for these techniques endangers the perforation of globe, piercing the
optic nerve and entering crowded retrobular space and even touching the intracranial
space on forceful injection of copious amounts.
Anesthetics given through local injection with little knowledge of anatomy of this area.
Retrobulbar hemorrhage with its adverse effects on nerve and globe is very common
complication of this technique.
Injury caused by perforation of globe can lead to hole formation, retinal detachment,
vitreous hemorrhage and central and branch vein occlusions.
Phacoemulsification
236
To overcome all these practical difficulties use of topical anesthesia in intraocular surgery
has been widely suggested and used at an International ophthalmic level. Topical
anesthesia meaning topical application of 4 percent Xylocaine or 0.50.75 percent
proparacaine one drop 34 times at regular intervals in the eye has become increasingly
popular and accepted. In present day hightech intraocular surgery specially phaco surgery
topical anesthesia is the anesthesia of choice with the eye surgeons worldwide.
Indications to use Topical Anesthesia
Its indications in intraocular surgery are mainly when performing phacoemulsification
and IOL implantation through a clear corneal tunnel and corneoscleral incisions.
Topical anesthesia is ideally suited for small incision and stitchless cataract surgery.
However, it is not a advocated to perform standard/ manual extracapsular cataract
extraction and IOL implantation.
Proper selection of patient is of great importance in this technique. It is important to
have a patient who will comply with the instructions given during surgery.
Patients who are non-cooperative, hard of hearing, with language problem and anxious
patients are poor candidates for surgery under topical anesthesia. Capsulorhexis
requires the maximum cooperation of the patient.
Intraocular surgery likely to be problematic in patients with rigid small pupils
responding poorly to dilating drops and eys with lenticular subluxation and high grade
nuclear sclerosis are relative contraindications for topical anesthesia.
Eye surgeon operating with topical anesthesia should be proficient and experienced at
This procedure requires the use of foldable IOL either as a silicone lens or an acrylic
lens. This is essential because corneal tunnel suture lens incision cannot be larger than
3.5 mm. Otherwise corneal complications may arise and the incision would not be
self-sealing.
How to Achieve Surface Anesthesia for Intraocular Surgery

Generally 3 applications of 4 percent Xylocaine or 0.4 percent Benoxinate HCl or 0.5
0.75 percent proparacaine 10 minutes apart starting 30 minutes before surgery are
recommended. A drop is thereafter instilled prior to the incision. 1 CC of 4 percent
Xylocaine or 0.4 percent Benoxinate HCI or 0.50.75 proparacaine (from fresh vail) is
drawn into sterile disposable syringe and OT staff person is asked to instil a few drops of
the same prior to cauterization of bleeders and if required during surgery conjunctival
anesthesia is used (pinpoint and mini pinpoint surface anesthesia)
Apart from giving topical anesthesia one has to give systemic analgesia. Besides it,
surgeon should have a commanding hypnotic voice (vocal local anesthesia).
Most surgeons doing corneal tunnel incision under topical anesthesia prefer to do it
from temporal side.
239
Can One Convert Half Way Through Surgery Under Topical

Anesthesia
Intraoperative conversion from topical to peribulbar anesthesia can definitely be achieved
if surgical situation. Warrants it. Since corneal tunnel incision is sutureless and selfhealing a peribulbar injection can safely be given during the surgery.
Advantages of Topical Anesthesia
1. Phacoemulsification experts feel that use of topical anesthesia with a clear corneal
tunnel self-healing incision is a significant advancement in intraocular surgery. With
topical anesthesia visual recovery is immediate.
2. It prevents the well known complications of retrobulbar and peribulbar injections as
mentioned in the early part of this chapter.
3. It lessens the time of operating room use thereby lowering costs.
4. There is no immediate postoperative ptosis as seen in retrobulbar or peribulbar and
Van Lint, OBrien infiltrations lasts for 68 hours due to temporary akinesia of the
lids.
5. With topical anesthesia photon laser intraocular surgery can be OPD procedure.
6. In practice we have seen the anxiety of patients to peribulbar and retrobulbar injections
prior to surgery. With topical anesthesia this problem is over and patient compliance
will be better during intraoperative period.
7. The need of qualified anesthesiologist is over in operation theater during the operation
as a number of ophthalmologists have been seen to prefer anesthesiologist by their
side for local anesthesia (retrobulbar and peribulbar anesthesia).
8. No risk of postponement of intraocular surgery as seen in cases of retrobulbar
hemorrhage.
Again its main advantage is that it provides for immediate postoperative visual recovery.
Disadvantages of Topical Anesthesia
1. Only a highly experienced surgeon can operate with topical anesthesia. The eye can
move which makes the operation more difficult. If the eye movement occurs when
capsulorrhexis is being done, an undesirable capsular tear may take place leading to
failure of this important step of the operation.
2. The chances of intraoperative complications with topical anesthesia can be high if the
surgeon is not highly skilled. If such complications arise surgeon should be ready to
convert to other methods of local anesthesia during the intraoperative stage, because
topical anesthesia along may not be adequate to handle intraoperative complications.
Surgeon should be of cool temperament who can handle such a situation without
anxiety.
3. Topical anesthesia is not indicated in all patients specially in anxious stressed patients,
people with hearing difficulties, children and very young patients.
Phacoemulsification
238
4. As in our country a large number of patients come from rural areas who are illiterate
and poor. Their compliance remains very poor and they do not respond adequately to
the command during surgery with topical anesthesia.
5. The presence of very opaque cataract is a contraindication to the use of topical
anesthesia. This is because surgeon depends on the patients ability to visually
concentrate on the operating microscope light in order to avoid eye movement during
the operation. Patients, who are not able to fix the eyes, may lead to complications.
6. Some patients may feel pain during surgery with topical anesthesia. One patient
observed a lot more pain and felt as if a sword was being used to cut him up. The pain
continued postoperatively for quite some time.
7. In principle, adequate selection of patients is fundamental when considering the use of
topical anesthesia.
In spite of these hurdles topical anesthesia will be a safe and common technique for local
anesthesia during intraocular surgery in the near future.
No Anesthesia Cataract Surgery
This is the latest technique of cataract surgery in which no anesthesia is required (whether
local or topical). Neither topical or intracameral anesthetics agents are used. This
technique is devised by Dr. Amar Agarwal (India) and has been acclaimed and accepted
worldwide.
Further Reading
1. Arora R et al: Peribulbar anesthesia. J Cataract Ref Surg 17:50608, 1991.
2. Bloomberg L: Administration of periocular anesthesia. J Cataract Ref Surg 12:67779, 1986.
3. Bloomberg L: Anterior peribulbar anesthesia. J Cataract Ref Surg 17:50811, 1991.
4. Davis DB: Posterior peribulbar anesthesia. J Cataract Ref Surg 12:18284, 1986.
5. Fichman RA: Topical anesthesia, Sanders DR, Slack 166172, 1993.
6. Furuta M et al: Limbal anesthesia for cataract surgery. Ophthalmic Surg 21:2225, 1990.
7. Garg A: Topical anesthesia: Current trends in ophthalmology. New Delhi: Jaypee Brothers
Medical Publishers (P) Ltd., 15, 1997.
8. Hay A et al: Needle perforation of the globe during retrobulbar and peribulbar injection.
Ophthalmology 98: 101724, 1991.
9. Kimble JA et al: Globe perforation from peribulbar injection. Arch Ophthalmol 105:749, 1987.
10. Shriver PA et al: Effectiveness of retrobulbar and peribulbar anesthesia. J Cataract Ref Surg
18:16265, 1992.
11. Zahl K et al: Ophthalmol Clin North Am. Philadelphia: WB Saunders, 1990.
15
Mydriatics and Cycloplegics
Ashok Garg
Introduction
Mydriatics are drugs which dilate the pupil while cycloplegics are agents which cause
paralysis of ciliary muscle (paralysis of accommodation). Mydriatics usually produce
paralysis of ciliary muscle in greater or lesser degree.
All these drugs when instilled into the conjunctival sac are rapidly absorbed through the
cornea and become effective in the inner eye.
Currently two classes of drugs: (i) adrenergic agonist, and (ii) cholinergic antagonist are
available for mydriatic purpose. For most dilatation procedures, the adrenergic or
anticholinergic agents can be used either alone or in combination for maximum
mydriasis. Anticholinergic agents used topically in the eye for the purpose of inhibiting
accommodation are termed cycloplegics. Their primary use is for cycloplegic refraction
and in the treatment of uveitis. Since these agents also inhibit action of the iris sphincter
muscle they are effective mydriatics and are commonly used for routine pupillary
dilatation.
Mydriatic Adrenergic Agents (Sympathomimetic Agents)
The effect of sympathomimetic agents on the eye include pupil dilatation, increase in the
outflow of aqueous humor and vasoconstriction (-adrenergic effects), relaxation of
ciliary muscle and decrease in the formation of aqueous humor. The various agents of
this group used in ophthalmology are as follows.
Adrenaline (Epinephrine)
Adrenaline acts on dilator fibers and directly produces dilatation after the instillation of
four drops of 1:1000 solution, the instillation being repeated in 5 minutes. It is mainly
used in the treatment of open angle glaucoma.
Adrenaline may be combined with procaine and atropine as a subconjunctival
injection to achieve mydriasis in severe cases of iritis.
Cocaine Hydrochloride
Cocaine hydrochloride is an alkaloid and is used as cocaine hydrochloride 2 percent and
4 percent drops. It acts as a mydriatic by inhibiting the action of amine oxidase. It is toxic
Phacoemulsification
240
to the cells of corneal epithelium and this effect may be used to advantage in that the
damage to the epithelium allows a greater penetration of drugs through the cornea.
It does not cause dilatation of pupil and pupil continues to react to light even after
prolonged application. It is, therefore, ineffective when the sympathetic nerve is
paralyzed.
Phenylephrine
Phenylephrine is one of the most common sympathomimetic agents (-adrenergic
stimulant) used in ophthalmology for dilatation purposes. It is used in the form of
hydrochloride. It acts directly on the -receptors of the dilator pupillae causing pupil
dilatation. Following topical instillation, it acts on the dilator muscles and smooth
muscles or conjunctival arterioles causing pupillary dilatation and blanching of
conjunctiva. Its action can be reversed by thymoxamine 0.1 percent.
Indications For pupil dilatation in diagnostic purposes (for complete fundus exam) and in
various pathological conditions of the eye [in uveitis (posterior synechiae)], open-angle
glaucoma in conjunction with miotics, refraction, ophthalmoscopic examination and
before intraocular surgery.
Contraindications Hypersensitivity to any of these agents, narrow-angle glaucoma,
patients with long standing insulin-dependent diabetes, hypertensive patients receiving
reserpine or guanethedine, aneurysm, cardiac diseases, debilitated and elderly patients
and patients with IOL implantation.
Dosage For pupillary dilatation commercial concentrations of 2.5 percent and 10 percent
(in 2.5 ml and 15 ml packs) ophthalmic solutions are available. Maximum dilatation
occurs in 45 to 60 minutes depending upon the concentration used and number of drops
instilled. The pupil size usually returns to predrug levels within 4 to 6 hours. Since
phenylephrine has little or no effect on the ciliary muscle, mydriasis occurs without
cycloplegia.
Phenylephrine 1 percent solution can be used in diagnosis of Horner syndrome.
Significantly mydriasis can occur in the eye with a postganglionic lesion as compared to
normal innervation.
The mydriatic response may be affected in cases of injury to corneal epithelium
(corneal abrasions and trauma). Concentration as small as 0.125 percent present in
decongestant solution has been reported to cause mydriasis if the corneal epithelium is
damaged. In general 2.5 percent topical concentration is used for routine dilatation,
specially in children and elderly patients because 10 percent concentration has clinical
ocular and systemic side effects.
For diagnostic purpose usual dosage is 1 drop of 2.5 percent solution in each eye
followed by one drop more in 5 to 10 minutes. Sufficient mydriasis is produced in 15 to
30 minutes and effect lasts for 4 to 6 hours. For pathological condition usual dosage is 1
drop of 2.5 percent or 10 percent solution (depending upon the condition) three times a
day till the desired result is obtained.
Topical phenylephrine can be used alone or in combination with other
mydriatic/cycloplegic agents in diagnostic procedures and pathological conditions of the
eye.
Mydriatics and cycloplegics
243
Adverse reactions On topical use it may cause transient stinging on initial instillation,
blurring of vision and rarely maculopathy with a central scotoma results from use in
aphakic patients.
Prompt reversal generally follows discontinuation.
Phenylephrine may cause rebound miosis and decreased mydriatic response to therapy
in older persons.
Systemic side effects include CVS effects like palpitation, tachycardia, extrasystole,
cardiac arrhythmia, hypertension, headache and browache but usually diminishes as the
treatment is continued.
Other effects include reflex bradycardia, pulmonary embolism, myocardial infarction,
stroke and death associated with cardiac reactions. Sometimes 10 percent phenylephrine
on conjunctival instillation may cause significant elevation of blood pressure. Exercise
caution with elderly patients and children and carefully monitor the blood pressure in
such cases.
Hydroxyamphetamine
Hydroxyamphetamine is an indirect acting adrenergic agonist. Its pharmacological action
is primarily due to release of norepinephrine from postganglionic adrenergic nerve
terminals. It has very little effect on accommodation.
Indications To dilate the pupil for diagnostic procedure and ophthalmoscopic
examination of the eye.
Dosage Hydroxyamphetamine is available as 1 percent topical solution (15 ml pack). It
has mydriatic effect comparable to 2.5 percent phenylephrine. Maximum pupillary
dilatation occurs in 25 to 40 minutes and effect lasts for 4 to 6 hours.
Since the drug stimulates the release of norepinephrine from adrenergic nerve
terminals, its mydriatic effect depends on the integrity of the adrenergic innervation to the
pupil. A pupil with postganglionic sympathetic lesion will fail to dilate.
Hydroxyamphetamine can be used to differentiate clinically postganglionic Horners
syndrome from one that is central or preganglionic. Hydroxyamphetamine is a slightly
weaker mydriatic in young children and infants because the adrenergic innervation to the
iris is not yet fully developed in this age group. Adverse effects are similar to those
reported with phenylephrine.
Cholinergic Antagonist as Mydriatic Agents
Cholinergic antagonist specially tropicamide differs from phenylephrine and
hydroxyamphetamine in its mechanism of action. Tropicamide blocks the effects of
acetylcholine released from cholinergic nerve endings at the iris sphincter and ciliary
muscle. The drug, therefore, causes mydriasis and cycloplegia. Compared to other
cycloplegics, the accommodative effect of tropicamide is less pronounced and of shorter
duration.
Dosage Following topical instillation of 0.5 percent or 1 percent ophthalmic preparation.
Mydriasis occurs within 20 to 30 minutes and effect lasts for 6 to 8 hours. The advantage
of tropicamide over adrenergic mydriatics is that mydriasis with it is more pronounced
Phacoemulsification
242
and bright illumination has no significant effect on pupil size. The mydriatic effect
appears independently of iris pigmentation.
Adverse reactions to tropicamide are quite rare. Since it is devoid of vasopressor
action, it is safe for use in patients with cardiac disease and hypertension. Due to its
relatively faster onset, short duration and intensity of mydriatic action, tropicamide is
presently the drug of choice for pupil dilatation. For clinical situations where maximum
pupillary dilatation is desirable, tropicamide is combined with phenylephrine or
hydroxyamphetamine. Various commercial combinations are available. The details are
given at the end of this chapter.
Cycloplegic Mydriatics
Cycloplegic mydriatics are commonly used for both objective and subjective refractive
procedures.
In different pathological conditions of the eye as treatment, specially strabismus in
children (esotropia), uveitis (anterior and posterior uveitis) these agents are commonly
used.
Parasympatholytic agents are commonly used as cycloplegic mydriatics.
Mechanism of Action
Anticholinergic agents block the responses of the sphincter muscle of the iris and the
muscles of the ciliary body to cholinergic stimulation producing pupillary dilatation
(mydriasis) and paralysis of accommodation (cycloplegia).
Indications
For cycloplegic refraction and for dilatation of pupil in the inflammatory conditions of
the iris and uveal tract.
Contraindications
Narrow angle glaucoma, sensitivity to belladona alkaloids or any component. In elderly
patients specially with atropine where undiagnosed glaucoma or extensive pressure in the
eye may be present.
Precautions
Avoid excessive systemic absorption by compressing the lacrimal sac by digital
pressure for 1 to 2 minutes after instillation.
Permanent mydriasis may occur in patients with keratoconus.
Use with caution longer acting agents (atropine and scopolamine) and they may cause
posterior synechiae formation when treating anterior segment inflammation.
Acute hypersensitivity reaction, discontinue use and have 1:1000 epinephrine solution
available.
245
Sulfite sensitivity.
Avoid potentially hazardous tasks (observe caution while driving or performing other
tasks requiring alertness).
Do not exceed recommended dosages.
Excessive use in children and suspectible cases should be avoided.
Adverse Reactions of Parasympatholytic Agents
On topical use adverse effects reported are increased IOP, transient stinging and burning
sensation, allergic lid reactions, hyperemia, follicular conjunctivitis vascular congestion,
edema, exudate, photophobia and eczematoid dermatitis.
Systemic adverse effects include systemic atropine toxicity manifested by flushing and
dryness of the skin, blurred vision, photophobia with or without corneal staining, dryness
of mouth and nose, anhydrosis, fever, rapid pulse, bladder distention, hallucinosis, loss of
neuromuscular coordination. Severe reactions are manifested by hypotension with
progressive respiratory depression, coma, medullary paralysis and death.
Other adverse effects reported are cardiac dysrhythmias especially in patients
undergoing surgery for glaucoma. Headache, parasympathetic stimulation, allergic
reactions and toxic manifestations of anticholinergic drugs.
In addition, use of cyclopentolate and tropicamide has been associated with psychotic
reactions and behavioral disturbances in children. CNS disturbances like ataxia,
incoherent speech, restlessness, seizures, disorientation to time and place and failure to
recognize peoples.
Overdosage
When symptoms of atropine toxicity develop (see adverse reactions) administer
parenteral physostigmine.
Various parasympatholytic agents used in ophthalmology as cycloplegic mydriatics
(Table 15.1) are:
Atropine
Homatropine
Scopolamine
Cyclopentolate
Tropicamide.
Individual drug monograph is as follows:
TABLE 15.1 Cycloplegic mydriatics

Drug
Atropine
Homatropine
Scopolamine
Onset
(minutes)
3040
4060
2030
Mydriasis
Duration
(hours/days)
710 d
13 d
37 d
Cycloplegia
Onset
Duration
(minutes)
(hours)
6090
3060
3060
710
13
57
Solution
Available
0.53%
25%
0.25%
Phacoemulsification
Cyclopentolate
Tropicamide
3060
2040
1d
48 hours
244
2045
2030
1d
48
0.52%
0.51%
Atropine Sulfate
Atropine sulfate is a potent parasympatholytic agent for use in producing cycloplegia and
mydriasis.
It is the strongest mydriatic for common use in ophthalmology.
It completely paralyzes the sphincter pupillae and ciliary muscle. It takes considerable
time to cause complete paralysis.
It is an alkaloid used in water soluble form (atropine sulfate).
Indication Atropine sulfate is used both for its cycloplegic and mydriatic effects for
cycloplegic refraction or for pupil dilatation in acute inflammatory conditions of the iris
and uveal tract. For cycloplegic refraction its use is on decline due to the availability of
faster acting, short duration parasympatholytic agents.
Dosage Atropine sulfate is available as topical ophthalmic solution in concentration of
0.5 percent, 1 percent, 2 percent and 3 percent. Atropine ointment is available in 0.5
percent and 1 percent concentrations.
A single drop of 1 percent atropine solution results in maximal mydriasis in about
three hours and effect of single dose lasts for 3 to 7 days.
For uveitis treatment usual dosage is to instill 1 to 2 drops of 1 percent solution into the
eyes four times daily while in children recommended dosage is to instill 1 to 2 drops
of 0.5 percent solution three times a day.
For refractioninstill one drop of 1 percent solution into the eye twice a day 1 to 2
days prior to examination. While in children recommended dosage is 1 to 2 drops of
0.5 percent solution twice daily 1 to 3 days before the examination and 1 hour before
examination.
Ophthalmologists consider atropine as first drug of choice for the first refraction in all
children under the age of 7 years or when there is risk of convergent strabismus. It may
also be used as type of occlusion in amblyopia, latent nystagmus and in difficult cases of
accommodative spasms.
Atropine is drug of choice in severe anterior segment inflammation reducing the risk
of posterior synechiae.
Adverse reactions Generalized adverse reactions of parasympatholytic agents are already
discussed in this chapter. As atropine has potential local and systemic side effects, it is
necessary to discuss these effects separately.
Ocular adverse effects Atropine may cause local irritation, accommodative spasm,
anterior movement of lens-iris-diaphragm, breakdown of blood-aqueous barrier,
decreased anterior chamber depth, drug-induced cicatrizing conjunctivitis, hyperemia,
corneal toxicity, increased intraocular pressure, cataract formation, allergic
blepharoconjunctivitis, twitching of orbicularis oculi, iris cyst, miosis, increased
peripheral vitreal traction.
Systemic effects Dose related side effects are depicted in Table 15.2.
247
TABLE 15.2 Side effects of atropine

Dose
Effects
0.52 mg (14 drops of 1% solution)
Tachycardia dry mouth

Mydriasis/cycloplegia
5 mg (10 drops, 1% solution)
In addition to above one speech disturbance.
Restlessness confusion. Hot/dry skin
Decreased GI motility urinary retention
>10 mg (20 drops or more of 1% solution) Above side effect and ataxia, hyperexcitability
Hallucination
Coma
Convulsion
Death
Homatropine
Homatropine is semisynthetic alkaloid prepared from atropine. It is used in its water
soluble formhomatropine hydrobromide.
Indications Homatropine is moderately long-acting mydriatic and cycloplegic for
refraction and in treatment of inflammatory conditions of the uveal tract, for preoperative
and postoperative states when mydriasis is required and as an optical aid in certain cases
of axial lens opacities.
Dosage Homatropine is available as 2 percent and 5 percent ophthalmic solution.
For refraction instill 1 to 2 drops of 2 percent solution into the eyes and repeat it 5 to
10 minutes if necessary.
For uveitis instill 1 to 2 drops of 2 percent solution into the eyes every 3 to 4 hour
interval.
It acts more quickly than atropine, mydriasis being usually complete within 40
minutes and cycloplegia after one hour of instillation. The duration of action is shorter
than atropine and recovery occurs in about 24 hours.
Adverse effects have already been covered in general monograph of
parasympatholytic agents.
Scopolamine
Scopolamine is used in its water soluble form of scopolamine hydrobromide.
Indications Scopolamine is an anticholinergic agent for use in producing cycloplegia and
mydriasis, for preoperative and postoperative states in the treatment of iridocyclitis.
Dosage Scopolamine is available as 0.25 percent ophthalmic solution. Usual dosage for
refraction is to instill 1 to 2 drops into the eye 1 hour before refraction.
For uveitis, instill 1 to 2 drops four times daily into the affected eyes.
Its mydriatic effect starts in 20 to 30 minutes and cycloplegic effect appears in 30 to
60 minutes and duration of effect lasts for 3 to 7 days.
Phacoemulsification
246
Cyclopentolate HCl
Cyclopentolate hydrochloride is a synthetic mydriatic and cycloplegic agent. It is very
effective and short-acting.
Indications Cyclopentolate hydrochloride is used for mydriasis and cycloplegia in
diagnostic procedures.
Dosage Cyclopentolate is available as 0.5, 1 and 2 percent ophthalmic solution.
Maximal mydriasis occurs in 30 minutes and cycloplegia is usually complete in 40
minutes.
To ensure complete cycloplegia two applications of Cyclopentolate HCl are used at 10
minutes interval.
Recovery of accommodation usually occurs in 8 to 24 hours.
Recommended dosage in adultsinstill one drop of 1 percent solution, repeat in 5 to
10 minutes. Although complete recovery occurs in 24 hours time, yet 1 to 2 drops of 1
percent or 2 percent pilocarpine reduces recovery time to 3 to 6 hours in most eyes.
In children usual dosage is to instill 1 drop of 0.5 percent, 1 percent or 2 percent
solution in each eye followed 5 minutes later by second application. Observe patient
closely for at least 30 minutes following instillation.
Tropicamide
Tropicamide is another rapidly acting mydriatic and cycloplegic agent and acts faster
than Cyclopentolate (Short-acting anticholinergic agent).
It blocks the parasympathetic fibers and causes relaxation of sphincter pupillae muscle
of the iris producing mydriasis.
Indications For mydriasis and cycloplegia for diagnostic purposes, when short-acting
mydriatic is needed for some preoperative and postoperative states.
It prevents constriction of pupil caused by intense light stimulation during indirect
ophthalmoscopy or retinal photography.
Dosage Tropicamide is available as 0.5 percent and 1 percent ophthalmic solutions.
Recommended dosage for refraction is to instill 1 to 2 drops of 1 percent solution into
the eyes, repeat after 5 minutes an additional drop to prolong mydriatic effect.
For fundus examination, instill 1 to 2 drops of 0.5 percent solution 15 to 20 minutes
prior to examination.
On account of its short latency, brief duration and effective mydriasis, it is perhaps the
best mydriatic for the usual fundus examination.
Due to shorter duration of action, it is used as provocative test for acute glaucoma
though under strictly controlled conditions.
It is used alone or in combination of sympathomimetic agent (phenylephrine) to
produce much better response and mydriatic effect persists to facilitate ocular
examination.
Some other drugs of this group were previously used for mydriatic and cycloplegic
effect but now not in use.
1. Duboisine (0.11.0% drops)
2. Lachesine or E3 (0.5 drops)
249
TABLE 15.3 Relative efficiency of cycloplegics

Drug
% Efficiency
1% Atropine
1% Cyclopentolate
1% Tropicamide
5% Homatropine
0.25% Scopolamine
100
92
80
54
48
Mydriatic Combinations
Phenylephrine is commonly used with tropicamide, cyclopentolate or scopolamine to
induce mydriasis which is greater than of either drug alone.
Phenylephrine 5 percent and Cyclopentolate HCl 1 percent Instill 1 drop into each eye
every 5 to 10 minutes not to exceed three times.
Phenylephrine 10 percent and Scopolamine 0.3 percent For mydriasis, cycloplegia and to
break posterior synechiae in iritis.
Dosage For mydriasis 1 to 2 drops into the eye and repeat in 5 minutes if necessary.
Postoperatively 1 to 2 drops into the eyes 3 to 4 times daily.
Phenylephrine 5 percent with tropicamide 0.8 percent
For short acting mydriasis in refraction and in pre- and postoperative states.
For refraction instill 1 to 2 drops and repeat at 5 minutes interval, if necessary.
For postoperative stage instill 1 to 2 drops three times a day.
Cyclopentolate HCl 1 percent with Dexamethasone sodium phosphate 0.1 percent
For postoperative inflammation where mydriatic and inflammatory therapy is
simultaneously required.
Dosage Instill 1 to 2 drops into the affected eyes three times a day.
Atropine Sulfate 1 percent solution with Dexamethasone sodium phosphate 0.1 percent
For postoperative inflammation and anterior and posterior uveitis where mydriatic and
inflammatory therapies are required in addition also.
Dosage Instill 1 to 2 drops into the affected eyes three a day.
Phenylephrine (5%) and tropicamide (0.8%) combination is commonly used in
ophthalmology today. The major advantage of this combination is that it produces quick
mydriasis and mydriatic effect persists to facilitate ocular examination.
Indications This preparation is mainly indicated for
Ophthalmoscopic examination
Slit lamp examination
Retinal photography
Prior to ocular surgery and other diagnostic procedures.
It is also used
Phacoemulsification
248
As an adjunct in the treatment of anterior uveitis

In the management of anterior segment burns (to dilate the pupil and prevent iris
adhesions to the lens)
In cycloplegic refraction
For the management of iridocyclitis associated with stromal keratitis
For the management of uveal inflammation associated with fungal keratitis.
Dosage This combination is available as topical ophthalmic solution (in 5 ml pack). For
ophthalmological examinations, 1 to 2 drops in the eye 15 to 30 minutes prior to the
procedure are advised. For other indications frequency should be as per direction of
ophthalmologists.
This preparation is contraindicated in patients suffering from closed angle glaucoma
and hypersensitivity to any ingredient of this formulation.
Adverse reactions On topical application there may be transient burning or stinging
sensation and lacrimation. Blurred vision, photophobia and allergic reactions may occur.
16
Update on Ophthalmic Viscosurgical Devices
Suresh K Pandey, Jaya Thakur
Liliana Werner, Andrea M Izak
David J Apple
Background
Viscoelastic substances are solutions with dual properties; they act as viscous liquids as
well as elastic solids or gels. The ideal viscoelastic substance in ophthalmology should be
viscous enough to prevent collapse of the anterior chamber at rest, yet liquid enough to be
injected precisely through a small cannula. It should be elastic or shock absorbing and
should enhance coating yet have minimal surface activity. It should be cohesive enough
to be easily removed from the anterior chamber but not so cohesive that it is aspirated
during irrigation and aspiration, which would provide no protection to endothelial cells
during surgical manipulations. It should be eliminated from the eye in the postoperative
period without an effect on intraocular pressure.68,20,22,23
Viscosurgery was a term coined by Balazs10,11 to describe the use of these solutions
that had viscous, elastic and pseudo plastic properties during and after surgical
procedures. During viscosurgery, viscoelastic substances are used as a fluid or a soft
surgical instrument. The viscoelastic sodium hyaluronate was first used in ophthalmic
surgery in 1972, when it was introduced as a replacement for vitreous and aqueous
humor.10,11 Since then ophthalmic surgical procedures had undergone considerable
advancement. The use of viscoelastic materials has become common place in anterior and
posterior segment surgeries. These agents facilitate delicate and often difficult intraocular
manipulations during various ophthalmic surgical procedures. They are used during
cataract surgery and intraocular lens (IOL) implantation to maintain the anterior chamber
depth and capsular bag disten-tion, thus creating and preserving working space for the
ophthalmic surgeon. These agents are designed to protect the delicate corneal endothelial
cells during the surgery.20
The viscoelastic substances has been termed as ophthalmic viscosurgical devices
(OVDs).9 A detailed discussion regarding biocompatibility, physical, and rheological
properties of the OVDs are beyond the scope of this chapter. Interested readers may
consult the excellent review article(s) published by Liesegang on this topic.21,22 The
viscoelastic substances must be non-toxic, nonpyrogenic, noninflammatory,
nonimmunogenic, and sterile for use in the human eyes. The substance should not
interfere with the normal metabolism of the cells in contact with it. Substances that are
immunogenic, may cause granulation or capsule formation, stimulate cell invasion, or
interfere with epithelization or blood coagulation cannot be used in the eyes.17,22,23 Each
viscoelastic substance has unique physicochemical properties which determines its
Phacoemulsification
250
clinical appilications.22,23,38,39,44 Figures 16.1 A to C is a gross photograph showing

physical characteristics (viscosity) of 3 different concentration of the sodium hyaluronate
solution (Healon, Healon-GV and Healon-5).
In this chapter, we will provide an update of currently used OVDs and will focus on
the newly available viscoadaptive viscoelastics (e.g. Healon-5), their clinical
applications and complications. Some of the details related to OVDs had been discussed
in the previous chapter of this textbook.14 The current chapter is based on the review of
the published literature on this topic and also derived from the information and
illustrations available from the manufacturer.
Classification of the OVDs
Table 16.1 presents summary of the currently available OVDs. OVDs can be classified
according to their Zero shear viscosity and cohesion. The zero shear viscosity is directly
proportional to the molecular weight. This classification describes the surgical behavior
of the viscoelastics and is as follows.7
1. High viscosity-cohesive OVDs
a. Super viscous-cohesive OVDs (>1,000,000 mPs)
Update on ophthalmic viscosurgical devices
253
FIGURES 16.1A TO C Gross

photograph showing physical
characteristics (viscosity) of 3 different
concentration of the sodium
hyaluronate solution (A) Healon. (B)
Healon-GV (C) Healon-5
Phacoemulsification
252
TABLE 16.1 Classification of ophthalmic

Viscosurgical devices (OVDs)
Higher viscosity: Cohesive OVDs
Viscosurgical Manufacturer Molecular Source
Chemical compound
Osmolality Viscosity Vo
agents
Wt (D)
(mOsm/liter)
(mPs)
Viscoadaptive (fracturable)
Healon-5 Pharmacia
5.0 M
Rooster
Hyaluronic Acid
322
2.3 Na Ha 7.0 M
Inc.
Coombs
(23mg/ml)
Super Viscous
5.0 M
Rooster
Hyaluronic Acid
310
1.4 Na Ha 2.0 M
Healon-GV Pharmacia
Inc.
Coombs
(14 mg/ml)
I-Visc Plus I-Med
7.9 M
Rooster
Hyaluronic Acid
1.4 Na Ha 4.8 M
Pharma
Coombs
(14 mg/ml)
Viscous
I-Visc
I-Med
6.1 M
Roster
Hyaluronic Acid
336
1.0 Na Ha 1.0 M
Pharma
Coombs
(10 mg/ml)
Healon
Pharmacia
4.0 M
Rooster
Hyaluronic Acid
302
1.0 Na Ha 230
Inc.
Coombs
(10 mg/ml) K
Provisc
Alcon
2.0 M
Microbial
Hyaluronic Acid
307
1.0 Na Ha 280
fermentation
(10 mg/ml) K
IO lab (B and 1.0 M
Rooster
Hyaluronic Acid
340
1.6 Na Ha 100
Amvisc
L surgical)
Coombs
(16 mg/ml) K
Plus
Amvisc
IO Lab (B
1.0 M
Rooster
Hyaluronic Acid
318
1.2 Na Ha 100
and L
Coombs
(12 mg/ml) K
surgical)
Biolon
Biotech
3.0 M
Bacterial
Hyaluronic Acid
279
1.0 Na Ha 215
general corp
Fermentation
(12 mg/ml) K
Low viscosity: Dispersive OVDs
Medium Viscosity
Alcon
500 K
Bacterial
Hyaluronic acid Chondriotin 325
3.0 NaHa 41K
Viscoat
Fermentation Sulphate
4.0 CDS
Shark Fin
(40 mg/ml)
Vitrax
Allergan
500 K
Rooster
Hyaluronic Acid
310
3.0 Na Ha 25 K
Coombs
(30 mg/ml)
Cellugel
Vision
100 K
Synthetic
Hydroxypropylmethylcellulose 305
2.0
38 K
biology
Chemically
(Alcon)
modified
HPMC
Ocucoat
Storz (B and 86 K
Wood pulp Hydroxypropylmethylcellulose 285
2.0 HPMC 4 K
L surgical)
(20 mg/ml)
Visilon
Shah and
86 K
2.0 HPMC 4 K
Shah
(20 mg/ml)
Viscon
Dr.
86 K
Hydroxypropylmethylcellulose
2.0 HPMC 4 K
Agarwals
(20 mg/ml)
Pharma
Visicrome Croma
2.0 HPMC
Pharma
(20 mg/ml)
Vo (mPs)= Zero shear Viscosity (milli Pascal Seconds); (D)=Daltons; M=Millions; K=Thousand; NaHa=Sodium
hyaluronate; HPMC=Hydroxypropylmethylcellulose; CDS=Chondroitin sulphate
b. Viscous-cohesive OVDs (Between 100,000 and 1,000,000 mPs)
255
2. Lower viscosity-dispersive OVDs

3. Viscoadaptive OVDs (e.g. Healon-5)
High Viscous-cohesive OVDs
The super viscous-cohesive group includes Healon-GV and I-visc plus while the
viscous-cohesive group includes products like I-visc, Provisc, Healon, Amvisc,
Amvisc plus and others. All these products contain sodium hyaluronate.
High viscous-cohesive OVDs are indicated in many routine procedures and are used to
create space and also stabilize the surgical microenvironment. Examples of situations
where they are used include deepening the anterior chamber, to enlarge small pupils, to
dissect adhesions, and during IOL implantation to push back the iris and vitreous.
Super Viscous-cohesive OVDs
Healon-GV (greater viscosity) is a sterile, nonpyrogenic agent produced from rooster

coombs. It has a concentration of 1.4 percent sodium hyaluronate and a molecular weight
of 5 million Daltons.
It is used as a surgical aid in various anterior segment procedures such as cataract
extraction, IOL implantation, corneal transplant surgery and glaucoma surgery. In
presence of high positive pressure, Healon-GV has 3 times more resistance to pressure
than Healon. I-Visc was introduced as a Healon-GV clone. It has superior viscous and
cohesive properties at low shear viscosity when compared to Healon-GV (Table 16.1).
Super viscous-cohesive agents are better in current day techniques where topical and
intracameral anesthesia are used and the surgeries are entirely in-the-bag
phacoemulsification. High cohesiveness of superviscous and viscous materials result in
easy removal as a single mass at the end of the surgical procedure, thus preventing the
increased intraocular pressure postoperatively.
Lower Viscosity-dispersive OVDs
Dispersive agents have low molecular weight and shorter molecular chains. Medium
viscosity, dispersive OVDs possess zero shear viscosities between 10,000 and 100,000
mPs. Very Low viscosity, dispersive agents include all of the unmodified
hydroxypropylmethylcellulose (HPMC) agents.
These dispersive materials when injected into the eye have the property of fracturing
and breaking into smaller bits and thus disperse in the anterior chamber. They include
Viscoat, Cellugel, Vitrax, Ocucoat and others (Table 16.1).
Most of the dispersive OVDs are HPMC-hydroxypropyl methylcellulose, derived
from wood pulp. Cellugel is a chemically modified HPMC. Viscoat is a combination
of sodium hyaluronate and chondroitin sulphate. Vitrax is a compound of low molecular
weight molecular hyaluronate.
The clinical use of these agents is to hold back vitreous out of the surgical field
especially in cases of zonular disinsertion. They are helpful in a compromised corneal
endothelium conditions, as they are capable of dividing the anterior chamber into OVD-
Phacoemulsification
254
occupied space and surgical zone in which irrigation/aspiration can be continued without
the mixing of the two areas-known as surgical compartilization.
The disadvantage of lower viscosity dispersive OVDs is that they do not maintain or
stabilize spaces as compared to higher viscosity cohesive agents. They tend to be
aspirated in smaller fragments during irrigation/aspiration thus leading to irregular
viscoelastic aqueous interface, thus partially obscuring the surgical view of the posterior
capsule. They also form microbubbles and can be trapped at the irregular interface thus
further obscuring visibility. Moreover they are difficult to remove at the end of the
surgery because of low cohesion.
Soft Shell Technique
This technique was developed by Arshinoff, in order to take advantage of the best
properties of both lower viscosity-dispersive agents and high viscosity-cohesive agents
and to minimize the drawbacks of each by using them together.8 In this technique first the
lower viscosity dispersive is injected into the anterior chamber, followed by high
viscosity-cohesive agent, which is injected into the center of the lower viscositydispersive viscoelastic thus pushing it outwards and compressing it into a smooth, even
layer against the corneal endothelium. This protects the endothelium during lens removal.
Prior to the implantation of the IOL, the reverse is done. High viscosity cohesive is
injected first to partially fill the anterior chamber and the capsular bag, followed by
injection of lower viscosity dispersive into the center of high viscosity cohesive agent.
This allows the free movement of the IOL through the dispersive agent, with better
stabilization of the surrounding iris and the capsular bag by the high viscosity agent.48
Removal of the OVDs is easily accomplished at the end of the surgery, since low
viscosity dispersive OVA can be aspirated from the central anterior segment first,
followed by higher cohesive agent. Duo Visc-a combination of high viscosity-cohesive
Provisc and the lower viscosity dispersive Viscoat.
Viscoadaptive OVD-Healon-5
The existing viscoelastic products all have drawbacks. A cohesive viscous product used
to create and maintain space may not stay in the eye during phacoemulsification. On the
other hand, a less viscous dispersive product stays during phacoemulsification but often
traps fragments or air bubbles and does not maintain adequate space during the surgical
procedure.
Recently the new viscoadaptive viscoelastic Healon-5 has been developed to change
its behavior at different flow rates.3 It acts as a viscous cohesive viscoelastic agent at
lower flow rates and as a pseudodispersive viscoelastic agent at higher flow rates. It is all
in one device that adapts its behavior to the surgeons needs during the entire course of
surgery.
This is a steam sterilized, non-pyrogenic solution. It is highly purified noninflammatory, high molecular weight sodium hyaluronate at a concentration of 23 mg/ml
(2.3%) dissolved in a physiological buffer. It has an osmolality and a pH similar to those
of the aqueous humor. It has a viscosity at rest about 7 million times higher than aqueous
humor. It is extracted from rooster coombs.
257
Hyaluronate is a polysaccharide made up of disaccharide units linked by glycosides

bonds. It occurs naturally on the corneal endothelium bound to specific receptors. The
natural hyaluronate is reduced during irrigation but can be restored by an exogenous one.
Healon-5 has a high affinity to the receptors. It acts as a scavenger by neutralizing the
free radicals formed during cataract surgery using ultrasound.
Characteristics and Advantages of the Viscoadaptive OVDs
1. Viscoadaptive OVD (Healon-5) is specifically developed so that, at different flow
rates it has different functions. At lower flow rates it behaves as a very cohesive
viscoelastic like a Healon-GV. At higher flow rates, e.g. in chopping techniques, it
begins to fracture and behaves similarly to a dispersive viscoelastic, such as Viscoat.
Hence Healon-5 has features that can change according to the needs of the surgeon
during various stages of cataract surgery.
2. It is crystal clear as pure water and has somewhat higher refractive index than the
aqueous humor. Hence it increases the clarity within the surgical field.
3. It also has the ability to protect the delicate corneal endothelial cells from debris and
turbulence during phacoemulsification, particularly with very low endothelial cell
count. In a recent study by Holzer et al,16 the average loss of corneal endothelial cells
was lowest for their surgeries using Healon-5 compared to other OVDs.
4. Viscoadaptive OVD (Healon-5) is also helpful in patients with suboptimal pupil size
because the viscomydriasis allows for a larger capsulorhexis and keeps the pupil larger
during phacoemulsification thus increasing the visibility.
5. It also neutralizes the positive vitreous pressure and prevents capsulorhexis from
extending by temporarily stopping all action, thus allowing the surgeon to determine
what is going on inside the eye, analyze his or her options and effect the appropriate
management.
6. The high viscosity of Healon-5 creates space and stabilizes the anterior segment. The
elasticity absorbs shock and protects ocular tissues during IOL unfolding, which is
slowed down and is more controlled.
7. Healon-5 is also easy to remove. The Rock and Roll technique10 with suitable
settings for each type of phacoemulsifications, was found to be a safe method for
complete removal of it. In this technique there is sufficient turbulence created and this
fractures Healon-5 into small pieces. The other method for Healon-5 removal is the
two compartment technique (TCT).50 Full advantage of the agents viscoadaptive
properties is taken in this technique. The superior space maintaining capacity of
Healon-5 in the anterior chamber is utilized while removing the substance from the
capsular bag. In the second step the anterior chamber is cleaned.
There is a learning curve for surgeons using Healon-5, but as surgeons begin making a
number of small procedural adaptations, the advantages of the viscoadaptive OVD will
increasingly become apparent.
Phacoemulsification
256
Clinical Application of the OVDs

In recent years the field of viscosurgery has broadened rapidly. It has been used both
intraocularly as well as extraocularly, which includes cataract, cornea, glaucoma,
vitreoretinal, strabismus and oculoplastic surgeries.7,22,23,30
Use of OVDs in Cataract Surgery
OVDs are helpful in each step of modern cataract surgery using phacoemulsification with
IOL implantation.5,13,41,43 Some of these details are shown in the schematic photograph
(Figs 16.2A to F and 16.3).
Capsulorhexis
In order to perform an intact and successful capsulorhexis, the contents of the anterior
chamber have an important role. Till date balanced salt solution (BSS), air and OVDs
have been used. Out of these three the best is viscoelastic as it is considered the easiest,
safest, and the most reproducible method in both routine and difficult cases (Figs 16.2A
and B). To perform a good capsulorhexis, the viscoelastic to be used should have the four
basic features:
1. High molecular weight and high viscosity at zero shear rate, which maintains the
anterior chamber.
2. Excellent visibility provided by high transparency.
3. Make surgical maneuvers easy, due to high elasticity and pseudoplasticity.
4. It should give a good capsular flap control, providing the soft and permanent spatula
effect.
Cleavage of Lens Structure
It is best performed with the use of OVDs. The ideal viscoelastic material keeps the
anterior chamber shape unchanged during BSS injection and also avoids increase in
pressure, which can be produced with excessive amount of BSS known as capsular
blockade.
Nuclear Emulsification
During phacoemulsification, the viscoelastic is likely to remain in the anterior chamber
instead of leaking out of the eye (Fig. 16.2C). OVDs help in preserving the space and
also because of their low cohesiveness, they remain in the anterior chamber despite high
irrigation flow. Moreover OVDs adhere to the corneal endothelium, thus protecting the
corneal endothelial cells. Healon and Healon-GV does not trap the air bubble and
provide excellent endothelial protection (Fig. 16.2D). This is because of:
259
1. Scavenger effect: This effect captures the free radicals released during phaco with
consequent inactivation.
2. Binding sites: There are chemical receptors for viscoelastic materials on the corneal
endothelium. A molecular bond seems to occur between the viscoelastic solution and
the corneal endothelium.
3. High elasticity: This also smoothes the possible impacts of the lens material against the
endothelium.
FIGURES 16.2A TO F Schematic

photograph showing use of the OVD
(viscoadaptive OVD-Healon-5 in this
figure) during the various steps of the
cataract surgery. (Courtesy: Pharmacia
Inc. Peapack, NJ, USA). (A) Injection
of the viscoadaptive OVD in the
anterior chamber through a 25 G
cannula. (B) Capsulorhexis is in
progress. (C) Phacoemulsification in
Phacoemulsification
258
progress. (D) Viscoadaptive OVD is

transparent and easy to see during
removal (left). Note the presence of the
air bubbles within the anterior chamber
after use of dispersive viscoelastic
solution (right). (E) Implantation of a
posterior chamber intraocular lens in
the capsular bag. (F) Removal of the
viscoadaptive OVD using irrigationaspiration tip
FIGURE 16.3 Beside posterior

chamber IOL fixation in the capsular
bag, OVDs can also be used for
implantation of the various phakic and
aphakic IOL designs in the anterior
chamber, ciliary sulcus, etc. Use of the
OVD facilitated the implantation of the
Artisan IOL as shown in this
photograph (Courtesy: Camil Budo,
MD)
The phaco tip being in a closed system, its vibrations are transmitted to the internal
structures of the eye but viscoelastic provides a smothering shield against them.
Irrigation and Aspiration
The role of viscoelastic during this procedure is the protection of the endothelium. This is
possible due to high adhesiveness. It remains where it is placed, without mixing with the
cortex because of its low cohesiveness thus helping in easy removal of cortex.
261
Capsular Bag Filling and IOL Implantation

During IOL implantation, it is necessary to expand the capsular bag with a viscoelastic. It
allows the surgeon to keep the bag well opened and formed thus allowing the easy IOL
implantation. OVD is also helpful in correct positioning, centering and allowing for
possible IOL rotation maneuvers (Figs 16.2E and F). Beside posterior chamber IOL
implantation, OVD has also been used for implantation of other IOL designs (e.g.
anterior chamber, iris fixated, artisan lenses, etc.) (Fig. 16.3).52
Cataract Surgery in Pediatric Patient
Pediatric cataract surgery like the adult surgery has undergone major changes in recent
years with the evolution of techniques including small incision and the development of
modern IOLs. The main principle lies in the control of the very elastic nature of ocular
tissues.42
It is difficult to perform a good capsulorhexis in the presence of high capsular
elasticity. Moreover there is low scleral rigidity, greater intravitreal pressure that makes
the capsulorhexis even more difficult, as the pressure tends to curve the capsulorhexis.
But with the use of viscoelastic, e.g. Healon-GV the effective push is in the opposite
direction and hence completion of capsulorhexis can be done.
In pediatric cases, the capsulorhexis must be started in the central portion and not
towards the equator, in order to prevent radial extension. The high-density viscoelastic
agents stabilize the posterior chamber and pushed back the vitreous face during the
posterior capsulorhexis. During IOL implantation, the capsular bag is kept open and the
anterior chamber is well formed thus ensuring easy and safe implantation of the IOL in
the bag. These agents also help to dilate the pupil thus maintaining a good intraoperative
mydriasis.5557
OVDs like Healon-GV can easily be removed at the end of the surgery including the
position, which is behind the IOL due to its high cohesiveness thus preventing capsular
blockade.
Use of the OVDs in Glaucoma Surgery
Viscocanalostomy
Viscocanalostomy is a new surgical procedure for glaucoma therapy.45 Viscoelastics play
an important role in this procedure. Figures 16.4A to F illustrates the surgical steps of
Viscocanalostomy. Viscocanalostomy literally means opening of the canal by means of
viscoelastic substance. This procedure is a non-penetrating and independent from
external filtration. The advantages are decreased risk of infection, and decreased
incidence of cataract, hypotony and flat anterior chamber as the anterior chamber is not
opened, and moreover, with the absence of external filtration the bleb formation is
Phacoemulsification
260
FIGURES 16.4A TO F Surgical steps

of viscocanalostomy. (A) Deep block
construction incision. (B) Cutting the
deep block in a single plane with a
spoon blade. (C) Proximal to
Schlemms canal there is a subtle
change in the scleral fibers, from a
crossing pattern to a tangential pattern,
with an increased opacity. (D)
Descemets window. (E) Cannulating
Schlemms canal with three puffs of
263
viscoelastic directed at the osteum. (F)

Tight closure suture of the flap
(Courtesy: Dr. med. Tobias Neuhann,
MD, Munich, Germany)
prevented and also the related discomfort with it. It minimizes the risk of late infections
and is independent from conjunctival and episcleral scarring.
Viscocanalostomy allows the aqueous to leave the eye, through Schlemms canal and
episcleral veins thus restoring the natural outflow pathway. This procedure creates a
bypass by which aqueous humor reaches Schlemms canal, skipping the trabecular
meshwork. A chamber is produced inside the sclera, which is in direct communication
with the Schlemms canal. There is also a communication through the Descemets
membrane with the anterior chamber.
The OVDs should have high pseudoplasticity to allow injection into Schlemms canal
through a small needle and should have high viscosity at shear rate of zero to maintain
the spaces as long as possible. Healon-GV and Healon-5 are viscoelastics of choice for
this procedure.
OVDs for Intraocular Delivery of Dyes or Anesthetic Agents
Researchers and vision scientists have been using OVDs as a vehicle to deliver capsular
dyes for use during cataract surgery.1,25 Mixing these substances with the viscoelastic
agent was attempted to prolong their effect and to limit the adverse effect on ocular
tissues. Ciba Vision Corp. (Duluth, GA, USA), has recently proposed mixing an OVD
with lidocaine. This was termed viscoanesthesia and was intended to prolong the
anesthetic effect of intracameral lidocaine, as a complement to topical anesthesia. Also,
the steps of intracameral injection of OVDs and of intracameral injection of lidocaine, as
a complement to topical anesthesia, would be combined in only one step. In this chapter
we will briefly address the use of OVDs for viscostaining and viscoanesthesia.
Viscostaining of the Anterior Lens Capsule
Various non-toxic ophthalmic dyes have been extensively used as diagnostic agents for
the detection and management of different ocular disorders. Dyes such as fluorescein
sodium, indocyanine green (ICG), and trypan blue have been increasingly used for
enhancing visualization by staining intraocular tissues during the adult and pediatric
cataract surgery and vitreoretinal surgery. Staining of ocular tissues by using ophthalmic
dyes makes visual differentiation and manipulation of tissues easier. Enhanced viewing
of ocular tissues can assist a surgeons ability to evaluate clinical structural relationships
and may help attain surgical objectives with fewer complications.
Uses of various capsular dyes for staining the anterior lens capsule in white, mature
cataracts have been reported.3137,46,53 The techniques originally reported for staining the
anterior capsule using fluorescein sodium are: staining from above under an air bubble, as
proposed by Nahra and Castilla27 and intracameral subcapsular injection of fluorescein
sodium (staining from below) with blue-light enhancement. The first technique (staining
Phacoemulsification
262
under an air bubble) is currently used by most surgeons. One benefit is the staining of the
peripheral anterior capsular rim, which is otherwise difficult to visualize during the
phacoemulsification procedure. However, air in the anterior chamber makes it unsteady.
Any instrument entering the eye will cause some air to escape, with a rise of the lens-iris
plane. A small amount of high-density viscoelastic placed near the incision can prevent
the air bubble from escaping the anterior chamber, thus minimizing the risk of sudden
collapse. Also, with this technique, there is a progressive dilution of the dye by the
aqueous humor. This may be a possible explanation for the fainter staining observed with
this technique in recent clinical reports, without compromising its usefulness. Most of the
drawbacks of this technique can be avoided by careful use of a viscoelastic solution to
seal the incision site. Akahoshi1 proposed the soft shell stain technique for performing
a CCC in white cataract cases. A small amount of viscoelastic (Viscoat) was injected
into the anterior chamber followed by high molecular weight viscoelastic material
(Provisc) to fill up the chamber completely. The author then injected ICG solution on
the lens surface with a bent G27 viso cannula. The anterior capsule was uniformly stained
in green and easily visualized while the cornea remained unstained. According to the
author, the soft shell stain technique is extremely useful for CCC in white cataracts.
Alternatively, the dye solution can be mixed with viscoelastic agents a technique
known as viscostaining of the anterior lens capsule. Kayikicioglu and coworkers19
proposed a technique for limiting the contact of trypan blue to corneal endothelium by
mixing the dye with a viscoelastic solution. These researchers mixed 0.4 percent trypan
blue with 1 percent sodium hyaluronate in a 2 mL syringe. The dye, mixed in a
viscoelastic solution, is injected onto the anterior lens capsule, which covers the anterior
capsule without coming in contact with the corneal endothelium. Trypan blue mixed with
sodium hyaluronate greatly increases the visibility of the anterior lens capsule without
significantly touching the adjacent tissues. There is always a potential risk of corneal
decompensation after intraocular use of self-mixed solutions; however, these authors
used this technique without significant surgical and postoperative adverse effects.
Use of OVDs in Topical Ophthalmic Anesthesia (Viscoanesthesia)
Anesthetic techniques for cataract surgery have also advanced significantly. General
anesthesia was preferred in past years, followed by various techniques of injectable
anesthesia including retrobulbar, peribulbar, sub-tenon, and subconjunctival anesthesia.
Due to marked improvements in surgical techniques, it is no longer essential to ensure
complete akinesia of the eye and as a consequence, the technique of topical anesthesia
has been popularized as phaco anesthesia. This includes eyedrops application, sponge
anesthesia, eyedrops plus intracameral injection, and most recently gel application.15,40
Topical anesthesia is the preferred technique for the members of the American Society of
Cataract and Refractive Surgery (ASCRS) in the United States (49%; range 37%63%)
according to a survey conducted by David Learning in 2000.21 It revealed that as high as
82 percent of the respondents using topical anesthesia preferred eyedrops in association
with intracameral injection of lidocaine.
We have recently completed some studies to evaluate the use of viscoelastic agents
mixed with topical anesthetic solution (lidocaine). The aim of these studies was to
evaluate the safety of this new solution (termed as viscoanesthesia) to intraocular
265
structures.24,32,51 Our animal and experimental studies were divided into 3 parts. In Part
I,24 we determined the toxicity of the viscoanesthetic solution to the corneal endothelium
using a rabbit model. In Part II,51 we evaluated the toxicity of viscoanesthetic solutions to
uveal tissues and retina in a rabbit model after performing phacoemulsification. Finally,
in Part III,32 using postmortem human eyes, we evaluated and compared to currently
available OVDs in regard to the surgical aspects such as injection and aspiration of the
viscoanesthetic solutions. In brief, our experimental study demonstrated that addition of
varying concentrations of lidocaine to sodium hyaluronate (Ophthalin Plus) neither
significantly altered its viscosity or consistency nor changed its removal time from the
capsular bag. Our animal studies on viscoanesthesia (Part I, II) in rabbit eyes had
suggested that viscoanesthetic solution with lidocaine concentrations up to 1.65 percent
are non-toxic for the corneal endothelium, uveal or retinal tissues. Future clinical trails
are necessary to address the issue of efficacy of viscoanesthetic solutions to provide
prolonged topical anesthesia.
Removal of the OVDs
Several techniques have been reported in the literature for removal of the OVDs. These
include: Rock and roll technique, two-compartment technique and bimanual
irrigation/aspiration technique.4 Figures 16.5A to H are photographs from a human eye
obtained postmortem (Miyake-Apple posterior view) showing the sequence of the
experimental surgical technique of the removal of fluoresceincolored viscoelastic
solutions (green color as viewed with oblique illumination) from the capsular bag using
the rock and roll technique.
An effective technique to remove Healon-5 is to create maximum turbulence to make
it fracture into large pieces. This can be accomplished using rock and roll technique with
standard I/A tip, 0.3 mm, with high settings; a flow rate of 2530 ml/ min., and vacuum
350500 mm Hg, depending on the type of pump. If a peristaltic pump is used the
vacuum should be set towards the lower limit. A bottle height of 6070 cm above the eye
level. Figures 16.6A to C summarizes the removal technique of viscoadaptive agent,
Healon-5.
Phacoemulsification
264
FIGURES 16.5A TO H Gross

photographs from a human eye
obtained postmortem (Miyake-Apple
posterior view) showing the sequence
of the experimental surgical technique
of the removal of fluorescein-colored
viscoelastic solutions (green color as
viewed with oblique illumination)
from the capsular bag was documented
by videotaping. (A) This figure shows
the eye after capsulorhexis and
267
removal of lens substance (cortex and

nucleus) by phacoemulsification. Note
the edge of the anterior capsulectomy
(arrows). (B and C) Injection of
fluorescein-colored viscoelastic
solution (in this example, Ophthalin
Plus), with a 27 gauge Rycroft
cannula through the orifice of the
anterior capsulectomy. (D) Capsular
bag completely filled with viscoelastic
solution. (E) Same eye after insertion
of a one-piece modified C-loop
posterior chamber IOL in the capsular
bag (arrows). (F) Viscoelastic solution
removal with automated aspiration, set
at 250 mm Hg (Alcon Legacy 20,000).
(G) Final removal of viscoelastic
substance. The surgeon reached behind
the IOL optical edge to remove all the
viscoelastic material. (H) Aspect after
complete removal of the viscoelastic
solution
Phacoemulsification
266
FIGURES 16.6A TO C Schematic

photograph showing the one of the
removal technique of viscoadaptive
agent (Healon-5), as recommended
by the manufacturer. (A) The surgeon
circle the I/A hand piece in the anterior
segment at iris plane. (B and C) The
surgeon gently rests the I/A handpiece
on the anterior surface of the optic.
Press gently on the IOL optic on one
side and rotate the I/A handpiece
directing the flow into the bag. Direct
the handpiece port towards the equator
of the capsular bag and stay in this
269
position for a few seconds, and then

repeat on the other side of the IOL
optic until Healon-5 is completely
removed. Finally sweep the anterior
chamber including the angles and
repeat the step if necessary (Courtesy:
Pharmacia Inc. Peapack, NJ, USA)
FIGURES 16.7A AND B Schematic

photograph showing an alternative
removal technique of viscoadaptive
agent (Healon-5), as recommended
by the manufacturer. (A) Start the
removal directly after IOL
implantation, while the anterior
chamber is still filled with Healon-5
and before the IOL has been centered.
Go behind the IOL optic without
engaging the flow of the I/A tip (port
up) and then start flow. Remove
Healon-5 from the capsular bag first
Phacoemulsification
268
and ensure that lens has adequately

centered. During removal of Healon5 from the capsular bag, the
continuous flow of irrigation fluid
keeps the bag inflated and reduces the
risk of aspirating the capsular bag.
While maintaining continuous flow
remove the tip from behind the optic
and place it on top of optic. (B)
Continue the removal by circling the
I/A tip at the iris plane, or on the optic
surface, then make an additional sweep
in the anterior chamber paying
particular attention to angles
(Courtesy: Pharmacia Inc. Peapack,
NJ, USA)
An alternative technique has been developed allowing the use of less turbulence, using a
standard I/A tip, 0.3 mm, with effectual flow at 2025 ml and vacuum 2503000 mm Hg.
The bottle height should be 6070 cm above eye level. Figures 16.7A and B present the
steps of removal technique of the viscoadaptive agent, Healon-5, using another
technique.
We would like to emphasize that a careful and thorough removal of the OVDs from
the capsular bag and the anterior chamber of the eye is must after the end of the surgery.
This is important to avoid complications such as rise in intraocular pressure,
crystallization of the IOL surface (see later).47 Studies have shown that complete removal
of viscoelastic material from the capsular bag can be more difficult when some
hydrophobic acrylic lenses are used because of the IOLs tacky surfaces (Apple DJ,
Auffarth GU, Pandey SK. Miyake posterior view video analysis of dispersive and
cohesive viscoelastics, video presented at the Symposium on Cataract, IOL, and
Refractive Surgery, Seattle, WA, April 1999).
Complications of OVDs
OVDs have many positive attributes but their drawbacks and complications must be
given careful considerations. Some of the important complications are as follows:
Increase in Intraocular Pressure
Increase in intraocular pressure is the most important postoperative complication of
OVDs. It was first noted with Healon. The increase in pressure can be severe and
prolonged, if the material is not thoroughly removed at the end of the surgery. The rise in
271
pressure occurs in the first 6 to 24 hours and resolves spontaneously within 72 hours
postoperatively.2,12 The rise in pressure is due to the mechanical resistance of the
trabecular meshwork to the large molecules of the viscoelastic material, which decreases
the outflow facility. Hence to decrease the incidence of this complication, many have
advocated removing and aspirating the viscoelastic material from the eyes at the end of
the surgery.16
Crystallization on the IOL Surfaces
29
Olson et al reported a physician survey, laboratory studies, and clinical observations of

intraoperative crystallization on IOL surfaces. These authors sent a survey to all
ophthalmologists in the states of Wyoming, Idaho, Montana, Utah, and Colorado (USA)
asking whether crystallization on the IOL surface had occurred in any of their patients
and what viscoelastics, IOLs, and other solutions were used. All returned surveys were
tabulated and analyzed by standard statistical means. A sample of crystallization from an
IOL submitted by a physician on a glass slide was analyzed to ascertain the relative
elemental composition. During in vitro laboratory studies, BSS Plus (Alcon Surgical,
Fort Worth, Texas, USA) and BSS (Alcon Surgical) were analyzed for precipitation.
Healon-GV (Pharmacia/Upjohn, Kalamazoo, Michigan, USA) and calcium chloride
were combined in various solutions and examined for precipitate formation. Silicone
IOLs were placed in different BSS and BSS Plus solutions with different viscoelastics
and varying calcium concentrations. In seven patients, prominent crystallization on IOL
surfaces was examined, photographed, and followed for up to 3 years. Results of this
interesting survey showed that 206 surveyed ophthalmologists returned 181 surveys
(88%) and reported 29,609 cataract surgeries with IOL implantation. In 22 eyes (0.07%)
(22 patients) intraoperative crystallization was observed on the IOL surface during 1993.
The survey indicated there was a correlation with BSS Plus (chi-square=4.9, P=.0268)
and silicone IOLs (chi-square=6.8, P=.0093). The analyzed sample submitted by one of
the surgeons showed the cation to be calcium. The authors concluded that crystallization
on the IOL surface during cataract surgery is a rare occurrence that may be associated
with calcium as the cation. An osmotic gradient around the IOL is observed with
increased calcium concentration. If encountered surgically, the lens should be exchanged
in the operating theater after irrigating the anterior chamber with BSS and completely
filling the capsular bag with a low molecular weight viscoelastic.18,29
Since 1993 we received in our Center more than 9,000 IOLs explanted because of
different complications. During gross and microscopic analyses of these lenses, it was not
uncommon to find crystals on their surfaces, which exhibited some degree of
birefringence (Figs 16.8A and B). Sometimes they had the typical fern-like appearance
found after precipitation of viscoelastic or salt solutions. We believe those crystals
correspond to precipitation of viscoelastic solutions used by the surgeons during the
explantation procedure. These may crystallize on the surfaces of the IOLs sent to our
Center in a dry state.
Phacoemulsification
270
FIGURES 16.8A AND B

Crystallization on the IOL surfaces
secondary to precipitation of the OVDs
on the surfaces. (A) Light
photomicrographs taken from the
anterior surface of intraocular lenses,
which were explanted because of
different complications (including
error in power calculation) and sent to
our Center for analyses. A typical fernlike appearance of the crystals found
on the surface of the lenses can be
observed. Birefringence under
polarized light is observed in the
bottom picture. (B) Gross and light
microscopic photographs taken from
273
the posterior surface of a 3-piece

silicone lens explanted because of
opacification of the lens optic caused
by a whitish deposit. The crystals
found on the surface of the lens do not
have a typical fern-like appearance, but
exhibit birefringence under polarized
light (bottom picture)
Many lenses sent to our Center were explanted because of the presence of crystalline
deposits on their optical surfaces. They caused significant decrease in visual function
requiring lens esplantation/exchange (Figs 16.8A and B). Our analyses demonstrated that
these deposits were also composed of multiple confluent small crystals, which sometimes
did not assume a fern-like appearance, but rather an amorphous arrangement.54 Therefore,
it could not be confirmed whether they were related to deposition/crystallization of
viscoelastic material. Further studies are necessary to evaluate whether they may
correspond to the crystallization of residual viscoelastics in an aqueous environment, late
postoperatively. Most specifically, scanning electron microscopy coupled with a surface
analysis technique such as energy-dispersive X-ray analysis could determine the
elemental composition of the deposits observed on the surfaces of our explanted lenses.
These observations highlight the fact that any viscoelastic agent should be thoroughly
removed from the capsular bag and anterior chamber of the eye during cataract surgery.
Capsular Block Syndrome or Capsular Bag Distension Syndrome
Miyake and associate26 proposed a new classification of capsular block syndrome (CBS),
a newly described complication of cataract-IOL surgery, to improve understanding of the
etiology and provide effective treatment. Three groups of eyes with CBS were reviewed
by these authors: eyes originally reported and diagnosed as having CBS; eyes
experiencing CBS after hydrodissection and luxation of the lens nucleus; and eyes with
CBS accompanying liquefied after-cataract or capsulorhexis-related lacteocrumenasia.
These researchers noted that in all 3 groups, the CBS occurred in eyes with a
capsulorhexis. It was characterized by accumulation of a liquefied substance within a
closed chamber inside the capsular bag, formed because the lens nucleus or the posterior
chamber IOL optic occluded the anterior capsular opening created by the capsulorhexis.
Depending on the time of onset, CBS was classified as intraoperative (CBS seen at the
time of lens luxation following hydrodissection), early postoperative (originally described
CBS), and late postoperative (CBS with liquefied after-cataract or lacteocrumenasia). The
etiology of the accumulated substance and the method of treatment are different in each
type according to their study. These authors concluded that CBS is a complication of
cataract/IOL surgery that can occur during and after surgery. Correctly identifying the
type of CBS is crucial to understand the nature and effective treatment of this disorder.
Recently use of high-density viscoelastic agents, such as Healon-GV, has been found
to be associated with complication of late CBS. Sugiura and associates49 analyzed the
transparent liquid between the posterior lens capsule and the posterior chamber (PC) IOL
Phacoemulsification
272
in early postoperative capsular block syndrome and discussed the mechanism of posterior
capsule distention. These authors evaluated 3 cases of capsular block syndrome
presenting with transparent liquid in the distended capsular bag 1 day after cataract
surgery. The transparent liquid material between the posterior capsule and PC IOL was
aspirated and analyzed using high-performance liquid chromatography (HPLC). Also,
sodium hyaluronate was diluted using a dialyzer to determine whether the aqueous humor
was drawn into the capsular bag by an osmotic gradient across the capsule. Results of
their study suggested that the elution time of the samples was almost the same as that of
sodium hyaluronate 1.0 percent. The concentration of the samples ranged from 3.29 to
9.01 mg/mL by HPLC analysis. The sodium hyaluronate absorbed the physiological salt
solutions through the dialyzer and expanded to 1.9 times its original volume. These
results indicate that the main ingredient of the transparent liquid in capsular bags is
sodium hyaluronate and that the distention is caused by aqueous humor being drawn into
the capsular bag by an osmotic gradient across the capsule when the capsulorhexis
diameter is smaller than that of the PC IOL and by viscoelastic material retained and
trapped in the bag intraoperatively.
Pseudo-anterior Uveitis
The pseudo-anterior uveitis occurs because of the OVDs viscous nature and also the
electrostatic charge of the materials.28 The red blood corpuscles (RBCs) and
inflammatory cells remain in the anterior chamber, thus giving it the appearance of
uveitis. It spontaneously resolves within three days, requiring no treatment. Sometimes an
intraocular hemorrhage gets trapped between the vitreous space and the OVD in the
anterior chamber and mimics the appearance of vitreous hemorrhage.28
Summary and Conclusions
The choice of a viscoelastic substance depends largely on the intended surgical use. At
the present time, no single viscoelastic agent is ideal under all circumstances. For any
particular surgical task, the surgeon should consider the multiple physicochemical
characteristics of each viscoelastic material available as well as their desirable and
undesirable clinical effects, then choose the most appropriate substance. As new
materials are developed and as our knowledge of the physical properties, clinical effects,
and surgical indications are better defined, the selection process for choosing the best
product should improve.20
Widespread success in clinical situations has been achieved with pure hyaluronate and
combination sodium hyaluronate chondroitin sulfate material. Although expensive,
viscoadaptive agent-Healon-5, has some distinct advantages. Methylcellulose possess
special advantages of lower cost, no requirement of refrigeration, a larger quantity of the
material per unit.
275
References
1. Akahoshi T: Soft shell stain technique for the white cataract, presented at the ASCRS
Symposium on Cataract, IOL, and Refractive Surgery, Boston, MA, May 2000.
2. Anmarkrud N, Begaust B, Bulie T: A comparison of Healon and Amvisc on the early
postoperative pressure after extracapsular cataract extraction with implantation of posterior
chamber lens. Acta Ophthalmol Scand 74:62628, 1996.
3. Anna D: Healon 5, The worlds first Viscoadaptive. Ophthalmic Express 6:4, 1998.
4. Arshinoff SA: Rock and roll removal of Healon GV (video). Presented at the American Society
of Cataract and Refractive Surgery Film Festival; Seattle, WA; 15, 1996.
5. Arshinoff SA, Hofmann I: Prospective, randomized trial comparing Micro Visc Plus and Healon
GV in routine phacoemulsification. J Cataract Refract Surg 24:81420, 1998.
6. Arshinoff SA, Opalinski YAV, Ma J: The pharmacology of lens surgery: Ophthalmic
viscoelastic agents. In Yanoff M, Ducker JS (Eds): Ophthalmology. Mosby-Yearbook: St Louis,
4:20.121.6, 1998.
7. Arshinoff SA: Dispersive and cohesive viscoelastics materials in phacoemulsification, Revisited
1998. Ophthalmic Practice 16:2432, 1998.
8. Arshinoff SA: Dispersive-cohesive viscoelastic soft shell technique. J Cataract Refract Surg
25:16773, 1999.
9. Arshinoff SA: New terminology: Ophthalmic viscosurgical devices. J Cataract Refract Surg
26:62728, 2000.
10. Balazs EA, Freeman MI, Kloti R, et al: Hyaluronic acid and replacement of vitreous and
aqueous humour. Mod Prob Ophthalmol 10:321, 1972.
11. Balazs EA: The development of sodium hyaluronate (healon) as a viscosurgical material in
ophthalmic surgery. In Eisner G, (Ed): Ophthalmic Viscosurgery. Bern, Switzerland:
Medicopia, 119, 1986.
12. Barren BA, Busin M, Page C, et al: Comparison of the effects of Viscoat and Healon on
postoperative intraocular pressure. Am J Ophthalmol 100:37784, 1985.
13. Cobo M, Beaty N: VITRAX? (sodium hyaluronate) in anterior segment surgery: A review and
clinical study summary. Adv Ther 7:5160, 1990.
14. Garg A: Viscoelastic substances and other surgical adjuncts. In Garg A, (Ed): Textbook of
Ophthalmology. Jaypee Brothers, New Delhi, India, 12638, 2001.
15. Pandey SK, Werner L, Apple DJ, et al: No anesthesia clear corneal phacoemulsification versus
topical and topical plus intracameral anesthesia: Randomized clinical trial. J Cataract Refract
Surg 27:164350, 2001.
16. Holzer MP, Tetz MR, Auffarth GU, et al: Effects of Healon 5 and 4 other viscoelastic
substances on intraocular pressure and endothelium after cataract surgery. J Cataract Refractive
Surg 27:21318, 2001.
17. Hyndiuk RA, Schultz RO: Overview of the corneal toxicity of surgical solutions and drugs and
clinical concepts in corneal edema. Lens Eye Toxic Res 9:33150, 1992.
18. Jensen MK, Crandall AS, Mamalis N, et al: Crystallization on intraocular lens surfaces
associated with the use of Healon GV. Arch Ophthalmol 112:103742, 1994.
19. Kayikicioglu O, Erakgun T, Guler C: Trypan blue mixed with sodium hyaluronate for
capsulorhexis. J Cataract Refract Surg 27:970, 2001.
20. Larson RS, Lindstrom RL, Skelnik DL: Viscoelastic agents. CLAO J 15:15160, 1989.
21. Learning DV: Practice styles and preferences of ASCRS members 2000 survey. J Cataract
Refract Surg 27:94855, 2001.
22. Liesegang TJ: Viscoelastics. Surv Ophthalmol 34:26893, 1990.
23. Liesegang TJ: Viscoelastics. Int Ophthalmol Clin 33:12747, 1993.
Phacoemulsification
274
24. Macky TA, Werner L, Apple DJ, et al: Viscoanesthesia Part II: Evaluation of the toxicity to
ocular structures after phacoemulsification in a rabbit model. J Cataract Refract Surg 2002 (in
press).
25. McDermott ML, Edelhauser HF: Drug binding of ophthalmic viscoelastic agents. Arch
Ophthalmol 107:26163, 1989.
26. Miyake K, Ota I, Ichihashi S, et al: New classification of capsular block syndrome. J Cataract
Refract Surg 24:123034, 1998.
27. Nahra D, Castilla M: Capsulorhexis in no view cataract: Staining of the anterior capsule with
2% fluorescein, presented at the annual meeting of the American Academy of Ophthalmology,
October 1996, Chicago, Illinois, USA.
28. Nirankari VS, Karesh J, Lakhanpal V: Pseudovitreous hemorrhage: A new intraoperative
complication of sodium hyaluronate. Ophthalmic Surg 12:50304, 1981.
29. Olson RJ, Caldwell AS, Jensen MK, et al: Intraoperative crystallization on the intraocular lens
surface. Am J Ophthalmol 126:17784, 1998.
30. Pandey SK, Ram J, Werner L, et al: Persistent pupillary membrane. Br J Ophthalmol 84:554,
2000.
31. Pandey SK, Werner L, Apple DJ, et al: Dye-enhanced pediatric cataract surgery. J Pediatr
Ophthalmol Strabismus 2002 (in press).
32. Pandey SK, Werner L, Apple DJ, et al: Viscoanesthesia Part III: Evaluation of the removal time
of viscoelastic/ viscoanesthetic solutions from capsular bag of human eyes obtained
postmortem. J Cataract Refract Surg 2002 (in press).
33. Pandey SK, Werner L, Apple DJ, et al: Update on dyeenhanced cataract surgery. In Chang DF,
(Ed): Hyperguide Online Textbook of Ophthalmology Thorofare, NJ, Slack, 2001,
(http://www.ophthalmic.hyperguide.com/).
34. Pandey SK, Werner L, Apple DJ: Capsular dye-enhanced cataract surgery. In Nema HV, Nema
N, (Eds): Recent Advances in Ophthalmology, Jaypee Brothers: New Delhi, India, 6:1129,
2002.
35. Pandey SK, Werner L, Apple DJ: Staining the anterior capsule. J Cataract Refract Surg
27:64748, 2001.
36. Pandey SK, Werner L, Escobar-Gomez M, et al: Dyeenhanced cataract surgery. Part I. Anterior
capsule staining for capsulorhexis in advanced/white cataracts. J Cataract Refract Surg
26:105259, 2000.
37. Pandey SK, Werner L, Escobar-Gomez M, et al: Dyeenhanced cataract surgery. Part III.
Staining of the posterior capsule to learn and perform posterior continuous curvilinear
capsulorhexis. J Cataract Refract Surg 26:106671, 2000.
38. Poyer JF, Chan KY, Arschin SA: New method to measure the retention of viscoelastic agents
on a rabbit corneal endothelial cell line after irrigation and aspiration. J Cataract Refract Surg
24:8490, 1998.
39. Poyer JF, Chan KY, Arschin SA: Quantitative method to determine the cohesion of viscoelastic
agents by dynamic aspiration. J Cataract Refract Surg 24:113035, 1998.
40. Ram J, Pandey SK: Anesthesia for cataract surgery. In Dutta LC, (Ed): Modern Ophthalmology.
Jaypee Brothers: New Delhi, India, 32530, 2000.
41. Ram J, Pandey SK: Indications and contraindications of phacoemulsification. In Dutta LC,
(Ed): Modern Ophthalmology. Jaypee Brothers: New Delhi, India, 43740, 2000.
42. Ram J, Pandey SK: Infantile cataract surgery: Current techniques, complications and their
management. In Dutta LC, (Ed): Modern Ophthalmology. Jaypee Brothers: New Delhi, India,
37884, 2000.
43. Saini JS, Pandey SK: Advances in techniques of penetrating keratoplasty. In Nema HV, Nema
N, (Eds): Recent Advances in Ophthalmology, Jaypee Brothers: New Delhi, India, 4:3751,
1998.
44. Silver FH, Librizzi JJ, Benedetto D: Physical properties of model viscoelastic materials. J Appl
Biomater 5:22734, 1994.
277
45. Stegmann R, Pienaar A, Miller D: Viscocanalostomy for open angle glaucoma in black African
patients. J Cataract Refract Surg 25:31622, 1999.
46. Steinert RF: ICG dye aids in visualization of the anterior capsule. Ophthalmology Times, May
15, 1999.
47. Storr-Paulsen A: Analysis of the short-term effect of two viscoelastic agents on the intraocular
pressure after extracapsular cataract extraction. Sodium hyaluronate 1% vs hydroxypropyl
methylcellulose 2%. Acta Ophthalmol (Copenh) 71:17376, 1993.
48. Strobel J: Comparison of space maintaining capabilities of Healon and Healon GV during
Phacoemulsification. J Cataract Refract Surg 23:108184, 1997.
49. Sugiura T, Miyauchi S, Eguchi S, et al: Analysis of liquid accumulated in the distended
capsular bag in early postoperative capsular block syndrome. J Cataract Refract Surg 26:420
25, 2000.
50. Tetz MR, Holzer MP: Healon 5 clinical performance and special removal technique (Two
Compartment Technique). In Buratto L, Giardini P, Belluci R, (Eds): Viscoelastics in
Ophthalmic Surgery. Thorofare, NJ, USA, Slack 40104, 2000.
51. Trivedi RH, Werner L, Apple DJ, et al: Viscoanesthesia Part I: Evaluation of the toxicity to
corneal endothelial cells in a rabbit model. J Cataract Refract Surg 2002 (in press).
52. Werner L, Izak AM, Isaacs RT, et al: Evolution and pathology of intraocular lens implantation.
In Yanoff M, Ducker JS, (Eds): Ophthalmology. Mosby-Yearbook: St Louis, 2002 (in press).
53. Werner L, Pandey SK, Escobar-Gomez M, et al: Dyeenhanced cataract surgery. Part II. An
experimental study to learn and perform critical steps of phacoemulsification in human eyes
obtained post-mortem. J Cataract Refract Surg 26:106065, 2000.
54. Werner L, Shugar JK, Apple DJ, et al: Opacification, of piggyback IOLs associated to an
amorphous material attached to interlenticular surfaces. J Cataract Refract Surg 26:161219,
2000.
55. Wilson ME, Trivedi RH, Apple DJ, et al: Ophthalmic viscosurgical agents (OVAs): A guide
for the pediatric cataract surgeons. J Cataract Refract Surg 2002.
56. Wilson ME, Pandey SK, ThakurJ: Pediatric cataract surgery in the developing world. Br J
Ophthalmol 2002.
57. Wilson ME, Pandey SK, Werner L, et al: Pediatric Cataract Surgery: Current Techniques,
Complications and Management. In Agarwal S, Agarwal A, Sachdev MS, et al: (Eds):
Phacoemulsification, Laser Cataract Surgery and Foldable IOLs. Jaypee Brothers Medical
Publishers: New Delhi, India, 36988, 2000.
Section III
Phaco Steps
17. The Dynamics of Sutureless Cataract Incisions
18. Incisions
19. Capsulorhexis
20. Hydrodissection and Hydrodelineation
17
The Dynamics of Sutureless Cataract
Incisions
Samuel L Pallin
History
Prior to the advent of silk sutures, sutureless cataract incisions were the norm of necessity
in ophthalmology but they were not self-sealing for obvious reasons relating to technique
and instrumentation. Many advances in technique and technology have taken us through
several stages in the evolution of modern cataract operations. The earliest mentions of
self-sealing cataract incisions were made by Richard P Kratz in 19801 and by Louis J
Girard in 1984.2,3 Dr Kratz viewed the scleral tunnel incision as an astigmatism-neutral
method of entering the anterior segment and felt that the sutures which he routinely used
provided a belt and suspenders secure closure. In 1980s, a mention was made by Jim
Gills at a meeting in Atlanta, Georgia, USA, that a sutureless cataract closure should be
possible. In March, 1990, Steven B Siepser described a radial transverse incision which
admitted only foldable implants.4 This was a workable but technically difficult incision,
and was potentially dangerous in inexperienced hands. A brief published report in Ocular
Surgery News in March, 1990 quoted Michael McFarland5 who indicated he had
developed a sutureless incision for foldable implants which was based on a series of
relaxing incisions in the bed of a scleral tunnel. In April, 1990 a Chevron-shaped
sutureless scleral tunnel incision (Fig. 17.1) was described by the author in a letter to the
Editor of the Journal of Cataract and Refractive Surgery.6 The Chevron incision was
designed to admit not only foldable but rigid lenses as well, and was practical and easily
adopted by cataract surgeons. Preliminary results with the Chevron incision7 were
presented at the
FIGURE 17.1 Artists depiction of the

authors Chevron incision
1991 American Society of Cataract and Refractive Surgeons (ASCRS) meeting in
Boston, Massachusetts. A similar incision called the Frown incision was widely
The dynamics of sutereless cataract incisions
281
popularized by Jack Singer. Dr. Singer initially closed with one suture and later adapted
the Frown incision to sutureless cataract surgery.8
Sutured wounds were not all bad. Like all stages in the advancement of technology,
they participated in a cascade of improvements to the field, not the least of which was the
use of the operating microscope. It was the quest for finer sutures and better wounds that
stimulated the transition to modern microsurgery in ophthalmology.
The incision preferred by the majority of ophthalmologists in the United States today
is the clear-corneal incision (Fig. 17.2). Most current incisions are designed to be suture
free and self-sealing.9 It has become clear that the more corneal the placement of the
incision, the certainty of self-sealing without sutures decreases. A scleral tunnel incision
or a limbal tunnel incision in most hands will seal if the geometry is correct. Corneal
incisions still require sutures in some cases because of the nature of corneal tissue
which resists stretching, and because of the tendency of the incision to tear during
implant insertion.10,11 According to Nick Mamalis,12 corneal incisions measured preand post- insertion of folded implants show a mean increase in internal width
FIGURE 17.2 Artists depiction of a

corneal incision
of 4.4 to 6.2 percent, depending upon whether forceps or injector insertion technique is
used.
Common Denominator
Having come to this point in the history of the cataract incision, it is appropriate to see
what might be the common denominator of self-sealing incisions. The earliest theory
proposed was called the corneal flap mechanism. In this therapy, a layer of deep cornea
seals from the interior against the wound creating a trap-door effect when the eye is
reinflated. This was a popular theory to explain self-sealing incisions until April, 1995. In
that year at the annual meeting of the ASCRS in San Diego, California, this author
presented gonioscopic photographs (Fig. 17.3) showing insertion of an implant through
the angle with a slit-like internal incision and no corneal flap.13 The incision was in fact
self-sealing, as have been many others like it.
Phacoemulsification
280
Properties
So, to what factors can we ascribe the self-sealing quality of a cataract incision? One
theoretical principle which seems to stand the test of time is the so-called square
incisional geometry. This means that the length of the tunnel must be equal to or
exceed the width of the incision. In other words, a short tunnel with a long incision is
less
FIGURE 17.3 Internal view through

gonioscopic lens: 1IOL haptic, 2
wound, 3leading edge of optic, and
4trabecular meshwork
likely to be self-sealing than a long tunnel with a short incision.
Square incisional geometry should be understood to be a general concept, a guideline,
and not a strict rule for surgical planning. While the theoretical ideal of a self-sealing
tunnel would be a figure in which length is equal to width, in the real world self-sealing
incisions only strive to approach that configuration. Rarely does the length of the tunnel
actually equal the width of the entry incision and more commonly is marginally smaller.
But there is a definite relationship in which the probability that a given wound will be
self-sealing is proportional to the successful approximation of square geometry.
It is pertinent to discuss two incisions, one at either end of the tunnel: the first is the
external entry wound to the tunnel, and the second is the internal communication between
the tunnel and the anterior chamber. The reason for the importance of this distinction is
that one can make an incision into becoming a self-sealing wound by making the external
incision small and the internal incision larger. Lest the reader assume this configuration
violates the square geometry rule, bear in mind that the tunnel is still nearly as long as the
internal incision and longer than the external incision. In fact a smaller external incision
is more reliably self-sealing than a larger external incision. Since a small incision
presents an obstacle to the insertion of lens implants, the external incision can be made in
a geometric shape which lends itself-to stretching and thus will admit a lens implant
without difficulty (e.g. Chevron or Frown). The internal incision located in corneal
territory does not lend itself to stretching and tearing can be dangerous. Therefore, the
283
internal incision must be of a size to admit the chosen lens implant. So, the properties of
the reliable self-sealing incision are
Square incisional geometry
Relatively short external incision, with a tunnel that flares to a larger internal incision
A geometric external incision shape which lends itself to stretching.
Incisions which do not meet these criteria are subject to tearing or are problematic when
required to be self-sealing.
Given the above answers to the question, What constitutes the essential elements of a
self-sealing cataract incision? One also might like to know what explanation we have for
the fact that a pressurized sphere refrains from ejecting its contents through an incision to
the atmosphere? In practical terms one can think about the globe as a double-walled
structure, at least in the vicinity of the wound. For the purposes of a cataract incision, one
wall is the roof of the tunnel and one is the floor of the tunnel. It is these two layers
acting in a predictable manner when pressure is applied from within during reformation
of the anterior chamber that results in closure of the wound. Visualize for example two
latex balloons of the kind we see at childrens parties. One balloon is inserted inside the
other balloon. One can make an incision in the outer balloon and then inflate the inner
balloon and no air escapes. This is intuitively obvious. If on the other hand, one were to
make an incision in the inner balloon as well but place that incision in a remote location
away from the incision in the external balloon, and then inflate the internal balloon, one
can imagine that the two disparate incisions would fail to communicate and inflation
would still be viable. This mechanism is similar to what occurs in the globe after
reinflation of the anterior chamber following cataract removal and lens implantation. The
internal incision in the anterior chamber, whether it be in clear cornea or at the limbus, is
remote from the external incision on the sclera, the limbus, or the cornea. The two
incisions do not communicate directly. Communication can be forced by accessing the
tunnel between them. When the internal pressure of the eye is re-established and the
tunnel reacts to increased pressure from the interior as compared with ambient
atmospheric pressure on the exterior surface of the globe, the tunnel collapses and the
two incisions, in disparate locations, no longer communicate.
The current popularity of clear-corneal incisions is understandable considering several
advantages
Topical and intracameral anesthesia have been shown to be most effective in clearcorneal procedures.14,15
Corneal incisions are usually located at the temporal aspect of the anterior segment
which tends to counteract against-the-rule (ATR) astigmatism found in the elderly
population most commonly.16,17
The lack of the necessity to incise conjunctiva and cauterize blood vessels saves time
and is esthetically pleasing to the surgeon.
However, there are some disadvantages also to corneal incisions:
It is difficult to obtain square incisional geometry since a long tunnel through cornea
presents a problem during manipulations in the anterior chamber.18,19 This
phenomenon has been called oarlocking (Fig. 17.4).
Phacoemulsification
282
FIGURE 17.4 Artists depletion of an

example of oarlocking
Since the tunnel in a clear-corneal incision cannot be very long, square geometry
dictates the external incision be limited in length. Short external corneal incisions tend
to tear when a lens implant is forced through an incision of marginal size.11,12,20,21
Corneal tissue does not heal quickly, is not usually subject to fibrosis, and forms
relatively weak adhesive bonds making the incisions less secure.11,22
Corneal incisions depend for their integrity upon swelling of the lips of the incision
initially. However, swelling is a transient phenomenon and the incision which appears
to be self-sealing at surgery may be easily induced to leak in the postoperative period.
According to Kurt Buzard, It is by no means certain that the shift of the external opening
of the incision toward the cornea [from the sclera] is beneficial, and in fact it is our
contention that it is a negative development with disadvantages that are hidden by the
smaller size routinely used for clearcorneal incisions.23
With respect to iatrogenic astigmatismthere is a controversy over whether a
superior scleral tunnel incision or a temporal clear-corneal incision induces less
astigmatism. If there is a difference, it appears to be a small one. But there is
agreement over the fact that earlier stabilization occurs with scleral tunnel
incisions.2426
A few words about folding lens implants versus rigid implantssince small incisions
in general and clear-corneal incisions in particular are favored based upon the premise
that smaller and smaller incisions are preferable, it is necessary to regard the lens implant
as the limiting factor in the tendency to decreasing size of incision. Bear in mind that the
geometry of a lens implant is three-dimensional. One has to account for the diameter of
the implant, but what is often forgotten is that one must also account for the thickness.
For example, a planoconvex implant of 15 diopters might have a calculated central
optical thickness of 0.64 mm. A 25-diopter similar lens would have a central thickness of
0.98 mm.27 Therefore if a very high-powered implant (for example, a +25 diopter lens) is
folded or rolled, the thickness constitutes a significant part of the challenge in the
insertion sequence. In other words, an incision which is sufficient in length to admit a
15-diopter implant which is folded, may not be sufficiently large to admit a 25diopter folded lens. As a result there is a law of diminishing returns in choosing
folding lens implants over rigid implants solely for the purpose of making the
incision smaller. It is possible to imagine that a rigid implant of say, 15 diopters may
285
actually require a smaller incision than a very thick folded implant of 25 diopters. Add to
this the fact that some soft lens materials have a lower index of refraction than the
polymethylmethacrylate (PMMA) of hard implants. With a lower index of
refraction, the foldable implant must be thicker than its hard counterpart of the
same power.
It is also true that the smaller is better dictum as applies to incisions has limitations.
Transitioning from a large planned extracapsular incision to a small phacoemulsification
incision does provide increased wound integrity and decreased iatrogenic astigmatism.
But it is not clear that the same advantage applies, for instance, when the transition is
from a scleral tunnel incision of 4.0 or 4.5 mm to a clear-corneal incision of
approximately 3.2 mm (notethe authors Chevron incision stretches from
approximately 4.0 mm to more than 5.5 mm).7
Nevertheless, clear-corneal incisions and folded lens implants have become the most
popular combination of choice by United States surgeons today.9 With the burgeoning
numbers of clear-corneal procedures it is not surprising that some of these are
subject to tearing during implant insertion and may require a suture for security
more often than a scleral tunnel or limbal tunnel incision does.
Conclusion
In conclusion, it is proper to say that many variations of incisional design and incisional
closure are viable and successful. Modern cataract incisions vary in geographic and
anatomical location from superior to temporal and from scleral to clear corneal in
position and location. There is agreement in two areas: (i) it is generally accepted that a
smaller incision is better than a larger incisionthis is true for reasons of wound integrity
and the control of iatrogenic astigmatism, and (ii) there seems to be agreement among
surgeons and patients that self-sealing incisions are preferred to sutured incisions. No
doubt there will be continued progress in the area of wound construction and there is a
plethora of solutions and more on the horizon with respect to management of
astigmatism. Wound length, wound placement, tee-cuts, relaxing incisions, toric
intraocular implants, and laser ablations in the photorefractive keratectomy (PRK) and in
the LASIK configurations are available to modify astigmatism at the present time.
Astigmatism historically has been the greatest stimulus to the exploration of cataract
wound design. It is possible that with laser ablation and wavefront analysis the treatment
of first order and higher order aberrations will be accomplished as a distinct and separate
procedure making the astigmatism concern of very little significance in cataract wound
design. The one challenge that will always attend cataract surgery is a secure suture-free
closure. In this discussion a description of those principles which lead to reliable selfsealing closures is presented.
Phacoemulsification
284
References
1. Kratz RP, Colvard DM, Mazzocco TR et al: Clinical evaluation of the Terry surgical
keratometer. Am Intraocular Implant Soc J 6:24951, 1980.
2. Girard LJ, Hofmann RF: Scleral tunnel to prevent induced astigmatism. In Emery JM, Jacobson
AC (Eds): Current Concepts in Cataract Surgery: Proceedings of the Eighth Biennial Cataract
Surgical Congress Norwalk: Appleton-Century-Crofts 101102, 1984.
3. Girard LJ: Origin of the Scleral Tunnel Incision (letter). J Cataract Refract Surg 21:7, 1995.
4. Radial Incision Helps Reduce Astigmatic Forces. Ocular Surgery News 1, 1990.
5. Surgeon Undertakes Phaco, Foldable IOL Series Sans Sutures. Ocular Surgery News 1, 1990.
6. Pallin SL: Chevron incision for cataract surgery (letter). J Cataract Refract Surg 16:77981,
1990.
7. Pallin SL: Chevron sutureless closurea preliminary report. Proceedings American Society of
Cataract and Refractive Surgery Annual Symposium Boston, MA, 1991, and later published. J
8. Singer JA: Frown incision for minimizing induced astigmatism after small incision cataract
surgery with rigid optic intraocular lens implantation. J Cataract Refract Surg 17:67788, 1991.
9. Learning DV: Practice styles and preferences of ASCRS members1998 survey. J Cataract
Refract Surg 25:85159, 1999.
10. Ernest PH: Cataract incisionsrationale for the limbus. EyeWorld 2(9): 56, 1997.
11. Radner W, Amon M, Mallinger R: Diamond-tip versus blunt-tip caliper enlargement of clear
corneal incisions. J Cataract Refract Surg 23:27276, 1997.
12. Mamalis N:. Incision width after phacoemulsification with foldable intraocular lens
implantation. J Cataract Refract Surg 26:23741, 2000.
13. Pallin SL: Self-sealing versus corneal flap. Proceedings of the American Society of Cataract
and Refractive Surgery Annual Symposium San Diego, CA. 1995
14. Gills J: The Use of Intraocular Xylocaine to Control Intraoperative Discomfort During IOL
Surgery. Proceedings from the Fifth Annual Ocular Surgery News Symposium Cataract and
Refractive Surgery (Suppl) 22, 1997.
15. Koch P: Anterior chamber irrigation with 1% unpreserved lidocaine for anesthesia for cataract
surgerya prospective sutdy of 400 cases. Proceedings from the Fifth Annual Ocular Surgery
News Symposium Cataract and Refractive Surgery (Suppl) 32, 1997.
16. Fine IH: Corneal tunnel incision with a temporal approach. In Fine IH, Fichman RA, Grabow
HB (Eds): Clear-Corneal Cataract Surgery and Topical Anesthesia Thorofare: Slack, 528,
1993.
17. Fine IH: Self-sealing corneal tunnel incision for small-incision cataract surgery. Ocular Surgery
News 3839, 1992.
18. Ernest PH, Lavery KT, Kiessling LA: Relative strength of scleral corneal and clear corneal
incisions constructed in cadaver eyes. J Cataract Refract Surg 20:62629, 1994.
19. Mackool RJ, Russell RS: Strength of clear corneal incisions in cadaver eyes. J Cataract Refract
Surg 22:72125, 1996
20. Kohnen T, Lambert RJ, Koch DD: Incision size for foldable intraocular lenses. Ophthalmology
104:127786, 1997.
21. Steinert RF, Deacon J: Enlargement of incision with phacoemulsification and folded intraocular
lens implant surgery. Ophthalmology 103:22025, 1996.
22. Ernest P, Tipperman R, Eagle R et al: Is there a difference in incision healing based on
location? J Cataract Refract Surg 24:48286,1998.
23. Buzard, KA, Febbraro, JL: Transconjunctival corneoscleral tunnel blue line cataract incision.
J Cataract Refract Surg 26:24249, 2000.
287
24. Lyhne N, Krogsager J, Corydon L et al: One year followup of astigmatism after 4.0 mm
temporal clear corneal and superior scleral incisions. J Cataract Refract Surg 26: 8387, 2000
25. Olse T, Dam Johansen M, Bek T et al: Corneal versus scleral tunnel incision in cataract
surgery: a randomized study. J Cataract Refract Surg 23:33741, 1997.
26. Huang FC, Tseng SH: Comparison of surgically induced astigmatism after sutureless temporal
clear corneal and scleral frown incisions. J Cataract Refract Surg 24:47781, 1998.
27. Naeser K, Naeser EV: Calculation of the thickness of an intraocular lens. J Cataract Refract
Surg 19:4042, 1993.
18
Incisions
Luis W Lu, Alejandro Espaillat
Ana Claudia Arenas
Francisco Contreras-Campos
Introduction
Intracapsular cataract extraction, popular during the 1970s, generally utilized a large
corneal incision performed superiorly creating an against-the-rule astigmatism as a
consequence. The switch to extracapsular cataract extraction (ECCE) with intraocular
lens (IOL) implantation was a real improvement in the quality of vision, but did little to
resolve the post cataract astigmatic errors due to the large incisions needed to introduce
the IOL. With the introduction of phacoemulsification, and new foldable IOL designs,
creating the correct small incision became crucial to determine the successful outcome of
the procedure, and minimize the residual amount of astigmatism.
The Limbal Incision
In 1989, McFarland and Ernest introduced an incision architecture that allowed the
phacoemulsification, and intraocular lens implantation without the need of suturing.
Besides lengthening the scleral tunnel, as named by Girard and Hoffmann, this incision
ended in a corneal entrance and a posterior lip, the so-called corneal lip, which acted as a
one-way valve with self-sealing characteristics. Paul Koch described what he called the
incision funnel indicating that there were certain characteristics of self-sealing incisions
with respect to length and configuration, that imparted self-sealability as well as but also
astigmatism neutrality.
There are two aspect views of these incisions: sagittal and anteroposterior; and three
components: the external incision, the intratissue tunnel and the internal incision. From
the sagittal aspect, limbal incisions can be made in one of the following configurations
varying between single-plane, grooved beveled and, triplane with a groove and a bevel.
The external component may also be in one of the following theoretical
configurations: the singlestep stab incision, as initially introduced by Howard Fine, and
the two-step grooved incision by Charles Williamson, who felt that the wound should be
larger on the outside than the inside, creating a trapezoid configuration.
The sagittal shape, and the direction of the tunnel may also vary, but usually are made
flat by blades advancing in a single plane. On the other hand, its anteroposterior
configuration can be as a parallelogram.
Incisions
289
The third component of these incisions, the internal opening, may have a single-plane
Stab or biplane Steeped sagittal shape. The anteroposterior aspect of the wound
incision could be made limbus-parallel, tangential, or limbus antiparallel corneal
frown.
The limbal incision could be located superior, oblique or temporal. Superiorly located
incisions, when not under the influence of sutures, are known to have an against-the-rule
astigmatic effect. The oblique location, whether nasal or temporal, is advocated by some
surgeons who prefer this site for ergonomic reasons as well as for greater wound stability.
The temporal wound incision has been shown to be the most astigmatically neutral of
these three locations, achieving stability almost immediately, and maintaining it for
life.1,2
The limbal incision is very simple to perform making the maneuvers of entrance, and
instrumental manipulation easy for the surgeon. It is used primarily by the surgeon in
transition to phacoemulsification from the classic ECCE. The technique usually starts
with a conjunctival peritomy, followed by a perpendicular limbal incision made with a
metal or diamond blade, and an oblique entrance to the anterior chamber (Fig. 18.1). The
length of the incision could be as small as 2.5 mm initially to keep a close system, and a
deep anterior chamber during the phacoemulsif ication procedure, then it could be
enlarged up to 6.0 mm, depending on the type of the IOL used.
FIGURE 18.1 Limbal incision.

Oblique entrance to the anterior
chamber
Both limbal and clear corneal incisions heal by fibroblast response. The key is the timing
of the healing process: 7 days for vascular origin (limbal) and 60 days for a vascular
origin (corneal). Clear corneal incisions are also more subject to foreign body sensation
than limbal incisions.1,2
Phacoemulsification
288
The Scleral Incision

The scleral pocket incision was developed to provide a self-sealing and an astigmatically
neutral incision.1,2 The incision size, and configuration are determined by the surgeons
preference, and the chosen style of intraocular lens. The options for incision
configuration include, linear shape or tangential to the limbus, smile shape or concentric
to the limbus, and frown shape or opposite of the limbal curvature (Figs 18.2A and B).
The frown configuration minimizes against-the-rule astigmatism, and is reportedly the
most astigmatically neutral of these incision.3,4 A potential disadvantage of the frown
incision is the difficulty in enlarging it, if conversion to ECCE is necessary.
The technique usually follows the creation of a conjunctival flap with the base at the
fornix, and blunt dissection of the sub-Tenons space with scissors. Mild cautery of the
bleeding conjunctival and episcleral vessels is performed with high frequency bipolar
diathermy. The globe is fixated, and the scleral incision is then made in three steps. The
first step is to mark the lateral limits of the
FIGURES 18.2A AND B Smile

(18.2A), and Frown (18.2B)
configuration scleral tunnel incision
Incisions
291
scleral incision with calipers, followed by the creation of a vertical groove of a desired
length and configuration, 40 to 50 percent scleral depth, using a microsurgical steel or
diamond blade held perpendicular to the surface of the sclera. The second step is the
creation of the scleral tunnel, with a rounded crescent blade, dissecting a lamellar flap
anteriorly through the sclera, 1 to 2 mm into clear cornea. The dissection is carried
forward to Descemets membrane at the anterior edge of the vascular arcade. The last
step is the advancement of the scleral tunnel incision, aiming the tip of the keratome
toward the center of the lens, dimpling the Descemets membrane of the cornea, before
entering the anterior chamber creating a triplanar self-sealing incision.
The scleral tunnel must extend into the clear cornea to avoid the prolapse of the iris,
damage to the structures of the chamber angle, fluid loss and a flat anterior chamber, and
to create a valve effect which will seal the wound at the end of the surgery. Some of the
disadvantages of the scleral tunnel incisions are that it can surgically induce astigmatism,
from the use of cautery to control bleeding conjunctival, and episcleral vessels,5,6 presents
a difficult access to the anterior chamber with limited movement of the surgical
instruments, and a difficult access to the lens nucleus, aspiration of the lens cortex, and
IOL manipulation.
The Clear Corneal Incisions
The more advanced incision for phacoemulsification surgery is the clear-cornea incision.
The indications for clear corneal cataract surgery have expanded significantly since the
last few years. Initially the indications were limited to those patients on anticoagulants,
with blood dyscrasias, patients with cicatrizing diseases such as ocular pemphigoid, or
Stevens Johnson syndrome. However, the greatest advantage of the clear corneal incision
has been the ability to do surgery with topical anesthesia. Another big advantage of clear
corneal incisions is the tremendous safety with relative astigmatism neutrality, coupled
with exceptional results.
This is a bloodless, self-sealing, sutureless, and quick incision, best performed
temporally, where the distance from the visual axis to the periphery is longer, and
accessibility to the eye is optimal. This temporal approach includes also better
preservation of pre-existing corneal configuration, and of the limbal zone at the 12
oclock position in case of a future filtering surgery. It can also be used to reduce the
patients natural astigmatism by approximately 0.50 diopters in that meridian.5,6
This type of incisions can be classified, after Fine, depending on:
I-Location
Corneal tunnel incision: entry posterior to limbus, exit at the cornea-scleral junction.
Corneal tunnel incision: entry just posterior to the limbus, exit in clear cornea.
Clear corneal tunnel incision: entry and exit in the clear cornea.
II-Architecture
Single plane no groove
Phacoemulsification
290
Shallow groove<400 microns

Deep groove>400 microns
III-Size and Planar Configuration
Single-plane incision 2.5 by 1.5 mm, rectangular tunnel
Two-plane incision 2.5 by 1.5 mm rectangular tunnel
Three-plane incision 2.5 by 1.5 mm rectangular tunnel plus perpendicular arcuate
component.
When making the incision, a decision must be made as whether to groove or not to
groove, the external aspect to the incision. Non-grooved single-plane incisions utilize a
2.5 to 3.0 mm steel or diamond knife.7 First the anterior chamber is filled with a
viscoelastic agent through the paracentesis site, giving the eye stability prior to entry into
the anterior chamber. The globe is then fixated with a fixation ring or forceps to avoid
creating conjunctival tears, hemorrhages, or corneal abrasions. The uniplanar incision is
made inserting the blade in-and-out through the cornea at the surgical limbus, 1 mm
anterior to the limbal vessels in the plane of the cornea until the shoulders, which are 2
mm posterior to the point of the knife, touch the external edge of the incision. After the
tip enters the anterior chamber, the initial plane of the knife is re-established to cut
through Descemets in a straight line configuration.
A grooved, triplanar, self sealing, clear-cornea incision has three steps. The first step is
the creation of an approximately 300 m deep, perpendicular incision to the corneal
surface, 1 mm anterior to the limbal vessels, using steel or preferably a calibrated
diamond blade. The second step is the creation of a 1.75 to 2 mm stromal tunnel, parallel
to the iris plane, dissecting the corneal stroma in a lamellar fashion.
The third and final step is to downward tilt the keratome blade 30 degrees toward the
visual axis, in order to penetrate the anterior chamber.8 The stability of the wound
depends on the construction of the internal valve, the total width of the incision, and the
length of the tunnel.9 Generally, the clearcorneal incision is limited to 4 or 5 mm in
length in order to be self-sealing. The use of a foldable IOL that could be inserted
through a 3 to 4 mm incision allows the surgeon to perform a purely corneal sutureless
tunnel of 1.5 to 2.0 mm length, with minimal variation in the preexisting astigmatism.10
When properly created, the clear-cornea incision will seal by itself. This can be
hastened by stromal hydration.11 Stromal hydration is best accomplished by the injection
of fluid via syringe attached to a 27-gauge cannula tightly against the lateral wall of the
deeper layers of the incision causing immediate opacification. All properly created
incisions usually seal after 1 to 2 minutes, when the stroma opposes properly.
In summary, one has to understand the rationale of clear corneal incisions:
Excellent access to the anterior chamber for proper capsulorrhexis performance, access
to the cataract, and IOL placement.
Virtually bloodless incision.
Enables the formation of a self-sealing incision, resistant to deformation or leakage.
Variable incision architecture capable of eliminating pre-existing astigmatism.
Faster physical rehabilitation of the patient.
Incisions
293
Being an anastigmatic incision, the refractive stability is almost perfect, enabling

additional reading spectacles to be prescribed in a short period of time.
Faster healing with virtually no irritation, and redness.
The Side Port Incision

A side port incision is a small paracentesis limbal incision 1 mm wide, and 0.75 mm
long, usually created 90 degrees away from the main incision, using a 1530 degrees
metal blade, or a 1 mm diamond blade.
The side port incision should always be used during phacoemulsification because it
provides an access route for the introduction of viscoelastic, saline, anesthetics, and
antibiotics to the anterior chamber. It can also be used to introduce additional instruments
during the surgery to stabilize the globe, manipulate the lens nucleus, protect the
posterior capsule, keep the iris in place, and facilitate the removal of the lens cortex, as
well as the insertion of the IOL.
The paracentesis incision is generally performed with the anterior chamber still closed,
or with the chamber open but previously filled with a viscoelastic agent. The incision is
performed through the clear cornea, just in front of the limbal vessels, tangential to the
iris. The external end of the incision is usually larger than the internal wound, to facilitate
the introduction of the surgical tools. When performed correctly the paracentesis incision
is self-sealing. It is very important to avoid creating a paracentesis that is too narrow,
wide, superficial, deep, anterior, or posterior, to facilitate the introduction of surgical
instruments, and prevent fluid leakage, iris prolapse, and corneal folds.
Relaxing Incisions
Improved spherical and astigmatic outcomes are now well-recognized benefits of modern
small-incision cataract surgery. The combination of limbal or corneal relaxing incisions
with cataract surgery is fundamental to the current definition of Refractive Cataract
Surgery, which has come to represent a reality for cataract patients.
Over the past several years, great efforts have been made to study the astigmatic
effects of various cataract incisions. By manipulating the size, location, and shape of the
incisions, surgeons could tailor the astigmatic outcome according to the patients preexisting astigmatism. If a patient has enough pre-existing astigmatism to warrant
reduction, modern astigmatic keratotomy may then be conservatively added to arrive at
the desired cylindrical outcome. Arcuate astigmatic relaxing incisions (RIs) have proven
to be extremely safe and reliable,12 and have been used since the early 1970s to reduce
high pre-existing astigmatism in cataract surgery.13 The RIs can be made at the limbus
(LRIs), or at the cornea (CRIs), depending on the amount of astigmatism. Although CRIs
remain a powerful tool for correcting high astigmatism, they have a limited predictability,
and often may result in overcorrection particularly in patients with lower amounts of
preoperative astigmatism. Most surgeons prefer to use LRIs to correct the pre-operative
astigmatism, because they are easy to perform, more comfortable for the patient, result in
more regular corneal topographies with less corneal distortion, postoperative refractions
Phacoemulsification
292
are less variable, overcorrections are rare, and are effective in patients with low to
moderate astigmatism, usually 3 diopters or less.
To create a relaxing incision some surgeons advocate placing an orientation mark at
the limbus at the 12 oclock position before the patient is supine. The surgeon will then
determine the amount, and axis of the corneal cylinder through corneal topography. The
refractive cylinder is usually not considered in phakic patients, because any lenticular
astigmatism would be removed by the cataract surgery, and cannot be included in the
surgical plan. The LRIs are created using a diamond blade which incorporates an special
preset 600-m diamond microknife. The globe is fixated with a modified Fine-Thornton
fixation ring, and the diamond blade is placed in the steep axis at the limbus just anterior
to the palisades of Vogt, creating an incision of an appropriate length by visually
following the degree marks on the metal ring. The number, and length of incisions are
determined according to the various nomograms previously published.1215 Astigmatic
keratotomy, whether primary or associated with cataract surgery, is a simple, low-cost,
and effective procedure. Following surgery, these incisions appear to heal quickly, and
are nearly unidentifiable within several days leaving a long lasting effect on the patients
quantity and quality of vision.
Cataract surgery is a procedure which is in a constant evolution, and undoubtedly will
continue to improve in the future. In the mean time, following the previous suggestions
will help surgeons achieve a successful outcome of a phacoemulsification cataract
extraction.
References
1. Fine HI: Architecture and construction of a self-sealing incision for cataract surgery. J Cataract
Refract Surg 17 (Supp):67276, 1991.
2. Steinert RF, Brint SF, White SM, et al: Astigmatism after small incision cataract surgery: A
prospective, randomized, multicenter comparison of 4 and 6.5 mm incisions. Ophthalmology
98:41724, 1991.
3. Singer JA: Frown incision for minimizing induced astigmatism after small incision cataract
surgery with rigid optic intraocular lens implantation. J Cataract Refractive Surgery 17(Supp):
67788, 1991.
4. Koch PS: Mastering phacoemulsification: A simplified manual of strategies for the spring, crack
and stop and chop technique. 4th ed. Thorofare, NJ: Slack, 19, 1994.
5. Long DA, Monica ML: A prospective evaluation of corneal curvature changes with 3.0 to 3.5
corneal tunnel phacoemulsification. Ophthalmology 103:22632, 1996.
6. Ley land MD: Corneal curvature changes associated with corneal tunnel phacoemulsification.
Ophthalmology 103: 86788, 1996. Letter.
7. Fine IH: Self-sealing corneal tunnel incision for smallincision cataract surgery. Ocular Surgery
News 1, 1992.
8. Williamson CH: Cataract keratotomy surgery. In: Fine IH, Fichman RA, Grabow HB, (Eds):
Clear-Corneal Cataract Surgery and Topical Anesthesia. Thorofare, NJ: SLACK; 8793, 1993.
9. Buratto LL: Phacoemulsification: Principles and Techniques. 1st ed. Thorofare, NJ: Slack, 41,
1998.
10. Albert DM: Ophthalmic Surgery: Principles and Techniques. 1st ed. Maiden, MA: Blackwell
Science, 25(283):1999.
11. Mackool RJ: Current Personal Phaco Procedure. In Fine IH (Ed): Clear-Corneal Lens Surgery.
Thorofare, NJ: SLACK; 23950, 1999.
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295
12. Gills JP, Gayton JL: Reducing pre-existing astigmatism. In Gills JP, Fenzl R, Martin RG, (Eds):
Cataract Surgery: The State-of-the Art. Thorofare, NJ: SLACK Inc; 1998.
13. Troutman RC: Management of pre-existing corneal astigmatism. In: Emery JM, Paton D, (Eds):
Current Concepts in Cataract Surgery. St. Louis, Mo: CV Mosby; 1976.
14. Masket S, Tennen DG: Astigmatic stabilization of 3.0 mm temporal clear corneal cataract
incisions. J Cataract Refract Surg 22:145155, 1996.
15. Nichamin LD: Intraoperative astigmatism. In Ford JG, Karp CL, (Eds): Cataract Surgery and
Intraocular Lenses, a 21st Century Perspective. Ophth. Monographs 7, 2nd ed. AAO, LEO
series. 2001.
19
Capsulorhexis
Tobias Neuhann
History
Cataract surgery has been developed to its ultimate state and any improvements from
this date will be insignificant, said one of the most renowned US ophthalmologists in
1962. Fortunately, this statement proved to be wrong throughout the four decades to
follow until today and ophthalmological progress has continued to solve major problems
and challenges managing both a multitude of different anatomic conditions as well as of
material characteristics and designs of ophthalmic implants and devices.
One of the major problems of the late 1970s and early 1980s was pupil capture of
intraocular lenses due to sulcus implantation. This problem was seriously by the members
of todays ASCRS. As result of this discussion was favorising the idea of intraocular lens
implantation into the capsular bag. The Simcoe loops (modified C-loop), a new design of
that time, provided a considerable improvement in intracapsular centration compared to
the generally used J-loops. However, the problem of decentration remained in 1015
percent.
Analyzing this decentration showed that disregarding targeted and correct
endocapsular implantation tears of the anterior capsule originated, so that at least one
loop luxated into the sulcus, thus mostly forming the precondition for later decentration.
The Kelman Christmas-tree and also the Galand letter-box technique as well as the most
frequently applied can-opener technique produced jagged edges which formed a locus
minoris resistentiae, so that the logical conclusion was to develop a method to open the
capsular bag in such a way that only smooth edges were created.
Based on mutual experiences and observations my brother, Thomas E Neuhann, and
myself were the first to describe the reproducible method of capsulorhexis.1
At the same time and completely independent of our development Howard Gimbel
worked on the same idea, produced the same result and called his new technique
continuous tear capsulotomy. In the attempt to find the most suitable and precise term for
the new technique and to take the original terminological approach of both inventors into
account Neuhann and Gimbel finally decided to call their mutual development
continuous curvilinear capsulorhexis 2 the CCC. It has become the standard technique
for planned anterior as well as posterior capsular opening. Taking into account that two
independent developments had been made in the Old as well as in the New World
and that this approach has remained the method of choice for opening all kinds of
capsules until today shows that the CCC simply was the most logical conclusion
summing up the experiences of the past (Fig. 19.1).3,4
Capsulorhexis
297
Needle Technique
Using the needle technique, first an initial puncture of the anterior capsule within the
central area to be removed is required. This puncture is then extended in a curve-shaped
manner to the targeted eccentric
FIGURE 19.1 CCC with IOL in situ;

clinical picture
FIGURE 19.2 Basic principle of the

CCC
Phacoemulsification
296
FIGURE 19.3 The right and safe way

to perform the CCC
circle to be described. Either pushing starts the circular tear or pulling the central anterior
capsule in either direction, while the flap to be created is gently lifted. The next step is to
turn over the flap and apply the vectorial forces in tearing with the needle in such a way
that a more or less concentrically opening originates. Once the full circle is almost
completed the end will automatically join the beginning of the curve outside in (Figs 19.2
to 19.4).
FIGURE 19.4 Right and wrong

approach to close the CCC
Capsulorhexis
299
Another option is to place the first puncture directly within the planned curvature and
start the rhexis with a curved enlargement of this tiny hole. In this case the tear is brought
around on both sides, until the ends finally join together as already described above.5
The needle technique can be performed using BSS or viscoelastics. In addition the
below factors are essential for the success of the needle capsulorhexis:
Needle
1. Although many different needles could theoretically be applied, only the 23 gauge
needle is recommended. The lumen of this type of needle is just sufficient to produce a
pressure exchange between the anterior chamber and the BSS irrigating bottle.
2. The metal of such a cannula offers just enough rigidity to provide the necessary
resistance for difficult manipulations. Needles with higher gauge do not meet the
described requirements, and this alone may cause a CCC failureeven though this
fact is unfortunately not generally known.
3. A higher, i.e. positive pressure in the anterior chamber compared to the intracapsular
pressure
FIGURE 19.5 Stellate burst created by

a blunt needle
is mandatory. This becomes especially noticeable with intumescent lenses, where
the lens protein is hydrated resulting in a volume increase inside the capsular bag,
which results in a considerable increase in the endocapsular pressure as a
consequence. The necessary prerequisite for a successful capsulorhexis is a
pressure of the anterior chamber that is greater than or equal to that inside the
capsular bag. The pressure in the anterior chamber can be adjusted via the height
of the infusion bottle.
4. The needle tip should be as sharp as possible, since a blunt needle will lead to stellate
burst, which is more difficult to handle (Fig. 19.5).
Phacoemulsification
298
Forceps Technique
The principle of the forceps capsulorhexis exactly follows the principle of the needle
technique. In addition to the known Utrata forceps there are mini forceps that are similar
in construction to the forceps developed for the posterior segment of the eye. The
advantage of the mini forceps is that they can be inserted into the anterior chamber via a
paracentesis, so that the incision is not exposed to needless strain (Figs 19.6A to C).5
FIGURES 19.6A TO C CCC

performed with capsulorhexis forceps;
clinical pictures
Capsulorhexis
301
Comparison of the Needle and Forceps Technique

The forceps technique is easier to learn. For this reason it is also the most frequently
applied capsulorhexis technique. However, applying the forceps technique, the use of
viscoelastics is mandatory.
The advantage of the needle technique is that it is economical, since it can be
performed with application of BSS as well as viscoelastics and the cost of the needles is
neglectable.
To point out the difference between the needle and the forceps technique, the
following example might be appropriate: To turn over a page of a book you can take the
sheet between two fingers and turn it from one side to the other (this is what you do with
the forceps), or you take a moistened finger, press the page a bit down and then turn it
over (that is what you do with the needle; the counter hold is the cortex). With this in
mind the consequences appear quite clear cut. I will always use a needle technique, the
initial puncture peripheral or central, for the great majority of my cases. The forceps I
will use in those situations where the needleso to saylacks the other branch. This is
mainly the case in the presence of a liquefied cortex or in cases where a secondary
enlargement of the capsulorhexis diameter is required.5
The Two-Step Needle Technique
Today the two-step needle technique belongs to the past. Here, the capsule is first opened
peripherally with the needle below the incision and the incision is enlarged in a curveshaped manner to the right and left applying the sharp edges of the needle accordingly, so
that a larger flap is created. By bending the same needle now in such a way that the flap,
which was transformed into an incision, is flipped around the tear is completed in the
known way.5
Capsulostripsis
This technique was invented by F.Rentsch and described by J.H.Greite at the 1995
ASCRS meeting (Fig. 19.7). This approach is specifically designed for difficult cases,
where the intracapsular pressure exceeds that of the anterior chamber. With this method a
vitrector with infusion sleeve is used to create an irregular opening in the anterior
capsule. Experience shows that a guillotine-type cutter is preferable to a rotating system.
To prevent the capsule from tearing, extremely slow motion is essential. The resulting
opening in the capsule is a jagged, however, the rounded, mouse-bite-like cuts of the
vitrector tip nevertheless produce a stable rim, because of the favorable distribution of
forces of this series of mini arcs.
Phacoemulsification
300
FIGURE 19.7 Capsulostripsis opening

and IOL in situ (Courtesy of JH
Greite)
This technique is rather time-consuming compared to conventional CCC performed by
an experienced surgeon. On the other hand, it is easy to perform and provides a reliable
alternative for hypermature or even milky cataracts without sufficient red reflex and other
cases with difficult CCC, such as subluxated lenses or cataracts in children with elastic
capsules.68
Diathermy Capsulotomy
Another alternative method to create a circular and stable aperture of the anterior capsule
that has been quite frequently discussed for some time is diathermy capsulotomy. In the
attempt to create a circular rim in opening the capsule with this method mostly bridges
remain that have to be cut with micro-scissors. To perform this technique, the use of
viscoelastics is required. The method is especially recommended for intumescent
cataracts, but a number of surgeons find it easier to perform than the CCC in general.
However, even though the postoperative result may resemble that of a capsulorhexis,
it should not be neglected that comparative studies demonstrated that the CCC is more
stable and has a perfectly smooth edge, in contrast to the diathermy opening, which is
marked by multiple irregularities and offers less stability and less elasticity. Hence, the
application of diathermy in routine cataract surgery cannot be recommended.911
Capsulorhexis Size
The author prefers a capsulorhexis that is somewhat smaller than the optic diameter of the
IOL to be implanted. The CCC provides enough stability and elasticity to allow
intraocular manipulations even with a smaller anterior aperture without any hazard. In
fact, no study has ever been able to show that a larger CCC diameter relative to the IOL
optic is more advantageous. Supporting this preference, comparative studies found that in
Capsulorhexis
303
addition a slightly smaller capsulorhexis diameter seems to reduce the postoperative

opacification of the posterior capsule.1214 When it comes to rhexisfixated IOL
implantation, this type of IOL is completely excluded in the presence of an excessive
rhexis diameter, for instance in case of damage of the posterior capsule, which is another
reason why the rhexis size should be kept somewhat smaller than the lens optic.
Furthermore, study results suggest that a smaller capsulorhexis size is likely to produce a
smaller postoperative IOP as well as better effectivity of sharp edges of some IOL
designs.
Difficult Cases
Small Pupil
The fact that several different methods are available to intraoperative extend a narrow
pupil has made capsulorhexis easier to perform in such cases. The generally applied
measures in such cases are:
Removal of the pupillary membrane;
Bimanual stretching;
Removal of synechiae;
Iris hooks;
Pupil dilator.
To perform a capsulorhexis in the usual way, first the pupil is extended using one of these
methods. This is followed by creation of the CCC with needle or forceps.
Pseudoexfoliation Syndrome, Uveitis und Pigmentosa
With these patients often a thickened anterior capsule can be clinically observed, which is
hard to tear. Another common finding in such cases is also a subluxated lens, which is
only diagnosed intraoperative. An important aspect of surgery in such patients is to
strictly refrain from a rather small capsulorhexis, as the result of this might be an
undesired shrinkage of the anterior capsule.
Capsules of Infants, Children and Juveniles
Due to the high elasticity of the anterior capsule a smaller rhexis must be performed in
such patients than is the case with adults. Here it must be taken into account that the
rhexis opening still enlarges by 0.5 to 1.0 mm after completion of the rhexis. Regarding
pediatric posterior capsulorhexis, the necessity of an accompanying anterior vitrectomy is
controversially discussed. Here, in a number of cases a self-sealing closure provided by
the IOL could be successfully achieved.15
A new method to create a CCC in infantile and juvenile capsules was recently
described by Nischal.16 This new modification is called the two-incision push-pull
capsulorhexis. Here, two stab incisions are made proximally and distally to the incision
approximately 4.5 to 5.0 mm apart in the anterior capsule, thus outlining the diameter of
Phacoemulsification
302
the planned capsulorhexis. One end of the distal edge of the proximal anterior capsule
stab is grasped using a fine capsulorhexis forceps and gently pushed toward the
corresponding point of the distal stab incision and continued until halfway to the distal
stab incision. A corresponding procedure is performed with the proximal edge of the
distal anterior capsule stab incision until half a CCC has been created. An analogous
procedure is performed on the other side, resulting is a complete capsulorhexis opening.
This technique is specifically designed to meet the special conditions of the elastic
pediatric capsule, because the tearing forces are always directed to the pupillary center,
thus resulting in a curvilinear tear. The technique can be applied for the anterior as well
as posterior CCC.
Capsulorhexis in Calcified Capsules or Anterior Flaps
These cases mostly require a completely individual CCC, where an additional application
of Ong 01 Vannas scissors or comparable tools is required.
Posterior Capsulorhexis
A series of indications, such as large-scale capsular fibroses, damage of the posterior
capsule17 or less frequent conditions like persisting arteria hyaloidea as shown by Greite
at the 1990 ESCRS meeting may require a primary or secondary posterior capsulotomy.
In the same way as the anterior CCC also the posterior capsulorhexis offers the
preservation of a stable capsule. First the anterior capsulorhexis is performed using
forceps or needle in the usual way and phacoemulsification or IOL explantation are
carried out as preferred. The anterior segment is filled with viscoelastics to stabilize the
posterior capsule. Then the posterior capsule is first only perforated and viscoelastics are
injected prior to further manipulations. This instillation of viscoelastics behind the
capsule is vital to prevent a vitreous prolaps. The posterior CCC can then be carried out
with needle or forceps in the same way as an anterior CCC. In some cases a successive
vitrectomy may be necessary to prevent the vitreous from invading the capsular bag via
the posterior opening. The remaining tire-like capsular residue provides a stable and
secure site for intraocular lens fixation.18 Gimbel especially recommends a posterior
capsulorhexis in pediatric cataract surgery to avoid secondary membrane formation after
cataract extraction.19
Capsulorhexis in the Presence of a Broken Posterior Capsule
If ruptures of the posterior capsule occur intraoperative and cannot be transformed into a
posterior CCC placement of the IOL in the ciliary sulcus with the known disadvantages
of this fixation as listed below seems to be the only option. To avoid this, rhexis fixation
of the IOL is the possible solution. The author at the 1991 ASCRS Film Festival first
presented the applicable technique. The precondition for this method is an intact anterior
capsulorhexis with a diameter that is smaller than that of the IOL optic. In rhexis fixation,
the lens optic is manipulated behind the anterior capsulorhexis rim with a spatula, while
the loops remain in the sulcus. This approach leaves the IOL optic securely positioned
inside the capsule in a button-like manner (Figs 19.8 and 19.9). This method is also an
Capsulorhexis
305
option for pediatric surgery, where mostly a posterior capsulorhexis is performed as well
to prevent secondary cataract formation.25,26 The only restriction using this method is the
implied exclusion of plate-haptic IOLs.
The advantages of this technique are:
No sunset or sunrise syndrome are possible;
Rotation and decentration are excluded;
The calculated lens power is effective because of the reliable location of the optic;
Iris chafing cannot occur;
Vitreous prolaps is prevented by stable endocapsular placement of the implant;
FIGURE 19.8 Principle of rhexis

fixation of an IOL
FIGURE 19.9 Rhexis fixation of an

IOL; clinical picture
Secondary cataract formation is avoided due to removal of the posterior capsule.
Howard Gimbel described a variation of this technique in the middle of the 1990s. In his
modified approach, he used the opened posterior capsule as support/fixation location in
Phacoemulsification
304
infantile or juvenile lens implantation, thus trying to prevent a vitreous prolaps calling
this procedure capsular capture.19
Anterior and Posterior Capsulorhexis
M.J.Tassignon works on that same topic to fixated IOLs on the capsulorhexis. Her
technique is called bag in the lens. The IOL has no haptics but only a hinge of the IOL
edge and is fixated while clipping the two capsular leaves in this edge hinge. Further
clinical investigation is currently running to evaluate this very interesting IOL design and
technique.
Insufficient Red Reflex
In cases of an insufficient or completely missing red reflex due to mature or hypermature
cataract blue staining of the anterior capsule is now possible to increase the visibility for
performance of the CCC. This method became very fast the recommended technique in
such cases.2024
Another option to deal with this problem is capsulostripsis instead of a capsulorhexis,
as already described earlier in this chapter.
Complications and Pitfalls
There are three major potential intraoperative problems an ophthalmic surgeon may find
himself confronted with performing the CCC:
Discontinuity of the Capsulorhexis
To avoid this complication the capsulorhexis should never be completed from inside out.
But also stellate bursts originating from initial puncturing attempts with a blunt needle
may destroy an intact capsular margin in the course of surgery to form a discontinuity
which presents a most critical source for a radial tear down into the peripheral capsule. In
the presence of such a discontinuity the entity of mechanical forces inside the capsular
bag concentrate on this weakest point, and the only effective remedy is to repair the
discontinuity immediately. If such a repair by transformation of the tear into a smooth
edge is no longer possible, utmost care must be employed in the remaining intracapsular
manipulations.
Tear into the Zonula
If a tear has already reached a zonular fiber, a conventional repair of the capsulorhexis is
too hazardous, because it might result in further rupture right along the zonular fiber
toward the equator. To cope with this critical situation two different approaches are
available. One way is to follow the end of the respective zonula down to its origin, gently
free it with the forceps and use this singled-out zonular fiber to tear a smooth-edged
Capsulorhexis
307
curve to unite with the otherwise intact capsulorhexis. The other and more risky approach
is to firmly and briskly pulls the flap toward the center.
Insufficient Capsulorhexis Size
Realizing during the process of circular tearing that the capsulorhexis will be smaller than
originally planned is not really an intraoperative problem. In such cases all the surgeon
has to do is to direct the vector forces in such a way that the circle is not closed but rather
proceeds further into the periphery. With this kind of spiral-shaped enlargement the CCC
diameter can be increased to the desired size. Once the capsulorhexis is large enough the
circle is closed in the usual way.
Captured Viscoelastics
If the anterior capsular rim adheres to the anterior IOL surface after implantation
viscoelastics residues may be trapped behind the lens. Usually this problem does not
occur if the viscoelastics are carefully removed. If it does, mostly the lens blocks the
passage for the viscoelastics into the anterior chamber and at the same time allows the
aqueous to invade the area behind the implant, thus pushing the IOL against the cornea.
In such a situation an additional puncture of the peripheral anterior orin comparably
narrow pupilsposterior capsule is required to provide for a release of the viscoelastics
into the anterior chamber or the vitreous, respectively.
Disadvantages of the CCC
As of the introduction of the CCC, a new problem was described over time, which is the
capsular shrinkage syndrome or capsular phimosis.27 This complication is not known in
any other capsulotomy technique and solely relates to the CCC. The genuine
pathomechanism could not be clarified until today. Clinically this problem can be
observed especially in patients suffering from Pseudoexfoliation syndrome (PEX),
uveitis, retinopathy pigmentosa or subluxation in combination with PMMA or silicone
IOL implantation. All these diseases have a considerably reduced number of zonula
fibers in common. The fact that up to now this complication has not been described in
patients suffering from these diseases in context with an acrylic IOL implantation allows
the conclusion that a certain mechanical interaction of acrylic lens surface and capsule
successfully prevents this problem, so that the acrylic IOL is presently the lens of choice
in such cases. This, however, is not valid for low-water acrylics.
A potential remedy to avoid the problem of capsular shrinkage is the insertion of a
capsular tension ring.
Phacoemulsification
306
Discussion
The development of the capsulorhexis definitely introduced a new age in small incision
cataract surgery. This applies both for the development of new phacoemulsification
techniques as well as for the important role phacoemulsification plays in modern cataract
surgery in general. In addition, the CCC has opened the gate for the development of a
multitude of new and refined foldable IOLs and implantation devices, because it was the
first capsulotomy technique to offer a stable and reliable anterior capsular opening, so
that today even a toric correction is possible with implantation of posterior chamber IOL.
While capsulorhexis as a principle is well established, its technical performance is
being refined and advanced. In this context I would like to stress once again that
capsulorhexis in essence really is not a technical procedural detail but a fundamental
surgical principle. Its theory needs to be well understoodthen its technical details
emanate as a logical consequence. In other words, you should be convinced that this
anterior capsular opening is what you want to have.
Also secondary surgery including intraocular lens exchange benefits from the specific
properties of the capsulorhexis aperture. Intraocular manipulations in the anterior as well
as posterior segment of the eye belonging to the realm of phantasy only two decades ago
are feasible today; now that circular apertures at any required number and dimensions in
both the anterior and the posterior capsule can be created securely and without taking the
risk of tear originating from intraoperative manipulations. And what is more, the
structural integrity of the capsule is not only maintained throughout the course of surgery
but also postoperatively, thus forming the precondition for stable, safe and permanent
IOL placement. From its invention 20 years ago the CCC has managed to form a reliable
basis for all new developments of the ophthalmic market and no comparable technique to
open the capsular bag has been invented ever since. In this way, the CCC occupies its
place as one of the important milestones of ophthalmology.
References
1. Neuhann T: Theorie und Operationstechnik der Kapsulorhexis. Klin Monatsbl Augenheilkd
190:54245, 1987.
2. Gimbel HV, Neuhann T: Continuous curvilinear capsulorhexis (letter). J Cataract Refract Surg
17:11011, 1991.
3. Assia EI, Apple DJ, Barden A et al: An experimental study comparing various anterior
capsulectomy techniques. Arch Ophthalmol 109(5):64247, 1991.
4. Krag S, Thim K, Corydon L et al: Biomechanical aspects of the anterior capsulotomy. J
Cataract Refract Surg 20(4): 41016, 1994.
5. Neuhann T: Capsulorhexis, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs, In
Agarwal S, Agarwal A, Sachdev MS, et al: (Eds): Jaypee Brothers Medical Publishers (P) Ltd:
New Delhi 8188, 1998.
6. Wilson ME, Bluestein EC, Wang XH et al: Comparison of mechanized anterior capsulectomy
and manual continuous capsulorhexis in pediatric eyes. J Cataract Refract Surg 20(6):602
06,1994.
Capsulorhexis
309
7. Wilson ME, Saunders RA, Roberts EL, et al: Mechanized anterior capsulectomy as an
alternative to manual capsulorhexis in children undergoing intraocular lens implantation, J
Pediatr Ophthalmol Strabismus 33(4):23740, 1996.
8. Andreo LK, Wilson ME, Apple DJ: Elastic properties and scanning electron microscopic
appearance of manual continuous curvilinear capsulorhexis and vitrectorhexis in an animal
model of pediatric cataract, J Cataract Refract Surg 25(4):53439, 1999.
9. Morgan JE, Ellingham RB, Young RD, et al: The mechanical properties of the human lens
capsule following capsulorhexis or radiofrequency diathermy capsulotomy, Arch Ophthalmol
114:111015, 1996.
10. Krag S, Thim K, Corydon L: Mechanical properties of diathermy capsulotomy versus
capsulorhexisa biomechanical study. J Cataract Refract Surg 23:8690, 1997.
11. Sugimoto Y, Kuho E, Tsuzuki S et al: Histological observation of anterior capsular edges
produced by continuous curvilinear and diathermy capsulorhexis. J Jpn Ophthalmol Soc
100(11):85862, 1996.
12. Ravalico G, Tognetto D, Palomba M et al: Capsulorhexis size and posterior capsule
opacification. J Cataract Refract Surg 22(1):98103, 1996.
13. Hollick EJ, Spalton DJ: Capsulorhexis size? Smaller seems better. J Cataract Refract Surg
2(5):12, 1997.
14. Cekic O, Batman C, Effect of capsulorhexis size on postoperative intraocular pressure, J
Cataract Refract Surg 25(3): 41619, 1999.
15. Gimbel HV, Chin PK, Ellant JP: Capsulorhexis, Ophthalmol Clin North Am 8(3):44145, 1995.
16. Nischal KK: Two-incision push-pull capsulorhexis for pediatric cataract surgery, J Cataract
Refract Surg 28:59395, 2002.
17. Galand A, Van Cauwenberge F, Moossavi J: Le capsulorhexis posterieur chez ladulte. J Fr
Ophtalmol 19(10):57175, 1996.
18. Sandler G: Pediatric Ophthalmology, Benefits seen to posterior capsulorhexis, anterior
vitrectomy in children, http://news.eyeworld.org/October/08%20Kellan%20WZ.%20html.html.
19. Gimbel HV, DeBroff BM: Posterior capsulorhexis with optic capturemaintaining a clear
visual axis after pediatric cataract surgery. J Cataract Refract Surg 20(6):65864, 1994.
20. Fritz WL: Fluorescein blue, light-assisted capsulorhexis for mature or hypermature cataract, J
Cataract Refract Surg 24(1):1920, 1998.
21. Nahra D, Castilla M: Fluorescein-stained capsulorhexis, J Cataract Refract Surg, 24(9):1169
70, 1998.
22. Melles GR, de Waard PW, Pameijer JH, et al: Frbung der Linsenkapsel mit Trypanblau zur
Visualisierung der Kapsulorhexis bei Maturkataraktchirurgie, Klin Monatsbl Augenkeilkd
215(6):34244, 1999.
23. Gotzaridis EV, Ayliffe WH: Fluorescein day improves visualization during capsulorhexis in
mature cataracts, J Cataract Refract Surg, 25(11):1423, 1999.
24. Nodarian M, Feys J, Sultan G, et al: Utilisation du bleu trypan pou la realisation du
capsulorhexis dans la chirurgie de la cataracte blanche, J Fr Ophthalmol 24(3): 27476, 2001.
25. Behrendt S, Wetzel W: Vollstndige Okklusion der Kapsulorhexisffnung durch
Vorderkapselschrumpfung. Ophthalmologe 91(4):52628, 1994.
26. Neuhann T: When posterior capsule tears, use capsulorhexis for IOL fixation. Phaco and
Foldables 4(6):13, 1991.
27. Sabbagh LB: Rhexis can hold IOL when posterior capsule breaks. Ocular Surgery News
3(3):110, 1992.
20
Hydrodissection and Hydrodelineation
I Howard Fine, Mark Packer
Richard S Hoffman
Hydrodissection
Hydrodissection of the nucleus in cataract surgery has traditionally been perceived as the
injection of fluid into the cortical layer of the lens under the lens capsule to separate the
lens nucleus from the cortex and capsule.1 With increased use of continuous curvilinear
capsulorhexis2,3 and phacoemulsification in cataract surgery, hydrodissection became a
very important step to mobilize the nucleus within the capsule for disassembly and
removal.47 Following nuclear removal, cortical cleanup proceeded as a separate step,
using irrigation and aspiration handpieces.
Fine has previously described cortical cleaving hydrodissection,7 which is a
hydrodissection technique designed to cleave the cortex from the lens capsule and thus
leave the cortex attached to the epinucleus. Cortical cleaving hydrodissection usually
eliminates the need for cortical cleanup as a separate step in cataract surgery by
phacoemulsification, thereby eliminating the risk of capsular rupture during cortical
cleanup.
Technique
A small capsulorhexis, 5 to 5.5 mm, optimizes the procedure. The large anterior capsular
flap makes this type of hydrodissection easier to perform. The anterior capsular flap is
elevated away from the cortical material with a 26-gauge blunt cannula (e.g., Katena
Instruments No. K75150) prior to hydrodissection (Fig. 20.1). The cannula maintains
FIGURE 20.1 Placement of the

cannula under the anterior
Hydrodissection and hydrodelineation
311
capsulorhexis in one of the distal

quadrants, elevating the capsule
the anterior capsule in a tented-up position at the injection site near the lens equator.
Irrigation prior to elevation of the anterior capsule should be avoided because it will
result in transmission of a fluid wave circumferentially within the cortical layer,
hydrating the cortex and creating a path of least resistance that will disallow later cortical
cleaving hydrodissection. Once the cannula is properly placed and the anterior capsule is
elevated, gentle, continuous irrigation results in a fluid wave that passes circumferentially
in the zone just under the capsule, cleaving the cortex from the posterior capsule in most
locations. When the fluid wave has passed around the posterior aspect of the lens, the
entire lens bulges forward because the fluid is trapped by the firm equatorial corticalcapsular connections (Fig. 20.2). The procedure creates, in effect, a temporary
intraoperative version of capsular block syndrome as seen by enlargement of the diameter
of the capsulorhexis. At this point, if fluid injection is continued, a portion of the lens
prolapses through the capsulorhexis. However, if prior to prolapse the capsule is
decompressed by depressing the central portion of the lens with the side of the cannula in
a way that forces fluid to come around the lens equator from behind (Fig. 20.3), the
cortical-capsular connections in the capsular fornix and under the anterior capsular flap
are cleaved. The cleavage of cortex from the capsule equatorially and anteriorly allows
fluid to exit from the capsular bag via the capsulorhexis, which constricts to its original
size, and mobilizes the lens in such a way that it can spin freely within the capsular bag.
FIGURE 20.2 Enlargement of

capsulorhexis as seen following second
cortical cleaving hydrodissection fluid
wave placed in the opposite distal
quadrant just prior to decompression of
the capsular bag
Phacoemulsification
310
FIGURE 20.3 Return of capsulorhexis

to its original size following
decompression of the bag
Repeating the hydrodissection and capsular decompression starting in the opposite distal
quadran may be helpful. Adequate hydrodissection at this point can be demonstrated by
the ease with which the nuclear-cortical complex can be rotated by the cannula.
Hydrodelineation
Hydrodelineation is a term first used by Anis8 to describe the act of separating an outer
epinuclear shell or multiple shells from the central compact mass of inner nuclear
material, the endonucleus, by the forceful irrigation of fluids (balanced salt solution) into
the mass of the nucleus.
Our technique uses the same hydrodissection cannula as previously described. The
cannula is placed in the nucleus, off center to either side, and directed at an angle
downward and forward towards the central plane of the nucleus. When the nucleus starts
to move, the endonucleus has been reached; it is not penetrated by the cannula. At this
point, the cannula is directed tangentially to the endonucleus, and a to-and-fro movement
of the cannula is used to create a tract within the nucleus. The cannula is backed out of
the tract approximately halfway, and a gentle but steady pressure on the syringe allows
fluid to enter the empty distal tract without resistance. Driven by the hydraulic force of
the syringe, the fluid will find the path of least resistance, which is the junction between
the endonucleus and the epinucleus, and flow circumferentially in this contour. Most
frequently, a circumferential golden ring will be seen outlining the cleavage between the
epinucleus and the endonucleus. Sometimes the ring will appear as a dark circle rather
than a golden ring.
Occasionally, an arc will result and surround approximately one quadrant of the
endonucleus. In this instance, creating another tract the same depth as the first but ending
at one end of the arc, and injecting into the middle of the second tract, will extend that arc
(usually another full quadrant). This can be repeated until a golden or dark ring verifies
circumferential division of the nucleus.
313
For very soft nuclei, the placement of the cannula allows creation of an epinuclear
shell of any thickness. The cannula may pass through the entire nucleus if it is soft
enough, so the placement of the tract and the location of the injection allow an epinuclear
shell to be fashioned as desired. In very firm nuclei, one appears to be injecting into the
cortex on the anterior surface of the nucleus, and the golden ring will not be seen.
However, a thin, hard epinuclear shell is achieved even in the most brunescent nuclei.
That shell will offer the same protection as a thicker epinucleus in a softer cataract.
Hydrodelineation circumferentially divides the nucleus and has many advantages.
Circumferential division reduces the volume of the central portion of nucleus removed by
phacoemulsification by up to 50 percent. This allows less deep and less peripheral
grooving and smaller, more easily mobilized quadrants after cracking or chopping. The
epinucleus acts as a protective cushion within which all of the chopping, cracking and
phacoemulsification forces can be confined. In addition, the epinucleus keeps the bag on
stretch throughout the procedure, making it unlikely that a knuckle of capsule will come
forward, occlude the phaco tip, and rupture.
Completion of the Procedure
After evacuation of all endonuclear material, the epinuclear rim is trimmed in each of the
three quadrants (Fig. 20.4), mobilizing cortex as well in the following way. As each
quadrant of the epinuclear rim is rotated to the distal position in the capsule and trimmed,
the cortex in the adjacent capsular fornix flows over the floor of the epinucleus and into
the phaco tip (Fig. 20.5). Then the floor is pushed back to keep the bag on stretch until
three of the four quadrants of the epinuclear rim and forniceal cortex have been evacuated
(Fig. 20.6). It is important not to allow the epinucleus to
FIGURE 20.4 Purchase of the

epinuclear rim and roof in foot position
2, being pulled central to the
capsulorhexis. The cortical layer is
seen superior to the rim and roof of the
epinuclear shell
Phacoemulsification
312
FIGURE 20.5 Following trimming of

the initial purchase of the rim and roof
in foot position 3, one can see the
cortex flow over the floor and into the
tip, removing it from that same
quadrant
FIGURE 20.6 Repositing of the floor

of the epinucleus after rim and roof of
the epinuclear shell has been trimmed
and the cortex has been evacuated
from the third epinuclear quadrant
flip too early, thus avoiding a large amount of residual cortex remaining after evacuation
of the epinucleus.
The epinuclear rim of the fourth quadrant is then used as a handle to flip the
epinucleus (Fig. 20.7). As the remaining portion of the epinuclear floor and rim is
evacuated from the eye, 70 percent of the time the entire cortex is evacuated with it (Fig.
20.8).9 Downsized phaco tips with their increased resistance to flow are less capable of
mobilizing the cortex because of the decreased minisurge accom-
315
FIGURE 20.7 Initiating the flipping

maneuver of the residual epinucleus
utilizing the fourth quadrant of
epinuclear rim and shell
FIGURE 20.8 The capsular bag is

clear of cortex, except for a single
strang to the right following flipping
and evacuation of the residual
epinucleus
panying the clearance of the tip when going from foot position two to foot position three
in trimming of the epinucleus.
After the intraocular lens is inserted, these strands and any residual viscoelastic
material are removed using the irrigation-aspiration tip, leaving a clean capsular bag.
If there is cortex still remaining following removal of all the nucleus and epinucleus,
there are three options. The phacoemulsification handpiece can be left high in the anterior
chamber while the second handpiece strokes the cortex-filled capsular fornices.
Frequently, this results in floating up of the cortical shell as a single piece and its exit
through the phacoemulsification tip (in foot position two) because cortical cleaving
hydrodissection has cleaved most of the cortical capsular adhesions.
Phacoemulsification
314
Alternatively, if one wishes to complete cortical cleanup with the irrigation-aspiration

handpiece prior to lens implantation, the residual cortex can almost always be mobilized
as a separate and discrete shell (reminiscent of the epinucleus) and removed without ever
turning the aspiration port down to face the posterior capsule.
The third option is to viscodissect the residual cortex by injecting the viscoelastic
through the posterior cortex onto the posterior capsule. We prefer the dispersive
viscoelastic device chondroitin sulfate-hyaluronate [Viscoat]. The viscoelastic material
spreads horizontally, elevating the posterior cortex and draping it over the anterior
capsular flap. At the same time the peripheral cortex is forced into the capsular fornix.
The posterior capsule is then deepened with a cohesive viscoelastic device [e.g., Provisc]
and the IOL is implanted through the capsulorhexis, leaving the anterior extension of the
residual cortex anterior to the IOL.
Removal of residual viscoelastic material accompanies mobilization and aspiration of
residual cortex anterior to the IOL, which protects the posterior capsule, leaving a clean
capsular bag.
Conclusions
In summary, the lens can be divided into an epinuclear zone with most of the cortex
attached and a more compact central nuclear mass. The central portion of the cataract can
be removed by any endolenticular technique, after which the protective epinucleus is
removed with all or most of the cortex attached. In most cases, irrigation and aspiration
of the cortex as a separate step are not required, thereby eliminating that portion of the
surgical procedure and its attendant risk of capsular disruption. Residual cortical cleanup
may be accomplished in the presence of a posterior chamber IOL, which protects the
posterior capsule by holding it remote from the aspiration port.
References
1. Faust, KJ: Hydrodissection of soft nuclei. Am Intraocular Implant Soc J 10:7577, 1984.
2. Neuhann T: Theorie und Operationstechnik der Kapsulorhexis. Klin Monatsbl Augenheilkd
190:54245, 1987.
3. Gimbel HV, Heuhann T: Development, advantages, and methods of the continuous circular
capsulorhexis technique. J Cataract Refract Surg 16:3137, 1990.
4. Davison JA: Bimodal capsular bag phacoemulsification: A serial cutting and suction ultrasonic
nuclear dissection technique. J Cataract Refract Surg 15:27282, 1989.
5. Sheperd JR: In situ fracture. J Cataract Refract Surg 16:43640, 1990.
6. Gimbel HV: Divide and conquer nucleofractis phacoemulsification: Development and variations.
7. Fine IH: The chip and flip phacoemulsification technique. J Cataract Refract Surg 17:36671,
1991.
8. Anis A: Understanding hydrodelineation: The term and related procedures. Ocular Surg News
9:13437, 1991.
9. Fine, IH: The choo-choo chop and flip phacoemulsification technique. Operative Techniques in
Cataract and Refractive Surgery 1(2):6165, 1998.
Section IV
Phaco Techniques
21. Divide and Conquer Nucleofractis Techniques
22. Single Instrument Phacoemulsification through a Clear Corneal Microincision
23. The Use of Power Modulations in Phacoemulsification of Cataracts: The Choo
Choo Chop and Flip Phacoemulsification Technique
24. Lens Quake Phaco
25. Supracapsular Phacoemulsification
26. New Non-laser Phacoemulsification Technologies
21
Divide and Conquer Nucleofractis
Techniques
Howard V Gimbel
Ellen Anderson Penno
Introduction
Phacoemulsification, since its origin in the 1960s, has changed through the years and
phacotechniques are still evolving. Besides the advantages of a smaller wound,
phacoemulsification allows for the removal of even dense brunescent nuclei through
continuous curvilinear capsulorhexis (CCC) openings. In the early 1980s, as
phacoemulsification was being applied to more and more dense nuclei, the author
developed in-situ nuclear fracturing techniques which added to the safety and efficiency
of phacoemulsification.13 With the preservation of an intact capsular bag using CCC,
fixation and centration of the intraocular lens (IOL), is ensured after safe and efficient inthe-bag phacoemulsification.3
The two-instrument nucleofractis technique was developed to facilitate subdivision of
the nucleus into small pieces so that they could be removed more efficiently through the
phacoemulsification handpiece and thus through a small cataract incision. The term
derives from the Latin divide et impera, and nucleofractis comes from the prefix nucleo
(nucleus) and the Greek suffix fractis (to fracture). Good nucleofractis skills can be
learned by most ophthalmologists. Recent studies have demonstrated rates of vitreous
loss by third-year resident surgeons learning nucleofractis techniques to be comparable to
those found with standard extracapsular techniques.46 Because the fracturing procedure
in divide and conquer places a stretching force on the anterior capsular opening, canopener-type capsulotomies are associated with an unacceptably high rate of peripheral
capsular tears. This led to the development of the CCC, which provides a strong tearresistant border that maintains its integrity despite the stretching forces produced with
nucleofractis.3,7,8
The basic technique of nucleofractis is founded on the anatomic relationship of the
lens fibers and the lenticular sutures. During embryologic development lens fibers
elongate and join, forming the two Y sutures, one anterior and one posterior. As more
fibers are added, these sutures branch out into increasingly complex patterns.9 These
radially oriented sutures create potential cleavage planes that are susceptible to fracturing.
The lens epithelial cells lay down concentric layers of nuclear tissue that become more
dense peripherally. These concentric layers resemble the lamellar organization of a treetrunk or an onion. Radial and lamellar zones form cleavage planes within the lens nucleus
and may be split by instruments and divided into smaller and more manageable pieces for
Divide and conquer nucleofractis techniques
321
Divide and conquer nucleofractis can be viewed as four basic steps: (i) sculpting until
a thin posterior plate of nucleus remains, (ii) fracturing of the posterior plate and nuclear
rim, (iii) breaking away a wedge-shaped section of nuclear material for emulsification,
and (iv) rotating the remaining nucleus for further fracturing and emulsification. All of
the techniques described in this chapter represent variations on this theme. Which one is
used depends on surgeon preference, density of the nucleus, degree of pupillary dilation,
and whether or not an intact CCC is present.
Down-Slope Sculpting
Divide and conquer nucleofractis begins with sculpting until a thin posterior plate of
nucleus remains. A variation from the traditional sculpting method involves nudging the
lens inferiorly with the second instrument. With the lens nudged towards the 6 Oclock
position, the surgeon can sculpt very deeply down the slope of the posterior curvature of
the upper part of the capsule. This technique has thus been termed down-slope
sculpting.10
The author first began using this nudging maneuver in small pupil cases out of
necessity because of limitations of pupil size and capsular opening. The technique was
then extended to almost all cases. It was found that down-slope sculpting greatly
enhanced the speed and efficiency of the nucleofractis techniques and has increased the
safety, because the sculpting is parallel rather than somewhat perpendicular to the
posterior capsule.
With traditional techniques, if the nucleus is broken through unexpectedly when
sculpting a deep, long trench towards 6 Oclock, the tip is more perpendicular to the
inferior portion of the posterior capsule because of its concavity and is directly
perpendicular to the equatorial capsule. With down-slope sculpting, considerable nuclear
material remains ahead of the tip at the end of each sculpting, pass (Fig. 21.1). Therefore,
breaking through is unlikely with the cushion present. The risk of engaging the capsule
is thus minimized.
FIGURE 21.1 Down-slope

sculptingthe lens is nudged
inferiorly by the second instrument and
Phacoemulsification
320
deep sculpting is done from just inside

the continuous curvilinear
capsulorhexis to the center of the lens:
Then the tip will travel parallel to the
concave slope of the posterior aspect
of the nucleus and the posterior
capsule
Down-slope sculpting in the upper pole of the lens to just past the center reduces the
chance of posterior capsule rupture with the phaco port. If the lens is nudged inferiorly by
the second instrument and deep sculpting is done from just inside the continuous
curvilinear capsulorhexis to the center of the lens, then the tip will travel parallel to the
concave slope of the posterior aspect of the nucleus and the posterior capsule. Although
the surgeon cannot visualize the tip when going down-slope, the depth of the sculpting
is determined by visualizing the depth of the groove and translucency of the remaining
tissue.
Furthermore, with traditional sculpting techniques the deepest part of the sculpting
inevitably ends up inferior to the center of the lens. If the surgeon rotates the lens 90
after sculpting each quadrant, then the nuclear material deep in the center or posterior
pole of the nucleus may still impede complete fracturing to the center, and the sections
will tend to hang together in the middle of the lens. However, with down-slope sculpting,
complete and efficient fracturing and subsequent emulsification can be accomplished by
sculpting deeply and fracturing through the entire posterior plate of the nucleus.
The surgeon must be cautious when the CCC is small to avoid tearing the edge of the
anterior capsule superiorly with the tip or the sleeve of the phaco instrument. In the
authors experience, small CCCs are most likely to occur in cases with poor visualization,
such as when hypermature, white cataracts are present. Ordinarily, the risk is low because
one is not sculpting much past the center when first beginning the trench.
Care must also be exercised in displacing the nucleus within the capsular bag so that
the whole bag is not displaced, and the upper zonular ligaments are not unduly stretched
and broken. Adequate hydrodissection is essential to allow inferior nucleus displacement
while minimizing stress to the upper zonular apparatus. Also, when tipping the handle of
the phaco handpiece upto sculpt down towards the posterior pole, the surgeon must not
push the tip posteriorly faster than the tip is chiselling its way through the lens material.
The zonular ligaments may also be torn with such a maneuver. These risks are greatest in
lenses with hard epinuclei and where the zonules are already weakened.
Limiting sculpting to the superior part of the nucleus adds safety because of the
reduced risk of contacting the posterior capsule and adds efficiency because of the
rapidity with which the posterior pole of the nucleus is reached with the phaco tip. With
instruments this deep in the nucleus, the fracturing can be effectively initiated and safely
completed.
323
The Fracture
The fundamental principle underlying nucleofractis is the creation of fractures within the
nucleus to facilitate the removal of the cataract through a small incision while causing the
least possible trauma to the eye. If the nuclear rim is very hard or if the CCC is not intact,
splitting the nucleus along a groove is achieved using a bimanual technique or a nuclear
cracker. Regardless of the fracturing technique used, nucleofractis is facilitated by deep
sculpting of the posterior pole of the lens nucleus. This will be discussed in more detail
under polar expenditions.
With the parallel instrument technique, a deep central groove is sculpted within the
lens nucleus and the phaco probe is placed deep within the groove against the right-hand
wall (for right-handed surgeons). A second instrument is placed in the groove against the
other wall. The fracture is created by pushing the two walls away from each other.
Alternatively, with a cross-handed technique, each instrument is placed against the
opposite wall of the groove. With both the parallel instrument and cross-handed
techniques, placing the two instruments as deeply as possible within the groove provides
the most efficient application of the cracking force.
An alternative fracturing technique involves creating a full diameter groove, aligning
the groove midway between the main incision and moving the two instruments away
from each other deep within the trench. The density of the lens and the preference of the
surgeon will dictate the appropriate fracturing techniques necessary to achieve consistent
and predictable results in nucleofractis. All fracturing techniques currently used by the
author use the principles of deep sculpting followed by fracturing of the posterior plate of
the nucleus and then the posterior rim. Once the initial fracture is achieved, rotation and
additional fractures are used to break away wedge-shaped sections of the lens nucleus for
emulsification.
FIGURE 21.2 The phaco tip is used in

a lateral motion (nasal to temporal and
back again) to sculpt the central
nucleus quickly and deeply while
maintaining constant visualization of
the tip of the instrument. With a 30
Phacoemulsification
322
Kelman tip, the removal of lens

material is more efficient and easier to
perform. However, this technique is
also possible with standard straight tip
phacoemulsification handpieces
Phaco Sweep
Another variation on the theme of sculpting is a technique the author calls phaco
sweep.11 In traditional sculpting techniques, the phaco tip is moved from the superior to
the inferior portion of the nucleus to create a groove. By using the phaco tip in a lateral
motion (nasal to temporal and back again), the central nucleus can be sculpted quickly
and deeply while maintaining constant visualization of the tip of the instrument. The
author prefers to use a 30 Kelman tip to perform phaco sweep (Fig. 21.2). With this tip,
the removal of lens material is more efficient and easier to perform. However, this
technique is also possible with standard straight tip phacoemulsification handpieces. The
engineers at Alcon Surgical explain this difference on the basis of a three-dimensional
propagation of the ultrasound wave front from the bent Kelman tip. Standard handpieces
tend to direct their ultrasound power primarily in the forward direction, somewhat
limiting their cutting efficiency for this technique.
As sculpting proceeds to deeper layers, the phaco tip is moved in a lateral sweeping
motion. It is important to avoid occlusion of the tip during this
FIGURE 21.3 Phaco sweepas

sculpting proceeds to deeper layers the
phaco tip is moved in a lateral
sweeping motion. It is important to
avoid occlusion of the tip during this
procedure. The lens is stabilized
inferior to the groove with a second
instrument through the paracentesis
325
procedure. The lens is stabilized inferior to the groove with a second instrument through
the paracentesis (Fig. 21.3). After lateral sculpting is sufficiently deep, a horizontal
fracture is created as described later in the multidirectional divide and conquer section
of this chapter (Fig. 21.4). Phaco sweep is a variation of down-slope sculpting which
enhances visualization of the phaco tip and results in increased safety for the removal of
central nuclear
FIGURE 21.4 Phaco sweepafter the

lateral sculpting is sufficiently deep, a
horizontal fracture is created
FIGURE 21.5 Crater divide and

conquer (CDC)after adequate
hydrodissection, a deep crater is
sculpted into the center of the nucleus,
leaving a dense peripheral rim that can
later be fractured into multiple
sections. It is important that the crater
include the posterior plate of the
nucleus, otherwise, fracturing of the
rim will be much more difficult
Phacoemulsification
324
material. In addition, the motion of the probe remains parallel to the posterior capsule,
diminishing the risk of its inadvertent rupture.
Crater Divide and Conquer (CDC) Technique
Divide and conquer nucleofractis phaco, described by the author was the first
nucleofractis (two-instrument) cracking technique developed.1,12 It is still used for hard
lenses and is now combined with the phaco chop for dense brunescent nuclei. The phaco
chop technique will be discussed later in this chapter.
After adequate hydrodissection, a deep crater is sculpted into the center of the nucleus,
leaving a dense peripheral rim that can later be fractured into multiple sections (Fig.
21.5). The crater must include the posterior plate of the nucleus, otherwise, fracturing of
the rim will be much more difficult. A shaving action is used to sculpt away the central
nuclear material. When the central material is no longer accessible to the phaco probe, the
lens should be rotated and additional central sculpting performed to enlarge and deepen
the crater. The size of the central crater should be expanded for progressively denser
nuclei. Enough of the dense material must be left in place, however, to allow the phaco

conquer (CDC)rather than emulsify
the sections as they are broken away
the sections should be left in place
within the rim to maintain the circular
rim and the tension on the capsule.
Leaving the sections in place also
facilitates rotation and the progressive
fracturing of the remaining rim
probe and second instrument to engage the rim and fracture the lens into sections.
The surgeon uses experience as a guide to determine how deeply the central crater
should be sculpted. The peripheral nuclear rim stretches the entire capsular bag and acts
as a safety mechanism to prevent the posterior capsule from suddenly moving anteriorly
and being cut by the phacoprobe. For harder nuclei, small sections should be fractured
327
from the rim. Rather than emulsify the sections as they are broken away, the sections
should be left in place within the rim to maintain the circular rim and the tension on the
capsule. Leaving the sections in place also facilitates rotation and the progressive
fracturing of the remaining rim (Fig. 21.6). It is sometimes advisable to initially remove
one small section to allow space for fracturing the other segments of the remaining rim
(Fig. 21.7). If one small fragment is removed, the remaining segment can maintain
capsular stretch and help to avoid rupture of the capsule. After the rim is fractured around

conquer (CDC)it is sometimes
advisable to initially remove one small
section to allow space for fracturing
the other segments of the remaining
rim

conquer (CDC)after the rim is
fractured around the entirety of its
circumference, each segment can then
Phacoemulsification
326
be brought to the center of the capsule

for safe emulsification
the entirety of its circumference, each segment can then be brought to the center of the
capsule for safe emulsification (Fig. 21.8). One must be more cautious at this point
because as more segments are removed, less lens material is available to expand the
capsule, and the capsule will have a greater tendency to be aspirated into the phaco tip,
especially if high aspiration flow rates are used (Fig. 21.9).
Trench Divide and Conquer (TDC) Technique
Recognizing the efficiency of fracturing maneuvers during CDC, the author stopped
sculpting the right side of soft lenses after making the central trench
FIGURE 21.9
Crater divide and conquer (CDC)as
segments are removed less lens
material is available to expand the
capsule and the capsule will have a
greater tendency to be aspirated into
the phaco tip, especially if high
aspiration flow rates are used
329
FIGURE 21.10 Trench divide and

conquer (TDC)using the down-slope
sculpting technique described earlier
enables the phaco tip to remove more
of the upper part of the nucleus during
sculpting and to reach the posterior
pole of the lens very early for effective
fracturing
and instead made a central fracture. Using the down-slope sculpting technique described
earlier allows the phaco the tip to remove more of the upper part of the nucleus during
sculpting and to reach the posterior pole of the lens very early for effective fracturing
(Fig. 21.10). Then the left side is divided by fracturing, and also the right side. These
variations were named trench divide and conquer (TDC) techniques.10,13,14

conquer (TDC)using a 30 or 45
tip, the TDC technique begins with a
shallow trench or trough sculpted
slightly to the right of the center of the
Phacoemulsification
328
lens surface. The lens is stabilized with

the spatula through the paracentesis
Using a 30 or 45 tip, the TDC technique begins with a shallow trench or trough
sculpted slightly to the right of the center of the lens surface. The lens is stabilized with
the spatula through the paracentesis (Fig. 21.11). Then, nudging the loosened lens
nucleus inferiorly with the second instrument, down-slope sculpting is performed very
deeply to the posterior pole of the lens. Adequate hydrodissection is essential to downslope sculpting because then the nucleus is not attached to the peripheral cortex and
capsule, and the nucleus can easily be displaced in the capsular bag.
Placing the instrument tips deep in the center of the lens, fracturing is accomplished by
pushing towards the right with the phaco tip as the cyclodialysis spatula is pushed to the
left. This is accomplished in foot position two (irrigation/ aspiration only and no
ultrasound power). The lens usually splits from the center to the superior and inferior rim
of the nucleus if the instruments are held deep in the center. If the split does not readily
extend to the equator inferiorly or superiorly, moving the instruments away from the
center can produce the mechanical advantage necessary to extend the fracture through the
nuclear rim.
After this first crack has been obtained, the depth of the sculpted groove in the lens
can be determined, and the surgeon can gauge how much deeper sculpting should be
continued to facilitate

conquer (TDC)keeping the probe
deep in the tissue and close to the
posterior cortex, the surgeon then
burrows deeply into the hemisection
and creates a second crack that
intersects with the first, isolating a pieshaped section of nucleus
further fracturing. In all but brunescent nuclei, usually three to five sculpting passes allow
one to get deep enough into the lens to start fracturing.
331
Either before the first fracture or immediately afterward, the Down-slope technique
may be used to sculpt the majority of the upper part of the lens. Keeping the probe deep
in the tissue and close to the posterior cortex, the surgeon then burrows deeply into the
left hemisection and creates a second crack that intersects with the first, isolating a pieshaped section of nucleus. In soft nuclei, this is usually performed about 60 from the
first fracture, but in hard nuclei, the crack is shortened to about 30 away (Fig. 21.12).
The isolated pie-shaped section can then either be emulsified or left in place as the
next crack is made in a similar fashion (Fig. 21.13). The remaining right section of
nucleus is then maneuvered with the second instrument and brought to the midpupillary
zone. A final split is made after impaling the tip with a short burst of ultrasound, pushing
with the phaco tip towards the 6 Oclock position while stabilizing the upper portion (Fig.
21.14). The piece can then be fractured into halves or thirds and emulsified as they are
fractured. Alternatively, the right hemisection may be rotated to the left side and
fractured in a way similar to the first hemisection.

conquer (TDC)the isolated pieshaped section can then either be
emulsified or left in place as the next
crack is made in a similar fashion

conquer (TDC)a final split is made
Phacoemulsification
330
after impaling the tip with a short burst

of ultrasound, pushing with the phaco
tip toward the 6 Oclock position while
stabilizing the upper portion. The piece
can then be fractured into halves or
thirds and emulsified as they are
fractured
Rather than utilizing grooves to start the fractures, the surgeon simply needs to get the
instruments deep into the center of the lens to fracture through the naturally occuring
radial fault lines of the lens. Except in brunescent nuclei where notches are sculpted in
the nuclear rim so that the spatula has a wall to push against, the principal advantage of
the technique is that pregrooving the nucleus for subsequent fracturing is completely
unnecessary.
FIGURE 21.15 Multidirectional

divide and conquer (MDC)the phaco
sweep technique is initiated with small
lateral movements of the phacotip at
the bottom of the previously formed
groove. The Kelman tip works very
well for this side-to-side movement to
create a deep groove horizontally. The
phaco tip is then used to stabilize the
upper portion, while the spatula pushes
inferiorly against the wall, creating a
horizontal fracture
333
Multidirectional Divide and Conquer (MDC) Technique

Down-slope multidirectional nucleofractis is begun by debulking the superior part of the
lens. The phaco sweep technique is initiated with small lateral movements of the phaco
tip at the bottom of the previously formed groove. The Kelman tip works very well for
this side-to-side movement to create a deep groove horizontally. The phaco tip is then
used to stabilize the upper portion while the spatula pushes inferiorly against the wall,
creating a horizontal fracture (Fig. 21.15).
This horizontal fracture is a combination of separation, and shearing. The second
instrument pushes towards 6 Oclock and the phaco tip pushes down and away so that
these opposing forces result in the splitting of the nucleus as the horizontal fracture.
FIGURES 21.16 TO 21.18

Multidirectional divide and conquer
Phacoemulsification
332
(MDC)Multidirectional
nucleofractis occurs when the phaco
tip is used to engage the inferior
hemisection and multiple pie-shaped
sections are fractured using the second
instrument to stabilize the nucleus. The
multidirectional fracturing is
accomplished without rotating the lens
Multidirectional nucleofractis occurs when the phaco tip is used to engage the inferior
hemisection and multiple pie-shaped sections are fractured using the second instrument to
stabilize the nucleus (Figs 21.16 to 21.18). The sections are brought into the central
pupillary zone for safe emulsification. The multidirectional fracturing is accomplished
without rotating the lens. With the natural fault lines in the lens, this can be accomplished
very easily without the chopping technique through the use of two-instrument separation.
The fracturing is enhanced by not only separation but again by shearing (pushing down
on one segment and away on the other) so that the separation is in two planes.
The superior hemisection is rotated inferiorly and emulsified in a similar fashion.
Alternatively, the superior section is nudged inferiorly with the spatula and the phaco tip
is burrowed into the bulk of the nucleus, which is fractured without rotation.
Phaco Chop
Kunihiro Nagahara first introduced the phaco chop technique in 1993 at the annual
meeting of the American Society of Cataract and Refractive Surgery (ASCRS) in Seattle,
Washington. This technique also uses the lamellar structure of the nucleus to create radial
fractures in the lens. The phacoemulsification probe is directed into the central core of the
nucleus until occlusion of the port occurs. A modified lens hook is then inserted just
beneath the anterior capsular leaflet at the 6 Oclock position just adjacent to the phaco
probe, but extending to the equator of the lens. The tip is drawn centrally from the
equator of the lens towards the phaco tip. This chop must encompass at least half of the
anteroposterior diameter of the lens. The two instruments can then be used in a standard
bimanual technique to complete the fracture. The nucleus is rotated slightly after the first
chop and the procedure is repeated until pie-shaped wedges are created throughout the
lens. These wedges can then be aspirated into the center of the capsular bag for safe
emulsification.
While the phaco chop technique can reduce phacoemulsification time significantly,
this technique poses a persistent threat to anterior capsular integrity. Traversing the
chopping instrument through the cortex towards the equator ensures that the anterior
capsule remains anterior to the chopping instrument. The risk to capsular integrity with
the phaco chop technique is greatest for surgeons with limited experience.
335
FIGURES 21.19 AND 21.20 Crater

divide and conquer (CDC) variation
using phaco chopin this modified
technique the central nucleus is
sculpted away. Rather than fracture the
remaining nucleus by traditional
nucleofractis techniques, the chop
maneuver is used to split and than
separate the nuclear rim using shearing
forces. Creating a central crater
provides a space where rim segments
can be easily maneuvered following
the chop
As discussed earlier, the author has incorporated this phaco chop technique into the crater
divide and conquer method for dense brunescent nuclei.15 It can be difficult to separate
the nuclear rim in very hard lenses. In this modified technique, the central nucleus is
sculpted away as described earlier (see Crater Divide and Conquer section). However,
rather than fracture the remaining nucleus by traditional nucleofractis techniques, the
chop maneuver is used to split and then separate the nuclear rim using shearing forces
(Figs 21.19 and 21.20). Creating a central crater provides a space where rim segments
Phacoemulsification
334
can be easily maneuvered following the chop. Fracturing is thus made easier and zonular
and capsular stress is reduced.
The use of the chop technique is safer in the presence of anterior capsular tears
because stretching of the capsule is reduced. For soft and moderately soft nuclei, the chop
technique does not offer sufficient added efficacy to offset the increased risk of capsular
tears.
Steve Arshinoff recently presented his slice and separate modified phaco chop
technique at the 1997 annual meeting of the American Society of Cataract and Refractive
Surgery. This method is designed to be used for moderately dense nuclei. Dr Arshinoff
describes impaling the nucleus and using a phaco chopper to slice across the nuclear part
of the lens from anterior to posterior, passing by the phaco tip. The nucleus is then rotated
15 to 20, and the same maneuver is repeated on the distal half. After the second slice,
the segment is vacuumed out and the procedure is repeatedslice and vacuumuntil the
nucleus is removed. The slice maneuver is always started in the lens center, and the
posterior capsule remains protected by the remaining nuclear and cortical material. Dr.
Arshinoff emphasizes the need for good hydrodissection for success in this technique and
notes that the slice and separate technique is difficult to perform on very soft nuclei due
to difficulty in stabilizing the lens.
Polar Expeditions
Regardless of the fracturing technique usedcrater divide and conquer (CDC), trench
divide and conquer (TDC), or multidirectional divide and conquer (MDC)the key is to
sculpt nuclear material away centrally, leaving a thin layer of epinuclear material. Deep
sculpting to the posterior pole of the lens facilitates the fracturing of the nucleus because
it provides for safe and efficient segmentation and removal of the nuclear segments by
taking advantage of the natural fault lines of the lens. Deep sculpting also allows one to
obtain the mechanical advantage required to effectively fracture through the entire lens.
Sculpting should be deep enough to be right through the nucleus into the epinucleus. The
bent Kelman tip facilitates this deep sculpting.
The expedition to the posterior pole can be accomplished with forward sculpting or
phaco sweep lateral sculpting to thin the posterior plate before fracturing is attempted.16
Once a thin posterior plate is achieved, the segments fracture very easily with the twohanded technique. In a brunescent lens, the phaco chop instrument is used to fracture
segments in the crater chop so that the segments are smaller and more easily managed.
In trench divide and conquer (TDC) nucleofractis, polar sculpting is limited to a
central trough or trench. This works best in a very soft nucleus where one has to maintain
most of the nucleus which is firm enough to fracture. The nucleus is nudged slightly
inferiorly and stabilized with the second instrument. Then the polar expedition for the
posterior pole of the lens begins. The trench has to be wide enough to allow the phaco
sleeve to get down into the nucleus. Once deep enough, the fracture is obtained with the
two instruments. The segments are broken away, similar to the other nucleofractis
techniques. Once the fracture is through the posterior plate of the lens, the fractured
segments fracture completely without being tied together at the apices, and small
segments are easier to manage than large segments. Only low-ultrasound power is
necessary for these small nuclear segments to be emulsified.
337
In multidirectional divide and conquer, downslope sculpting towards the posterior pole
is used initially. The upper part of the nucleus is removed, and then with phaco sweep,
polar expedition involves sculpting of the posterior pole before the horizontal fracture.
The lens is stabilized and nudged inferiorly, and the sculpting is done with forward
passes until one is deep in the lens. Then phaco sweep is used to delicately sculpt through
the deepest part of the nucleus to the epinucleus before the horizontal fracture is made.
The Small Pupil
The most important goal in small pupil cataract surgery is to limit serious surgical
complications. Relatively complication-free surgery in small pupil cases can be achieved
with phacoemulsification techniques. These techniques also help to attain other goals
such as the use of a small incision, the minimal use of pupil enlarging surgery and certain
verification, of in-the-bag placement of a posterior chamber intraocular lens. The
placement verification, long-term stability, and centration can be virtually assured by
obtaining and maintaining a continuous curvilinear capsulorhexis opening in the anterior
capsule.17 The lens nucleus, even though dense and large, can be fractured into small
segments and removed by emulsification through relatively small capsule openings, small
pupil openings, small scleral incisions and small conjunctival incisions. These are
important considerations in many glaucoma patients who have small pupils from longterm miotic therapy and who have had or may in the future require filtering surgery
The author developed the down-slope sculpting method, as described earlier in this
chapter, in small pupil cases to quickly reach the posterior pole of the nucleus for
efficient fracturing. The lens is nudged inferiorly, using a second instrument and the
phacotip sculpts down the concave posterior capsule towards the posterior pole as
described earlier, parallel to the capsule as opposed to perpendicular to it. Once the pole
is reached, the two-instruments are held deep in the center. The spatula pushes inferiorly
while the phaco tip pushes superiorly to create a horizontal fracture. The two instruments
are repositioned to create a vertical fracture. The fractured segments can remain in the
bag to stabilize it or be removed piece by piece. The second instrument holds back
segments, while other segments are emulsified in the center of the lens. As well, the
spatula brings nuclear material to the phaco tip to be emulsified. The phaco tip itself,
stays mainly in the center of the lens.
Small pupil cases demonstrate the distinct advantage of nucleofractis techniques in
that the phaco tip does not have to be put under the iris or under the small openings in the
capsule. As such there is little risk of iris or capsule flowing unexpectedly with the lens
material into the tip of the phaco port. One should use a lower flow when the pupil is
small. This may reduce efficiency, but certainly increases safety. Again, epinuclear
material is brought to the phaco port using the second instrument. The phaco port itself
does not go searching for this material in a small pupil case.
Intumescent Lens
The nucleus in an intumescent lens can be safely and efficiently fractured and
phacoemulsified using the down-slope sculpting technique.18 In intumescent cases with
Phacoemulsification
336
primary, small capsulorhexis openings, the nucleus is nudged inferiorly with a second
instrument. The upper portion of the nucleus is then sculpted using the down-slope
sculpting technique. The nudging maneuver allows the phacotip to get very deep into the
nucleus for subsequent fracturing. The phaco tip should be maintained centrally to avoid
stress on either the small capsulorhexis rim or a can-opener margin. Mechanical stress to
the ring of the can-opener with the use of the phaco handpiece, or by a second instrument,
should be avoided. This is another instance in which down-slope sculpting nucleofractis
is advantageous for safe emulsification, because the phaco tip always stays in the center
of the lens. The second instrument is used to rotate, maneuver, and help fracture the
nuclear rim.
The depth of the sculpting is quite easy to gauge in an intumescent lens due to the
whiteness of the nucleus and the red reflex exposed during fracturing. In doing
phacoemulsification out near the periphery or up near the capsule in the epinucleus, a low
flow and low vacuum should be used so that a sudden breakthrough with a high flow and
high vacuum can be avoided. This will avoid engaging the equatorial capsule with the
phaco tip. The intumescent lens is usually easy to fracture and quite often the lens will
fracture spontaneously just with the attempt at rotation.
Capsular Tension Rings
Since phacoemulsification and continuous curvilinear capsulorhexis were developed, it
has become possible to remove a cataract through a small incision and implant an
intraocular lens (IOL) into the capsular bag. The centration and stability of the IOL inthe-bag is critical for maintaining excellent visual outcome. In some situations, placing an
IOL in the capsular bag may be insecure, as in the case of a traumatic cataract with
broken or loose zonules. To manage this situation, many anterior segment surgeons
(including the first author) prefer to use phacoemulsification if possible, even if the
capsular bag cannot be used for IOL placement. A sutured posterior chamber IOL (PCIOL) or an anterior chamber IOL (AC-IOL) may be placed after phacoemulsification is
completed. Sutured fixation of a PC-IOL significantly increases surgery time and axial
tilt of the IOL often occurs postoperatively. Implantation of an AC-IOL may be
associated with postoperative corneal pathology, chronic cystoid macular edema, or
secondary glaucoma.
In 1991, Hara et al introduced an equator ring for maintaining the circular contour of
the capsular bag after cataract removal.19 Following their work, different types of rings of
varied material were developed. Cionni and Osher reported on four cataract surgery cases
with extensive zonular dialysis managed with endocapsular rings.20 The results showed
that the ring facilitated phacoemulsification and PC-IOL in-the-bag implantation. In
January 1995, the author began using a polymethylmethacrylate (PMMA) capsular
tension ring (Morcher GMBH, Germany) to manage patients with zonular dialysis
requiring cataract surgery (Fig. 21.21).21
339
FIGURE 21.21
Polymethylmethacrylate (PMMA)
capsular tension ring (Morcher
GMBH, Stuttgart, Germany) type 14
(dimensions 12.5 10.0 mm)
A capsular tension ring may have potential benefits for cataract surgery patients with
zonular dialysisa capsular tension ring appears to enhance safety and efficacy during
the phacoemulsification and PC-IOL implantation, it may help to avoid vitreous
herniation, it maintains the circular contour of the capsular bag, it may reduce IOL
decentration, and it may inhibit lens epithelial cell proliferation on the posterior capsule
by compression, which may reduce the incidence of secondary cataract.
Clinically, cataracts with loose zonules or broken zonules are commonly seen which
present a challenge for surgeons when performing phacoemulsification and PC-IOL
implantation. The capsular tension ring provides an alternative means to manage this
situation.
Challenges to Topical Anesthesia in Small-Incision Cataract Surgery
The use of topical anesthesia in cataract operations requires that surgeons learn new
techniques and adapt to challenges not faced with the use of local or general anesthesia.22
The transition to topical anesthesia means that surgeons cannot use some of the
techniques that have been entirely safe on the immobilized eye. Under topical anesthesia,
one cannot rely on the patients fixation or on voluntary immobilization of the eye, and
persistent ocular movements on a regular or irregular basis may occur. In some
circumstances, the globe must be immobilized with a second instrument.
The author began using topical anesthesia for cataract surgery in 1993, specifically
because of a case involving a very myopic eye with an axial length of 36.3 mm. In this
case, it was felt that the risks of using peribulbar or even pin-point anesthesia were too
high. The patient was relatively co-operative and communicative and fixated well. The
author became convinced that topical anesthesia in long eyes adds an element of safety,
reducing or eliminating the risks of the local anesthetic.
Topical anesthesia introduces new challenges to cataract surgery. A learning curve
presents itself with changes in surgical technique, and modifications must be made in
Phacoemulsification
338
reflex and habit that have evolved while doing surgery with peribulbar anesthesia
surgery. Two-handed cataract extraction techniques are relatively advantageous in topical
anesthesia cases, particularly because the second instrumentat almost 90 from the
firsthelps to stabilize the eye against unwanted movements in both the vertical and
horizontal directions.
In general, the learning curve involves modifications to almost every stage of cataract
surgery. The eye must be stable even before the paracentesis is done. If an eye is not very
quiet, it is valuable to use a ring to stabilize the eye while making the paracentesis. Next,
the eye needs to be stabilized with forceps during the incision. The surgeon cannot afford
any sudden movements (particularly when using diamond knives) of an eye anesthetized
only topically. Scleral incisions under topical anesthetic must be made with the eye
stabilized with forceps (unlike clear corneal incision where the eye is stabilized by a
ring), grasping and regrasping the sclera before continuing with dissection. Sometimes,
with local anesthesia, when the incision is being made, the grasp on the sclera is released
and reapplied in a different place when the blade is in the tunnel. In eyes under topical
anesthesia, the author advocates that the blade be removed from the tunnel before the
forceps are released and the sclera be grasped at another location before the blade is reentered. One should never release the eye with the second instrument unless the sharp
instrument is taken away first, because if the eye moves unexpectedly with only the sharp
instrument in the tunnel, the sclera could be inadvertently cut.
Another area of concern is the injection of viscoelastic. One cannot simply insert the
cannula into the eye to inject viscoelastic, because the eye can move before the surgeon
has an opportunity to fill the chamber. Any sudden movement may cause a tear to the
anterior or posterior capsule. It is best to hold the eye while injecting viscoelastic.
Furthermore, instead of inserting the viscoelastic cannula directly perpendicular to the
eye, insert it so that it approaches the eye tangentially so that the side of the cannula is
pushing or nudging the side of the wound. Any sudden movement of the eye towards the
cannula will push the side of the cannula rather than allow the cannula to puncture the
capsule unexpectedly.
Some extremely nervous patients do not agree to topical anesthesia even after
sedation. In patients with language barriers we now bring an interpreter or family
member into the operating room. When faced with communication difficulties with
extremely deaf or demented patients, we sometimes opt for a local anesthetic. However,
nonverbal communication for instructions allows surgery to be done under topical
anesthesia in many cases.
Topical anesthesia appears to be the growing trend in cataract surgery. It avoids the
potential risks of damage to vessels, globe, and nerves that exist when a needle is used.
Surgeons who use topical anesthesia should already be experienced in
phacoemulsification. A surgeon in the transition to phacoemulsification should probably
not consider topical anesthesia until confident with phacoemulsification first. Initially, a
surgeon should use topical anesthesia only on routine unchallenging cases. At the outset,
surgeons should avoid using topical anesthesia on uncooperative patients or with patients
who have difficulty in communicating. As one becomes more experienced and more
confident, topical anesthesia can be used in more challenging cases. Cases in which local
or general anesthesia is preferred will always exist, and these include patients who are
341
unable to co-operate, have extremely small pupils, or very dense or subluxated lenses,
and those requiring more complex surgery or delicate dissection.
Summary
Each of the nucleofractis techniques described in this chapter are variations of four basic
steps: (i) sculpting to obtain a thin posterior plate of nucleus, (ii) fracturing the posterior
plate and nuclear rim, (iii) breaking away wedge-shaped sections of nuclear material for
emulsification, and (iv) rotating the nucleus for further fracturing and emulsification. The
techniques of continuous curvilinear capsulorhexis, down-slope sculpting, phaco sweep
and polar expeditions are refinements which add efficacy and safety to the divide and
conquer nucleofractis techniques. The surgeon should be familiar with the variety of
nucleofractis techniques described and be able to modify the surgical strategy as dictated
by specific patient characteristics and intraoperative events.
References
1. Gimbel HV: Divide and conquer nucleofractis phacoemulsificationdevelopment and
variations. J Cataract Refract Surg 17:28191, 1991.
2. Gimbel HV, Ellant JP, Chin PK: Divide and conquer nucleofractis. Ophthalmol Clin North Am
8(3):45769, 1995.
3. Gimbel HV, Neuhann T: Development, advantages, and methods of the continuous circular
4. Cruze OA, Wallace GW, Gay CA et al: Visual results and complications of phacoemulsification
with intraocular lens implantation performed by ophthalmology residents. Ophthalmology
99:44852, 1992.
5. Noecker RJ, Allinson RW, Snyder RW: Resident phacoemulsification experience using the in
situ nuclear fracture technique. Ophthalmology 25:21521, 1994.
6. Pearson PA, Owen DG, Van Meter WS et al: Vitreous loss rates in extracapsular cataract
surgery by residents. Ophthalmology 96:122527, 1989.
17:110, 1991.
8. Neuhann T: Theorie und operationstechnik der kapsulorhexis. Klin Monatsble Augenheilkd
190:54245, 1987.
9. Hogan M, Alvaradd J, Weddell J: Histology of the Human Eye. Philadelphia: WB Saunders
1971.
10. Gimbel HV: Down slope sculpting. J Cataract Refract Surg 18:61418, 1992.
11. Gimbel HV, Chin PK: Phaco Sweep. J Cataract Refract Surg 21:49396, 1995.
12. Gimbel HV: Divide and Conquer. (Video) Presented at the European Intraocular Implant Lens
Council meeting 1987.
13. Gimbel HV: CCC and nucleus fracturing. Ophthalmol Clin North Am 4:235, 1991.
14. Gimbel HV: Evolving techniques of cataract surgerycontinuous curvilinear capsulorhexis,
down-slope sculpting and nucleofractis. Semin Ophthalmol 7:193207, 1992.
15. Gimbel HV: Nuclear phacoemulsificationalternative methods. In: Steinert RF (Ed) Cataract
Surgery: Technique, Complications, and Management Philadelphia: WB Saunders 14881,
1995.
Phacoemulsification
340
16. Gimbel HV, Austin A: Polar expedition technique expedites phaco. Ocular Surgery News
15(9): 2732, 1997.
17. Gimbel HV: Nucleofractis phacoemulsification through a small pupil. Can J Ophthalmol
27(3):11519, 1992.
18. Gimbel HV, Willerscheidt AB: What to do with limited viewthe intumescent cataract. J
Cataract Refract Surg 19: 65761, 1993.
19. Hara T: Endocapsular phacoemulsification and aspiration (ECPEArecent surgical technique
and clinical results. Ophthalmic Surg 20:46975, 1989.
20. Cionni RJ, Osher RH: Endocapsular ring approach to the subluxated cataractous lens. Cataract
Refract Surg 21:24549, 1995.
21. Gimbel HV, Sun R, Heston JP: Management of zonular dialysis in phacoemulsification and
IOL implantation using the capsular tension ring. Ophthalmic Surgery and Lasers 28(4):273
81, 1997.
22. Gimbel HV: Challenges of topical anesthesia in small incision cataract surgery. Ophthalmic
Practice 14(3):12324, 1996.
22
Single Instrument Phacoemulsification
through a Clear Corneal Microincision
Robert M Kershner
Introduction
An increasing number of surgeons have adopted phacoemulsification as the preferred
method for cataract removal, since its introduction as a method of cataract removal over
one-quarter of a century ago, The advantages of removing a cataract through a small
incision have been recognized by surgeons the world over. Phacoemulsification has made
it possible to abandon suture closure, utilize smaller incisions, replace injection
anesthesia with topical anesthesia, and improve our ability to correct refractive error with
cataract surgery.1
Todays new techniques of topical anesthesia, clear corneal cataract surgery, and
injection of elastic intraocular lenses through small incisions have placed new constraints
on the ability of the surgeon to perform phacoemulsification. Introducing the
phacoemulsification tip through a small clear corneal refractive microincision limits
access to the cataract and can restrict the surgeons ability to manipulate the lens within
the capsular bag. As a result of the challenge and demands of smaller incision cataract
surgery, surgeons have adopted several new approaches to the strategy for
All methods of cataract removal have essentially one goal in commonto take a large
anatomic structure (the lens) and dismantle it into smaller pieces for ease of removal
through an incision smaller than the overall size of the lens. Whether one adopts a divide
and conquer technique, a quadrantic phacoemulsification method, a chip and flip, or a
stop and chop method, the goal remains the same. One can either mechanically divide the
cataract into segments and remove the individual segments, or chip away at the larger
structure and remove it piece by piece.
Many surgeons use two incisions through the cornea, and two instruments for phaco:
one for the phaco tip and one for a sideport lens manipulating instrument. The author
does not believe that a second-handed instrument is necessary for effective and efficient
phacoemulsification of the cataract. There are distinct advantages of maintaining the
phaco incision as one incision. Placing an additional incision in the eye is not only
unnecessary, but it increases the likelihood of incisional leaks, an additional portal for
infection, synechiae and encourages excessive instrumentation of the eye. We learned to
drink a glass of milk as children by holding onto the glass with two hands. As adults, we
can learn to hold a glass with one hand, freeing up the other hand for other needs. So, it is
with phacoemulsification.
Phacoemulsification
342
Single Incision Phacoemulsification: The Four-step Keyhole

Technique
Early in its development, phacoemulsification was performed entirely through a single
incision. This single incision or single instrument phacoemulsification technique has
previously been called a one-handed phaco technique. The name is a misnomer,
however, as two hands are required to successfully perform phaco. They just do not each
require their own incision! The maneuvers of lens rotation and segmental removal of the
cataract can be performed with a single hand on the instrument, thus, freeing the left hand
for manipulating the eye, stabilization of the globe, retrieval of instruments, or to hold the
phacoemulsification handle and tubing.
It is important that the surgeon adopt an efficient method of phacoemulsification
through todays small corneal microincisions. The single instrument phaco technique is
elegant, more efficient, easier to learn, and less traumatic to the eye. The time is right, as
we enter the next millennium, to take a new look at an old techniquethe single incision
or single instrument phacoemulsification method that the author calls the keyhole
technique.6
Incision Construction
The clear corneal microincision has placed new demands on the surgeon for evacuating
the cataract through a single small corneal incision. These incisions can be very
unforgivingthey must not be distorted, torn or heated during the procedure without
creating profound refractive effects for the eye.
Incision construction is critical to a successful phacoemulsification procedure. The
incision needs to be accurately sized for the size of the phacoemulsification tip to be
used. Todays microincision corneal procedures utilize an incision of 2.5 mm or smaller
that must accommodate a micro phaco tip. The clear corneal refractive microincision
technique has been described elsewhere.13 Following fabrication of the clear corneal
incision with a diamond keratome, the anterior chamber is entered, and a viscoelastic
placed to deepen the chamber. Capsulorhexis is performed using the technique of onestep capsulorhexis with a cystotome/forceps which the author developed in 1984.4,5
In early phacoemulsification methods, it was important to maintain the position of the
cataractous lens within the capsular bag to stabilize it. Following the introduction of
capsulorhexis, it was found that the limited access into the capsular bag created
difficulties for the surgeon in rotating the lens for emulsification and removal. To
facilitate these maneuvers, hydrodissection must be performed to cleave the strong
cortical attachments between the lens capsule and the cortex of the cataract. By slipping a
curved 27-gauge cannula through the incision and positioning it beneath the subincisional
anterior lens capsule, a fluid wave can be created across the posterior lens. This maneuver
prematurely loosens the cortex beneath the incision making it easier to remove with
irrigation and aspiration later in the procedure.
Single instrument phacoemulsification
345
Phacoemulsification Parameters
It is preferable to use a phacoemulsification machine whose individual parameters are
controllable by the surgeon. When utilizing a peristaltic pump, the factors of flow rate,
rise time, vacuum and phacoemulsification power can be set to the individual needs of
the surgeon. By setting the flow rate, the surgeon can control how rapidly the fluid moves
into the eye and out of the aspiration port. This is important in cooling the
phacoemulsification tip during brief bursts of phaco power. The faster the flow rate, the
quicker the rise time, and the more fluid which is utilized during aspiration. The vacuum
level can also be set by the surgeon. Under normal conditions, the vacuum level is zero
until the aspiration port of the phacoemulsification tip is occluded, when it will reach the
maximum preset. As soon as the occlusion is broken, the vacuum will return to zero.
Phacoemulsification power should be set to a reasonable level which allows the surgeon
adequate control with the phaco pedal. The author will rarely use phaco powers above 30
to 40 percent maximum. For most cataracts, the author uses a vacuum level of between
150 and 200 mm Hg and a flow rate of approximately 20 to 50 rpm of the peristaltic
pump (46 cc/minute). The higher the height of the infusion bottle, the greater the
pressure head of fluid within the eye. With single incision phacoemulsification, a higher
head of pressure is required. This maintains the chamber, and allows the delicate
maneuvers with the phaco tip without danger of collapsing the capsular bag or injuring
the corneal endothelium.
Phacoemulsification tips are available in zero degree, 15 degree, 30 degree, and 45
degree angulations. For most purposes, a 30 degree angulated tip is most effective for soft
to medium cataracts. Hard cataracts should be removed using a 45 degree tip which has a
sharper cutting edge but less occludability.
Step 1: Central Sculpting
When performing central sculpting, occlusion of the phacoemulsification tip rarely
occurs. Therefore vacuum levels can be quite low (less than 20 mm Hg). In fact, vacuum
levels of zero for central sculpting work quite well. Low flow rates are required during
the central sculpting maneuver. The goal of central sculpting is to remove the densest,
hardest part of the nucleus at the beginning of the procedure when it is easiest to do so.
The lens is kept entirely within the capsular bag. Using the phacoemulsification tip,
gentle sculpting of the central nucleus is carried out (Fig. 22.1). Many surgeons wonder
how far and how deep they should sculpt? Fortunately, there is a way to measure
within the eye when performing phacoemulsification. The phaco tip is approximately 1
mm in width, and therefore three phaco tip width is approximately 3 mm deep. The
average cataractous lens is at least 4.5 mm in anterior/posterior thickness, therefore one
would have to place the phaco tip at least 3 to 4 tip width deep until the posterior capsule
is encountered. With gentle aspiration and emulsification, the central nucleus can be
safely and completely removed without damaging the posterior capsule. In soft lenses,
the author suggests keeping the emulsification furrows narrow and shallow to leave
enough cortical rim to be removed in the second and third steps. With hard, more mature
cataracts, wide sculpting of the central dense nucleus and sculpting deep up to the level of
Phacoemulsification
344
the posterior capsule is necessary to allow the cortical rim to be opened and removed.
When removal of the central nucleus is completed, attention is then directed to removing
the cortical bowl.
FIGURE 22.1 Step 1: Central

sculpting of the cataractous nucleus
FIGURE 22.2 Aspiration of two clock

hours of cortical rimthe keyhole
technique
347
Step 2: Creating an Inferior Notch: The Keyhole Method

Once central sculpting is completed, the surgeon is left with a cortical bowl. To remove
the cortical bowl, an inferior notch must be aspirated to release the tension on the cortical
ring of the cataract (Fig. 22.2). Low-power phacoemulsification and a higher vacuum is
required to adequately aspirate and remove two clock hours of cortical rim. By gently
placing the phacoemulsification tip at the edge of the lens capsule, the cortex can be
aspirated into the tip and the vacuum level will rise. A small section of the rim can be
aspirated and pulled into the center of the pupil. Here it is in the deepest portion of the
chamber and furthest from the lens capsule, capsular rim, iris and endothelium. This is
the triangle of safety which is an imaginary triangle bordered by the corneal incision at
the apex and the east and west edges of the pupil. Only within this region should
emulsification be performed (Fig. 22.3).
Step 3: Removal of the Cortical Rim
Using the phacoemulsification tip as a fulcrum, the remaining cortical rim can be gently
rotated counterclockwise. The rotational maneuver is
FIGURE 22.3 The triangle of safety

that region bounded by the incision
and the east and west margins of the
pupil where the anterior chamber is
deepest and the furthest distance from
the phacoemulsification tip to the
corneal endothelium and the posterior
capsule. The safest zone in which to
perform phacoemulsification
Phacoemulsification
346
performed as follows: the tip is gently embedded into the cortical rim at a convenient
location (usually 3 Oclock), the tip is brought to the center of the lens within the triangle
of safety along with the rim of cortical cataract and gently emulsified (Fig. 22.4).
Consecutive low levels of emulsification power are applied until each individual quadrant
is removed.
Step 4: Removal of the Nuclear Plate
Following complete removal of the cortical rim, a small flat section of posterior nucleus
remains. The phacoemulsification tip is turned over (bevel down) and placed flat against
this plate. Using very low levels of aspiration, the remaining nuclear plate is elevated off
the posterior capsule and removed (Fig. 22.5). Low power levels are used at this the final
stage of cataract removal. To enhance followability, the surgeon can select pulsed phaco
mode. This prevents excessive pushing away of the final piece when emulsification is
engaged. Avoid the tendency to chase the final piece around the chamber
FIGURE 22.4 Step 3Removal of

the cortical rim
patience is rewarded if the surgeon waits for the piece to come to the tip.
Before removing the phacoemulsification tip, check on either side of the incision for
any loose remaining pieces of nucleus, which should be removed prior to completing the
phacoemulsification procedure.
349
FIGURE 22.5 Step 4Removal of

the nuclear plate
Conclusion
The single instrument phacoemulsification procedure is quick, requires only one incision,
one instrument and is less traumatic to the eye. The benefits of this technique are less
induced astigmatism, more rapid visual recovery, better uncorrected visual acuity and a
happier patient.1 Any difficulties encountered when using a single instrument technique
are quickly overcome when the surgeon performs all of the maneuvers of central
sculpting, aspiration of cortical rim, nuclear rotation and removal of the nuclear plate
using just one instrumentthe phacoemulsification tip alone.
The single incision or single instrument approach to phacoemulsification paves the
way to a fully integrated microincision refractive cataract procedure. With less portals
into the eye, the procedure is amenable to topical anesthesia. Suturing is no longer
required. Bandaging is unnecessary. The single microincision allows injection of onepiece elastic intraocular lenses without enlarging the incision. The patients refractive
status can therefore be taken into account when correcting both spherical and astigmatic
error simultaneously with one procedure. By using a single incision, implantation of a
toric or multif ocal intraocular lens is facilitated. This translates into immediate visual
recovery for the patient, without glasses.
The ultimate goal of outpatient cataract surgery is less intervention with better visual
results and more rapid visual rehabilitation. As our techniques to remove a cataract and
implant an intraocular lens evolve toward smaller and smaller incisions, the single
instrument method of phacoemulsification will become appealing to more and more
surgeons.
References
1. Kershner RM: Clear corneal cataract surgery and the correction of myopia, hyperopia and
astigmatism. Ophthalmology 104(3):38189, 1997.
2. Kershner RM (Ed.): Refractive Keratotomy for Cataract Surgery and the Correction of
Astigmatism Thorofare: Slack, 1994.
Phacoemulsification
348
3. Kershner RM: Keratolencticuloplastyarcuate keratotomy for cataract surgery and astigmatism.

4. Kershner RM: One-step forceps for capsulorhexis. J Cataract Refract Surg 16:76265, 1990.
5. Kershner RM: Embryology, anatomy and needle capsulotomy. In Koch PS, Davison JA (Eds):
Textbook of Advanced Phacoemulsification Techniques Thorofare: Slack, 3548, 1991.
6. Kershner RM: Sutureless one-handed intercapsular phacoemulsificationthe keyhole technique.
J Cataract Refract Surg 17(suppl):71925, 1991.
23
The Use of Power Modulations in
Phacoemulsification of Cataracts: The Choo
Choo Chop and Flip Phacoemulsification
Technique1
Richard S Hoffman
Introduction
In the late 1980s, as phacoemulsification was increasing in popularity, the desire on the
part of most phacoemulsification surgeons was for increased power availability in order
to address increasingly hard cataracts. In the 1990s this became available, as did other
very important technical innovations like high vacuum tubing and cassettes,
microprocessor controls integrated with central onboard computers, and downsized tips
with better holding power and increased followability. In the late 80s and early 90s, we
described two endolenticular phacoemulsification techniques, chip and flip2 and chop and
flip phacoemulsification3 in which we utilized pulse mode for the removal of nuclear
material. In doing so, we recognized decreased chattering and increased holding power of
the nuclear material. More recently, multiple modulations in the delivery of power have
become available which allow for dramatic reductions in the total amount of ultrasound
energy delivered into the eye. In addition, the Allergan systems provide occlusion mode
phaco allowing for different parameters of percent power, vacuum levels, and aspiration
flow rate on tip occlusion compared to an unoccluded tip. The Alcon Legacy has a
bimodal option allowing linear aspiration flow rate or vacuum in foot position 2. More
recently we described the use of burst mode4 and bevel down chop techniques.5
The Choo Choo Chop and Flip Phacoemulsification Technique
The choo choo chop and flip phacoemulsification technique is designed to take maximum
advantage of various new technologies available through the Alcon 20,000 Legacy6
(Alcon Surgical Inc., Ft Worth, TX), the AMO Diplomax7 (Allergan Medical Optics,
Irvine, CA), the Allergan Sovereign (Allergan Medical Optics, Irvine, CA), the Mentor
System (Mentor, Santa Barbara CA), the Storz Millennium (B and L Surgical, St. Louis,
MO), and the Staar Wave (Staar Surgical, Monrovia, CA) phacoemulsification systems.
These technologies include high vacuum cassettes and tubing, multiple programmable
features, as well as new tip designs. The result is enhanced efficiency, control, and safety.
The procedure is done as follows:
Phacoemulsification
350
A side-port incision is made to the left with a 1 mm-trifaceted diamond knife after
which the anterior chamber is irrigated with 1/2 cc preservative-free xylocaine. Utilizing
the soft-shell technique described by Steve Arshinoff,8 Viscoat (Alcon Surgical Inc) is
placed into the anterior chamber angle distal to the side port through the side-port
incision. It fills the anterior chamber but allows the eye to remain relatively soft. Provisc
is instilled on top of the center of the lens capsule under the Viscoat. Provisc (Alcon
Surgical Inc) forces the Viscoat up against the cornea, creating a soft shell which helps
stabilize the anterior chamber and protect the endothelium. Additionally Provisc, which is
a cohesive viscoelastic, decreases any tendency for iris prolapse during the hydro steps.
Following construction of a temporal 2.5 mm 2 mm clear corneal incision, cortical
cleaving hydrodissection9 is performed in the two distal quadrants followed by
hydrodelineation. After the two hydro steps, the nucleus should rotate easily within the
capsular bag. The Mackool/Kelman aspiration bypass microflare tip on the Legacy is
introduced bevel down to aspirate the epinucleus uncovered by the capsulorhexis, and is
then turned bevel up. Alternatively on other systems a MST chop series SP tip
(Microsurgical Technologies, Redmond, WA) or a 30 degree standard bevel down tip is
used throughout endonuclear removal. The Fine/Nagahara chopper (Rhein Medical,
Tampa, FL) is placed in the golden ring by touching the center of the epinucleus with the
tip and pushing it peripherally so that it reflects the capsulorhexis. The chopper is used to
stabilize the nucleus by lifting and pulling toward the incision slightly (Fig. 23.1),
FIGURE 23.1 Stabilization of the

nucleus during lollipopping for the
initia chop
after which the phaco tip lollipops the nucleus in either pulse mode at 2 pulses/second or
80 millisecond burst mode (Diplomax). Burst mode is a power modulation that utilizes a
fixed percent power (panel control), a programmable burst width (duration of power), and
a linear interval between bursts. As one enters foot position 3, the interval between bursts
is 2 seconds; with increasing depressions of the foot pedal in foot position 3 the interval
shortens until at the bottom of foot position 3 there is continuous phaco. In pulse mode,
there is linear power (%) but a fixed interval between pulses, resulting at 2 pulses/sec in a
The use of power modulations in phacoemulsification
353
250 millisecond pulse (linear power) followed by a 250 millisecond pause in power
followed by a 250 millisecond pulse, etc. However, in both of these modulations with tip
occlusion, vacuum is continuous throughout the pulse and pause intervals. With the
energy delivered in this way, we minimize ultrasound energy into the eye and maximize
our hold on the nucleus as the vacuum builds between pulses or bursts. Because of the
decrease in cavitational energy around the tip at this low pulse rate or in burst mode, the
tunnel in the nucleus in which the tip is embedded fits the needle very tightly and gives
us an excellent hold on the nucleus, thus maximizing control of the nucleus as we score
and chop it (Fig. 23.2) in foot position 2.
FIGURE 23.2 Completion of the

initial chop
The Fine/Nagahara chop instrument is grooved on the horizontal arm close to the vertical
chop element with the groove parallel to the direction of the sharp edge of the vertical
element. In scoring the nucleus, the instrument is always moved in the direction the sharp
edge of the wedge-shaped vertical element is facing (as indicated by the groove on the
instrument), thus facilitating scoring. The nucleus is scored by bringing the chop
instrument to the side of the phaco needle. It is chopped in half by pulling the chopper to
the left and slightly down while moving the phaco needle, still in foot position 2, to the
right and slightly up. Then the nuclear complex is rotated. The chop instrument is again
brought into the golden ring (Fig. 23.3), the nucleus is again lollipopped, scored, and
chopped with the resulting pie-shaped segment now lollipopped on the phaco tip (Fig.
23.4). The segment is then evacuated utilizing high vacuum and short bursts or pulse
mode phaco at 2 pulses/second (Fig. 23.5). The nucleus is continually rotated so that pieshaped segments can be scored, chopped, and removed essentially by the high vacuum
assisted by short bursts or pulses of phaco. The short bursts or pulses of ultrasound
energy continuously reshape the pie-shaped segments which are kept at the tip, allowing
for occlusion and extraction by the vacuum. The size of the pie-shaped segments is
Phacoemulsification
352
FIGURE 23.3 Stabilization of the

nucleus prior to commencing the
second chop
FIGURE 23.4 Pie-shaped segment

adherent to the phaco tip following
completion of the second chop
customized to the density of the nucleus with smaller segments for denser nuclei. Phaco
in burst mode or at this low pulse rate sounds like choo-choo-choo-choo; ergo the name
of this technique. With burst mode or the low pulse rate, the nuclear material tends to stay
at the tip rather than chatter as vacuum holds between pulses. The chop instrument is
utilized to stuff the segment into the tip or keep it down in the epinuclear shell.
355
FIGURE 23.5 Mobilization of the first

pie-shaped segment
FIGURE 23.6 Scoring of the second

hemi-nucleus
After evacuation of the first hemi-nucleus, the second hemi-nucleus is rotated to the distal
portion of the bag and the chop instrument stabilizes it while it is lollipopped. It is then
scored (Fig. 23.6) and chopped. The pie-shaped segments can be chopped a second time
to reduce their size (Fig. 23.7) if they appear too large to easily evacuate.
There is little tendency for nuclear material to come up into the anterior chamber with
this techni-que. Usually, it stays down within the epinuclear shell, but the chop
instrument can control the position of the endonuclear material. The 30-degree beveldown tip facilitates occlusion, as the angle of approach of the phaco tip to the
endonucleus through a clear corneal incision is approximately 30 degrees. This allows
full vacuum to be quickly reached which facilitates embedding the tip into the nucleus for
chopping and allows mobilization of pie-shaped segments from above rather than
Phacoemulsification
354
FIGURE 23.7 Mobilizing the final

quadrant
necessitating going deeperinto the endolenticular space as is necessary with a bevel-up
tip. In addition, the cavitational energy is directed downward toward the nucleus rather
than up toward the endothelium. Following evacuation of all endonuclear material (the 30
degree tip is turned bevel up) (Fig. 23.8), the epinuclear rim is trimmed in each of the
three quadrants, mobilizing cortex as well in the following way The distal rim and roof
are purchased in foot position 2. Upon occlusion, the roof and rim are drawn central to
the capsulorhexis and then foot position 3 is entered. This results in mobilization of the
roof and rim and clearance of occlusion. As each quadrant of the epinuclear rim is
trimmed, the cortex in the adjacent capsular fornix flows over the floor of the epinucleus
and into the phaco tip. Then the floor of the epinucleus is pushed back to keep the
capsular bag on stretch and the epinucleus is rotated to bring a new
FIGURE 23.8 The epinuclear shell

being rotated for trimming
quadrant of roof and rim to the distal position. This is repeated until three of the four
quadrants of epinuclear rim and forniceal cortex have been evacuated. It is important not
357
to allow the epinucleus to flip too early, thus avoiding a large amount of residual cortex
remaining after evacuation of the epinucleus.
The epinuclear rim of the fourth quadrant is rotated to the distal position, (i.e. nasally)
and then utilized as a handle to flip the epinucleus (Fig. 23.9) As the remaining portion of
the epinuclear floor and
FIGURE 23.9 Flipping of the

epinucleus
FIGURE 23.10 Empty capsular bag

following flipping of the epinucleus
rim is evacuated from the eye, 70 percent of the time all of the cortex is evacuated with it
(Fig. 23.10). Continuing with the soft-shell technique, the capsular bag is filled with
Provisc and Viscoat is injected into the center of the capsular bag to help stabilize the
anterior chamber and to blunt the movement of the foldable IOL as it is implanted into
the eye. If the cortex was incompletely mobilized during epinuclear removal, Viscoat
(rather than Provisc) is instilled first to viscodissect the cortex into the capsular fornix
and drape some of it on top
Phacoemulsification
356
FIGURE 23.11 Viscodissection of

residual cortex prior to IOL
implantation
FIGURE 23.12 Viscodissection of

residual cortex prior to IOL
implantation
of the capsulorhexis (Figs 23.11 and 23.12). Provisc is then injected into the bottom of
the bag, forcing the Viscoat anteriorly. The foldable IOL is then implanted. Residual
cortex is evacuated with residual viscoelastic, the posterior capsule being protected by the
optic of the IOL. Mobilization of Viscoat is greatly facilitated as it is encased within the
much more highly cohesive Provisc and less time is necessary to evacuate residual
viscoelastic.
359
Summary
The choo choo chop and flip technique utilizes the same hydro forces to disassemble the
nucleus, but substitutes mechanical forces (chopping) for ultrasound energy (grooving) to
further disassemble the nucleus. High vacuum is utilized as an extractive technique to
remove nuclear material rather than utilizing ultrasound energy to convert the nucleus to
an emulsate that is evacuated by aspiration. This technique maximizes safety and control
as well as efficiency in all cases, and allows for phaco of harder nuclei in the presence of
a compromised endothelium. This technique facilitates the achievement of two goals:
minimally invasive cataract surgery and maximally rapid visual rehabilitation.
References
1. Fine IH: The choo-choo chop and flip phacoemulsification technique, Operative Techniques in
Cataract and Refractive Surgery, 1(2), 6165, 1998.
2. Fine IH: The chip and flip phacoemulsification technique, Journal of Cataract and Refractive
Surgery, 17(3):36671, 1991.
3. Fine IH: Crack and flip phacoemulsification technique, Journal of Cataract and Refractive
Surgery, 19(6):797802, 1993.
4. Fine IH: Chop and flip phaco with high vacuum and burst mode, Clinical Education Videotapes,
American Academy of Ophthalmology, 1997.
5. Fine IH: Bevel down chop and flip phaco with Arshinoff soft shell technique, Clinical Education
Videotapes, American Academy of Ophthalmology, 1997.
6. Fine IH: Choo choo chop and flip with the soft-shell technique is safer and more efficient, Phaco
and Foldables, 1997.
7. Masket S, Thorlakson R: The OMS Diplomax in endolenticular phacoemulsification. In Fine IH
(Ed): Phacoemulsification: New Technology and Clinical Application, Slack, Inc., Thorofare,
NJ, 1996.
8. Arshinoff S: Dispersive-cohesive viscoelastic soft shell technique, Journal of Cataract and
Refractive Surgery, 25:167, 1999.
9. Fine IH: Cortical cleaving hydrodissection, Journal of Cataract and Refractive Surgery,
18(5):50812, 1992.
24
Lens Quake Phaco
Jack A Singer
Introduction
Lens quake phaco utilizes a hexagonal or diamond-shaped phaco tip to induce a
disturbance in the lens nucleus, which simulates a miniature earthquake called a lens
quake. The lens quake can be propagated along nuclear fault lines that run from the ysutures to the equator and posterior pole. Using this method, the nucleus can be cracked
from the center to the periphery without the need to place a sharp chopping instrument
near the equator of the lens.
TIPS
The Lens quake phaco cobra tip (Figs 24.1A to C) from surgical design has a modified
hexagon shape, a 15-degree curve, a 15-degree bevel that faces up when the curve is
pointing up, and a circular lumen (Fig. 24.2), which promotes occlusion. The hexagonal
shape permits lens quake propagation without tilting or zonular stress, which can occur
with a round phaco tip. Also, the additional mass in the head of the cobra tip focuses
additional cavitation inside the tip that enhances the efficiency of both lens quake
inducement and segment removal.
Mastel Precision Instruments can supply non-cobra hexagonal Lens quake phaco tips
for various other phaco systems. However, the additional mass in the head of the cobra
tip focuses additional cavitation inside the tip that enhances the efficiency of both lens
quake inducement and segment removal.
The author has used the Storz Osher nucleus manipulator for years and finds it ideal
for lens quake phaco. It has two blunt finger-like projections that can be used for a
variety of maneuvers. However, any nucleus manipulator that provides a firm grasp on
nuclear material will work. A sharp chopper is unnecessary but can be used for lens
quake phaco.
Lens quake phaco
361
FIGURES 24.1 A TO C Hard-Rock

Lens quake tip, with double 15-degree
bevel for enhanced cutting and
gripping
Phacoemulsification
360
FIGURE 24.2 Singen Lens quake tip

with external hexagonal shape and
circular internal lumen
Mechanism
We are all familiar with the annular structure of a tree. Similarly, the human lens is
composed of annular concentric layers of radial fibers, beginning with the fetal nucleus,
which becomes the hard adult nucleus through the addition of radial fibers throughout life
(Figs 24.3A to C). These radial lens fibers join at the anterior and posterior y-sutures,
which are encountered at times during central sculpting or during slit lamp examination
of the lens. These are natural fault lines in the lens corresponding to these radial layers
that are added through life. So, the lens not only has concentric layers but also has radial
cleavage planes, which can be used for lens quake propagation.
When the phaco tip is advanced into the center of the nucleus and is occluded, vacuum
energy and the wedge shape of the tip induces stress and strain near the y-sutures
resulting in lens quake induction.
Techniques
In order to perform lens quake phaco, set your machine at a low flow rate of 3 to 5
cc/minute and a vacuum limit of 200 mmHg. Rotate the infusion sleeve 90 degrees so
that the infusion stream is
Lens quake phaco
363
FIGURES 24.3A TO C Mechanism

of lens quake phaco
Phacoemulsification
362
FIGURES 24.4A TO C Hard-rock

lens quake tip, with double 15-degree
bevel for enhanced cutting and
gripping
directed sideways when the phaco tip bevel is sideways. Clean up the anterior cortex and
epinucleus inside the anterior capsulotomy for better visibility.
Next, orient the phaco tip bevel sideways so that the points of its hexagon are facing
up and down, and the flat areas are facing sideways. Then, place the tip just inside the
capsulorhexis at an angle pointing towards the center of the nucleus and place your
nucleus manipulator in a stand-by position about 90 degrees away (Figs 24.4A to C).
Using U/ S, drive the tip into the nucleus at a slow pace, switching between foot switch
positions 3 and 2 as needed but do not go into position 1. When the top of the hexagon is
Lens quake phaco
365
completely buried, begin leveling off the entry angle and continue advancing until the
port is at the central nucleus with its bottom point at half nuclear depth. Mute the U/S and
stay in foot switch position 2 holding the phaco tip still while the vacuum builds.
One of the most common causes of lens quake inducement failure is releasing the
vacuum after the tip is placed into position and occluded.
After the phaco tip is driven into position and vacuum is allowed to build, place the
second instrument into the nucleus directly above the stationary phaco tip until it touches
the tip. Now, hold it there for a second or two until you see a crack forming just in front
of the tip. This is the induced lens quake!
A simple manipulation will propagate the lens quake to the posterior pole and to the
equators. We need to mimic a strike-slip fault in which blocks of earth slide past each
other horizontally during an earthquake in order to induce lens quake propagation in the
lens nucleus.
Slide the nucleus manipulator downward along the side of the stationary phaco tip and
then move the phaco tip slightly forward and the nucleus manipulator slightly backward
to produce a strike-slip fault, sliding the nuclear segments past each other horizontally.
This will induce complete propagation of the lens quake to the posterior pole and to the
equators. While sliding the nuclear segments past each other horizontally, the lens and
phaco tip can be rotated into position for the subsequent lens quakes, which is performed
in a similar fashion on each heminucleus.
Lens quake phaco can be used on any nucleus that is sufficiently firm enough to crack,
and should not be used on soft lenses due to the risk of aspirating lens material distal to
the tip down to and including the posterior capsule.
Summary
In summary, lens quake phaco is a significant advance in phaco efficiency and safety,
which utilizes a hexagon-shaped phaco tip and high vacuum to induce a lens quake near
the y-sutures. A simple manipulation that mimics earthquake movements will propagate
the lens quake to the posterior pole and to the equators.
25
Supracapsular Phacoemulsification
Aamir Asrar
Introduction
Since Kelman18 first introduced phacoemulsification improvements have been made not
only with the instruments911 but in the technique also.1221 Phacoemulsification is now
the preferred choice of surgery for all types of cataracts, even the ones previously
considered to be pure extracapsular cataract extraction cases (ECCE). Divide and
conquer20 is still the favored technique for most of the phaco surgeons, as it is quite
comfortable to perform if the cataract is straightforward, but becomes much more
difficult with complicated cases as in weak zonules and small pupils. With the
introduction of David Browns,23 Phaco Flip and Jack Kearneys, Supracapsular
Technique, phacoemulsification entered into a new era. William F Maloneys,2428
contribution to this technique has been remarkable.
History of Supracapsular Phacoemulsification
The procedure of phacoemulsification has undergone great deal of change since it was
first introduced1,624 in 1967. This progress has been stepwise with the improvements
made in phaco machines, intraocular lenses (IOLs), and instrumentation, leading to
change in our techniques, thus making the whole procedure much safer and predictable to
a greater extent. William F Maloney has explained this whole process of evolution very
well by classifying it into different generations in the phacoemulsification era.2426
First generation (19671977) Anterior chamber
Second generation (19771987) Posterior chamber
Third generation (19871997) Endocapsular
Fourth generation (19972007) Supracapsular (?).
Changes that evolved each decade have been related with the availability of the
supporting equipment. With the introduction of larger capsulorhexis the idea of
Supracapsular phacoemulsification evolved. Introduction of new generation
phacoemulsification machines has further helped this technique of phacoemulsification. It
is still a bit early to say if this really is going to be the Supracapsular phacoemulsification
decade.
Supracapsular phacoemulsification
367
What is Supracapsular Phacoemulsification?

In Supracapsular phacoemulsification, the nucleus is maneuvered out of the capsular bag
through a 5 to 6 mm capsulorhexis in such a way that it finally lies in a upside down
position above the anterior capsule, i.e. in the Supracapsular space, where it can be
emulsified. There are many variations to this technique.
Surgical Technique
Patient Selection
As with any other surgical procedure in order to achieve good results and to gain
confidence, patient selection is of importance. However, with experience any patient
suitable enough to undergo phacoemulsification surgery, Supracapsular approach can be
utilized. The author has used this procedure in difficult cataract cases (pseudoexfoliation,
small pupil, unstable capsulorhexis, etc.) and found it safer and as effective.
Anesthesia
There is no specific preference for any type of anesthesia.2944 The author always lets the
patient decide regarding the type of anesthesia they feel comfortable with. The procedure
may require less time and can easily be done under topical anesthesia.
Incisions
Site and type of incision is mainly surgeons preference.4552 The author prefers a corneal
incision but he alters the site and type according to the needs and requirement of the
surgery.
Paracentesis incision for the side-port instrument is placed 2 Oclock hours left of the
main incision (for-right-handed surgeon and reverse for the left-handed surgeons).
If placing an anterior chamber maintainer, the author prefers infratemporal
position in the case of superior incision and is placed infranasally if temporal
incision is made.
Viscoelastic
There is no actual indication that this procedure is effected by any specific sort of a
viscoelastic.53,54 The author has used various types of viscoelastic for this procedure
(mainlyViscoat by Alcon, Healon by Pharmacia & Up John, Provisc by Alcon Fig.
25.1) but have not found any significant difference between them.
Viscoelastics are used during phacoemulsification for the following main advantages
Keep the anterior chamber formed during capsulorhexis
Phacoemulsification
366
Protection of corneal endothelium

Stabilize the anterior capsule during capsulorhexis
Insertion of IOL
Flip the nucleus out of the bag.
FIGURE 25.1 Viscoelastic with

cannula
FIGURE 25.2 Cystotome on a

viscoelastic syringe
In addition to the one mentioned above there are many other uses, that make viscoelastic
an integral part of eye surgery.
Capsulorhexis
After the introduction of the continuous curvilinear capsulorhexis (CCC)5557 in the mid
to the late 80s its advantages were soon evident to the cataract surgeons. As the
capsulorhexis was 3 to 4 mm in size the nucleus could not be taken out of the bag and
had to be emulsified in it. All the techniques developed during this stage were keeping in
mind the limits imposed by the capsular bag. As the surgeons enjoyed the advantages5860
of CCC, at the same time the restrictions6162 and the problems of doing
phacoemulsification in the bag started becoming more evident. With the introduction of a
larger capsulorhexis of 5 to 6 mm in diameter it was easier to flip the nucleus out of the
bag, allowing us to emulsify the nucleus in the supracapsular space away from the
capsular bag restriction.
The author normally starts the capsulorhexis, after injecting the viscoelastic in the
anterior chamber, by making a flap in the anterior capsule with the help of a cystotome
on a viscoelastic syringe (Fig. 25.2). Once the flap is lifted the whole capsulorhexis of 5
369
to 6 mm (Figs 25.3 and 25.4) diameter is completed with the help of a Utrata forceps
(Fig. 25.5). The cystotome can also be used to complete the whole capsulorhexis from
start to finish.
Hydrodissection/Hydrodelineation
Hydrodissection or hydrodelineation is done with the help of a 26 G-hydrodissection
cannula
FIGURE 25.3 5 to 6 mm
capsulorhexis
FIGURE 25.4 5 to 6 mm
capsulorhexis
FIGURE 25.5 Utrata forceps
Phacoemulsification
368
(Fig. 25.6)63,6669 on a 3- or 5 CC-syringe filled with balanced salt solution (BSS). For
hydrodissection the author injects small amount of fluid (Fig. 25.7) under the capsule first
at 4 Oclock and then at 7 Oclock and looks for the fluid wave to pass under the nucleus
and it is considered completed when he can see the sommer ring (golden ring) or the tilt
in the nucleus.
For hydrodelineation,64,65 the author places the cannula between the epinucleus and the
nucleus. For supracapsular phacoemulsification the author does not find any special
advantage of hydrodelineation over hydrodissection. They both work well for him.
Rotation of the Nucleus
It is important to free the nucleus from any adhesion with the lens cortex so that it lies
freely in the capsular bag, as this makes it easier to flip it out of the bag. Presence of a
golden ring around the nucleus or a small tilt in the nucleus is an indicator
FIGURE 25.6 26-G Hydrodissection

cannula on a balanced salt solution
(BSS) syringe
FIGURE 25.7 Injection of BSS under

the anterior capsule to achieve
hydrodissection
371
FIGURE 25.8 Direction for rotation of

the nucleus
FIGURE 25.9 Direction for rotation of

the nucleus following hydrodissection
that the nucleus is lying free in the bag. It can be confirmed by using the hydrodissection
cannula to rotate the nucleus70 taking care not to push it towards the vitreous and not to
force it in any direction (Figs 25.8 and 25.9). Another important point while carrying out
nuclear rotation is to keep the tip of the cannula in view as it might pass through the lens
rupturing the lens capsule.
Once the nucleus lies free in the bag supracapsular phacoemulsification can be started.
There are many variations to this approach. The author has mentioned the one that he
used and found safe and effective.
Phaco-hemi Flip
Phacoemulsification71 is started with the standard settings (low aspiration and ultrasound
power) on the phaco machine. Nuclear sculpting is done in the area of capsulorhexis
along an imaginary line extending from the site of incision vertically downwards (Fig.
Phacoemulsification
370
25.10). Once the sculpting is completed to half the thickness of the nucleus it is rotated
by 90 degrees (Fig. 25.11). Keeping the phaco probe and the side-port instrument
(nucleus rotator) in the sculpted groove of the nucleus (Fig. 25.12), it is cracked into two
halves by moving the instrument in the opposite direction (Fig. 25.13).
Then the settings on the phaco machine are changed, by increasing the vacuum to 200
mmHg
FIGURE 25.10 Sculpting of the

nucleus
FIGURE 25.11 Rotation of the

nucleus by 90 degrees
and raising the bottle to the maximum height. The author keeps both the instruments
(phaco probe and the nucleus rotator) in the eye. Now the two nuclear fragments are
arranged in the bag so that the smaller one is away from the site of incision. The phaco
probe is brought near the superior edge of the nucleus and the smaller piece of the
373
nucleus fragment is engaged in the phaco tip by only utilizing the vacuum. The nucleus
rotator is taken
FIGURE 25.12 Insertion of the

instruments and their placement in the
nuclear groove
FIGURE 25.13 Cracking the nucleus

by moving the instruments in the
opposite direction
to the base of the nuclear fragment (Fig. 25.14). Now with a bimanual motion, i.e.
utilizing the rotatory movement of the nucleus rotator to sweep the inferior surface of the
lens fragment over the posterior capsule and at the same time helped with the vacuum of
the phaco instrument the nuclear fragment is flipped out of the bag into the pupillary
plane (Figs 25.15 to 25.17). The nuclear fragment being smaller than the size of the
whole nucleus can easily be emulsified in the iris plane (Figs 25.18 and
Phacoemulsification
372
FIGURE 25.14 Placement of

instruments for flipping the nucleus
out of the bag
FIGURE 25.15
25.19). The other nuclear piece in the capsular bag keeps the bag formed and the
posterior capsule away from the phaco probe. Flipping of the other piece and its
emulsification in the iris plane follows this.
Phaco Flip
David Brown,23,25 introduced this supracapsular phacoemulsification technique, and so
was the
375
FIGURE 25.16
FIGURE 25.17
FIGURES 25.15 TO 25.17
Maneuver of flipping the nucleus out
of the bag
actual birth of the new generation supracapsular phacoemulsification. After completing
the basic steps mentioned above one can proceed with this technique (Fig. 25.20). The
nucleus is depressed at the superior equator. This can be done with the help of a
viscoelastic cannula, spatula, hydrodissection cannula or a nucleus rotator. As the
capsulorhexis is large the depression on the nucleus in such a way causes the nucleus to
move out of the bag. This maneuver is continued so that the nucleus flips
Phacoemulsification
374
FIGURE 25.18 Final position of the

nuclear segment in the pupillary plane
before starting emulsification
FIGURE 25.19 Emulsification of the

nucleus in the pupillary plane
completely and lies almost facing upside down. Emulsification of this nucleus can now
be started by bringing the phaco probe tip at the level of the iris plane in the pupillary
area. Nucleus is engaged from the posterior side and emulsification started. The phaco
probe is kept static in this position and the nucleus is fed into the tip with the help of a
sideport instrument.
This whole process is very fast with effective utilization of ultrasound energy. With
the develop-
377
FIGURE 25.20 Phacoflipemulsification of the nucleus from

down under
ment of new generation of phacoemulsification machines, more reliance on vacuum can
achieve the end point quickly.
Tilt and Tumble Phaco
Tilt and tumble phaco has been described by Richard L Lindstrom in a recently published
textbook74 Clear Cornea Lens Surgery by Howard Fine published by Slack
Incorporated.
After completing the CCC, hydrodissection is performed by placing the
hydrodissection cannula under the anterior capsule approximately 180 from the site of
incision. BSS is injected until a fluid wave is seen. The hydrodissection is continued
which causes the nucleus to tilt out of the bag. The nucleus can also be tilted out of the
bag by retracting the anterior capsule at 7:30 Oclock position. If the nucleus does not tilt
out of the bag at the superior edge then it can always be rotated to face the site of
incision. Otherwise the inferior half of the nucleus is depressed which causes the superior
edge of the nucleus to tilt out of the bag. Viscoelastic is injected anterior and posterior to
the nucleus to protect the cornea, iris and posterior capsule. Nucleus is kept in this
position supported by the nucleus rotator and can be emulsified using high vacuum (Fig.
25.21). Once half of the nucleus is emulsified the half left can be tumbled upside down
Phacoemulsification
376
FIGURE 25.21 Tilt and tumble phaco

and can now be emulsified by a direct approach on to the posterior surface of this
fragment. The whole nucleus can also be emulsified without tumbling the last fragment.
This has also been described as a transitional step from endocapsular to supracapsular
phacoemulsification procedure.
Supracapsular Quick Chop Phaco
William F Maloney introduced supracapsular quick chop phacoemulsification.2428 In this
procedure he tilts the lens early during hydrodissection by continuing it even after the
fluid wave is seen (Fig. 25.21). If not successful, one can repeat hydrodissection after
nuclear rotation. He advises to convert it into an endocapsular approach if the lens fails to
tilt. Once a lens tilt is achieved the process to flip the nucleus can be carried out further,
by depressing the posterior half of the tilted nucleus with a hydrodissection cannula (Fig.
25.22) and then gently sweeping the posterior equator of the nucleus over the posterior
capsule, till the superior equator lies just pass the midline (Fig. 25.23). Now viscoelastic
is injected as needed (Fig. 25.24) and at the same time the viscoelastic cannula continues
to flip the nucleus so that it finally lies in a horizontal position but only upside down (Fig.
25.25). With the help of the same cannula the nucleus is moved into the posterior
chamber, i.e. between the iris and the anterior capsule outside the capsular bag (Fig.
25.26).
The tip of the phaco probe is extended 1.5 to 2.00 mm beyond the irrigation sleeve
(Fig. 25.27) as this will act as safeguard to deeper penetration. He also advises to use 100
percent linear phaco power with slow pulse mode of 2 to 4 pulse/second. Introduce the
phaco tip (Fig. 25.28) and the quick chopper into the anterior chamber.
The phaco probe is buried deep into the central nucleus up to its sleeve and then
maintaining the
379
FIGURE 25.22 Flipping of the

nucleus out of the bag following
hydrodissection
FIGURE 25.23 Sweeping the lens

over the posterior capsule with the
hydrodissection cannula
FIGURE 25.24 Nucleus almost lying

past midline
Phacoemulsification
378
FIGURE 25.25 Viscoelastic used to

complete the flipping of the nucleus
aspiration to stabilize the nucleus till the nuclear chop is completed. Quick chopper is
buried into the nucleus just above the phaco tip (Fig. 25.29). Now the nucleus is
separated vertically by briskly depressing the nucleus straight down accounting for 80
percent displacement and elevating the embedded phaco tip accounting for the remaining
20 percent of the vertical displacement (Fig. 25.30). This causes the division to appear in
the center of the nucleus (Fig. 25.31). Now the phaco tip and the quick chopper are
separated laterally causing a complete break in the nucleus. Nucleus is rotated by 90
degrees. The separation can now be confirmed
FIGURE 25.26 Nucleus being placed

in the posterior chamber above the
anterior capsule
381
FIGURE 25.27 Introduction of phaco

tip into anterior chamber with sleeve
drawn posteriorly
again by moving the two halves in opposite direction with the chopper and the phaco tip.
The second chop is done on the inferior half of the nucleus. By placing the phaco tip
in the middle wall, exposed in the crack. Machine settings are kept the same as initially.
The chop is repeated in the same fashion as the first one. First by vertical and then by
horizontal separation of the two instruments causing division of the nucleus fragment.
Soft lenses are divided into four but for the harder ones may need further disassembly
into smaller pieces (Figs 25.32A and B). As there is no
FIGURE 25.28 Aim the tip of the

probe towards the center
Phacoemulsification
380
FIGURE 25.29 Phaco tip and the

chopper tip buried in the center of the
nucleus
capsular bag to keep the nuclear pieces organized it is better to evacuate them as soon as
liberated (Figs 25.33 and 25.34). For emulsification of the nuclear pieces the phaco tip
extension is shortened to 1 mm and the settings on the machine are changed to traditional
linear phaco power control with higher aspiration flow. WF Maloney has advised an
aspiration flow setting of 160 mmHg for supracapsular quadrant removal.
Once the nucleus is out of the bag the usual techniques for endocapsular
phacoemulsifica-
FIGURE 25.30 Opposite direction

movement of the instruments to
achieve a crack in the nucleus
383
FIGURE 25.31 Appearance of

division in the center of the nucleus
tion18,22,69,70 can also be used like cracking, chopping, sculpting or manual prechopping,
etc (Figs 25.35 to 25.40).
Other Variations
Bruce Wallace
Dr Wallace begins sculpting the nucleus in the bag. Completes a classic criss-cross
pattern. Then flips the nucleus outside the bag so that it lies in an upside down position.
The criss-cross pattern is still visible from the inverted side. This can be used as a
landmark for chopping and completing the sculpting and emulsification.
Phacoemulsification
382
FIGURES 25.32A AND B

Completion of second chop
Irrigation, Aspiration and IOL Insertion
Once all the nuclear fragments are emulsified irrigation and aspiration can be started. It is
important to remove all the soft lens matter and then to clean the capsule properly. This
should not only be done in the obvious visible areas of the capsule but the author prefers
to clean the cells from the remaining anterior capsule and the equator. Polishing of the
posterior capsule is also essential. Once convinced that no more polishing is required the
lens can be introduced in the bag.
385
FIGURE 25.33 Division of nucleus in

four and start of their emulsification
FIGURE 25.34 Emulsification of each

fragment independently
Advantages
Emulsifying the nuclear fragments in the supracapsular space protects the posterior
capsule from rupture. The author found that phaco hemiflip could be performed easily in
small pupils without the need of stretching the iris, using iris clips, sphincterotomy or any
other damaging procedures to the iris. At the same time the zonules are not damaged to
the same extent as if the phacoemulsification is done in the bag.
Phacoemulsification
384
FIGURE 25.35 Splitting of the

nucleus
FIGURE 25.36 Separating the nucleus

pieces further by lateral movement of
the instruments
Protection of posterior capsule Once the nucleus is flipped out of the bag it can be
emulsified in the iris plane or in the posterior chamber above the capsular bag, away from
its restrictions. This leads to less pressure and danger to rupture of the posterior
capsule.7579 Emulsification is helped by the use of higher vacuum, which normally is not
used in the bag, as chances of catching the capsule in the phaco tip are minimal.
Less zonular damage Small amount of manipulation is done in the bag, which prevents
any
387
FIGURE 25.37 Splitting of nucleus

further into four quadrants
FIGURE 25.38 Emulsification of each

fragments
FIGURE 25.39 Removal of fragments

individually
Phacoemulsification
386
FIGURE 25.40 Final outcome

damage to the zonules.80,81,86 Emulsification performed outside the bag in the
supracapsular space prevents damage to the zonules.
Effective utilization of ultrasound energy Since the nucleus is easily approachable in the
supracapsular space and in the upside down position the use of ultrasound energy is
utilized very effectively. At the same time it is helped by the added high aspiration flow
rate, which keeps the nucleus near the phaco tip.
High volume surgery For high volume phaco surgeons this is an effective way of doing
surgery, as the average time required for supracapsular phaco is less than that of the
endocapsular approach.
Advantages of larger capsulorhexis Larger capsulorhexis is the key for a supracapsular
phacoemulsification. Other than allowing one to flip the nucleus out of the bag it has
following main advantages.
Prevents IOL decentration.
Prevents capsular phimosis.82,83
Good retinal view following phacoemulsification.
Easy access to the equator of the capsule for removal of cells thus preventing posterior
capsule opacification.
Supracapsular Phacoemulsification in Difficult Cases

Difficult cases are the test of endurance for any procedure. The credibility and efficiency
of a procedure can be honored by its effectiveness in difficult cases. The author has used
these techniques in cases like small pupil, pseudoexfoliation, vitrectomized eyes, hard
nucleus, white cataracts and others and found these procedures very effective with
excellent results.
Pseudoexfoliation
In a pseudoexfoliation8487 case, the surgeon is always concerned about the status of the
zonules. Excessive manipulation of the lens in the bag can lead to damage of the zonules.
389
This damage can be significant enough to cause a dislocated or dropped nucleus or

unstable bag at the end of surgery not suitable enough to support an IOL. Capsule tension
rings are a good option but they also have their limits. With supracapsular
phacoemulsification there is little amount of manipulation in the bag and once the
nucleus is removed out of the bag no further pressure is exerted on the zonules.
Small Pupil
Phacoemulsification in small size pupils8893 is always a challenge. Mainly because it is
difficult to achieve a good size capsulorhexis and then it is difficult to do sculpting and
aspiration of soft lens matter under the iris. One can use iris hooks, stretching of the iris,
or sphincterotomy for such eyes to increase the pupillary diameter. The author always
does phaco hemiflip procedure for such cases.
To have good pupillary aperture the author tries to dilate the iris by stretching but if
this does not work then he does the following procedure.
Lifting the flap of anterior capsule towards the paracentesis incision with the help of a
cystotome starts the capsulorhexis. Then introduce a Sinskey hook from the paracentesis
incision and Utrata forceps through the main incision. Pull the iris to the paracentesis side
with the help of a Sinskey hook exposing 5 to 6 mm zone of the capsule. Once this area is
exposed hold the flap of the capsule with the help of Utrata forceps held in the other
hand. Now start rotating the flap to attain capsulorhexis in 5 to 6 mm zone of the anterior
capsule, exposing that area of capsule by dragging iris toward the periphery. Once pass
the 6 Oclock position when it is required to push the iris then to pull it away the author
uses the Y-shaped instrument as he finds Sinskey hook to be a sharp instrument for this
purpose. The capsulorhexis continues in the same fashion as to expose with the side-port
instrument and tearing of the flap with Utrata forceps. Once the capsulorhexis is
completed phaco hemiflip can be started by just burring the phaco tip in the center of the
nucleus to create groove almost two-third of the thickness of the nucleus then it is divided
and flipped out of the bag as discussed before. As it is half the size of the whole nucleus
it can fit in the pupillary plane where it can be emulsified easily. Aspiration of the lens
cortex can also be done with the same exposure technique as used for doing
capsulorhexis.
Vitrectomized Eyes9497
As there is no support of the vitreous the posterior capsule is quite flabby and the
dynamics in the anterior and posterior segment are very different than in the normal eye.
With this technique the lens is out of the bag in the early stages and the posterior capsule
does not come in the way of the phaco probe. On occasions, the author has used an
anterior chamber maintainer in these eyes which makes phacoemulsification very easy. It
is important to note that the pressure in the anterior segment should not be increased to an
extent that the bag ruptures. The author has seen people using posterior segment
infusion but he thinks this is really not required.
Phacoemulsification
388
Hard Nucleus
These types of nuclei are not difficult with supracapsular approach as a high aspiration
flow rate can be used to help the emulsification of the nucleus.
Low Endothelial Cell Count Cornea
The author prefers to use a phaco flip technique in these cases. As his average percentage
of endothelial cell loss with this technique is 7.00 percent.98112 The main reason for less
endothelial cell loss (ECL) is that
The pieces are smaller than the whole nucleus and can be emulsified in the pupillary
plane.
Less instrumentation required as compared to the cracking technique as one does not
need to insert and reinsert different instruments.
Less operation time is required.
Less ultrasound time, as most of the time high vacuum is assisting.
New Generation Phaco Machines and Supracapsular

Phacoemulsification
The new generation phaco machines have provided us with a new dimension of
phacoemulsification. With the availability of high aspiration flow rate supracapsular
phacoemulsification is much simpler, more effective and safer. This is especially
important for the high volume phaco surgeons.
Supracapsular phacoemulsification is a step forward in the phacoemulsification
technique. Flipping the nucleus out of the bag not only allows easy approach to the
nucleus but as it is in the supracapsular plane there is less chance of rupturing the
posterior capsule and damaging the zonules. At the same time, the posterior surface is
directly approachable which allows effective utilization of ultrasound energy. All these
factors help to make it not only a safer and effective technique but quicker too.
References
1. Kelman CD: Phacoemulsification and aspirationa new technique of cataract removala
preliminary report. Am J Ophthalmol 64(1):2335, 1967.
2. Kelman CD: Phacoemulsification and aspirationa progress report. Am J Ophthalmol
67(4):46477, 1969.
3. Kelman CD, Brooks DL: Ultrasonic emulsification and aspiration of traumatic hyphemaa
4. Kelman CD: Phacoemulsification and aspirationa report of 500 consecutive cases. Am J
Ophthalmol 75(5):76468, 1973.
5. Kelman CD: Phacoemulsification in the anterior chamber. Ophthalmology 86(11):198082,
1979.
391
6. Kelman CD: History of phacoemulsification. In Little JH, Emery JM (Eds): Phacoemulsification

and Aspiration of Cataracts. St Louis: CV Mosby.57, 1979.
7. Kelman CD: The history and development of phacoemulsification. Int Ophthalmol Clin 34(2):1
12, 1994.
8. Kelman CD: In tune with the father of phacoemulsification. J Cataract Refract Surg 23(8):1128
29, 1997.
9. Hoh H, Fischer E: Erbium laser phacoemulsificationa clinical pilot study. Klin Monatsbl
Augenheilkd 214(4):20310, 1999.
10. Tunc Z: Laser phacoemulsification with the Paradigm Photon Lasersurgical technique and
first results. J Fr Ophthalmol 22(1):3940, 1999.
11. Neubaur CC, Stevens G Jr: Erbium: YAG laser cataract removalrole of fiberoptic delivery
system. J Cataract Refract Surg 25(4):51420, 1999.
12. Lee SY, Tan D: Changing trends in cataract surgery in Singapore. Singapore Med J 40(4):256
59, 1999.
13. Thatte S, Raju VK: Phacosandwich technique. J Cataract Refract Surg 25(8):103940, 1999.
14. Gonglore B, Smith R: Extracapsular cataract extraction to phacoemulsificationwhy and how?
Eye 2(Pt 6):97682, 1998.
15. Kohlhaas M, Klemm M, Kammann J et al: Endothelial cell loss secondary to two different
phacoemulsification techniques. Ophthalmic Surg Lasers 29(11):89095, 1998.
16. Garcia AS, Limao AM, Sampaio AM et al: Chop and rechop. J Cataract Refract Surg
24(2):14748, 1998.
17. Lampe Z, Vamosi P, Berta A: Changing concept and modern techniques in cataract surgery
Acta Chir Hung 36(14):18485, 1997.
18. Fine IH, Maloney WE, Dillman DM: Crack and flip phacoemulsification technique. J Cataract
Refract Surg 17:797802, 1993.
19. Fine IH: Chip and flip phacoemulsification technique. J Cataract Refract Surg 17:36671,
1991.
20. Gimbel HV: Divide and conquer nucleofractis phacoemulsificationdevelopment and
variations. J Cataract Refract Surg 17:28191, 1991.
21. Arnold PN: Nuclear flip technique in small pupil phacoemulsification. J Cataract Refract Surg
17(2):22527, 1991.
22. Koch PS, Katzen LE: Stop and chop phacoemulsification. J Cataract Refract Surg 20:56670,
1994.
23. Brown D: Phaco flip, course presented at the Symposium on Cataract, IOL and Refractive
Surgery, Seattle, Washington, 1996.
24. Maloney WF, Dillman DM, Nichamin LD: Supracapsular phacoemulsificationa capsule-free
posterior chamber approach. J Cataract Refract Surg 23:32328, 1997.
25. Maloney WF: For more and more surgeons phaco is on its way outout of the capsular bag,
that is. Ocular Surg News, 1997.
26. Maloney WF: Supracapsular phacothe next generation? Ocular Surg News, 1996.
27. Maloney WF: Supracapsular and quick chop phaco combines safety, efficiency. Ocular Surg
News, 1998.
28. Maloney WF: Supracapsular phaco and its larger continuous curvilinear capsulorrhexis may
allow for more efficient cataract surgery. Ocular Surg News, 1999.
29. Findl O, Dallinger S, Menapace R et al: Effects of peribulbar anesthesia on ocular blood flow
in patients undergoing cataract surgery. Am J Ophthalmol 127(6):64549, 1999.
30. Gillart T, Barrau P, Bazin JE et al: Lidocaine plus ropivacaine versus lidocaine plus
bupivacaine for peribulbar anesthesia by single medical injection. Anesth Analg 89(5):119296,
1999.
31. Schwarz EC, Gerdemann M, Hoffmann R et al: Strabismus and diplopia as complications after
cataract surgery with IOL implantation. Ophthalmology 96(10):63539, 1999.
Phacoemulsification
390
32. Anders N, Heuermann T, Ruther K et al: Clinical and electrophysiologic results after
intracameral lidocaine 1% anesthesia: a prospective randomized study. Ophthalmology
106(10):186368, 1999.
33. Nociti JR, Serzedo PS, Zuccolotto EB et al: Ropivacaine in peribulbar blocka comparative
study with bupivacaine. Acta Anaesthesiol Scand 43(8):799802, 1999.
34. Brown SM, Brooks SE, Mazow ML et al: Cluster of diplopia cases after periocular anesthesia
without hyaluronidase. J Cataract Refract Surg 25(9):124549, 1999.
35. Eke T, Thompson JR: The National Survey of Local Anaesthesia for Ocular Surgery: Isurvey
methodology and current practice. Eye 13(Pt 2):18995, 1999.
36. Yepez J, Cedeno de Yepez J, Arevalo JF: Topical anesthesia for phacoemulsification,
intraocular lens implantation, and posterior vitrectomy. J Cataract Refract Surg 25(8):116164,
1999.
37. Edge R, Navon S: Scleral perforation during retrobulbar and peribulbar anesthesiarisk factors
and outcome in 50,000 consecutive injections. J Cataract Refract Surg 25(9):123744, 1999.
38. Warwar RE, Bullock JD: Globe rupture after peribulbar anesthesia. J Cataract Refract Surg
25(7):88081, 1999.
39. Bellucci R: Anesthesia for cataract surgery. Curr Opin Ophthalmol 10(1):3641, 1999.
40. Rigal-Sastourne JC, Huart B, Pariselle G et al: Diffusion if lidocaine after intracameral
injection. J Fr Ophthalmol 22(1):2124, 1999.
41. Winder S, Walker SB, Atta HR: Ultrasonic localization of anesthetic fluid in sub-Tenons,
peribulbar, and retrobulbar techniques. J Cataract Refract Surg 25(1):5659, 1999.
42. Rous SM: Simplified sub-Tenons anesthesia: miniblock with maxiblock effect. J Cataract
Refract Surg 25(1):1015, 1999.
43. Johnston RL, Whitefield LA, Giralt J et al: Topical versus peribulbar anesthesia, without
sedation, for clear corneal phacoemulsification. J Cataract Refract Surg 24(3):40710, 1998.
44. Roman SJ, Chong Sit DA, Boureau CM et al: Sub-Tenons anaesthesia: an efficient and safe
technique. Br J Ophthalmol 81(8):67376, 1997.
45. Rainer G, Menapace R, Vass C et al: Corneal shape changes after temporal and superolateral
3.0 mm clear corneal incisions. J Cataract Refract Surg 25(8):112126, 1999.
46. Vass C, Menapace R, Rainer G et al: Comparative study of corneal topographic changes after
3.0 mm beveled and hinged clear corneal incisions. J Cataract Refract Surg 24(11):1498504,
1998.
47. Vass C, Menapace R, Rainer G: Corneal topographic changes after frown and straight
sclerocorneal incisions. J Cataract Refract Surg 23(6):91322, 1997.
48. Huang FC, Tseng SH: Comparison of surgically induced astigmatism after sutureless temporal
clear corneal and scleral frown incisions. J Cataract Refract Surg 24(4):47781, 1998.
49. Simsek S, Yasar T, Demirok A et al: Effect of superior and temporal clear corneal incisions on
astigmatism after sutureless phacoemulsification. J Cataract Refract Surg 24(4):51518, 1998.
50. Kohnen T, Dick B, Jacobi KW: Comparison of the induced astigmatism after temporal clear
corneal tunnel incisions of different sizes. J Cataract Refract Surg 21(4):41724, 1995.
51. Fine IH: Corneal tunnel incision with a temporal approach. In Fine IH, Fichman RA, Grabow
HB (Eds): Clear Corneal Cataract Surgery and Topical Anesthesia. Thorofare: NJ Slack 526,
1993.
52. Fine IH: Architecture and construction of a self-sealing incision for cataract surgery. J Cataract
Refract Surg 17(Suppl):67276, 1991.
53. Schmidl B, Anterist N, Mester U: Corneal endothelial protection in phacoemulsification of high
risk eyes with cornea guttata. Intraindividual comparison of 2 viscoelastic substances of
different viscosity and molecular size. Ophthalmology 96(6):38286, 1999.
54. Lehmann R, Brint S, Stewart R et al: Clinical comparison of Provisc and Healon in cataract
surgery. J Cataract Refract Surg 21(5):54347, 1995.
55. Gimbel HV: Two-stage capsulorhexis for endocapsular phacoemulsification. J Cataract Refract
Surg 16(2):24649, 1990.
393
17:11011, 1991.
57. Gimbel HV, Neuhann T: Development, advantages and methods of the continuous circular
58. Tahi H, Fantes F, Hamaoui M et al: Small peripheral anterior continuous curvilinear
capsulorhexis. J Cataract Refract Surg 25(6):74447, 1999.
59. Andreo LK, Wilson ME, Apple DJ: Elastic properties and scanning electron microscopic
appearance of manual continuous curvilinear capsulorhexis and vitrectorhexis in an animal
model of pediatric cataract. J Cataract Refract Surg 25(4):53439, 1999.
60. Luck J, Brahma AK, Noble BA: A comparative study of the elastic properties of continuous
tear curvilinear capsulorhexis versus capsulorhexis produced by radio-frequency
endodiathermy. Br J Ophthalmol 78(5):39296, 1994.
61. Assia EI, Apple DJ, Tsai JC et al: The elastic properties of the lens capsule in capsulorhexis.
Am J Ophthalmol 111(5):62832, 1991.
62. Cochener B, Jacq PL, Colin J: Capsule contraction after continuous curvilinear capsulorhexis
poly(methyl methacrylate) versus silicone intraocular lenses. J Cataract Refract Surg
25(10):136269, 1999.
63. Gimbel HV: Hydrodissection and hydrodelineation. Int Ophthalmol Clin 34(2):7390, 1994.
64. Anis AY: Understanding hydrodelineationthe term and the procedure. Doc Ophthalmol
87(2):12337, 1994.
65. Beyer RW: Distinguishing hydrodissection and hydrodelineation. Ophthalmic Surg 24(2):135,
1993.
66. Brierley L: Hydroexpression of the nucleus. J Cataract Refract Surg 19(5):66667, 1993.
67. Allarakhia L, Pearce JL: A new cannula for nucleus hydrodissection. Ophthalmic Surg
20(4):29697, 1989.
68. Ayaki M, Ohde H, Yokoyama N: Size of the lens nucleus separated by hydrodissection.
Ophthalmic Surg 24(7):49293, 1993.
69. Shephered JR: In situ fracture. J Cataract Refract Surg 16:43640, 1990.
70. Maloney WF, Grindle L: Textbook of phacoemulsification. Fallbrook, CA, Lasenda, 1988.
71. Fine IH: Cortical cleaving hydrodissection. J Cataract Refract Surg 18(5):50812, 1992.
72. Braverman SD: Braverman-Bechert nucleus rotator. J Cataract Refract Surg 18(4):41011,
1992.
73. Asrar A, Flitcroft I, Tormey P: Phaco-Hemiflipa suitable technique for small pupil and weak
zonules. Ocular Surgery News 17(11):28, 1999
74. Lindstrom RL: Tilt and tumble phacoemulsification technique. In Fine HI (Ed): Textbook of
Clear Corneal Lens Surgery. Slack Inc, 1999.
75. Meng YA, Wang YF, Liu XM: Management of posterior capsule rupture and vitreous loss
during IOL implantation. Chung Hua Yen Ko Tsa Chih 30(3):17476, 1994.
76. Mulhern M, Kelly G, Barry P: Effects of posterior capsular disruption on the outcome of
phacoemulsification surgery. Br J Ophthalmol 79(12):113337, 1995.
77. Koch PS: Managing the torn posterior capsule and vitreous loss. Int Ophthalmol Clin
34(2):11330, 1994.
78. Traianidis P, Sakkias G, Avramides S: Prevention and management of posterior capsule
rupture. Eur J Ophthalmol 6(4):37982, 1996.
79. Osher RH, Cionni RJ: The torn posterior capsuleits intraoperative behavior, surgical
management, and long-term consequences. J Cataract Refract Surg 16(4):49094, 1990.
80. Saber HR, Butler TJ, Cottrell DG: Resistance of the human posterior lens capsule and zonules
to disruption. J Cataract Refract Surg 24(4):53642, 1998.
81. Mackool RJ, Sirota MA: Intracapsular foldable posterior chamber lens implantation in eyes
with posterior capsule tears or zonular fiber instability. J Cataract Refract Surg 24(6):73940,
1998.
Phacoemulsification
392
82. Hayashi H, Hayashi K, Nakao F et al: Anterior capsule contraction and intraocular lens
dislocation in eyes with pseudoexfoliation syndrome. Br J Ophthalmol 82(12):142932, 1998.
83. Sugimoto Y, Takayanagi K, Tsuzuki S et al: Postoperative changes over time in size of anterior
capsulorhexis in phacoemulsification/aspiration. Jpn J Ophthalmol 42(6): 49598, 1998.
84. Breyer DR, Hermeking H, Gerke E: Late dislocation of the capsular bag after
phacoemulsification with endocapsular IOL in pseudoexfoliation syndrome. Ophthalmology
96(4):24851, 1999.
85. Fine IH, Hoffman RS: Phacoemulsification in the presence of pseudoexfoliation: challenges
and options. J Cataract Refract Surg 23(2):16065:1997.
86. Gimbel HV, Sun R, Heston JP: Management of zonular dialysis in phacoemulsification and
IOL implantation using the capsular tension ring. Ophthalmic Surg Lasers 28(4):27381, 1997.
87. Dosso AA, Bonvin ER, Leuenberger PM: Exfoliation syndrome and phacoemulsification. J
Cataract Refract Surg 23(1):12225, 1997.
88. Kadonosono K, Ohno S: New iris retractor for pupil dilatation during anterior vitrectomy:
double-hook iris retractor. Ophthalmic Surg Lasers 30(3):24143, 1999.
89. Novak J: Flexible iris hooks for phacoemulsification. J Cataract Refract Surg 23(6):82831,
1997.
90. Masket S: Avoiding complications associated with iris retractor use in small pupil cataract
extraction. J Cataract Refract Surg 22(2):16871, 1996.
91. Federman JL, Anand R: Surgical dilation of the pupil during pars plana vitrectomy. Ophthalmic
Surg 20(1):4648, 1989.
92. Eckardt C: A modified technique of pupillary stretching. Dev Ophthalmol 14:3236, 1987.
93. Yuguchi T, Oshika T, Sawaguchi S et al: Pupillary functions after cataract surgery using
flexible iris retractor in patients with small pupil. Jpn J Ophthalmol 43(1):2024, 1999.
94. Katsu Y, Ogino N, Kumagai E: Posterior chamber lens implantation concurrent with vitrectomy
for proliferative diabetic retinopathy. Nippon Ganka Gakkai Zasshi 95(1):8691, 1991.
95. Grusha YO, Masket S, Miller KM: Phacoemulsification and lens implantation after pars plana
vitrectomy. Ophthalmology 105(2):28794, 1998.
96. McDermott ML, Puklin JE, Abrams GW et al: Phacoemulsification for cataract following pars
plana vitrectomy. Ophthalmic Surg Lasers 28(7):55864, 1997.
97. Kang YH, Lee JH: Phacoemulsification and posterior chamber intraocular lens implantation
after scleral buckling, vitrectomy, or both. Ophthalmic Surg Lasers 29(1):2327, 1998.
98. Asrar A: Effect of site of incision on corneal endothelial cell following phacohemiflip surgery.
Presented in Irish Academy of Medicine Ophthalmology faculty meeting in Dublin, Ireland.
Nov 1999. Bourne WM, Kaufman HE. Endothelial damage associated with intraocular lenses.
Am J Ophthalmology 81:48285, 1976.
99. Bourne WM, Kaufman HE: Cataract extraction and the corneal endothelium. Am J
Ophthalmology 82:4447, 1976.
100. Waltman SR, Cozean CH Jr: The effect of phacoemulsification on the corneal endothelium.
Ophthalmic Surg 10(1):3133, 1979.
101. Beesley RD, Olson RJ, Brady SE: The effects of prolonged phacoemulsification time on the
corneal endothelium. Ann Ophthalmol 18:21622, 1986.
102. Zetterstrom C, Laurell CG: Comparison of endothelial cell loss and phacoemulsification
energy during endocapsular phacoemulsification surgery. J Cataract and Refract Surg 21:55
58, 1995.
103. Sugar J, Mitchelson J, Kraff M: The effect of phacoemulsification on corneal endothelial cell
density. Arch Ophthalmol 96:44648, 1978.
104. Beesley RD, Olson RJ, Brady SE: The effects of prolonged phacoemulsification time on the
corneal endothelium. Ann Ophthalmol 18:21622,1986.
105. Binder PS, Sternberg H, Wickman MG et al: Corneal endothelium damage associated with
phacoemulsification. Am J Ophthalmol 82:4854, 1976.
395
106. Kaufman E, Katz JI: Endothelium damage from intraocular lens insertion. Invest Ophthalmol
15:9961000, 1976.
107. Mc Carey BE, Polack FM, Marshall W: The phacoemulsification procedure. Ithe effect of
intraocular irrigating solution on corneal endothelium. Invest Ophthalmol 15: 44957, 1976.
108. Matsuda M, Kinoshita S, Ohashi Y et al: Comparison of the effects of intra-ocular irrigating
solution on the corneal endothelium in intra-ocular lens implantation. Br J Ophthalmol
75(8):47679, 1991.
109. Craig MT, Olson RJ, Mamalis, Olson RJ: Air bubble endothelial damage during
phacoemulsification in human eye bank eyesthe protective effects of Healon and Viscoat. J
110. Hoyashi K, Nakao F, Hayashi F: Corneal endothelium cell loss following phacoemulsification
using the small port-phaco. Ophthalmic Surg 25:51013, 1994.
111. Lane SS, Naylor DW, Kullerstrand LJ et al: Prospective comparison of the effects of
Occucoat, Viscoat and Healon on Intra Ocular Pressure and endothelial cell loss. J Cataract
Refract Surg 17:2126, 1991.
112. Dick HB, Konen T, Jacobi KW: Long term endothelial cell loss following phacoemulsification
through a temporal clear corneal incision. J Cataract Refract Surg 22(1):6367, 1996.
26
New Non-laser Phacoemulsification
Technologies
Richard S Hoffman
Introduction
New technology brings challenges and opportunities to the anterior segment surgeon. The
drive towards less traumatic surgery and more rapid visual rehabilitation after cataract
surgery has spawned various modalities for reducing incision size and decreasing energy
utilization.
Although ultrasonic phacoemulsification allows for relatively safe removal of
cataractous lenses through astigmatically neutral small incisions, current technology still
has its drawbacks. In ultrasonic phacoemulsification piezoelectric crystals convert
electrical energy into mechanical energy which emulsifies the lens material by means of
tip vibration. Ultrasonic tips create both heat and cavitational energy. A conventional
phaco tip moves at ultrasonic frequencies of between 25 KHz and 62 KHz. The amount
of heat generated is directly proportional to the operating frequency. In addition,
cavitational effects from the high frequency ultrasonic waves generate even more heat.
Because of the liberation of heat, phacoemulsification needles have required an
irrigation sleeve for cooling. This irrigation sleeve carries heat away from the tip and
necessitates an incision size larger than the tip alone would require. Nevertheless,
standard ultrasonic phacoemulsification with an irrigation sleeve still carries with it the
potential for thermal injury to the cornea in case of diminished flow. Flow and aspiration
problems may be caused by compression of the irrigation sleeve at the incision site,
kinking of the sleeve during manipulation of the handpiece, tip clogging by nuclear or
viscoelastic material and inadequate flow rate or vacuum settings.1 Heating of the tip can
create corneal incision burns.2 When incisional burns develop in clear corneal incisions,
there may be a loss of self-sealability, corneal edema, and severe induced astigmatism.3
Cavitational energy results from pressure waves emanating from the tip in all
directions. Although increased cavitational energy can allow for phacoemulsification of
dense nuclei, it can also damage the corneal endothelium and produce irreversible corneal
edema in compromised corneas with pre-existing endothelial dystrophies. Reduction in
average phaco power and effective phaco time has been correlated with improved patient
outcomes after cataract surgery.4 Low power phaco technology will have an important
advantage in minimizing intraoperative damage to ocular structures and maximizing the
level and rapidity of visual rehabilitation of the patient.
The last decade has given rise to some of the most profound advances in both
phacoemulsification technique and technology. Techniques for cataract removal have
New non-laser phacoemulsification technologies
397
moved from those that use mainly ultrasound energy to emulsify nuclear material for
aspiration to those that utilize greater levels of vacuum and small quantities of energy for
lens disassembly and removal. Advances in phacoemulsification technology and fluidics
have allowed for this ongoing change in technique by allowing for greater amounts of
vacuum to be safely utilized, while power modulations that have allowed for more
efficient utilization of ultrasound energy with greater safety for the delicate intraocular
environment.5
Elimination of the frictional heat produced during ultrasound phacoemulsification and
reduction of the power required for cataract extraction represent important steps towards
the goal of atraumatic surgery. The sonic phacoemulsification system (Staar Wave, Staar
Surgical) demonstrates another new approach to elimination of heat and the danger of
thermal injury to the cornea. Modification of ultrasound energy through refinement of
power modulation offers yet another route leading to elimination of heat and reduction of
incision size (White Star, Allergan). The introduction of innovative oscillatory tip motion
in coordination with power modulation permits further reduction of average phaco power
and effective phaco time (NeoSonix, Alcon). Other new modalities under investigation,
which promise low-energy, non-thermal cataract extraction, include vortex
phacoemulsification (Avantix, Bausch and Lomb) and Aqualase (Alcon), a fluid-based
cataract extraction system.
Sonic Phacoemulsification
Sonic technology offers an innovative means of removing cataractous material without
the generation of heat or cavitational energy by means of sonic rather than ultrasonic
technology. Its operating frequency is in the sonic rather than the ultrasonic range,
between 40 Hz and 400 Hz. In contrast to ultrasonic tip motion, the sonic tip moves back
and forth without changing its dimensional length. The tip of an ultrasonic handpiece can
exceed 500 degrees Celsius, while the tip of the Wave handpiece in sonic mode barely
generates any frictional heat. In addition, the Sonic tip does not generate cavitational
effects and thus fragmentation, rather than emulsification or vaporization, material takes
place.
The same handpiece and tip can be utilized for both sonic and ultrasonic modes. The
surgeon can alternate between the two modes using a toggle switch on the foot pedal
when more or less energy is required. The modes can also be used simultaneously with
varying percentages of both sonic and ultrasonic energy. We have found that we can use
our same chopping cataract extraction technique in sonic mode as we utilized in
ultrasonic mode with no discernable difference in efficiency.
The Staar Wave also allows improved stability of the anterior chamber with coiled
SuperVac tubing, which increases vacuum capability to upto 650 mmHg (Fig. 26.1). The
key to chamber maintenance is a positive fluid balance between infusion flow and
aspiration flow. When occlusion is broken, vacuum previously built in the aspiration line
generates a high aspiration flow that can be higher than the infusion flow. This results in
anterior chamber instability. The coiled SuperVac tubing limits surge flow resulting from
occlusion breakage in a dynamic way. The continuous change in
Phacoemulsification
396
FIGURE 26.1
FIGURE 26.2 Postocclusion surge

comparison chart
FIGURE 26.3 Postocclusion surge

comparison chart
direction of flow through the coiled tubing increases resistance through the tubing at high
flow rates such as upon clearance of occlusion of the tip (Figs 26.2 and 26.3). This effect
only takes place at high flow rates (greater than 50 cc/minute). The fluid resistance of the
Super Vac tubing increases as
399
FIGURE 26.4 NeoSonix handpiece

a function of flow and unoccluded flow is not restricted (personal communication, Alex
Urich, Staar Surgical).6
The Staar Wave combines important innovations in phacoemulsification technology,
which satisfy the demands of non-thermal, low power cataract extraction.
Neo Sonix Phacoemulsification
NeoSonix technology (Alcon) represents a hybrid modality involving low frequency
oscillatory movement that may be used alone or in combination with standard high
frequency ultrasonic phacoemulsification (Fig. 26.4). Softer grades of nuclear sclerosis
may be completely addressed with the low frequency modality, while denser grades will
likely require the addition of ultrasound.
In the NeoSonix mode, the phaco tip has a variable rotational oscillation upto two
degrees, at 120 Hz. As with sonic phacoemulsification, this lower frequency does not
produce significant thermal energy and so minimizes the risk of thermal injury.
The Legacy may be programed to initiate NeoSonix at any desired level of ultrasound
energy. Thus, the surgeon may utilize the low frequency mode to burrow into the nucleus
for stabilization prior to chopping by setting the lower limit of NeoSonix to zero percent
phaco power. This approach works best with a straight tip, which acts like an apple corer
to impale the nucleus. Alternatively, NeoSonix may be initiated as an adjunct to
ultrasound at the 10 or 20 percent power level.
We have found NeoSonix most efficacious at 50 percent amplitude with a horizontal
chopping technique in the AdvanTec burst mode at 50 percent power, 45 ml/minute
linear flow and 450 mmHg vacuum. A 0.9 mm microflare straight ABS tip rapidly
impales and holds nuclear material for chopping. During evacuation of nuclear segments
the material flows easily into the tip, with very little tendency for chatter and scatter of
nuclear fragments. With refinement of our parameters, we have found a 57 percent
reduction in average phaco power, and an 87 percent reduction in effective phaco time,
compared with the data we previously published with the Legacy system.7
NeoSonix has permitted further reduction in the application of ultrasonic energy to the
eye when used in conjunction with ultrasound, and allowed nonthermal cataract
extraction when used alone. It represents an important new modality in
phacoemulsification technology.
Phacoemulsification
398
White Star Technology

White Star (Sovereign, Allergan) represents a new power modulation within ultrasonic
phacoemulsification that virtually eliminates the production of thermal energy.
Analogous to the ultrapulse mode familiar to users of carbon dioxide lasers, White Star
extrapolates pulse mode phacoemulsification to its logical limit. As the duration of the
energy pulse is reduced it eventually becomes less than the thermal relaxation time of
ocular tissue. Thus, it is theoretically impossible to produce a corneal wound burn.
White Star technology sets the stage for bimanual cataract extraction with the
Sovereign phacoemulsification machine. The absence of thermal energy obviates the
need for an irrigation sleeve on the phaco tip, thus permitting reduction of incision size
and allowing irrigation through a second instrument, such as an irrigating chopper, placed
through the side-port. With an incision size for cataract extraction less than 1 mm, the
challenge becomes production of intraocular lenses capable of insertion through such
microphaco incisions.
Olson8 and Packard9 have reported exciting results using a 21-gauge irrigating chopper
and a 21-gauge bare phaco needle with the bimanual technique. Olsons study of cadaver
eyes has demonstrated that thermal injury does not occur even in the absence of
aspiration with 100 percent power for three minutes. Packard reported an absence of
wound burns with excellent surgical ease and efficiency via sub-2 mm incisions.
The White Star technology demonstrates important advantages in improved safety and
efficiency of cataract extraction, whether used in standard fashion or with the microphaco
technique.
Avantix
Vortex phacoemulsification involves placement of a tiny rotary impeller inside the
capsular bag through a 1 mm capsulorhexis. The impeller rotates at 60 kHz and causes
expansion of the capsular bag with rotation of the nuclear complex, thus allowing
extraction of the cataract from a nearly intact lens capsule. Expansion of the capsular bag
minimizes risk of capsular rupture.
The tiny circular capsulorhexis is constructed with a round diathermy instrument, thus
reducing the technical demands of such a surgical feat. The irrigation/aspiration tube
containing the rotary impeller is placed over the capsulorhexis while hydrodissection is
performed with gentle irrigation. The tube is then inserted into the capsular bag through
the 1 mm capsulorhexis prior to initiation of rotation, thus completely isolating the
anterior chamber from the activity of cataract extraction. Nuclear material is effectively
removed from the capsular bag with vortex action, after which cortex is actually stripped
away and extracted.
The advantages of leaving nearly the entire capsular bag in situ following cataract
extraction will not be realized until an injectable artificial crystalline lens becomes
available and the problem of capsular opacification is eliminated. Okahiro Nishi and
others are currently investigating these devices, and may soon have a prototype
available.10
401
Aqualase
Research at Alcon has led to the development of a fluid-based cataract extraction system.
Another nonthermal modality, Aqualase employs pulses of balanced salt solution at 50 to
100 Hz to dissolve the cataract. This modality may potentially demonstrate advantages in
terms of safety and prevention of secondary posterior capsular opacification. Still early in
its development, Aqualase represents an innovative and potentially advantageous
modality for cataract extraction.
Conclusion
Since the time of Charles Kelmans inspiration in the dentists chair (while having his
teeth ultrasonically cleaned), incremental advances in phacoemulsification technology
have produced ever-increasing benefits for patients with cataract. The modern procedure
simply was not possible even a few years ago, and until recently prolonged hospital stays
were common after cataract surgery. The competitive business environment and the
wellspring of human ingenuity continue to demonstrate synergistic activity in the
improvement of surgical technique and technology. Future advances in cataract surgery
will continue to benefit our patients as we develop new phacoemulsification technology.
References
1. Sugar A, Schertzer RIO: Clinical course of phacoemulsification wound burns. J Cataract Refract
Surg 25:68892, 1999.
2. Majid MA, Sharma MK, Harding SP: Corneoscleral burn during phacoemulsification surgery. J
3. Sugar A, Schertzer RM: Clinical course of phacoemulsification wound burns. J Cataract Refract
Surg 25:68892, 1999.
4. Fine IH, Packer M, Hoffman RS: Use of power modulations in phacoemulsification. J Cataract
Refract Surg 27: 18897, 2001.
5. Fine IH: The choo choo chop and flip phacoemulsification technique. Operative Techniques in
Cataract and Refractive Surgery 1:6165, 1998.
6. Fine IH, Hoffman RS, Packer M: The Staar Wave in Kohnen T (Ed). Modern Cataract Surgery
Update. Dev Ophthalmol. Basel, Karger, 2002, vol 34 (in press).
7. Fine IH, Packer M, Hoffman RS: Use of power modulations in phacoemulsification. J Cataract
Refract Surg 27: 18897, 2001.
8. Olson RJ, Soscia WL: Safety and efficacy of bimanual phaco chop through two stab incisions
with the Sovereign. XIII Congress of the European Society of Ophthalmology, Istanbul, 37,
2001.
9. Packard R: Evaluation of a new approach to phacoemulsification: bimanual phaco with the
Sovereign system rapid pulse software. XIII Congress of the European Society of
Ophthalmology, Istanbul, 37, 2001.
10. Nishi O, Nishi K: Accommodation amplitude after lens refilling with injectable silicone by
sealing the capsule with a plug in primates. Arch Ophthalmol 116(10):135861, 1998.
Section V
No Anesthesia Cataract
Surgery
27. No Anesthesia Cataract Surgery with the Karate Chop Technique
28. No Anesthesia Cataract Surgery
29. No Anesthesia Cataract Surgery: Comparision Between Topical, Intracameral
and No Anesthesia
30. Ocular Anesthesia for Small Incision Cataract Surgery
27
No Anesthesia Cataract Surgery with the
Karate Chop Technique
Amar Agarwal
Introduction
On June 13th, 1998 at Ahmedabad, India the first no anesthesia cataract surgery was done
by the authors (Amar Agarwal) at the Phako and Refractive Surgery conference. This was
performed as a live surgery in front of 250 delegates. This has opened up various new
concepts in cataract surgery.14 In this surgery the technique of karate chop was used.
For high refractive errors, clear lens extraction with phacoemulsification is a very
good alternative. In such cases, if necessary one can implant an IOL. This technique is
very useful in hypermetropes, as LASIK does not give excellent results in such cases. The
most commonly done refractive surgery in the world is not PRK or LASIK it is cataract
surgery. This is why this chapter will discuss phacoemulsification techniques for removal
of cataract as well as clear lens extraction.
Nucleus Removal Techniques
Since the introduction of phacoemulsification as an alternative to standard cataract
extraction technique, surgeons throughout the world have been attempting to make this
new procedure safer and easier to perform while assuring good visual outcome and
patient recovery. The fundamental goal of Phaco is to remove the cataract with minimal
disturbance to the eye using least number of surgical manipulations. Each maneuver
should be performed with minimal force and maximal efficiency should be obtained.
The latest generation Phaco procedures began with Dr. Howard Gimbels divide and
conquer nuclear fracture technique in which he simply split apart the nuclear rim. Since
then we have evolved through the various techniques namely four quadrant cracking,
chip and flip, spring surgery, stop and chop and phaco chop.
Clear lens removal by phacoemulsification is a very good alternative to manage
refractive errors. In these cases, as the nucleus is soft one can use only Phacoaspiration
to remove the nuclei, rather than use ultrasound power.
Phacoemulsification
404
Karate Chop
Unlike the peripheral chopping of Nagahara or other stop and chop techniques we have
developed a safer technique called Central Anterior chopping or karate chop. In this
method the phaco tip is embedded by a single burst of power in the central safe zone and
after lifting the nucleus a little bit (to lessen the pressure on the posterior capsule) the
chopper is used to chop the nucleus. In soft nuclei, it is very difficult to chop the nucleus.
In most cases, one can take it out in toto. But if the patient is about 40 years of age then
one might have to chop the nucleus. In such cases we embed the phaco probe in the
nucleus and then with the left hand cut the nucleus as if we are cutting a piece of cake.
This movement should be done three times in the same place. This will chop the nucleus.
Soft Cataracts
In soft cataracts, the technique is a bit different. We embed the phaco tip and then cut the
nucleus as if we are cutting a piece of cake. This should be done 23 times in the same
area so that the cataract gets cut. It is very tough to chop a soft cataract, so this technique
helps in splitting the cataract.
Agarwal Chopper
We have devised our own chopper. The other choppers, which cut from the periphery, are
blunt choppers. Our chopper is a sharp chopper. This is a 28 gauge chopper made by
Gueder (Germany). It has a sharp cutting edge. It also has a sharp point. The advantage of
such a chopper is that you can chop in the center and need not go to the periphery.
In this method by going directly into the center of the nucleus without any sculpting
ultrasound energy required is reduced. The chopper always remains within the rhexis
margin and never goes underneath the anterior capsule. Hence, it is easy to work with
even small pupils or glaucomatous eyes. Since we dont have to widen the pupil, there is
little likelihood of tearing the sphincter and allowing prostaglandins to leak out and cause
inflammation or cystoid macular edema. In this technique we can easily go into even hard
nuclei on the first attempt.
Our Karate Chop Technique
Incision
Ours is a modification of the Nagahara chop. The important feature is that we dont chop
the periphery. A temporal clear corneal section is made. If the astigmatism is plus at 90
degrees then the incision is made superiorly.
No Anesthesia cataract surgery with the karate
407
First of all, a needle with viscoelastic is injected inside the eye in the area where the
second site is made (Fig. 27.1). This will distend the eye so that when you make a clear
corneal incision, the eye will be tense and one can create a good valve. Now use a
straight rod to stabilize the eye with the left hand. With the right hand make the clear
corneal incision (Fig. 27.2).
When we started making the temporal incisions, we positioned ourselves temporally.
The problem by this method is that, every time the microscope has to be turned which in
turn would affect the cables connected to the video camera. Further the theater staff
would get disturbed between right eye and left eye. To solve this problem, we then
decided on a different strategy. We have operating trolleys on wheels. The patient is
wheeled inside the operation theater and for the right eye the trolley is placed slightly
obliquely so that the surgeon does not change his or her position. The surgeon stays at the
12 oclock position. For the left eye the trolley with the patient is rotated horizontally so
that the temporal portion of the left eye comes at 12 oclock. This way the patient is
moved and not the surgeon.
FIGURE 27.1 Eye with cataract.

Needle with viscoelastic entering the
eye to inject the viscoelastic. This is
the most important step in no
anesthesia cataract/clear lens surgery.
This gives an entry into the eye
through which a straight rod can be
passed to stabilize the eye. Note no
forceps holds the eye
Phacoemulsification
406
FIGURE 27.2 Clear corneal incision.

Note the straight road inside the eye in
the left hand. The right hand is
performing the clear corneal incision.
This is a temporal incision and the
surgeon is sitting temporally
FIGURE 27.3 Rhexis being done with

a needle
409
Rhexis
Capsulorhexis is then performed through the same incision (Fig. 27.3). While performing
the rhexis it is important to note that the rhexis is started from the center and the needle
moved to the right and then downward. This is important because today concepts have
changed of temporal and nasal. It is better to remember it as superior, inferior, right or
left. If we would start the rhexis from the center and move it to the left then the weakest
point of the rhexis is generally where you finish it. In other words, the point where you
tend to lose the rhexis is near its completion. If you have done the rhexis from the center
and moved to the left, then you might have an incomplete rhexis on the left hand side
either inferiorly or superiorly. Now, the phaco probe is always moved down and to the
left. So every stroke of your hand can extend the rhexis posteriorly creating a posterior
capsular rupture. Now, if we perform the rhexis from the center and move to the right and
then push the flap inferiorly then if we have an incomplete rhexis near the end of the
rhexis it will be superiorly and to the right. Any incomplete rhexis can extend and create
a posterior capsular tear. But in this case, the chances of survival are better. This is
because we are moving the phaco probe down and to the left, but the rhexis is incomplete
up and to the right.
If you are a left handed person start the rhexis from the center and move to the left
and then down.
Hydrodissection
Hydrodissection is then performed (Fig. 27.4). We watch for the fluid wave to see that
hydrodissection is complete. We do not perform hydrodilenation or test for rotation of the
nucleus. Viscoelastic is then introduced before inserting the phaco probe.
Karate ChopTwo Halves
We then insert the Phaco probe through the incision slightly superior to the center of the
nucleus (Fig. 27.5). At that point apply ultrasound and see that the phaco tip gets
embedded in the nucleus (Fig. 27.6). The direction of the phaco probe should be
obliquely downwards toward the vitreous and not horizontally towards the iris. Then only
the nucleus will get embedded. The settings at this stage are 70 percent phaco power, 24
ml/minute flow rate and 101 mmHg suction. By the time the phaco tip gets embedded in
the nucleus the tip would have reached the middle of the nucleus. We do not turn the
bevel of the phaco tip downwards when we do this step, as the embedding is better the
other way. We prefer a 15-degree tip but any tip can be used.
Phacoemulsification
408
FIGURE 27.4 Hydrodissection
FIGURE 27.5 Phaco probe placed at

the superior end of the rhexis
411
FIGURE 27.6 Phaco probe embedded

in the nucleus. We started from the
superior end of the rhexis and note it
has got embedded in the middle of the
nucleus. If we had started in the middle
then we would have embedded only
inferiorly that is at the edge of the
rhexis and chopping would be difficult
Now stop phaco ultrasound and bring your foot to position 2 so that only suction is
being used. Now lift the nucleus. When we say lift it does not mean lift a lot but just a
little so that when we apply pressure on the nucleus with the chopper the direction of the
pressure is downwards. If the capsule is a bit thin like in hypermature cataracts you might
rupture the posterior capsule and create a nucleus drop. So when we lift the nucleus the
pressure on the posterior capsule is lessened. Now, with the chopper cut the nucleus with
a straight downward motion (Fig. 27.7) and then move the chopper to the left when you
reach the center of the nucleus. In other words, your left hand moves the chopper like a
laterally reversed L.
Remember do not go to the periphery for chopping but do it at the center
Once you have created a crack, split the nucleus till the center. Then rotate the nucleus
180 degrees
Phacoemulsification
410
FIGURE 27.7 Left hand chops the

nucleus and splits like a laterally
reversed L, that is downwards and to
the left
and crack again so that you get two halves of the nucleus. In brown cataracts, the nucleus
will crack but sometimes in the center the nucleus will still be attached. You have to split
the nucleus totally in two halves and you should see the posterior capsule throughout.
Karate ChopFurther Chopping
Now that you have two halves, you have a shelf to embed the probe. So, now place the
probe with ultrasound into one-half of the nucleus (Fig. 27.8). You can pass the direction
of the probe horizontally as now you have a shelf. Embed the probe, then pull it a little
bit. This step is important so that you get the extra bit of space for chopping. This will
prevent you from chopping the rhexis margin. Apply the force of the chopper
downwards. Then move the chopper to the left so that the nucleus gets split. Again, you
should see posterior capsule throughout so that you know the nucleus is totally split.
Then release the probe, as the probe will still be embedded into the nucleus. Like this
create three quadrants in one-half of the nucleus. Then make another
413
FIGURE 27.8 Phaco probe embedded

in one-half of the nucleus. Go
horizontally and not vertically as you
have now a shelf of nucleus to Embed.
Chop and then split the nucleus
three halves with the second-half of the nucleus. Thus, you now have 6 quadrants or pieshaped fragments. The settings at this stage are 50 percent phaco power, 24 ml/minute
flow rate and 101 mmHg suction.
Remember 5 wordsEmbed, Pull, Chop, Split and Release.
Pulse Phaco
Once all the pieces have been chopped, take out each piece one-by-one and in pulse
phaco mode aspirate the pieces at the level of the iris. Do not work in the bag unless the
cornea is preoperatively bad or the patient is very elderly. The setting at this stage can be
phaco power 5030 percent, flow rate 24 ml and suction 101 mmHg.
RememberIt is better to have striate keratitis than posterior capsular rupture.
Cortical Washing and Foldable IOL Implantation
The next step is to do cortical washing (Fig. 27.9). Always try to remove the
subincisional cortex first, as that is the most difficult. In Figure 27.10 note the cortical
aspiration complete. Note also the rhexis margins. Note also that everytime the left hand
has the straight rod controlling the movements of the eye. If necessary use a bimanual
irrigation aspiration technique. Then inject viscoelastic and implant the foldable IOL. We
use the plate haptic foldable IOL (Fig. 27.11) with large fenestrations generally as we
find them superior. Take out the viscoelastic with the irrigation aspiration probe (Fig.
27.12).
Phacoemulsification
412
Stromal Hydration
At the end of the procedure, inject the BSS inside the lips of the clear corneal incision
(Fig. 27.13). This will create a stromal hydration at the wound. This will create a
whiteness, which will disappear after 45 hours. The advantage of this is that the wound
gets sealed better.
No PAD, S/C Injections
No subconjunctival injections or pad are put in the eye. The patient walks out of the
theater and goes home. The patient is seen the next day and after a month glasses
prescribed.
FIGURE 27.9 Cortical aspiration

completed. Note the straight rod in the
left hand which helps control the
movements of the eye
415
FIGURE 27.10 Eye distended with

viscoelastic. Note the rhexis margins
No Anesthesia Clear Lens Extraction
In cases of clear lens removals, the same technique is followed. No anesthesia is used. If
one is not good
FIGURE 27.11 Plate haptic foldable

IOL with large fenestrations being
implanted
Phacoemulsification
414
FIGURE 27.12 Foldable IOL in

capsular bag. Viscoelastic removed
with the irrigation aspiration probe
then it is advisable to use a parabulbar anesthesia (pin-point anesthesia) rather than a
peribulbar
FIGURE 27.13 Stromal hydration

done and the case completed
block. The reason is that in such cases one could perforate the globe with the needle.
Once the patient is draped, the syringe with viscoelastic is taken and the viscoelastic
417
injected inside the eye using a 26 gauge needle. Then the temporal clear corneal incision
is made. If the astigmatism is + at 90 degrees then a superior incision is made.
The rhexis is then done using a needle. This is followed by hydrodissection. The
phaco probe is passed into the eye and using phaco aspiration the soft nucleus removed.
One does not have to use ultrasound, as the nucleus in such cases is very soft. This is
followed by cortical aspiration. Depending on the biometry a foldable IOL is implanted
in the eye. If the patient has high myopia and an IOL is not required then an IOL is not
implanted. The authors have realized that chances of retinal detachment do not increase
just because the eye is aphakic. The authors prefer to keep one eye emmetropic and the
other slightly myopic to about 1 to 1.5 D so that the patient can see without glasses for
distance and near with both eyes open.
Compared to LASIK this is a very good alternative, as LASIK does not help much in
hyperopes and in high myopes (powers above 15 D).
Phacodynamics of the Phaco Chop Technique
We should take full advantage of the phaco machines capability thereby decreasing
physical manipulation of the intraocular tissues. In this phaco chop technique, we use a
vacuum of 101 mm Hg, about 70 percent phaco power and the flow rate is 24 ml/minute.
In this phaco chop technique, the most important is the vacuum, which needs to be
sufficient to stabilize the nucleus while the chopper is splitting it. If the action of the
chopper is dislodging the vacuum seal on the phaco tip, it is said that the vacuum can be
raised from 120 to 200 mm Hg. After embedding the phaco needle with mild linear
ultrasound power in foot switch position 3, it is important to raise the pedal back to foot
switch position 2, while the vacuum builds up. This is because the purpose of ultrasound
was to completely embed the aspiration port into the nucleus to obtain good vacuum seal.
In foot switch 3, there is risk of adverse heat build up because the occluded tip prohibits
any flow of cooling. Also, when manipulating the nucleus by pulling with the embedded
tip, the vacuum seal is likely to be compromised by the vibrating needle if it is in foot
switch position 3.
Advantages
The phacoemulsification procedure has been proved to be reasonably safe to the
endothelium. As compared to the divide and conquer technique, this phaco karate chop
technique eliminates the need for trenching thereby producing significant reduction in
phaco time and power consumed which in turn decreases endothelial cell damage. Even
with increased density of cataract, there is a less pronounced increase in phaco time. Here
we utilize the Chop to divide the nucleus by mechanical energy. It is safe and effective
in nuclear handling during phacoemulsification.
In conventional chop, the disadvantage is that the chopper is placed underneath the
anterior capsule and then pulled towards the center. This can potentially damage the
capsule and the zonules. In phaco chop, we dont go under the rhexis, the vertical element
of the chopper remains within the rhexis margin and is visible at all stages. Hence very
Phacoemulsification
416
easy to work with even in small pupils or glaucomatous eyes. The stress is taken by the
impacted phaco tip and the chopper rather than transmitting it to the fragile capsule.
By going directly into the center of the nucleus with the phaco tip and not doing any
sculpting, we dont need as much ultrasound energy as is usually required. It is safe and
easy to perform and we dont have to pass as much balanced salt solution (irrigating
fluid) through the eye.
Disadvantages
This technique demands continuous use of the left hand and hence requires practise to
master it.
Topical Anesthesia Cataract/ Clear Lens Surgery
All cases done by the authors were previously done under topical anesthesia. Four
percent xylocaine drops was instilled in the eye about 3 times 1015 minutes before
surgery. No intracameral anesthesia was used. It is not advisable to use xylocaine drops
while operating. This can damage the epithelium and create more trouble in visualization.
No stitches and no pad are applied. This is called theNo injection, no stitch, no pad
cataract surgery technique. Now the authors have shifted all their cases 100 percent to
the no anesthesia technique.
No Anesthesia Cataract/ Clear Lens Surgery
We had been wondering whether any topical anesthesia is required or not. So we then
operated patients without any anesthesia. In these patients no xylocaine drops were
instilled. The patients did not have any pain. It is paradoxical because we have been
taught from the beginning that we should apply xylocaine. This is possible because we do
not touch the conjunctiva or sclera. We never use any one-tooth forceps to stabilize the
eye. Instead what we use is a straight rod which is passed inside the eye to stabilize it
when we are performing rhexis etc. The first step is very important. In this we first enter
the eye with a needle having viscoelastic and inject the viscoelastic inside the eye. This is
done in the area of the side port. Now, we have an opening in the eye through which a
straight rod can be passed to stabilize the eye. The anterior chamber should be well
maintained and the amount of ultrasound power used very less. If you tend to use the
techniques like trenching then the ultrasound power generated is high, which in turn
generates heat. This causes pain to the patient. If you follow these rules one can perform
o anesthesia cataractor clear lens extraction surgery. It is not necessary to do this, as there
is no harm in instilling some drops of xylocaine in the eye. The point that there is always
a discussion which anesthetic drop to use. It does not matter. The technique, which you
perform, should not produce pain to the patient.
419
Conclusion
As in any other field, progress is inevitable in ophthalmology more so in refractive
surgery. We have started to look on refractive surgery as a craft and should constantly try
to improve our craft and become better every day. By this, we will be able to provide
good vision to more people than any one dared dream a few decades ago. It also goes
without saying that we are and will be forever grateful to all our patients because without
their faith, we would never have had the courage to proceed.
Keeping this in mind, we hope and wish that the effectiveness and the advantages of
this No Anesthesia Clear Lens Extraction Technique be realized and practiced thereby
making the technique of phacoemulsification safer and easier providing good visual
outcome and patient recovery.
References
1. Agarwal S, Agarwal A, Mahipal S Sachdev, et al: Phacoemulsification, Laser Cataract Surgery
and Foldable IOLs; (2nd ed); Jaypee Brothers; Delhi, India, 2000.
2. Agarwal A, Agarwal S, Agarwal A: No anesthesia cataract surgery with the karate chop
technique; In Amar Agarwals Presbyopia: A Surgical Textbook; Slack Incoporated USA; 177
85, 2002.
3. Agarwal A, Agarwal S, Agarwal A: No anesthesia Cataract and clear lens extraction with Karate
chop; In Agarwals Phako, Phakonit and laser Phako: A quest for the best; Highlights of
Ophthalmology Panama; 11320, 2002.
4. Agarwal A, Agarwal S, Agarwal A: No anesthesia Cataract and clear lens extraction with Karate
chop; In Boyd-Agarwals Lasik and beyond Lasik; Highlights of Ophthalmology Panama; 451
62, 2001.
28
No Anesthesia Cataract Surgery
Tobias Neuhann
Introduction
As we all know, the surface of the human eye is highly sensitive. A quick approach, a
dust particle, a gust of air to dry out the ocular surfacethe eyelids will close
immediately in a protective reflex. To operate an eye without any anesthesia? The mere
idea seems to be absurd. However, disregarding all that we know, it is possible.
On June 13, 1998, Amar Agarwal successfully performed the first no anesthesia
cataract operation during the Phaco and Refractive Surgery conference in Ahmedabad,
India, in front of an audience of 250 persons, applying the karate chop technique.1,2 On
the occassion of the 1999 ASCRS convention in Seattle, live surgery was performed in
India by Sunita Agarwal, Amar Agarwal and Mahipal S Sachdev and communicated via
satellite to the meeting in Seattle. All these operations were performed under NO
ANESTHESIA. The cataracts were removed through a sub 1 mm incision by Sunita
Agarwal and Amar Agarwal using a technique called PHAKONIT. Sunita Agarwal
demonstrated laser phacoemulsification, while Mahipal S Sachdev performed high
vacuum phacoemulsification.3
In the 1999 Indian Intraocular Implant and Refractive Surgery conference, I had the
opportunity to personally attend live no anesthesia cataract surgery by Amar Agarwal. He
kindly offered me the to perform a live no anesthesia cataract operation, myself. It was a
fascinating experience, and even during the operation itself, it was hard to believe that it
was really possible.
Back in Munich, I successfully operated two patients under the age of 40 using this
astounding new methodboth upon their own request. Fourteen other cases followed.
However, the specific preconditions of this particular group of patients will be discussed
lateron in this chapter.
Incision
Without any anesthesia, naturally the incision is much more critical than in routine
cataract surgery under topical (retrobulbar, parabulbar or surface anesthesia) or even
general anesthesia.4 The entire procedure is only possible if neither the sclera nor the
conjunctiva are touched. In addition, no one-toothed forceps is used to stabilize the eye.
Instead, a straight rod is inserted into the eye to guarantee a stable position during the
operation.
No Anesthesia cataract surgery
421
The first step is essential. A side port is created with a diamond and viscoelastic is
injected. This incision is then used to insert a straight rod to stabilize the eye. This is
followed by a clear corneal incision.1,2
Capsulorhexis
The capsule is opened using capsulorhexis, like in any routine cataract surgery. The
capsulorhexis can be performed alternatively using the needle or the forceps technique.
The needle technique first requires an initial puncture of the anterior capsule within
the central area to be removed, which is then extended in a curve-shaped manner to the
targeted eccentric circle to be described. The circular tear is started by either pushing or
pulling the central anterior capsule in either direction, while the flap to be created is
gently lifted. The next step is to turn over the flap and apply the vectorial forces in tearing
with the needle in such a way that a more or less concentrical opening originates. Once
the full circle is almost completed the end will automatically join the beginning of the
curve outside in (Fig. 28.1). It is also possible to place the first puncture directly within
the planned curvature and start the rhexis with a curved enlargement of this tiny hole.
With this approach, the tear is brought around on both sides, until finally the ends join
together.5
Advantages of the needle technique are that it is economical, since it can be performed
with
FIGURE 28.1 The ideal capsulorhexis

application of BSS as well as viscoelastics and the cost of the needles is neglectable. The
following factors are essential for the success of the needle capsulorhexis: I highly
recommend the use of a 23 gauge needle, because the lumen of this type of needle is just
sufficient to produce a pressure exchange between anterior chamber and BSS irrigating
bottle and the metal of such a cannula supplies just enough rigidity to provide the
necessary resistance for difficult manipulations. A higher, that is positive pressure in the
anterior chamber compared to the intracapsular pressure is mandatory. This becomes
especially noticeable with intumescent lenses, where the lens protein is hydrated resulting
Phacoemulsification
420
in a volume increase inside the capsular bag, so that also the endocapsular pressure is
considerably increased. Only if the anterior chamber pressure is greater than or equal to
that inside the capsular bag can a successful capsulorhexis be performed. The pressure in
the anterior chamber can be adjusted by varying the height of the infusion bottle. In
addition, the needle tip should be as sharp as possible, since a blunt needle may create
stellate burst (Fig. 28.2).5
The forceps technique is easier. For this reason it is also the most frequently applied
capsulorhexis technique, which, however, can only be performed after viscoelastic
instillation. The principle of the forceps capsulorhexis exactly corresponds to the
principle of the needle technique. In addition to the
FIGURE 28.2 Stellate burst

known Utrata forceps there are mini forceps which are similar in construction to the
forceps developed for the posterior segment of the eye. The advantage of these newly
designed forceps is that they can be inserted into the anterior chamber via a paracentesis,
so that the incision is not exposed to needless strain.5
To point out the difference between the needle and the forceps technique, the
following example might be appropriate: To turn over a page of a book you can take the
sheet between two fingers and turn it from one side to the other (this is what you do with
the forceps), or you take a moistened finger, press the page a bit down and then turn it
over (that is what you do with the needle; the counterhold is the cortex). With this in
mind the consequences appear quite clear cut. I will always use a needle technique, the
initial puncture peripheral or central, for the great majority of my cases. The forceps I
will use in situations where the needleso to saylacks the other branch. This is mainly
the case when liquified cortex is apparent or secondary enlargement of the capsulorhexis
diameter is necessary.5
423
Phacoemulsification Techniques
A variety of phacoemulsification techniques has been developed with the aim to
disintegrate the nucleus in the safest and most efficient way. When Howard Gimbel
introduced his divide and conquer technique, it was adopted enthusiastically by
ophthalmologists throughout the world.6 For many years after, divide and conquer
remained the outstanding technique for all nuclei hard enough not to be simply aspirated,
until Nagahara presented his new technique, phaco chop, the big brother of divide and
conquer. Other than in divide and conquer, the nucleus is no longer divided with the
phaco tip, but with a second instrument, the chopper, so that hardly any manipulations
with the tip itself were necessary any longer, thus reducing the risk to damage the
sensitive intraocular structures with the tip to a minimum.7
The phaco chop technique has remained one of the most efficient methods in
phacoemulsification until today. The advantages are obvious. The lens can be divided up
mechanically into 4, 6 and 8 or more pieces. In this process, the originating forces
counteract, since the force exerted by the chopper is directed against the phaco tip. The
result is that all force vectors go centrally, so that there is no hazard for the lens capsule
or the corneal endothelium.
The phaco chop technique is especially suitable for mature cataracts or cataracta nigra,
where mostly weak zonulas are found. A beneficial side effect for the surgeon is the ease
of work, because the nucleus can always be rotated into the most favorable position.
However, an important aspect of phaco chop is that it is only a technique for experienced
surgeons, whereas beginners should start with divide and conquer to develop a feeling for
the consistency of the nucleus to stay on the safe side. For the first chopping attempt, a
medium nuclear sclerosis should be selected.
To understand the mechanism of phaco chop, you have to consider the anatomic
structure of the nucleus, where the crystalline lens fiber runs from one side of the equator
towards the opposite side through the center of the nucleus. As a logical consequence, the
natural cracking direction follows the lens fiber. As is usual in modern cataract surgery,
the capsule is opened with the CCC and hydrodissection is carried out. Then the
epinucleus is aspirated inside the CCC with weak phaco energy. For your first chop, you
have to catch the lens with your phaco tip at the 12 hours position, advance the phaco tip
until you have firm hold of the nucleus and then insert the chopper into the space between
the equator and the capsule at the 6 hours position. As the chopper is gradually brought
closer to the tip, the nucleus will crack into two halves. Then the nucleus is rotated 90
and the inferior heminucleus is cracked into quadrants applying the same principle. If the
nucleus is relatively soft, the quarters can be aspirated and emulsified with the phaco tip.
In this process, the tip opening should remain in the center of the lens capsule not to
increase the hazard of damaging either the posterior capsule or the corneal endothelium
unnecessarily. When aspiration and emulsification of the inferior heminucleus are
completed, the superior heminucleus is rotated 180 and disintegrated accordingly. In the
case of harder nuclei, a subdivision of the nucleus into 8 or more pieces may be required
to exclude that residual fragments escape into the anterior chamber and damage the
corneal endothelium with their sharp edges.
Phacoemulsification
422
Experience in phacoemulsification shows that it is beneficial to reduce the overall

phaco time and power to the necessary minimum. An additional advantage of the phaco
chop technique is that here the nuclear matter is first aspirated and then emulsified. In this
way, the entire phaco energy is used for emulsification of the nucleus, the aspiration
volume concentrates on the nucleus, and less phaco energy and time are required, thus
reducing strain for the incision as well as for the corneal endothelium.
The initial phaco chop technique has been modified several times by different
ophthalmologists including Nagahara, its inventor. He uses his karate chop technique,7,8
which was also applied in the first live no anesthesia cataract surgery by Amar
Agarwal,1,2 for cases with poor mydriasis to be able to perform the whole
phacoemulsification procedure within the range of the pupil or the CCC. Other than in
the initial phaco chop technique, karate phaco chop goes from the anterior pole to the
posterior pole of the crystalline lens. For hard nuclei with a thin epinucleus and the
typical dual structure of soft periphery and hard core Nagahara suggests the crater phaco
chop technique. To be able to grab hold of the hard core of the nucleus with the phaco tip,
first a crater is excavated providing enough space for easy insertion of the tip.
My personal method of choice is the quick-chop technique when performing no
anesthesia cataract surgery because of the above mentioned advantages, such as stressand pain-free intraocular manipulations.
Intraocular Lens Implantation
Using no anesthesia cataract surgery, I recommend an implantation of a soft, foldable
silicone or acrylic IOL to be able to make use of the advantages of small incision surgery,
especially under the aspect that a clear corneal incision is inevitable, because the sclera as
well as the conjunctiva must not even be touched. For both intraocular lens families,
acrylic as well as silicone, a large variety of IOL models and types from the different
manufacturers is available in the market. In this way it is easy to find a lens to meet the
specific requirements of the individual patient. As one of the newest developments, even
a foldable toric IOL can be implanted using a ring-haptic-fixation with a specific
indented capsular tension ring (*Acri.Clip) (Figs 28.3 and 28.4).9 Foldable IOLs can be
implanted with forceps or with an injector, which is mostly the easier alternative.
No Anesthesia Clear Lens Extraction
At the Agarwal eye hospitals in Chennai and
425
FIGURE 28.3 Ring-haptic fixation;

computer animation
FIGURE 28.4 Ring-haptic fixation;

clinical case
Bangalore, India, clear lens extractionalso without anesthesiais applied for the
surgical treatment of high refractive errors as an alternative to PRK or LASIK, especially
in hyperopic or high myopic patients (more than 15 D). Depending on the specific case,
an IOL is then implanted or, in cases of extremely high myopia, the patient is left
aphakic. The operation follows the same procedure as no anesthesia cataract surgery. For
less experienced surgeons, a parabulbar anesthesia is recommended instead of a
peribulbar block to avoid the hazard of globe penetration with the needle.1,2
Specific Precautions in No Anesthesia Cataract Surgery
Experience shows that it is beneficial to cover the cornea with HPMC 2.4 percent to
reduce the surface sensitivity of the eye. In addition, it is essential to maintain the
moisture of the cornea throughout the operation.
Phacoemulsification
424
It is important, not to inform the patient prior to the operation to exclude the danger of
increased sensitivity caused by the patients fear of pain. In addition, it is very important
to exclude any sharp or pointed instrument, such as Colibri forceps. However, the use of
diamond knives is appropriate.
Furthermore, utmost care with the eyelid is required, because it is experienced as
highly disturbing by the patients.
During phacoemulsification, it is very important to only apply low amounts of
ultrasound power to avoid the origination of heat, which would be painful for the patient.
In addition, the anterior chamber should be well maintained throughout the procedure.1
Recent Cases
Recently, I operated two female patients with a history of allergic shock. In both cases, a
severe allergic reaction to anesthetics administered during treatment by their dentist had
occurred. In these patients, there was a high probability of allergy against the CAINgroup, thus forming an indication for no anesthesia cataract surgery. One of the patients
had been looking desperately for a possibility to have cataract surgery performed despite
her allergy.
Both patients were highly motivated, and surgery could be performed without any
problems. As a new step in the procedure, I applied very cold BSS solution in the area of
the limbus immediately prior to the incision to decrease the ocular sensitivity.
Discussion
No anesthesia cataract surgery is a surprising new development in our highly refined
techniques in ophthalmic surgery that have been achieved to date. Without any doubt, the
mere existence of this new option is very exciting and also might be very helpful in cases
with specific indications. However, in my opinion, the different preconditions of the
patient goods in different areas of the world need to be briefly discussed. As we all know,
a series of amazing phenomena exists in India. Which other country on earth has been
able to produce individuals who are able to stick knives and sabres through their bodies
and faces and pull them out again without a drop of blood dripping down and without any
wound remaining? On the other hand, documentations of almost unbelievable practices
also exist from other areas in the world, like in parts of Africa, where trepanation is
performed without any anesthesia, too, and the patients maintain not to feel too much
pain when their skulls are opened without any anesthetic relief. On this basis, the no
anesthesia approach should be further investigated in terms of its introduction in suitable
countries, also taking into account the poverty in large parts of the world, where no
anesthesia cataract surgery might be a step into the right direction to improve health care
for the population by lovering the costs of treatment.
Generally, in the Western World this method is only suitable for especially old
patients, where the surface sensitivity of the eye is already considerably reduced or for
highly motivated patients. In my own practice, I operated a total of 18 patients without
anesthesia to date. All of these patients had a particular mental attitude in common, which
427
enabled them to undergo this kind of procedure, and which considerably differs from that
the majority of the population in any of our industrialized countries. All of these patients
asked me to perform no anesthesia cataract surgery, while the larger majority especially
of the younger patients rather tend to consider the advantages of general or topical
anesthesia, instead, and would not even dream of having an operation performed without
any anesthesia. In this way, the special motivation of my 18 cases formed the only
possible basis for this new approach.
No anesthesia cataract surgery is a highly fascinating new alternative. It is certainly
not designed for routine practice. However, it remains an excellent method for patients
with specific indications, where our common forms of anesthesia are not possible, for
example in hemophilics.
References
1. Agarwal A, Agarwal S, Agarwal A: No anesthesia cataract/clear lens extraction. Refractive
Surgery New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 48798, 2000.
2. Agarwal A, Agarwal S, Agarwal A: No Anesthesia Cataract Surgery. Phacoemulsification, Laser
Cataract Surgery and Foldable IOLs New Delhi: Jaypee Brothers Medical Publishers (P) Ltd,
13943, 1998.
3. Azim Siraj A: Dr Agarwals Homepage Volume II, No 2: Issues Conference and Seminars:
1999.
4. Lang GK: Operative Therapy. Augenheilkunde Georg Thieme Verlag, Stuttgart: 19093, 1998.
5. Neuhann T: Capsulorhexis. Phacoemulsification, Laser Cataract Surgery and Foldable IOLs
New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 8188,1998.
6. Gimbel HV, Anderson PE: Divide and Conquer Nucleofractis Techniques. Phacoemulsification,
Laser Cataract Surgery and Foldable IOLs New Delhi: Jaypee Brothers Medical Publishers (P)
Ltd, 97109, 1998.
7. Nagahara KB: Phaco ChopDevelopment and Recent Advances. Atlas of Cataract Surgery
London: Martin Dunitz Ltd, 98109, 1999.
8. Agarwal A, Agarwal S, Agarwal A: Karate Chop. Phacoemulsification, Laser Cataract Surgery
and Foldable IOLs New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 14454, 1998.
9. Neuhann T: New Foldable IOLs. Atlas of Cataract Surgery London: Martin Dunitz Ltd, 16980,
1999.
29
No Anesthesia Cataract Surgery:
Comparison Between Topical, Intracameral
and No Anesthesia
Suresh K Pandey
Liliana Werner, Amar Agarwal
Introduction
Ophthalmic surgeons have witnessed a significant evolution in surgical techniques for
cataract extraction in the 20th century.1 The most remarkable advance is, of course, the
considerable decrease in the size of the wound incision. Small-incision cataract surgery
using phacoemulsification through clear corneal self-sealing incisions avoids
cauterization, suturing and intraocular pressure (IOP) fluctuations. Moreover, this is
faster, more controlled and less traumatic when compared with conventional largeincision extracapsular cataract extraction (ECCE). With the advent of the phaconit
technique, today it is possible to remove the cataract through a 0.9 mm incision.2 The
evolution in surgical techniques for cataract extraction is summarized in Table 29.1.
Anesthetic techniques for cataract surgery have also advanced significantly (Table
29.2).3,4 General anesthesia was preferred in past years, followed by various techniques of
injectable anesthesia including retrobulbar, peribulbar, sub-Tenon, and subconjunctival
anesthesia. Due to marked improvements in surgical techniques, it is no longer essential
to ensure complete akinesia of the eye and as a consequence, the technique of topical
anesthesia has been popularized as phaco anesthesia.522 This includes eyedrops
application, sponge anesthesia, eyedrops plus intracameral injection, and most recently
gel application.5,7,1115,1821,23,24 Topical anesthesia is the preferred technique for cataract
surgeons in the USA (37%; range 2263%) according to a survey conducted by David
Learning in 1998.25 It revealed that as high as 76 percent respondents using topical
anesthesia preferred eyedrops in association with
TABLE 29.1 Evolution of techniques for cataract

surgery
Technique
Year Author/Surgeon
Couching
ECCE* (inferior incision)
ECCE* (superior incision)
ICCE** (tumbling)
ECCE with PC-IOL***
800 Sushruta
1745 Daviel
1860 von Graefe
1880 Smith
1949 Ridley
429
ECCE with AC-IOL**** 1951 Strampelli

Phacoemulsification
1967 Kelman
Foldable IOLs
1984 Mazzocco
Capsular surgery
1992 Apple/Assia
Accommodating IOLs
1997 Cummings/Kamman
Phakonit
1998 Agarwal
*ECCE: extracapsular cataract extraction
**ICCE: intracapsular cataract extraction
***PC-IOL: posterior chamber intraocular lens
****AC-IOL: anterior chamber intraocular lens
TABLE 29.2 Evolution of anesthetic techniques for

cataract surgery
Technique
Year Author
General anesthesia
Topical cocaine
Injectable cocaine
Orbicularis akinesia
1846 ?
1885 Koller
1884 Knapp
1914 Van Lint, OBriens
Atkinson
Hyaluronidase
1948 Atkinson
Retrobulbar (4% cocaine) 1984 Knapp
Posterior peribulbar
1985 Davis and Mandel
Limbal
1990 Furata and coworkers
Anterior peribulbar
1991 Bloomberg
Pinpoint anesthesia
1992 Fukasawa
Topical
1992 Fichman
Topical plus intracameral 1997 Gills
No anesthesia
1998 Agarwal
Cryoanalgesia
1999 Gutierrez Carmona
Xylocaine jelly
1999 Koch, Assia
intracameral injection of lidocaine. In a recent, prospective, randomized, double-masked

clinical trial, Gillow et al26 evaluated the efficacy of supplementary intracameral
lidocaine in routine phacoemulsification under topical anesthesia. There was no
significant relationship between the use of intracameral lidocaine and either
intraoperative or postoperative pain scores. The authors concluded that the routine use of
intracameral lidocaine as a supplement to topical anesthesia did not have any clinically
useful role.
Clear corneal phacoemulsification has the advantage of avoiding touching any
superficial sensitive ocular tissue (other than the peripheral cornea) during the surgery.
Preserved ocular motility can be used to improve the operating conditions by optimizing
the red reflex and wound access. Compared to regional anesthetic techniques such as
peribulbar anesthesia, the topical approach does not increase the vitreous pressure, and
there is no effect on the optic nerve blood flow. Postoperative recovery is quicker,
Phacoemulsification
428
postoperative pain is reduced, and the patient may prefer this technique. Recently,
various authors reported their experience concerning topical anesthesia.1113,15,1821
However, neither injectable nor topical anesthetics are completely safe, injectable
techniques of these agents can lead to various complications which can be non-sightthreatening, sight-threatening and very rarely, life-threatening.3,4,6,8,27 Topical anesthesia
prevents these complications but it can lead to corneal epithelial, corneal endothelial,
and/or retinal toxicity, mostly due to the preservatives in the anesthetic solutions.2832
Moreover, topical anesthetic agent and its vehicle may serve as reservoir of microbial
contamination with the potential for causing an infection. Some of these agents (e.g.
proparcaine) can lead to allergic and idiosyncratic reactions. Manifestations of such
reactions include periocular swelling, erythema, and the typical rash of contact dermatitis.
Further, preoperative instillation of some of the topical anesthetics (e.g. lidocaine) may
cause burning and stinging sensations and multiple applications sometimes lead to mild
haziness of the cornea during the surgical procedure. There is a potential for cumulative
toxicity on account of need for administration of several doses. Recent reports suggested
that cataract surgeons should be aware of the potential for endothelial injury if anesthetic
agents are injected into the eye.3032 This is not surprising because the intraocular
concentration of the anesthetic agent after intracameral injection can be 250 times higher
than the concentration after topical application.32 Complications associated with topical
anesthesia are summarized in Table 29.3.
TABLE 29.3 Side effects and complications of

topical ocular anesthetics
1. Alteration of the stability of lacrimal and tear films
2. Delayed healing of the epithelium in presence of epithelial defects
3. Toxicity to the corneal endothelium secondary to preservative benzalkonium
4. Surface keratopathy
5. Retinal and macular toxicity
The modern cataract surgical procedures are currently so well defined and quickly
performed that we can question whether the topical anesthesia represent a dead end or if
it is possible to perform the surgery without using it.
Indeed, one of the major advances documented in the last decade of the 20th century is
the performance of cataract surgery without using topical anesthesia.34 This was first
done by Amar Agarwal (AA), in June, 1998. Interestingly, this happened as an accident.
A case of posterior polar cataract was scheduled for an ECCE in the early 1998, under
pinpoint anesthesia (preferred by the surgeon: AA) rather than topical anesthesia. At the
last moment, the surgeon decided to perform the surgery using phacoemulsification
instead of ECCE. In the middle of the surgery, he came to know that he was performing it
without anesthesia. To his surprise, the patient was lying comfortably without pain. Since
then, more than 5,000 cataract surgeries have been performed using this technique.
We recently completed a collaborative study on no anesthesia cataract surgery in
comparison to topical and topical plus intracameral anesthesia. The aim of the study was
to avoid the use of topical anesthesia during cataract surgery and to evaluate the efficacy
of this technique. We also compared the comfort of the patient and the stress for the
surgeon during the surgery in the three groups.
431
Randomized Study
Patients
Seventy-five patients were enrolled in this prospective, randomized, double blind study.
Informed consent was obtained from the patients after explaining in detail the outline of
the study, which was reviewed and approved by the ethics committee of the hospital. All
patients were randomized to one of the three groups: group Ino anesthesia, 25 patients;
group IItopical anesthesia, 25 patients; group IIItopical plus intracameral anesthesia,
25 patients. The patients included in the study were between 38 and 79 years of age. The
density of the cataracts varied from grade 2 to 4 (Emery-Little classification).35
Excluded were patients with barrier to communication or cooperation during surgery
(extreme anxiety, language and/or hearing impairment, mental retardation, dementia,
Parkinsons disease, very young, etc). Monocular patients and those with hard, mature
cataracts (grade 5 Emery-Little classification), shallow anterior chamber(s), pupil(s) less
than 5 mm in diameter (when fully dilated), and inability to understand a visual analog
pain scale were also excluded.
The patients were prepared for cataract surgery without preoperative (or
intraoperative) sedation. The pupils were preoperatively dilated using phenylephrine
(5%), cyclopentolate (0.5%) and tropicamide (1%) eyedrops. Nonsteroidal antiinflammatory drugs (NSAIDs) were not used.
Anesthetic Techniques
Patients in group I received, while still in the preoperative area, two drops of balanced
salt solution (BSS Alcon, Forth Worth, TX) every 5 minutes three times, beginning 10
to 15 minutes before the procedure. After the corneal endothelium was coated with
viscoelastic, before performing the capsulorhexis, an intracameral injection of BSS via a
25-gauge Rycroft cannula (Beaver and Visitec Products, Bidford on Avon, England) was
performed. Patients randomized to group II received lidocaine (4%) eyedrops
preoperatively, and an intracameral injection of BSS, as described above. Patients in
group III received both, preoperative 4 percent lidocaine eyedrops and intracameral
injection of preservative-free lidocaine (1%), using the same methods as in the other 2
groups.
The protocol established for the supplemental anesthesia for breakthrough pain during
the surgery, if it should occur, was as follows: if the patient was in pain, two additional
drops of lidocaine (4%) would be placed in the eye. If the pain persisted, a peribulbar or
retrobulbar block would be used.
Surgical Technique
All cataract surgical procedures in this study were performed in a referral institute of
South India by the same surgeon (AA). A wire speculum was placed and the patients
were asked to look down. No superior rectus sutures were used in any group. Patients
were informed that they would be aware of the sensation of touch and would be able to
move their eyes. First of all, viscoelastic (Healon, Pharmacia and Upjohn, Uppasala,
Phacoemulsification
430
Sweden) was injected into the anterior chamber using a needle through the area where the
second (paracentesis) site was made. This was important in order to distend the eye to
create a good self-sealing corneal valve. A straight rod was then used to stabilize the eye
(with the left hand) at the 2 Oclock position for the right eye and at the 10 Oclock
position for the left eye. With the right hand, a 3.2 mm groove was made in clear
temporal cornea using a diamond knife. During the entire surgical procedure care was
taken to avoid grasping of the conjunctiva or sclera by tooth forceps. The globe was
stabilized by the straight blunt rod during the entire surgery. A 5.0 to 5.5 mm wide
capsulorhexis was performed using a 26-gauge bent needle cystotome. Hydrodissection
was performed with BSS. Nuclear emulsification (Alcon, Master 10,000, Fort Worth,
TX) was performed with Karate chop technique using less ultrasound power. The
capsular bag was filled with viscoelastic. Foldable one-piece plate hap tic PCIOL lenses
were then implanted (STAAR Surgical Co, Monrovia, CA). Intracameral miotics were
not used in any of the patients. The viscoelastic was removed from the anterior chamber
and the capsular bag by irrigation. The corneal incisions were secured by performing
stromal hydration.
The operating microscope light was kept at its lowest level and gradually increased in
intensity. The level was up to the usual operating levels after hydrodissection and the
patient was encouraged to fix the eye toward the microscope light during the surgery. No
subconjunctival injections or an eyepad was applied at the completion of the surgery.
Parameters Assessed
After the surgery, the patients were taken to the postoperative area where vital signs were
obtained. There, one constant observer also collected patient assessment responses.
Questions were presented to the patients in a standardized written form. Each patient was
shown a 10-point visual analog graphic pain scale with numeric and descriptive ratings
where 0 represented no pain and 10 represented severe, unbearable pain.35 They were
asked to grade the level of discomfort or pain during the surgery and postoperatively, on
separate scales. If the patient was unable to see the scale or read the accompanying text,
the scale was described and verbal score was obtained. They were also asked to
differentiate pain or discomfort from touch or movement sensation. The degree
to which the patients were bothered due to ability to move their eyes, sense of touching
their eyes and by the operating microscope light was also assessed. This was graded as
not at all (0), not very much (1) and very much (2). If the surgeon was bothered by
the patients eye movement, it was also graded as not at all (0), not very much (1)
and very
TABLE 29.4 Characteristics of the patients

included in each group
*Group I **Group II ***Group III
Number of cases
25
25
25
Average age
59.669.54 56.809.35 60.0010.17
Males/females
18/7
15/10
14/10
Nuclear density
2.501.10 2.640.90
2.280.79
Operating time (min) 8.251.78 8.882.24
8.381.70
Race (% non-white)
100
100
* No anesthesia
** Topical anesthesia
*** Topical and intracameral anesthesia
433
100
much (2). Stress for the surgeon during the surgery (from 02) and total surgical time
(minutes) were also noted. The patients were kept in the recovery area for a minimum of
30 minutes. The surgeon also completed a questionnaire on the surgical conditions,
complications and need for supplemental anesthesia.
Comparison of various parameters between the three groups was performed using
analysis of variance (ANOVA). A P value inferior to 0.05 was considered statistically
significant.
Results
A total of 75 patients were recruited into the study. No patient refused to take part.
Patient data are listed in Table 29.4. There was no significant difference in age and
density of cataracts of the patients from the three groups (Figs 29.1A and B). Therefore,
the patients included in the study were comparable. The average surgical time was
8.251.78 minutes for the no anesthesia group (group I), 8.882.24 minutes in the topical
anesthesia group (group II) and 8.38 1.70 minutes in the topical plus intracameral
anesthesia group (group III). The surgical time was slightly higher in the topical
anesthesia group when compared to the no anesthesia or topical plus intracameral
anesthesia groups, but this difference was not significant (P=0.3562Fig. 29.1C). No
patients in any group required supplemental anesthesia.
FIGURE 29.1A
Phacoemulsification
432
FIGURE 29.1B
FIGURE 29.1C
The results from the questionnaires are summarized in Table 29.5. The mean score of
intraoperative pain (scale from 0 to 10) in the no anesthesia group was slightly superior
than in the topical and topical plus intracameral groups. However, this difference was not
statistically significant (P=0.6101Fig. 29.1D). In other words, there was no significant
difference in the subjective sensation of pain during
FIGURE 29.1D
FIGURE 29.1E
FIGURE 29.1F
FIGURE 29.1G
FIGURE 29.1H
435
Phacoemulsification
434
FIGURE 29.1I
FIGURES 29.1A TO I
Graphs showing the results of the
parameters assessed in the randomized
study
cataract surgery either with or without topical anesthesia. The mean score of patient
discomfort due to the microscope light was slightly higher in the no anesthesia group, but
this difference was again not statistically significant (P=0.2115Fig. 29.1E). Patient
discomfort due to ability to move the eyes had a significantly higher mean score in the no
anesthesia group (P=0.0235Fig. 29.1F) when
TABLE 29.5 Parameters (and scores) evaluated in

the three groups
Group I*
(N=25)
Group II**
(N=25)
Group III***
(N=25)
P value
Pain (010)
1.541.84
1.441.04
1.161.17
0.6106
Discomfort due to microscope
0.200.41
0.040.20
0.160.37
0.2115
light (02)
Discomfort due to ability to move 0.250.44
0.400.20
0.400.20
0.0235****
the eye (02)
Discomfort due to sense of touch 0.370.64
0.200.40
0.280.45
0.0629
(02)
Surgeons discomfort during
0.300.57
0.120.33
0.280.45
0.158
surgery (02)
Stress for surgeon during surgery 0.400.58
0.080.27
0.160.37
0.0206****
(02)
*No surgery, **Topical anesthesia, ***Topical and intracameral anesthesia, ****
Statistically significant (P<0.05)
compared to the two other groups. Regarding patient discomfort due to sense of touching
the eyes the mean score was higher in the no anesthesia group. However this difference
was not statistically significant (P=0.0629Fig. 29.1G). Concerning surgeon discomfort
437
due to the ability of the patients to move the eyes, the difference between the three groups
was also not statistically significant (P= 0.1580Fig. 29.1H). However, the stress for the
surgeon during the surgery was significantly greater in the no anesthesia group when
compared to the topical or topical plus intracameral group (P =0.0206Fig. 29.1I).
In summary, the only two parameters that differed significantly in the 3 groups were
patient discomfort due to ability to move the eyes and stress for the surgeon during the
entire surgical procedure.
Current Study/Experience of Other Surgeons
This is the first randomized, double-masked, controlled trial comparing three techniques,
namely no anesthesia, topical anesthesia and topical plus intracameral anesthesia. The use
of either topical anesthesia or topical anesthesia combined with intracameral lidocaine
was not associated with significantly lower intraoperative and early postoperative pain
scores.
Assessments of other parameters in the 3 groups besides the pain scores revealed that
only patient discomfort due to ability to move the eyes and stress for the surgeon during
the procedure were significantly different.
No anesthesia cataract surgery has been currently performed by other surgeons in
various countries. Dr Francisco J Gutierrez-Carmona performed no anesthesia cataract
surgery on 50 patients in Spain.37 He used cooled balanced salt solution in the operating
eye and termed this technique as cryoanalgesia. The experience of Dr Tobias Neuhann
from Germany concerning no anesthesia cataract surgery performed on 30 cases is also
interesting (Neuhann T, personal communication). He performed it mostly on patients
over 50 years, but interestingly some of the patients less than 50 years of age also asked
for the no anesthesia technique. This is due to a trend of no medical treatment, which is
common in very selective group of peoples in Germany. The use of 2 percent
hydroxypropylmethyl cellulose (HPMC) to cover the cornea, helped in avoiding corneal
dryness during the surgery. Although motivation is important, according to Dr Neuhanns
experience no anesthesia cataract surgery works better in older patients. Dr Keiki R
Mehta from India also performed more than 450 cases using this technique (Mehta KR,
personal communication). The need for supplemental anesthesia in his series was about
10 to 12 percent. He believes that the limbus is a watershed area for tactile sensations and
therefore the corneal sensitivity in the peripheral cornea is significantly lower than the
central cornea (see below: anatomical factors). Other surgeons currently performing this
technique include Drs Oman Almullah (USA), Mohan Rajan (India) etc.
No Anesthesia Cataract Surgery: Why Does it Work?
It seems surprising that cataract surgery can be performed through one of the most
sensitive structures (cornea) without using any anesthesia. The precise explanation for
this fact is still unknown to us. However, we can advance some hypotheses related to
surgical factors and anatomical factors.
Phacoemulsification
436
Surgical Factors
The skill and experience of the surgeon is one of the most important factors for the no
anesthesia cataract surgery. While using this technique, it is important to avoid grasping
the conjunctiva or sclera with tooth forceps. The surgeon should use a straight and
relatively blunt rod to stabilize the eye during the entire procedure. Also, the use of a
clear corneal incision avoids the use of cautery, necessary to achieve hemostasis with
scleral tunnel incisions. In addition, gradual increase in the microscope luminance,
minimization of the iris-lens-diaphragm movement and iris manipulations are important
factors for topical as well as no anesthesia techniques. The phaco power should be used
minimally to avoid excessive heating of the phaco tip, which in turn can produce pain.
Anatomical Factors
The cornea is supplied by the medial and lateral long ciliary nerves, which are branches
of the trigeminal nerve. It is sensitive to touch, pain and temperature.38 However, there
are marked topographical variations in the corneal sensitivity. Besides the diurnal
variations, corneal sensitivity also varies according to age, sex and race.3840 The central
part of the cornea is the most sensitive. There is an overall reduction in the corneal
sensitivity from the center to the periphery. The superior part of the cornea is the least
sensitive, probably because of a decreased concentration of acetylcholine.
Concerning the diurnal variations, corneal sensitivity is the lowest in the morning and
highest in the evening. This decreased sensitivity in the morning must be attributed to the
reduction in oxygen tension at the epithelium surface when the eye is closed.39
Corneal sensitivity remains practically unchanged from 10 to about 50 years of age.
Beyond that age, the decline is significant reaching a half beyond 65 years of age. The
precise mechanism is not clear, however, some authors relate it to the formation of arcus
senilis and to a decreased concentration of acetylcholine. In females, corneal sensitivity
decreases during the premenstrual and menstrual periods.
The role of racial factors should not be underestimated.40 It was documented during
contact lens fitting and many studies confirmed that corneal sensitivity in non-white
(dark-brown eyed: Indians, Chinese, and Negroes) peoples is 4 times less than in white
(blue-eyed: Caucasians) peoples. As reported by Michel Millodot in 1975, this
phenomenon is obviously relevant to the wearing of contact lenses.40 It may also have
some bearing on problems of anesthesia as it is possible that different quantities of
anesthetics may be needed according to eye color. This is similar to the clinical fact that
more ocular drugs are needed for people with dark rather than light-pigmented irises to
obtain the same effect (for example, cycloplegia). The reason for this is not known,
although it may be related to the amount of melanin pigment present in the iris. Since the
cornea does not contain any pigment, however, it is not easy to explain the diminution of
corneal sensitivity with darker pigmentation of the iris. It is not known whether the
thickness of the cornea varies with eye color. It has been shown that thicker corneas, as a
result of edema, are less sensitive than normal corneas. It is also unknown whether nerve
supply density varies widely among these different peoples. Another possibility is that
the difference in sensitivity arises in the central nervous system and not at the periphery
The difference in tactile sensitivity may also be relevant to understand that the practice of
439
acupuncture may be more acceptable in China than it is in countries inhabited by blueeyed people.
Finally, recent studies have documented that frequent exposure to ultraviolet rays
(between 280 and 310 nm) may give rise to a loss in corneal sensitivity, as high as 73
percent.38 Also, decrease in temperature can lead to reduction in corneal sensitivity,
which have been documented up to nine folds.38
Thus, no anesthesia cataract surgery works due to atraumatic surgical techniques in
suitable patients by a very experienced and confident surgeon. The speed and dexterity of
the surgeon are paramount to the successful use of this technique, as it is the proper
patient selection. Incision and manipulations through the least sensitive (superior) part of
the cornea are probably the most important factors. Further decrease in corneal sensation
due to the dark iris of patients in India, and aged patients exposed to ultraviolet rays
probably accounted for the results obtained in our study.
As mentioned earlier, the reasons for the racial variations are still unknown. However,
the differences may be important in adapting the technique for more sensitive corneas in
white patients, as did Dr Francisco Gutierrez-Carmonas in Spain by using cooled
balanced salt solution (cryoanalgesia) for corneal desensitization.37
Conclusion
In conclusion, we demonstrated that cataract surgery could be performed without the use
of anesthetic agents. The advantage is that it avoids any toxicity associated with topical
and/or intracameral anesthetic solutions. However, it is certainly not suitable for every
cataract surgeon or every patient and its real benefits have to be measured carefully, in a
case-by-case basis.
References
1. Linebarger EJ, Hardten DR, Shah GK et al: Phacoemulsification and modern cataract surgery.
Surv Ophthalmol 44:12347, 1999.
2. Agarwal A, Agarwal S, Agarwal A: Phakonit and laser phaconit: lens removal through a 0.9 mm
incision. In Agarwal A (Ed): Textbook of Ophthalmology Slack Inc: Thorofare 2:2000 (in
press).
3. Greenhalgh D: Anesthesia for cataract surgery. In Yanoff M, Ducker JS (Eds): Ophthalmology
Mosby-Yearbook: St Louis 21.521.6, 1998.
4. Ram J, Pandey SK: Anesthesia for cataract surgery. In Dutta LC (Ed): Modern Ophthalmology
Jaypee Brothers: New Delhi 32530, 2000.
5. Koch PS: Anterior chamber irrigation with unpreserved lidocaine 1% for anesthesia during
cataract surgery. J Cataract Refract Surg 23:55154, 1997.
6. Patel BCK, Burns TA, Crandall A et al: A comparison of topical and retrobulbar anesthesia for
cataract surgery. Ophthalmology 103:11961203, 1996.
7. Gills JP, Cherchio M, Raanan MG: Unpreserved lidocaine to control discomfort during cataract
surgery using topical anesthesia. J Cataract Refract Surg 23:54550, 1997.
8. Zehetmayer M, Radax U, Skorpik C et al: Topical versus peribulbar anesthesia in clear corneal
cataract surgery. J Cataract Refract Surg 22:48084,1996.
Phacoemulsification
438
9. Manners TD, Burton RL: Randomized trial of topical versus sub-Tenons local anaesthesia for
small-incision cataract surgery. Eye 10:36770, 1996.
10. Roman S, Auclin F, Ullern M: Topical versus peribulbar anesthesia in cataract surgery.
11. Crandall AS, Zabriskie NA, Patel BCK et al: A comparison of patient comfort during cataract
surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine.
12. Masket S, Gokmen F: Efficacy and safety of intracameral lidocaine as a supplement to topical
anesthesia. J Cataract Refract Surg 24:95660, 1998.
13. Martin RG, Miller JD, Cox CC III et al: Safety and efficacy of intracameral injections of
unpreserved lidocaine to reduce intraocular sensation. J Cataract Refract Surg 24: 96163,
1998.
14. Garcia A, Loureiro F, Limao A et al: Preservative-free lidocaine 1% anterior chamber irrigation
as an adjunct to topical anesthesia. J Cataract Refract Surg 24:40306, 1998.
15. Tseng HS, Chen FK: A randomized clinical trial of combined topical-intracameral anesthesia in
cataract surgery. Ophthalmology 105:200711, 1998.
16. John T: Simplified anesthesia technique for scleral tunnel phacoemulsification. J Cataract
Refract Surg 24:156265, 1998.
17. Pham DT, Scherer V, Wollensak J: Sponge-Oberfldchenandsthesie in der Kataraktchirurgie (bie
skleralem Tunnelschnitt). Klin Monatsbl Augenheilkd 209:34753, 1996.
19. Koch P: Anterior chamber irrigation with unpreserved lidocaine 1% for anesthesia during
20. Carino NS, Slomovic AR, Chung F et al: Topical tetracaine versus topical tetracaine plus
intracameral lidocaine for cataract surgery. J Cataract Refract Surg 24:160208, 1998.
21. Garcia A, Loureiro F, Limao A et al: Preservative-free lidocaine 1% anterior chamber irrigation
as an adjunct to topical anesthesia. J Cataract Refract Surg 24:40306, 1998.
22. Claoue C: Simplicity and complexity in topical anesthesia for cataract surgery (editorial). J
23. Koch PS: Efficacy of lidocaine 2% jelly as a topical agent in cataract surgery. J Cataract
Refract Surg 25:63234, 1999.
24. Assia EI, Pras E, Yehezkel M et al: Topical anesthesia for lidocaine gel for cataract surgery. J
25. Learning DV: Practice styles and preferences of ASCRS members1998 survey. J Cataract
Refract Surg 25:85159, 1999.
26. Gillow T, Scotcher SM, Deutsch J et al: Efficacy of supplementary intracameral lidocaine in
routine phacoemulsification under topical anesthesia. Ophthalmology 106:217377, 1999.
27. Davis DB, Mandel MR: Anesthesia for cataract extraction. Int Ophthalmol Clin 34:1330,
1994.
28. Rosenwasser GOD: Complications of topical ocular anesthetics. Int Ophthalmol Clin 29:153
58, 1989.
29. Maloney WF: Intraocular lidocaine causes transient loss in small number of cases. Ocul Surg
News 14:32, 1996.
30. Werner L, Legeais JM, Obsler C et al: Toxicity of xylocaine to rabbit corneal endothelium. J
31. Liang C, Peyman GA, Sun G: Toxicity of intraocular lidocaine and bupivacaine. Am J
Ophthalmol 125:19196, 1998.
32. Judge AJ, Najafi K, Lee DA et al: Corneal endothelial toxicity of topical anesthesia.
33. Behndig A, Linden C: Aqueous humor lidocaine concentrations in topical and intracameral
anesthesia. J Cataract Refract Surg 24:15981601, 1998.
441
34. Agarwal A, Agarwal A, Agarwal S: No anesthesia cataract surgery with karate chop. In
Phacoemulsification, Laser Cataract Surgery and Foldable IOLs. Slack Inc: Thorofare 14553,
1998.
35. Emery JM, Little JH: Phacoemulsification and Aspiration of Cataracts; Surgical Techniques,
Complications, and Results. CV Mosby: St Louis 4548, 1979.
36. Scott J, Huskisson EC: Graphic representation of pain. Pain 2:17584, 1976.
37. Gutierrez-Carmona FJ: Phacoemulsification with cryoanalgesia: A new approach for cataract
surgery. In Agarwal A (Ed): Text Book of Ophthalmology Slack Inc: Thorofare 2:2000 (in
press).
38. Millodot M: A review of research on the sensitivity of the cornea. Ophthal Physiol Opt 4:305
318, 1984.
39. Millodot M: Do blue-eyed people have more sensitive cornea than brown-eyed people? Nature
8:15152, 1975.
40. Millodot M: Diurnal variation of corneal sensitivity. Br J Ophthalmol 56:844, 1972.
30
Ocular Anesthesia for Small Incision
Cataract Surgery
Samuel Masket
Introduction
Traditional methods of local ocular anesthesia for cataract surgery have employed
injection of anesthetics to the periorbital region. It is well recognized that regional
infiltration can produce ocular anesthesia, ocular akinesia, orbicularis akinesia, and
varying degrees of amaurosis. However, recent trends strongly indicate that only ocular
anesthesia is necessary for routine small incision cataract surgery The 1997 American
Society of Cataract and Refractive Surgery member survey for the year 1996 suggests
that roughly 15 percent of surgeons employ non-injection anesthesia (topical with or
without intracameral agents) routinely.1 Nevertheless, the great majority of surgeons
continue to use anesthetic injections with some degree of risks, that include damage to
the globe, optic nerve, and periocular structures, and central nervous system (CNS)
toxicity including brainstem anesthesia, apnea, and death. Very rarely, the patient may
sustain bilateral ocular anesthesia as a result of anesthetic spread through the cavernous
sinus. Moreover, with anesthetic injection, there is the potential for cosmetic blemish of
the lids and conjunctiva. It is worth noting that patients often rate the quality of their
cataract surgery by how the eye looks as well as how the eye sees during the early
postoperative period.
The risks of periorbital anesthetic injections are of some consequence, in that the
overall occurrence rate for retrobulbar hemorrhage is in the vicinity of 1 percent of all
cases, the likelihood increases with long needles and intraconal injection.2 Furthermore,
ocular penetration and optic nerve damage are not terribly rare. The risks of those
maloccurrences increase in patients who are uncooperative for injection, those with high
myopia, those with prior scleral buckling surgery, and when the injections are
administered by non-ophthalmologists. Additionally, no needle types, injection sites, or
injection styles are immune to the risk for damage to the globe or other orbital
structures.35
Another issue regarding the blind passage of sharp needles into the orbit concerns
those patients on anticoagulant medications or those with naturally occurring
coagulopathies. It should be obvious that these patients are at greater risk for periocular
hemorrhage with needle injection, but often the medical necessity for anticoagulation
dictates that patients remain on treatment during the perioperative period. Often, the
systemic risk to cessation of anticoagulant treatment is greater than the risk of
intraoperative bleeding. Indeed, the published guidelines for cataract surgery in the
United Kingdom suggest that cataract surgery should proceed up to an INR (International
Ocular anesthesia for small incision
443
Normalized Ratio) of 4.0 for patients taking Coumadin. It is evident that non-injection
forms of local anesthesia are safer for anticoagulated patients.
Additional consequences of periocular anesthetic include an inability of the patient to
move the eye during and after surgery. While it was once considered essential that the
eye be fully still for safe surgery, it is now recognized that purposeful eye movements, on
command, can benefit the progress of surgery. As an example, in cases with narrow
palpebral fissures, the eye can be moved to facilitate incisions, etc. A further consequence
of regional anesthetic infiltration is amaurosis. As a result, the patient cannot see to fixate
a target. However, with topical/intracameral anesthesia, the patient can be asked to follow
a light source or other visual target to help fixate the globe in a satisfactory position for
surgery.
Movement away from periocular injection toward topical methods of ocular anesthesia
is natural, given the overall changes in small incision cataract surgery that have
progressed to outpatient surgery with methods that allow for immediate ambulation, rapid
return to a full lifestyle, and stable optical results of surgery within days.6 The immediate
use of the eye after cataract surgery is possible only with topical/intracameral methods
and is in keeping with the concepts of modern surgery.
Topical anesthesia resurfaced in this decade as a useful tool after Fichmans
suggestion regarding the use of tetracaine 0.5 percent applied to the eye as the only
anesthetic for cataract surgery.7 Other agents, such as bupivacaine and lidocaine have
been popularized because of a reduced tendency to cause corneal epitheliopathy and to
have a longer period of action as compared with tetracaine. However, patients are not
universally comfortable with topical anesthesia as the only agent. Many surgeons employ
small amounts of intravenous, oral, or sublingual sedation as an adjunct. However, in
1995 Gills suggested the routine use of intracameral non-preserved lidocaine in addition
to topical anesthesia with or without systemic sedation,8 although the concept had been
mentioned earlier by Fichman who considered intraocular tetracaine for use in difficult
case situations. Safety and efficacy of intracameral lidocaine has been further established
by Koch9 and Masket with Gokmen in separate studies.10 In the latter investigation,
approximately 40 percent of more than 300 patients receiving only topical anesthesia
required intraoperative conversion to a deeper level of local anesthesia, whereas fewer
than 1 percent of 300 cases receiving intracameral lidocaine had need for an additional
local anesthetic method. In the same study, safety was measured by comparing the degree
of corneal edema on the first postoperative day between the two groups, a reduced
likelihood for corneal edema was associated with the use of intracameral nonpreserved
lidocaine hydrochloride 1 percent, but this finding may be related to the use of chop style
phacoemulsification for the latter group. Nevertheless, based upon the early postoperative
appearance of the cornea, nonpreserved lidocaine is seemingly nontoxic although Koch
reports reduced contrast sensitivity and visual acuity in the first few hours after surgery.
Other methods to provide ocular anesthesia for cataract surgery without the risks of
blind pass, sharp needle orbital injection have evolved during the same era as the
movement to topical anesthesia. Posterior sub-Tenons infiltration employs a blunt
Phacoemulsification
442
FIGURE 30.1 Blunted reusable

cannula for sub-Tenons (parabulbar)
anesthesia. (Courtesy Rhein Medical,
Tampa, Florida)
cannula (Fig. 30.1) to place local anesthesia directly in the retrobulbar space. A
conjunctival button hole incision, performed under topical anesthesia, is necessary for the
cannula to gain direct access to the sub-Tenons space. This method was suggested as an
alternative to sharp needle orbital injection,11 and has been further popularized by
Greenbaum as a primary method for cataract anesthesia. He coined the term parabulbar
anesthesia to describe the concept.12 Additionally, the method may be used for surgeons
in transition to topical/intracameral anesthesia and is very useful to convert from topical
methods in cases where complications occur, surgery is prolonged, or if the patient is
otherwise in need of a deeper level of anesthesia. As long as the cataract incision is selfsealing, the parabulbar infiltration may be given at any time during the surgery. Varying
with the nature of the agent used for infiltration, parabulbar anesthesia may provide
complete ocular akinesia and amaurosis. Other alternatives include anterior
subconjunctival injection given diffusely or only focally in the region of the incision, socalled pin-point anesthesia.13
It is evident that traditional ocular anesthesia for cataract surgery, utilizing sharp
needles passed blindly through the skin of the lids or the conjunctiva engenders risks
(Table 30.1) that are avoidable with topical/intracameral or other recently developed
means for local anesthesia. However, in addition to the greater safety associated with
newer anesthetic systems, topical and topical/intracameral methods avoid the need for
patching and allow the patient the use of the eye immediately following surgery in the
overwhelming majority of cases. Advantages, therefore, include safety, improved
cosmesis, ability to use the eye immediately following surgery, and the ability to move
and fixate the eye during surgery in response to the surgeon as an aid to the procedure
(Table 30.2).
TABLE 30.1 Risk of injection anesthesia

Damage to optic nerve
Retrobulbar hemorrhage
Ocular penetration/perforation
445
Central nervous system anesthesia

Apnea
Unintended bilateral ocular anesthesia
Damage to extraocular muscles/diplopia
Aesthetic blemish
TABLE 30.2 Advantages of topical/intracameral

anesthesia
Avoids pain, blemish and risk of injection anesthesia
Allows immediate useful vision after surgery
Eliminates need for patch after surgery
Reduces anxiety and/or heavy sedation associated with injection anesthesia
Compatible for patients on anticoagulants
Patients can aid surgeon by moving eye for favorable exposure
TABLE 30.3 Contraindications to

topical/intracameral anesthesia
Relative
Language barrier
Anticipated difficult surgery
Poorly cooperative patient
Absolute
Total deafness
Coarse nystagmus
Varying with the experience of the surgeon, certain conditions may contraindicate the use
of topical/intracameral anesthesia (Table 30.3). Given the ability to move the eye, the
patient can aid in the surgery or create significant obstacles, cataract surgery under
topical/intracameral anesthesia is, by necessity, interactive. Poor patient cooperation is a
relative contraindication, as is the inability of the surgeon and patient to adequately
communicate in the same language. Often, an interpreter or bilingual family member can
be present in the operating theater in order to facilitate surgery without need for injection
anesthesia. However, absolute congenital deafness with speaking difficulty is an absolute
contraindication, since the patient may become disoriented under the surgical drapes and
cannot be expected to communicate by the usual means of lip reading or sign language,
patients of this nature often require general anesthesia. Ocular conditions may also act as
relative or absolute contraindications, cataracts too dense to allow fixation on the
microscope light, potentially complicated surgery (preoperative zonulysis, etc.), and
nystagmus are common examples. Nevertheless, the huge majority of patients may safely
experience small incision cataract surgery under topical/intracameral anesthetic with very
limited sedation.
Phacoemulsification
444
Methods
The author prefers the use of lidocaine HCl 4.0 percent nonpreserved for topical
anesthetic. It is long acting and nonmucogenic (previous experience with 0.75%
bupivacaine HCl suggests that it causes undesired mucus production.) Intracameral
anesthesia is achieved with unpreserved lidocaine HCl 1.0 percent. Some surgeons
advocate diluting the intracameral agent with balanced salt solution (BSS) solution in
order to raise the pH and reduce the mild discomfort associated with anterior chamber
instillation.
1. Administer topical proparacaine HCl 0.4 percent to initiate anesthesia with little sting.
Administer dilating agents (cyclopentylate or tropicamide and phenylephrine 2.5%),
topical antibiotics, a topical non-steroidal anti-inflammatory drug (NSAID), and
lidocaine HCl 4.0 percent four times at five minute intervals prior to surgery.
2. After the patient is brought into the theater, several drops of the 4.0 percent lidocaine
are administered prior to the sterile prep. The latter begins with instillation of two
drops of half strength Betadine solution (not Betadine scrub) directly to the operative
eye. At this time, very small amounts of intravenous sedation may be given,
depending upon the mental and medical status of the patient, the anxiety of the
surgeon, and the observations of the anesthetist or equivalent. The author generally
asks that 0.5 mg to 1.0 mg of midazolam HCl be administered IV.
3. During the draping process communicate with the patient about the operative process.
Tell them that they will feel slight pressure from the lid speculum and that they will
need to fixate on the light of the microscope. Tell them that requests to look up, down,
etc. should be achieved by moving the eye and not the head. Reassure them that they
will feel no pain.
4. Begin surgery with the microscope light at low levels of illumination, sufficient only to
perform a paracentesis. Place 0.2 cc of nonpreserved lidocaine HCl in the anterior
chamber and follow that with the viscoelastic of choice. The anesthetic will be washed
out as the viscoagent fills the chamber if the lip of the sideport is depressed as the
viscoelastic is injected. Slowly increase the microscope light and perform the clear
corneal incision. Continue with routine surgical procedure.
5. Generally, no further anesthesia is necessary. However, in situations with prolonged
surgery or very sensitive patients, additional intracameral anesthetic may be
administered for complaints of pressure or intraocular pain. For surface discomfort,
the conjunctiva may be swabbed with a pledget of any sterile topical anesthetic, but
care should be taken to avoid placing the agent near or in the incision if it contains
preservatives. Additionally, small increments of intravenous sedation can be added as
may be (rarely) necessary.
6. In the very unlikely case that the patient cannot tolerate the microscope light even at
low illumination and continues to squeeze the lids against the speculum, additional
doses of IV medicine could be given until the intracameral anesthetic is administered.
In authors observations, once the eye has received the intracameral agent, all lid
squeezing and signs of anxiety or discomfort abate rapidly. However, in extreme
situations or should an operative complication occur that will significantly prolong
447
surgery, one can stop surgery, given a self-sealing incision, pressurize the eye to
normal, and administer deep sub-Tenons local anesthetic with a blunt cannula (Fig.
30.1) through a conjunctival buttonhole entry in the superior or inferior nasal
quadrant.
Prior to incising the conjunctiva, a pledget of local anesthesia may be placed on the area
for a few moments. The cannula should reach the retrobulbar space with ease if the
buttonhole opening includes Tenons capsule. Only 2.0 cc of local agent is necessary,
given direct access to the muscle cone. Relative amaurosis will be achieved in a matter of
seconds, and, with strong local agents, akinesia can be established in a few minutes.
References
1. Learning DV: Practice styles and preferences of ASCRS members: 1996 survey. J Cataract
Refract Surg 23:52735, 1997.
2. Cionni R, Osher R: Retrobulbar hemorrhage. Ophthalmology 98:115355, 1991.
3. Duker JS, Belmont JB, Benson WE et al: Inadvertent globe perforation during retrobulbar and
peribulbar anesthesia. Ophthalmology 98:51926, 1997.
4. Hay A, Flynn HW Jr, Hoffman JI et al: Needle penetration of the globe during retrobulbar and
peribulbar injections. Ophthalmology 98:101724, 1991.
5. Grizzard WS, Kirk NM, Pavan PR et al: Perforating ocular injuries caused by anesthesia
personnel. Ophthalmology 98: 101116, 1991.
6. Masket S, Tennen DG: Astigmatic stabilization of 3.0 mm temporal clear corneal cataract
incisions. J Cataract Refract Surg 22(10):145155, 1996.
7. Fichman RA, Fine IH, Grabow HR: Clear-corneal Cataract Surgery and Topical Anesthesia
Thorofare: Slack Inc. 1993.
9. Koch PS: Anterior chamber irrigation with unpreserved lidocaine 1% for anesthesia during
10. Masket S, Gokmen F: Efficacy and apparent safety of intracameral lidocaine as a supplement to
topical anesthesia. J Cataract Refract Surg 1998 (in print).
11. Stevens JD: A new local anaesthesia technique for cataract extraction by one quadrant subTenons infiltration. Br J Ophthalmol 76:670, 1992.
12. Greenbaum S Anesthesia in cataract surgery. In Greenbaum S (Ed): Ocular Anesthesia,
Philadelphia: WB Saunders, 155, 1997.
13. Fukasaku H, Marron JA: Pin-point anesthesiaa new approach to local ocular anesthesia. J
Section VI
Phakonit
31. Phakonit
32. Microphaco: Concerns and Opportunities
33. Ultrasmall Incision Bimanual Phaco Surgery and Foldable IOL
34. Corneal Topography in Phakonit with a 5 mm Optic Rollable IOL
35. Phakonit with the Acritec IOL
31
Phakonit
Amar Agarwal
History
On August 15th 1998 the authors (Amar Agarwal) performed the first 1 mm cataract
surgery by a technique called Phakonit.1,2 Since Charles Kelman started phacoemulsif
ication, various new modalities have developed which have made this technique more
refined. One problem still persists which is the size of the incision. The normal size of the
incision is 3.2 mm. With time and more advances in phaco machines and phaco tips this
reduced to 2.8 mm and then to 2.6 mm. The authors (Amar Agarwal) performed this
technique for the first time in the world on August 15th 1998. It was performed without
any anesthesia. No anesthetic drops were instilled in the eye nor was any anesthetic given
intracamerally. The first live surgery in the world of Phakonit was performed on August
22nd 1998 at Pune, India by the authors (Amar Agarwal) at the Phako and Refractive
surgery conference. This was done in front of 350 ophthalmologists.1,2 In 1999 a live
surgery of Phakonit under no anesthesia was telecast live via satellite from India by the
authors to Scattle USA to the ASCRS 99 conference.
The problem with this technique was to find an IOL, which would pass through such a
small incision. Then on October 2nd 2001 the authors (Amar Agarwal) did the first case
of a Phakonit Reliable IOL. This was done in their Chennai (India) hospital. The lens
used was a special lens from Thinoptx. This was a Reliable IOL, which was implanted
after a Phakonit procedure, and as it was a rolled IOL it was called the Thinoptx Rollable
IOL. This lens uses the Fresnel principle and was designed by Wayne Callahan (USA). It
is manufactured by the company Thinoptx. The first Rollable IOL was implanted by
Jaino Hoyos (Spain). The authors (Am A) modified the lens to a 5 mm optic to make it
pass through a smaller incision. The lens goes through a sub 1.5 mm incision.
Principle
The problem in phacoemulsification is that we are not able to go below an incision of 3
mm. The reason is because of the infusion sleeve. The infusion sleeve takes up a lot of
space. The titanium tip of the phaco handpiece has a diameter of 0.9 mm. This is
surrounded by the infusion sleeve which allows fluid to pass into the eye. It also cools the
handpiece tip so that a corneal burn does not occur.3
The authors separated the phaco tip from the infusion sleeve. In other words, the
infusion sleeve was taken out. The tip was passed inside the eye and as there was no
Phakonit
451
infusion sleeve present the size of the incision was 1.2 mm. In the left hand an irrigating
chopper was held which had fluid passing inside the eye. The left hand was in the same
position where the chopper is normally held; i.e.; the side port incision. The assistant
injects fluid (BSS) continuously at the site of the incision to cool the phaco tip. Dr DP
Prakash (India) used a 0.8 mm phaco needle with a 21 gauge irrigating chopper and
demonstrated through a digital caliper the incision in this case would be a sub 1 mm
incision.
Terminology
The name PHAKONIT has been given because it shows phaco (PHAKO) being done
with a needle (N) opening via an incision (I) and with the phako tip (T). It is also because
it is phaco with a Needle Incision Technology.
Synonyms
1. Bimanual phaco
2. Micro phaco
3. Micro incision cataract surgery.
Technique of Phakonit for Cataracts

Anesthesia
All the cases done by the authors have been done without any anesthesia. But the
technique of Phakonit can be done under any type of anesthesia also. In the cases done by
the authors no anesthetic drops were instilled in the eye nor was any intracameral
anesthetic injected inside the eye. The authors have analyzed that there is no difference
between topical anesthesia cataract surgery and No anesthesia cataract surgery. They
have stopped using anesthetic drops totally in all their hospitals.
Incision
In the first step a needle with viscoelastic is taken and pierced in the eye in the area where
the side port has to be made. Then a special knife to create an incision is made (Fig.
31.1). The viscoelastic is then injected inside the eye. This will distend the eye so that the
clear corneal incision can be made. Now a temporal clear corneal incision is made. The
problem here is that the diamond knives are all 2.6 mm or larger. Since our aim is to
make only a 1.2 mm opening these diamond knives are not sufficient. So a special blade
is used (Fig. 31.2). This creates an opening of 1.2 mm. When this incision is made it
should be done in such a fashion that a clear corneal valve is made. The authors have
devised a keratome of 1.2 mm which they now use. This keratome creates a good valve.
Phacoemulsification
450
This keratome and other instruments for Phakonit are made by Microsurgical Technology
(USA) and Gueder (Germany).
FIGURE 31.1 A 26 gauge needle with

viscoelastic making an entry in the
area where the side port is. This is for
entry of the irrigating chopper
FIGURE 31.2 Clear corneal incision

made with the keratome (1.2 mm).
Note the left hand has a straight rod to
stabilize the eye as the case is done
without any anesthesia. These
instruments are made by Microsurgical
Technology (USA) and Gueder
(Germany)
Phakonit
453
Rhexis
The rhexis is then performed. This is done with a needle (Fig. 31.3). In the left hand a
straight rod is held to stabilize the eye. The advantage of this is that the movements of the
eye can get controlled as one is working without any anesthesia.
Hydrodissection
Hydrodissection is performed and the fluid wave passing under the nucleus checked.
Check for rotation of the nucleus.
FIGURE 31.3 Rhexis started with a

needle
Phakonit
After enlarging the side port a 20 gauge irrigating chopper connected to the infusion line
of the phaco machine is introduced with foot pedal on position 1. The phaco probe is
connected to the aspiration line and the phaco tip without an infusion sleeve is introduced
through the incision (Fig. 31.4). Using the phaco tip with moderate ultrasound power, the
center of the nucleus is directly embedded starting from the superior edge of rhexis with
the phaco probe directed obliquely downwards towards the vitreous. The settings at this
stage is 50 percent phaco power, flow rate 24 ml/min and 110 mmHg vacuum. When
nearly half of the center of nucleus is embedded, the foot pedal is moved to position 2 as
it helps to hold the nucleus due to vacuum rise. To avoid undue pressure on the posterior
capsule the nucleus is lifted a bit and with the irrigating chopper in the left hand the
nucleus chopped. This is done with a straight downward motion from the inner edge of
the rhexis to the center of the nucleus and then to the left in the form of an inverted L
shape (Fig. 31.5). Once the crack is created, the nucleus is split till the center. The
nucleus is then rotated 180 and cracked again so that the nucleus is completely split into
two halves.
Phacoemulsification
452
The nucleus is then rotated 90 and embedding done in one-half of the nucleus with
the probe directed horizontally (Fig. 31.6). With the previously described technique, 3
pie-shaped quadrants are
FIGURE 31.4 Phakonit irrigating

chopper and phako probe without the
sleeve inside the eye
FIGURE 31.5 Phakonit started. Note

the phako needle in the right hand and
an irrigating chopper in the left hand.
Phakonit being performed. Note the
crack created by karate chopping. The
assistant continuously irrigates the
phaco probe area from outside to
prevent corneal burns
Phakonit
455
FIGURE 31.6 Phakonit continued.

The nuclear pieces are chopped into
smaller pie-shaped fragments
created in one-half of the nucleus. Similarly 3 pie-shaped fragments are created in the
other half of the nucleus. With a short burst of energy at pulse mode, each pie-shaped
fragment is lifted and brought at the level of iris where it is further emulsified and
aspirated sequentially in pulse mode. Thus the whole nucleus is removed (Fig. 31.7).
Note in Figure 31.7 no corneal burns are present. Cortical wash-up is to be done with the
bimanual irrigation aspiration technique (Figs 31.8 and 31.9). Many doctors like Jorge
Alio (Spain), Richard Packard (UK), F Vejanaro (Columbia), Randall Olson (USA) have
devised their own instruments for Phakonit.
FIGURE 31.7 Phakonit completed.

Note the nucleus has been removed
and there are no corneal burns
Phacoemulsification
454
FIGURE 31.8 Bimanual irrigation

aspiration started

aspiration completed
FIGURE 31.10 Anti-chamber

collapser (air pump) in phakonit
Phakonit
457
Anti-chamber Collapser
One of the real bugbears in Phakonit when we started it was about the problem of
destabilization of the anterior chamber during surgery. This was solved to a certain extent
by using an 18 gauge irrigating chopper. A development made by us (SA) was to use an
anti-chamber collapser4,5 which injects air into the infusion bottle (Fig. 31.10). This
pushes in more fluid into the eye through the irrigating chopper and also prevents surge.
Thus we were not only able to use a 20 gauge on 21 gauge irrigating chopper but also
solve the problem of destabilization of the anterior chamber during surgery. This
increases the steady-state pressure of the eye making the anterior chamber deep and well
maintained during the entire procedure. It even makes phacoemulsification a relatively
safe procedure by reducing surge even at high vacuum levels. Thus this can be used not
only in Phakonit but also in Phacoemulsification.
Surge
When an occluded fragment is held by high vacuum and then abruptly aspirated, fluid
rushes into the phaco tip to equilibrate the built up vacuum in the aspiration line, causing
surge. This leads to shallowing or collapse of the anterior chamber. Different machines
employ a variety of methods to combat surge. These include usage of noncomplaint
tubing,4 small bore aspiration line tubing,4 microflow tips,4 aspiration bypass systems,4
dual linear foot pedal control4 and incorporation of sophisticated microprocessors4 to
sense the anterior chamber pressure fluctuations.
The surgeon dependent variables to counteract surge include good wound construction
with minimal leakage5 and selection of appropriate machine parameters depending on the
stage of the surgery.5 An anterior chamber maintainer has also been described in
literature to prevent surge, but an extra side port makes it an inconvenient procedure.
Another method to solve surge is to use more of phacoaspiration and chop the nucleus
into smaller pieces.
Technique
A balanced salt solution (BSS) bottle is used (Fig. 31.10). The bottle is kept at a height of
about 65 centimeters above the operating field. The automated air pump, which is similar
to the pump used in fish tanks to supply oxygen to the fish, is utilized to forcefully pump
air into the irrigation bottle at a continuous rate. The air pump is connected to the BSS
bottles through an IV set. A millipore air filter is used between the air pump and the
infusion bottle so that the air pumped into the bottle is sterile. Sterile air is pumped into
the infusion bottle, pressurizing it to force fluid into the anterior chamber, thereby
neutralizing surge and maintaining a deep anterior chamber through out the procedure.
Discussion
Surge is defined as the volume of the fluid forced out of the eye into the aspiration line at
the instant of occlusion break. When the phacoemulsification handpiece tip is occluded,
flow is interrupted and vacuum builds up to its preset values. Additionally the aspiration
Phacoemulsification
456
tubing may collapse in the presence of high vacuum levels. Emulsification of the
occluding fragment clears the block and the fluid rushes into the aspiration line to
neutralize the pressure difference created between the positive pressure in the anterior
chamber and the negative pressure in the aspiration tubing. In addition, if the aspiration
line tubing is not reinforced to prevent collapse (tubing compliance), the tubing,
constricted during occlusion, then expands on occlusion break. These factors cause a rush
of fluid from the anterior chamber into the phaco probe. The fluid in the anterior chamber
is not replaced rapidly enough to prevent shallowing of the anterior chamber.
The maintenance of intraocular pressure (steady-state IOP) during the entire procedure
depends on the equilibrium between the fluid inflow and outflow. In most
phacoemulsification machines, fluid inflow is provided by gravitational flow of the fluid
from the balanced salt solution (BSS) bottle through the tubing to the anterior chamber.
This is determined by the bottle height relative to the patients eye, the diameter of the
tubing and most importantly by the outflow of fluid from the eye through the aspiration
tube and leakage from the wounds.
The inflow volume can be increased by either increasing the bottle height or by
enlarging the diameter of the inflow tube. The intraocular pressure increases by 10
mmHg for every 15 centimeters increase in bottle height above the eye.5 High steadystate IOPs increase phaco safety by raising the mean IOP level up and away from zero,
i.e. by delaying surge related anterior chamber collapse. Air pump increases the amount
of fluid inflow thus making the steady-state IOP high. This deepens the anterior chamber,
increasing the surgical space available for maneuvering and thus prevents complications
like posterior capsular tears and corneal endothelial damage. The phenomenon of surge is
neutralized by rapid inflow of fluid at the time of occlusion break. The recovery to
steady-state IOP is so prompt that no surge occurs and this enables the surgeon to remain
in foot position 3 through the occlusion break. High vacuum phacoemulsification can be
safely performed in hard brown cataracts using an air pump. Phacoemulsification under
topical or no anesthesia6 can be safely done neutralizing the positive vitreous pressure
occurring due to squeezing of the eyelids.
Thinoptx Reliable IOL
Thinoptx the company that manufactures these lenses has patented technology that allows
the manufacture of lenses with plus or minus 30 dioptres of correction on the thickness of
100 microns. The Thinoptx technology developed by Wayne Callahan, Scott Callahan
and Joe Callahan is not limited to material choice, but is achieved instead of an
evolutionary optic and unprecedented nano-scale manufacturing process. The lens is
made from off-the-shelf hydrophilic material, which is similar to several IOL materials
already on the market. The key to the Thinoptx lens is the optic design and nanoprecision manufacturing. The basic advantage of this lens is that they are Ultra-Thin
lenses. Thinoptx has made a special lens for Phakonit which has a 5 mm optic.
Phakonit
459
Lens Insertion Technique

The lens is taken out from the bottle. The lens is then held with a forceps (Fig. 31.11).
The lens is then placed in a bowl of BSS solution that is approximately body temperature.
This makes the lens pliable. Once the lens is pliable it is taken with the gloved hand
holding it between the index finger and the thumb. The lens is then rolled in a rubbing
motion. It is preferable to do this in the bowl of BSS so that the lens remains rolled well.
FIGURE 31.11 The phakonit thinoptx

reliable IOL when removed from the
bottle
FIGURE 31.12 The reliable IOL

inserted through the incision
Phacoemulsification
458
FIGURE 31.13 The reliable IOL in

the capsular bag
The lens is then inserted through the incision carefully (Fig. 31.12). One can then move
the lens into the capsular bag (Fig. 31.13). The natural warmth of the eye causes the lens
to open gradually. Viscoelastic is then removed with the Bimanual irrigation aspiration
probes (Fig. 31.14). The tips of the footplates are extremely thin which allow the lens to
be positioned with the footplates rolled to fit the eye.
FIGURE 31.14 Viscoelastic removed

using bimanual irrigation aspiration
probes
Roller
Thinoptx have devised a special injector to implant the Reliable IOL after Phakonit. The
advantage of this roller is that it not only rolls the lens but also inserts the lens inside the
eye.
Phakonit
461
Topography
We also perfomed topography with the orbscan to compare cases of phakonit and phaco
and we found that the astigmatism in phakonit cases is much less compared to phaco
(Figs 31.15 to 31.18). Stabilization of refraction is also faster with Phakonit compared to
phaco surgery.
Laser Phakonit
Laser Phakonit uses laser energy (coupled with ultrasound energy in hard nuclei) to
remove the nucleus. This technique was started first time in the world by the authors
(Sunita Agarwal). The laser machine used is the Paradigm Laser Photon. In these cases,
two ports are used. One port has fluid (BSS) flowing through an irrigating chopper of 20
gauge and in the other hand is the phaco probe without a sleeve. In the center of the
phaco probe is passed the laser probe. The diameter of the phaco probe is 900 microns.
The laser probe reduces the orifice opening to 550 microns. Thus the nucleus can be
removed through a very small opening.
FIGURE 31.15 Phako foldable and

phakonit thinoptx IOL. The figure on
the left shows a case of phako with a
foldable IOL and the figure on the
right shows phakonit with a thinoptx
reliable IOL
Phacoemulsification
460
FIGURE 31.16 Phako foldable IOL

orbscan results. The figure on the left
is the preoperative orbscan. The figure
on the right is the one day
postoperative orbscan. Note the
difference between the two orbscan
pictures. This is the site where the
clear corneal temporal incision was
made
Three-Port Phakonit
Another technique by which one can perform Phakonit is to use an anterior chamber
maintainer. The authors started this technique. They call it three-port phakonit. Just as a
three port vitrectomy, here also we have three ports, hence the name- Three-Port
Phakonit.
There are pros and cons in every technique. The problem in three-port phakectomy is
that it is too
Phakonit
463
FIGURE 31.17 Phakonit thinoptx

reliable IOL orbscan results. The
figure on the left is the preoperative
orbscan. The figure on the right is the
one day postoperative orbscan. Note
the similarity between the two orbscan
pictures. This shows the minimal
astigmatism created even on one day
postoperative
FIGURE 31.18 Phakonit thinoptx

reliable IOL orbscan results. The
Phacoemulsification
462
figure on the left is the preoperative

orbscan. The figure on the right is the
one day postoperative orbscan. Note
the similarity between the two orbscan
pictures. This shows no astigmatism
created even on one day postoperative.
Do note the astigmatism preoperative
is 0.8 d and postoperative on day one
is 0.7 d
cumbersome. Surgeons prefer to have two ports only. Some surgeons prefer three ports as
an anterior chamber maintainer is present in the eye and thus the anterior chamber is
always formed. At present it is easier to perform Phakonit using a 20 gauge irrigating
chopper with the anti-chamber collapser.
AC Stability in Phakonit
One of the real bugbears in Phakonit when we started it was about the problem of
destabilization of the anterior chamber during surgery.15 This was solved to a certain
extent by using an 18 gauge irrigating chopper. Another solution would be to raise the
bottle to the roof which is not very practical. The main problem in Phakonit was that the
amount of fluid entering the eye through the irrigating chopper was not equal to the
amount of fluid exiting the eye through the sleeveless phaco needle. With better methods
as discussed below on AC stability one can use a 21 gauge irrigating chopper.
Solution
Different surgeons have tried different methods to solve this problem of anterior chamber
stability. The various methods are1. Air pump or Anti-chamber collapser
2. Anterior Vented Gas Forced Infusion System (VGFI) of the Accurus Surgical System
3. STAAR Surgicals disposable Cruise Control device
4. Well designed irrigating choppers from Duet (Microsurgical Technology).
The anterior vented gas forced infusion system (AVGFI) of the Accurus Surgical System
in the performance of phakonit
This was started by Arturo Prez-Arteaga from Mexico. The AVGFI is a system
incorporated in the Accurus machine that creates a positive infusion pressure inside the
eye; it was designed by the Alcon engineers to control the intraocular pressure (IOP)
during the anterior and posterior segment surgery. It consist of an air pump and a
regulator who are inside the machine; then the air is pushed inside the bottle of
intraocular solution, and so the fluid is actively pushed inside the eye without raising or
lowering the bottle. The control of the air pump is digitally integrated in the Accurus
Phakonit
465
panel; it also can be controlled via the remote. Also the footswitch can be preset with the
minimal and maximum of desired fluid inside the eye and go directly to this value with
the simple touch of the footswitch. Arturo Prez-Arteaga recommends to preset the
infusion pump at 100 to 110 cm H2O; it is enough strong irrigation force to perform a
microincision phaco. This parameter is preset in the panel and also as the minimal
irrigation force in the footswitch; then he recommends to preset the maximum irrigation
force at 130 to 140 cm H2O in the foot pedal, so if a surge exist during the procedure the
surgeon can increase the irrigation force by the simple touch of the footswitch to the
right. With the AVGFI the surgeon has the capability to increase even more these values.
Cruise Control
The Cruise Control is a disposable, flow-restricting (0.3-mm internal diameter) device
that is placed in between the phaco handpiece and the aspiration tubing of any phaco
machine. The goal is very similar to that of the flare tip (Alcon): combining a standard
phaco tip opening with a narrower shaft to provide more grip with less surge. This has
been popularized by David Chang (USA) for phakonit surgery. STAAR Surgical
introduced this disposable Cruise Control device, which can be used with any phaco
machine.
FIGURE 31.19 Phakonit knives. The

one on the left is the Agarwal sapphire
phakonit knife made by Huco
(Switzerland). The one on the right is
the one made by Microsurgical
Technology
Phacoemulsification
464
FIGURE 31.20 Duet system. These

are the handles of the Duet system
(Microsurgical Technology). The
irrigating choppers and bimanual
irrigation aspiration sets can be
interchanged with the handles
FIGURE 31.21 Two designs of

irrigating choppers. The one on the left
has a larger opening for fluid so that
AC stability is more. This has been
designed by Larry Laks (Microsurgical
Technology). The one on the right has
two openings on the sides (Gueder
Germany)
Duet System
Larry Laks (USA) created the Duet system (Micro-surgical Technology-MST). The
advantage of this was a whole bimanual phaco set for Phakonit. The Duet system has
Phakonit
467
phakonit knives also (Fig. 31.19) and also handles on which various irrigating choppers
can fit (Fig. 31.20). The Microsurgical Technologies (MST) 20 gauge Duet irrigating
choppers provide the best inflow of comparable

made with the microsurgical
technology knife
FIGURE 31.23 Phakonit being done

with the Agarwal sharp irrigating
chopper from Microsurgical
Technology
devices. The MST shaft design gives an impressive inflow rate of 40 cc/min at 30 in of
bottle height and is available with an assortment of interchangeable chopper tips. This
whole design was created by Larry Laks. The idea was to have the opening in the
irrigating choppers larger (Fig. 31.21). The clear corneal incision can be created with the
Phacoemulsification
466
MST knife (Fig. 31.22) and then Phakonit started using the Agarwal sharp MST
irrigating chopper (Fig. 31.23).

aspiration started using the Duet
system (MST)

Phakonit
469
TABLE 31.1 The differences between phako and

phakonit
FEATURE
COAXIAL PHAKO
INCISION SIZE
AIRPUMP
HAND USAGE
>3 MM
NON MANDATORY
SINGLE HANDED
PHAKO POSSIBLE
NON DOMINANT HAND LAST TO ENTER &
ENTRY & EXIT
FIRST TO EXIT
CAPSULORHEXIS
NEEDLE OR FORCEPS
IOL
FOLDABLE IOL
ASTIGMATISM
TWO UNEQUAL
INCISION CREATE
ASTIGMATISM
STABILITY OF
LATER THAN
REFRACTION
PHAKONIT
BIMANUAL PHAKO
(PHAKONIT)
SUB 1.4 MM
MANDATORY
TWO HANDS (BIMANUAL)
FIRST TO ENTER & LAST TO
EXIT
BETTER WITH NEEDLE
ROLLABLE IOL
TWO EQUAL ULTRA SMALL
INCISIONS NEGATE THE
INDUCED ASTIGMATISM
EARLIER THAN PHAKO
Once Phakonit is completed the Bimanual Irrigation aspiration set from the Duet system
is used (Fig. 31.24) and the cortical aspiration completed (Fig. 31.25).
Summary
There are various problems, which are encountered, in any new technique and so also
with Phakonit. With time these will have to be solved. The differences between phako
and phakonit are shown in Table 31.1. The important point is that today we have broken
the 1 mm barrier for cataract removals. This can be done easily by separating the phaco
needle from the infusion sleeve. As the saying goes
We have miles to go before we can sleep.
References
1. Agarwal S, Agarwal A, Sachdev MS et al: Phacoemulsification, Laser Cataract Surgery and
Foldable IOLs (2nd ed). Jaypee Brothers: Delhi, 2000.
2. Boyd BF, Agarwal S, Agarwal A et al: Lasik and Beyond Lasik; Highlights of Ophthalmology;
2000, Panama.
3. Ronge LJ: Clinical Update; Five Ways to avoid Phaco Burns; February 1999.
4. Fishkind WJ: The Phaco Machine: How and why it acts and reacts? In: Agarwals Four volume
Textbook of Ophthalmology. Jaypee Brothers: New Delhi, 2000.
5. Seibel SB: The fluidics and physics of phaco. In: Agarwals et al: Phacoemulsification, Laser
Cataract Surgery and Foldable IOLs (2nd ed). Jaypee Brothers: New Delhi; 4554, 2000.
6. Agarwal et al: No anesthesia cataract surgery with karate chop. In: Agarwals
Phacoemulsification, Laser Cataract Surgery and Foldable IOLs (2nd ed). Jaypee Brothers:
New Delhi, 21726, 2000.
32
Microphaco: Concerns and Opportunities
Randall J Olson
Introduction
Microphaco is a concept I define as completing cataract surgery through two stab
incisions of 1.5 mm or less in size. True, microphaco in my mind however, is two stab
incisions of no more than 1.0 mm. Microphaco can have as its energy source ultrasound,
laser or sonic energy. While certainly not a new subject, removing soft lenses such as in
pediatric cases through two stab incisions has a very long track record; it is just recently
that there has been interest and enthusiasm in this approach. With the predominant power
source for cataract removal being ultrasound, the concern about wound burn has been
substantial and that has been one of the major sources for emphasis on laser or sonic
energy to try to remove a cataract by microphaco.
The obvious first question one must ask prior to considering microphaco is the big
one, why do we need to consider a change? Certainly our present cataract surgery
through 2.5 to 3.0 mm incisions is well entrenched with great success and excellent
postoperative results. Astigmatism change is minimal and the wounds are required to
insert the present intraocular lenses. Simply removing a cataract through a smaller
incision for no obvious net gain makes no sense. Progress is only progress if, indeed,
doing something new adds to either the safety or the quality of our results.
In the past I felt that microphaco was unlikely to be advantageous; however, a series
of issues have convinced me that this is a subject worthy of serious consideration. It is
certainly obvious in very complicated cases where there have been an expulsive choroidal
hemorrhage, that the smallness of the incision would be protective for the eye. In the
present day, where we maintain positive pressure for most of the procedure, such
complications are exceedingly rare and that in and of itself would not be reason enough
to make a change. A second advantage, however, has to do with the ease of switching
from one wound to the other in regard to using our aspiration (phaco) needle. Certainly
complicated cases, either preoperatively complicated or complicated by the surgery, may
result in difficulty completing the procedure safely due to the position of the
complication. If our safe zone is right in the middle of our complicated area then
switching the aspiration needle to the opposite wound produces an entirely new safe
zone. This certainly has been understood as an advantage in regard to
irrigation/aspiration. In present phacoemulsification techniques there are those who put in
two stab incisions so they can do bimanual irrigation/ aspiration such that they can switch
wounds and obviate any subincisional cortex problem and at the same time use the two
instruments to manipulate removal of the cortex in a way that is simpler and safer than
the standard coaxial approach. For me this was still not enough reason for me to want to
proceed on this venture.
The main reason I moved into microphaco was the realization of what a problem
irrigation is presently for us in traditional phacoemulsification. We have wrapped
irrigation around our phaco aspiration needle to make sure that we have a cooling source
Microphaco: Concerns and opportunities
471
to avoid wound burn and to have plenty of irrigation to maintain the chamber. Certainly
this has been very good in the prevention of wound burn, which is a very uncommon
event, and also does a good job of maintaining the chamber. Irrigation surrounding
aspiration has necessitated wounds of at least 2.5 mm and it is unlikely, due to the law of
diminishing returns that we can go much smaller than that as long as we maintain a
coaxial approach to our irrigation and aspiration. The problem is irrigation maintains our
chamber but otherwise is not a positive force. Let me explain.
First of all some of the irrigation as it flows around the phaco needle is immediately
aspirated and therefore does no practical work. This is very similar to an arterial-venous
shunt in which the blood does nothing for the tissue just as shunted irrigant does nothing
for our cataract surgery. Also, we have more flow than we need creating increased
turbulence, which can be seen as lens fragments spinning and bouncing. Air bubbles and
lens particles can damage the endothelium by this turbulence.
Furthermore, irrigation pushes nuclear fragments away right when we want to have the
particles come to our phaco tip. This is quite apparent, clinically, as you watch nuclear
fragments being buffeted and even pushed away by irrigation until you can finally move
the phaco tip and find that aspiration vortex that sucks the particle back in. Larger
fragments are often, besides being repulsed by the ultrasound, also pushed away by
irrigation and all of this creates inefficiency. The other factor about irrigation is that when
it is separated from irrigation it can be a positive force. You can use it to open the fornix
so free nuclear fragments automatically flow to our phaco because this is the only exit if
our wounds are tight. All of these irrigation advantages combined, if appropriately
utilized in our microphaco technique, should significantly decrease the amount of fluid
necessary and improve our efficiency and safety. These reasons in combination were the
major impetus for me wanting to move forward in microphaco.
Prior to feeling comfortable with microphaco, it was critical to go to the lab to feel
safe about this approach. My standard phacoemulsification technique being phaco chop
has been ultrasound-assisted aspiration. Therefore to prove that microphaco was safe we,
in a series of eye bank eyes, mounted a thermister right in the wound for continuous
temperature monitoring.
With continuous ultrasound we determine how long it would take to create a wound
burn. Indeed, 100 percent power with aspiration and irrigation separated created wound
burn; however, it took several minutes and is only a minor concern. Our next phase,
which was clamping the aspiration line, certainly increased the problem, however, it still
occurred at 80 percent power and it took approximately one minute of continual power.
Interestingly, when we did a pulse mode at 50 milliseconds (6 per second), we actually
found less time was necessary in creating wound burn showing that just decreasing the
energy alone may not be the answer. We still have not figured out exactly why this result
(which was consistent with several eyes) occurred, but think it may be some type of
harmonics which induces greater tissue energy buildup and a burn.1
These results left us cautiously optimistic that microphaco was safe if you used
minimal amounts of ultrasound. Our original wounds were quite leaky and we recognize
the room for error is even less trying to produce tight wounds. We cautiously started with
microphaco and it was only when we realized that White Star (a new Allergan
technology) could potentially diminish the risk of wound burn that we decided to
Phacoemulsification
470
duplicate our experiments using White Star with a duty cycle of one-third on and twothirds off.
White Star is a technology in which the ultrasound vibration can be turned off and on
at levels of a millisecond or less. Previously such fine control had never been available,
and therefore, there is an infinite number of modalities that can be used. Largely, an off
cycle with very brief on cycles (about 20% on) enhances our ability to hold onto nuclear
fragments and to remove them without chatter. It was also found that sculpting could be
enhanced by this (usually 50% on and 50% off) with less energy utilized. Clearly,
microchatter must occur in that particles are repulsed by ultrasound and then brought
back by aspiration. This resulting in an inefficient use of energy which is obviated with
White Star with very brief pulses of energy such that when the repulsion occurs the
energy is off and energy is back on again when the item is aspirated. With all types of
techniques used by a multitude of surgeons, the total energy utilized has been
substantially less as one side benefit.
With microphaco we were mainly interested in claims of minimal energy heat
transference. By putting a microthermister in the wound we repeated our eye bank studies
and found that with 100 percent energy we never could get the temperature above 28C,
even after three minutes of continual energy! The temperature plateaued and we were
confident that twenty minutes would not have made any difference. The second step was
to block all aspiration that we found previously tremendously increased the risk of wound
burn, and we certainly have found the same thing clinically. Even with aspiration
blocked, the temperature never went above 32C after three minutes of continual energy.
We took this to the final stage in which we eliminated irrigation and just put a bare phaco
needle in the wound. Even in this situation with 100 percent energy it took 29 seconds
before we finally got a temperature elevation in the wound2! This technology is
incredibly forgiving and now we have an ultrasound variant that gives us the flexibility of
ultrasound and the elimination of wound burn risk. White Star ultrasound, therefore,
became our focus for microphaco. This has since been duplicated in a clinical study
where wound temperature averaged 30C.3
We considered laser and sonic energy but were disappointed in the results of others,46
that showed they took longer to remove the cataract and neither modality was particularly
effective in very hard nuclei. Our clinical experience with White Star was that it was
equally efficacious on the hardest of nuclei as regular ultrasound and, therefore, we felt
that we had the best of all worlds with lack of concern about wound burn.
Our clinical work has now proceeded for over one year with multiple issues
discovered. It has been an interesting experience and I think that it would be best for me
to categorize our experiences and concerns with each step of the procedure.
Initial Incisions
Certainly making two stab incisions should be no problem, however, the size of the
incision is particularly important. If the incisions were created too large, the leak is too
great and maintaining the anterior chamber is a big problem (Fig. 32.1). Furthermore,
nuclear fragments come to the wound and not to our phaco needle obviating a major
microphaco advantage. We have moved to 21 gauge technology largely because we
473
found this worked perfectly with our diamond blade, which makes an incision 0.8 mm
wide. This results in a very tight incision but not too small that we cant insert our
instruments. The tightness of the wound helps maintain the anterior chamber and keeps
lens fragments going to the phaco needle. For a
FIGURE 32.1 A large leak around the

irrigating chopper (a rush of fluid can
be seen above the chopper) results in
anterior chamber shallowing and
difficulty completing the procedure
20 gauge, the incision should be 1.0 to 1.1 mm and for 19 gauge between 1.3 and 1.4
mm. We found even 0.1 mm too large can result in difficulty with maintaining the
anterior chamber and let too much flow around the instruments. The incision size is
critical, too small and the wound is torn and tends to leak at the end of the procedure.
Location is also important in that we found we should insert the intraocular lens not
through either incision, which will be discussed later. We kept them, therefore, at least
45 apart and left them between parallel to the iris surface and perpendicular to the eye
and no longer than 1 mm. The length is critical in that the incisions being tight will
oarlock our instruments and if they are too long can make the surgery more difficult.
Also, anything other than almost parallel to the iris surface makes the incisions too long.
Capsulorhexis
Those who perform needle capsulorhexis will find microphaco incisions to be extremely
simple such that a cystotome or bent tip needle works just fine. I prefer using forceps, and
I had a difficult time finding forceps that work through a 21 gauge incision. Most small
microincision forceps were too big. Finally, a 21 gauge forcep, while tight, was
acceptable in completing my needle capsulorhexis
Phacoemulsification
472
FIGURE 32.2 A 23 gauge

capsulorhexis forceps by ASICO
makes work through a 0.8 mm incision
a simple task
incision. A 23 gauge microcapsulorhexis forcep is now available from ASICO that will
easily go through any of these incisions. The tip was originally too sharp and would cut
the capsule easily; however, the latest modification has been a joy to work with (Fig.
32.2). The capsulorhexis should be similar in size and shape to whatever you normally
do. However, I have been making my capsulorhexis smaller to make sure that it overlaps
the edge of the intraocular lens which is optimal for prevention of after-cataract
formation. This means the capsulorhexis should be well-centered and approximately 5
mm in diameter.
Hydrodissection/Delineation
Making sure that the nucleus will rotate is even more critical in microphaco than in
regular phaco. Because the instruments are relatively tightly controlled by the incision, it
is more difficult to manipulate the nucleus, therefore, free rotation is critical. I have found
the Chang cannula where the tip can be impaled in the nucleus extremely helpful in
guaranteeing easy rotation.
The other problem with hydrodissection and hydrodelineation is the smallness of the
incision and making sure there is egress of fluid such that positive pressure is not
produced to the point that the capsule or zonules are broken. Breaking the capsule or
zonules is much easier to do than you might imagine, particularly with very high
viscosity viscoelastics such as Healon 5. I make the fluid burst minimal and short but
rapid. Irrigate as you go in so that there is a fluid egress channel around the cannula.
Anterior Chamber Maintenance
This continues to be a major problem with microphaco. Irrigation through a 21 gauge
cannula requires unimpeded flow in order to maintain the chamber. Wounds that are too
475
large leak too much and a stable chamber is very problematic. Furthermore, the cannula
openings must be as large as possible with a single open end, the best option, which also
best utilizes irrigation as a positive directable force. Unfortunately, it also leaves little
strength on the end to mount a tip for chopping, etc. The second option we have used is
two oval holes as large as possible and as far forward as possible on each side of the
cannula to guarantee adequate flow. The cannula must be very thin walled and utilize a
large hollow handle in which the irrigation line can be directly inserted. Furthermore, I
put the irrigation bottle on an IV pole to raise it as high as possible. Dr. Agarwal has
pressurized the line to try to enhance anterior chamber maintenance. Our experiments
with the bottle at normal height showed large fluctuations in the intraocular pressure up
to 55 mmHg. My concern is that a constantly pressurized line could result in extremely
high pressures that may be dangerous to the optic nerve or could push the lens back if it is
trapped by the iris and causes zonular damage.
The solution to this would be an irrigation line that has positive pressure assistance to
maintain the pressure level at no less than 22 mmHg. I am sure such a pressurized system
will be available soon. Whatever instrument you use, and I have seen many proposed
lately that clearly will not maintain enough flow to maintain the chamber, should be
tested. It is simple to set the bottle at your working height and if you dont have at least
40 ml of fluid flow in one minute at free flow, then reconsider using that instrument!
FIGURE 32.3 Oar-locking by a

tight wound makes use of the irrigating
chopper on the left hemi-nucleus a
difficult task. Nucleus rotation is
critical here
Nucleus Removal
Nucleus removal using White Star with microphaco is no different than any other
techniques you may have used. My preference is vertical or horizontal chop and divide
and conquer works well. There are, however, some notable differences with which you
must become accustomed. The first is already mentioned and that is the oarlocking,
which makes movement of the irrigation instrument and the aspiration needle somewhat
Phacoemulsification
474
more difficult (Fig. 32.3). It is important to use the utility of the two instruments such that
between the two, all areas of the chamber can be covered. Simple irrigation will move
nuclear fragments to the safe zone. The importance of nucleus rotation will become
apparent once you start removing the nucleus.
The second difficulty has to do with the weight of the instrument, which is noticeably
heavier and stiffer due to the irrigation line. It will not feel as manipulable as second
instruments you have used. My experience is this only takes a little time to get used to
and is not a major problem. All of these issues are compounded very much if there is not
good anterior chamber (AC) maintenance, and I am convinced in talking to others that
AC stability is the biggest problem they are running into and not the actual nucleus
removal technique.
Microphaco is tailor-made for vertical chop. In vertical chop it is important to move
the sleeve back as far as possible. One of the first things you will find about microphaco
is that the sleeve mechanically blocks all penetration and that with the absence of the
sleeve your cutting will be much faster and much better. At first this was a little shocking
and I am sure if the surgeon is not careful you could easily penetrate the nucleus
(fortunately, I have not done this in nucleus removal to date). With vertical chop in
microphaco, the phaco needle easily cuts into the nucleus with no sleeve to block it.
Taking an irrigating chopper with a classical approach in the capsular fornix or lodged in
the nucleus can result in loss of flow with AC shallowing. Such is never necessary with
vertical chop in which the irrigating openings are always above the nucleus. I feel
microphaco vertical chop will come to be the superior technique.
Bimanual Irrigation and Aspiration
Having two instruments has already been seen by many as a distinct advantage. The
irrigating instrument and irrigation flow can open the capsular fornix and retract the iris,
making aspiration a snap. Subincisional cortex is removed by switching the two
instruments, which also works in creating a new safe zone should there be a problem
(Figs 32.4A and B).
Cortex removal is two-handed, and again the problem is anterior chamber
maintenance. If you have a 20 gauge incision to start with and then use 21 or 23 gauge
bimanual irrigating/aspirating instruments, you will not maintain the chamber because
your leak is too great. Your irrigation/ aspiration instruments should be the same size as
your original phaco instruments.
Intraocular Lens Insertion
Neoptics has a lens that has been put through a 1.5 mm incision. Other approaches will
take advantage of microphaco-type incisions. At present, however, the majority of
microphaco surgeons are enlarging the wound to insert an intraocular lens. There are
multiple ways to put the lens in; however, I found that making a totally
477
FIGURES 32.4A AND B Switching

the irrigating and aspirating
instruments from the regular position
(A) to an aspiration right position (B)
eliminates the sub-incisional cortex
problem
separate incision for the lens was best in that it was easiest to seal this wound (Fig. 32.5).
This does create some difficulty for final irrigation and aspiration such that you can either
use a typical coaxial system to remove the viscoelastic or, if you want to continue the
bimanual approach, then you must hydrate your intraocular lens wound or you will get
too much leakage from this wound and you will have difficulty in maintaining the
anterior chamber.
Closure of Microphaco Wounds
This has turned out to be a problem in microphaco and, in particular, when I made my
intraocular lens wound centered on one of the two stab incisions. It
Phacoemulsification
476
FIGURE 32.5 If a regular foldable

implant is to be used, I make a separate
incision with a diamond keratome to
facilitate wound closure
turns out that microphaco by putting our instrument through a very small and tight wound
results in stretching of the tissue and they tend to continue to leak. I had great difficulty in
getting these to seal and had to put a suture through several, which occurrence had been
exceedingly rare in the past. It turns out hydration of the edges of the wound does not
effect the original stretching that was in the center of the wound and this was the reason I
encountered difficulty. By making a separate intraocular lens wound and never having
manipulated or stretched it with phacoemulsification steps allowed spontaneous sealing
to occur even more often than usual.
The two stab incisions, however, will not spontaneously seal. I aggressively stromal
hydrate both stab incisions and found that getting a 19 gauge wound to seal was very
difficult while it was much easier with a 21 gauge wound. If it continues to leak, stromal
hydration directly in the center, either posteriorly or anteriorly, may work. Usually
stromal hydration does the trick. If it does not, invariably this is an incision where you
had to work to force the instrument in (usually the irrigating instrument) and therefore
stretched the wound. Understanding this problem is important in instrument development.
An additional approach I have found successful is to make the stab incision on the
edge of the phaco wound so that stromal hydration closes this wound more easily. In
talking to others however, getting the wounds to close is clearly a disadvantage. We will
develop technology to obviate this issue. Making the original incisions large enough so
that you dont have to stretch them is not effective due to the anterior chamber
maintenance problem secondary to the leak. Maintaining positive fluid flow in the face of
some leaking will certainly help the anterior chamber maintenance problem but not the
problem of nuclear particles coming to the wound and not to the phaco tip.
In summary, microphaco is a technique that is evolving and to take advantage of the
newer, smaller intraocular lenses that will be coming soon everyone will have to move to
microphaco. It is slightly more difficult; however with experience, success is achievable.
Twenty-one gauge technology has made it a little slower due to the smallness of the
phaco needle bore; however, 20 gauge technology is just as fast as regular phaco. The
irrigation advantages I have found to be real with basically the same sense of speed using
479
one-third less irrigation. White Star will safely work with the densest cataracts as another
significant advantage.
As this technology evolves not only will it take advantage of the new intraocular
lenses that can go through such small incisions, it may also prove to be safer with the
irrigation advantage, the opportunity to switch wounds and by obviating the need to chase
lens fragments with the ultrasound needle. In the meantime stay tuned to an interesting
and evolving approach to cataract surgery.
References
1. Soscia W, Howard JG, Olson RJ: Bimanual phacoemulsification through two stab incisions: A
wound temperature study. J Cataract Refract Surg 28:103943, 2002.
2. Soscia W, Howard JG, Olson RJ: Microphacoemulsification with White Star: A woundtemperature study. J Cataract Refract Surg 28:104446, 2002.
3. Donnenfeld ED, Olson RJ, Solomon R, et at: Efficacy and Wound Temperature Gradient of
White Star Technology Phacoemulsification Through a 1.2-mm Incision. J Cataract Refract
Surg; submitted
4. Kanellopoulos AJ: Laser cataract surgery. Ophthalmology 108:649, 2001.
5. Dodick JM: Laser phacolysis of the human cataractous lens. Dev Ophthalmol 22:5864, 1991.
6. Alzner E, Grabner G: Dodick laser phacolysis: Thermal effects. J Cataract Refract Surg 25:800
03, 1999.
33
Ultrasmall Incision Bimanual Phaco
Surgery and Foldable IOL
HiroshiTsuneoka
Introduction
The increasing use of phacoemulsification and aspiration (PEA) and the advent of
foldable intraocular lenses (IOLs) have been accompanied by dramatic advances in the
field of cataract surgery. Some ophthalmologists even suggest that this technology may
be reaching its peak, with fewer developments to be expected in the future. However, a
number of problems remain to be resolved.
One of these problems involves the need for further improvement in postoperative
visual acuity. Although the availability of IOLs has increased the likelihood of a good
outcome, numerous problems remain regarding lack of accommodation, glare,
deterioration in contrast sensitivity, and changes in color perception.
A second problem is the need for less invasive surgery. At present, cataract surgery
can be performed through an incision of 34 mm, and surgical procedures are under
development which will make it possible not only to remove the clouded lens through an
ultrasmall incision of approximately 1.0 mm, but also to insert the IOL without enlarging
that incision.
Ultrasmall-incision cataract/IOL surgery requires not only improved techniques for
lens extraction, but also the development of IOLs which can be inserted through these
ultrasmall incisions. Many companies are currently working to develop IOLs which can
be inserted through an incision of less than 2 mm, and a number of these products are
expected to be on the market soon.
Regarding lens extraction, considerable attention has been directed in recent years to
new emulsification and aspiration techniques using the erbium YAG laser and the
neodymium YAG laser. This technology provides numerous advantages, including the
absence of heat generated during phacoemulsification and minimal invasiveness of the
cornea of the capsular bag, and is expected to drive the next generation of cataract
surgery technology. However, it is not yet widely used because it currently takes longer
than phacoemulsification for nucleus removal. Recently AJ Kanellopoulos and JM
Dodick have reported on the results of bimanual laser phaco surgery using a Q-switched
neodymium YAG laser.1 They state that by improving laser surgery equipment and
surgical techniques it is possible to dramatically reduce operating time, and that a
dehydrated and folded acrylic IOL can be inserted through an incision of 1.6 to 1.8 mm
after YAG laser surgery. However, in contrast to the PEA equipment which is in wide
use today, laser phaco machines still have considerable room for improvement before the
technology will be fully matured, so we expect that it will be some time yet before these
Ultrasmall incision bimanual phaco
481
procedures become widely available. There is also some question about how well this
new IOL material will stand up over years of use.
Since 1999 we have been studying the use of PEA, a mature technology with highly
reliable equipment, for lens extraction through an ultrasmall incision. We have used this
equipment to perform basic research on lens extraction through an incision of 1.4 mm or
less,2 and have also developed a new type of foldable acrylic lens which can be inserted
through these incisions. The present article will address ultrasmall incision cataract
surgery using surgical equipment, surgical techniques, and IOL materials which are
widely available today.
Basic Research on Ultrasmall Incision Cataract Surgery Using Phaco
Machines
Use of the Sleeveless Phaco Tip Enables Ultrasmall Incision Cataract
Surgery
In ordinary PEA, the pahco tip is equipped with an infusion sleeve. In order to reduce
incision size, it has been necessary to decrease the outer diameter of the infusion sleeve.
Phaco machines in current use require an incision of at least 2.6 mm even when using a
thin phaco tip. In order to successfully utilize surgical incisions of less than 2.0 mm, the
infusion sleeve must be removed to leave the sleeveless phaco tip, with infusion provided
through a side port.
In order to use the sleeveless tip safely it is necessary to ensure that adequate infusion
is provided through the side port, that the phaco tip does not overheat during
emulsification and aspiration, and that there is no deformation of the incision due to
movement of the tip.
History of PEA Using a Sleeveless Phaco Tip
In 1984, Hara and colleagues began using a sleeveless phaco tip in intracapsular
phacoemulsification and aspiration for lens refilling.3 The technology attracted
considerable attention, particularly in the United States, but procedures for lens
emulsification and aspiration at that time were quite difficult and no suitable lens refilling
material was available, so the method was never widely adopted.
Fifteen years later, in 1999, we began working with bimanual PEA using a sleeveless
phaco tip in order to reduce incision size during cataract surgery. We first performed
basic research to make sure that the surgery would be safe, determining the feasibility of
bimanual nucleofractis with infusion through a side port, establishing methods for
ensuring adequate infusion flow volume, and investigating techniques to prevent thermal
burn and deformation at the incision site. We then applied these findings in a clinical
setting to develop procedures for lens extraction through a 1.2 to 1.4 mm incision.2
Prior to this, in 1998 A Agarwal and colleagues reported4 successful lens extraction
through a 0.9 mm incision using the Phakonit method with a sleeveless phaco tip. Under
this method thermal burn is avoided by providing external irrigation of the incision
through which the ultrasound probe is inserted.
Phacoemulsification
480
At almost the same time P Crozaf on reported the successful use of a sleeveless 21
gauge Teflon-coated tip for minimally invasive bimanual PEA through a 0.9 mm
incision. Crozafon felt that thermal burn could be prevented by coating the phaco tip with
Teflon, which has poor thermal connectivity.
In 2001 R Olson reported the feasibility of PEA through a 1.0 mm incision using the
new PEA machine, Sovereign (Allergan), with White Star software. Olson found that tip
heating could be minimized by setting the machine for pulse mode so that ultrasound was
generated for extremely short intervals.
In our ultrasmall incision cataract surgery we use a relatively large incision of 1.2 to
1.4 mm. We find that when the incision is slightly larger than the phaco tip, the tip can be
cooled by the leakage of infusion solution through the incision, and the extra space also
prevents deformation at the incision site due to tip movement.
Problems Related to PEA with a Sleeveless Tip
Major problems when using a sleeveless tip for PEA include thermal burn at the incision
site because of overheating of the phaco tip, and destabilization of the anterior chamber
due to inadequate infusion flow. Also, the necessity of providing infusion through the
side port means that the traditional nucleofractis hook cannot be used. Many surgeons
have been particularly concerned that ultrasound waves through the sleeveless tip could
cause a sudden rise in tip temperature, resulting in thermal burn at the incision site, and
that the sleeveless phaco tip would, therefore, be unfeasible for emulsification of hard
nuclei where the tip is sometimes fully occluded. To resolve these concerns, we measured
incision site temperature in postmortem porcine eyes during phacoemulsification with
full occlusion of the phaco tip. Our experiments confirmed the absence of thermal burn
when using a 20 gauge sleeveless phaco tip through an incision made by a 19 gauge
microvitroretinal (MVR) blade. We also modified a 20 gauge infusion cannula and
inserted it through a side port created with a 20 gauge MVR. The cannula modifications
ensured adequate infusion flow, stabilizing the anterior chamber, and also made it
possible to use the infusion cannula as a nucleofractis hook. This allowed us to safely
emulsify and aspirate nuclei with conventional bimanual nucleofractis techniques, and
enabled us to confirm the feasibility and safety of PEA through an incision of 1.2 to 1.4
mm using familiar techniques and widely available surgical equipment.2
Avoid Thermal Burn and Injury at the Incision Site: Widen the Incision
by 1 Gauge
We believed that if the incision was made slightly wider than the outer diameter of the
phaco tip, the tip would be satisfactorily cooled by the leakage of infusion solution
through the incision, preventing thermal burn at the incision site. To test this hypothesis
we measured temperature at the incision site in postmortem porcine eyes during
The PEA device used in our experiments was the Alcon Legacy 20000 with a 20
gauge Kelman phaco tip (manufactured by Alcon Laboratories, Inc). Temperature at the
incision site was measured with a sheathed thermocouple Model TSC-K0.3 manufactured
483
by Toa Electric Co, Ltd, and a thermometer Model AR5757-F00 manufactured by Chino
Co, Ltd.
We created a corneal incision in the postmortem porcine eye using a 19 gauge (1.4
mm) MVR. We also used the MVR to create a tunnel in the cornea above the incision and
parallel to it. We inserted the thermocouple electrode of the thermometer through that
tunnel, and performed 3 measurements of temperature elevation at the corneal incision
during ultrasound oscillation with the phaco tip fully occluded (Fig. 33.1). We used a
clamp to close the aspiration tube so that aspiration pressure was 0 mmHg during
ultrasonic wave generation.
We inserted a sleeveless 20 gauge Kelman microtip through the 19 gauge incision and
a 20 gauge infusion cannula through the corneal side port. The phaco tip was pressed
against the incision, and ultrasound waves were generated continuously for 2 minutes at
80 percent US power. Our results showed a mean temperature elevation of 8.4C. At no
time during the procedure did the temperature at the incision site exceed 40C, and no
thermal burn was observed (Fig. 33.2B).
FIGURE 33.1 Method for measuring

temperature at the incision site. The
thermocouple is inserted into a tunnel
created in the cornea above the
incision site, and temperature at the
incision site is measured with US in
operation
FIGURES 33.2A AND B Using a

thermometer to measure temperature at
Phacoemulsification
482
the incision site in postmortem porcine

eyes. Phaco machine setting:
Aspiration port occluded (aspiration
pressure: 0 mmHg). US power: 80%,
US duration: 2.0 min continuous. (A
left) A 20 gauge Kelman U/S tip with
the infusion sleeve was inserted
through a 3.0 mm incision, and US
were operated. Temperature at the
incision site rose only slightly while
the tip was kept from pressing on the
incision wall. But, once the tip was
pressed against the incision wall
during US operation, the temperature
at the incision site rose significantly
and a thermal burn developed. (B
right) A 20 gauge Kelman U/S tip
without the infusion sleeve was
inserted through a 19 gauge incision,
and US were operated. Temperature
did not rise at the incision site even
when the tip was pressed against the
incision, and no thermal burn
developed
When the phaco tip is not fully occluded in PEA, the tip lumen and outer wall are
bathed in infusion solution, so that even when friction develops there is a sufficient flow
of infusion solution to cool the tip. However, in phacoemulsification with full occlusion
the infusion solution is ordinarily unable to circulate within the phaco tip, so the amount
of infusion solution in contact with the outer wall of the tip is limited to the volume of
solution passing through the incision site. During fully occluded nucleofractis with a
phaco tip equipped with an infusion sleeve, there is a decrease in the volume of infusion
solution flowing around the tip. If the tip should press against the incision wall under
these circumstances, the infusion solution may not provide sufficient cooling to
compensate for the friction heat generated by the tip and sleeve. This can result in the
development of thermal burn at the incision site (Figs 33.2A and 33.3A). However, when
using a sleeveless phaco tip in an incision which is slightly larger than the tip itself, there
is still considerable leakage of infusion solution through the incision site even during
fully occluded phacoemulsification when the tip may be moved in multiple directions and
pressed against the incision in order to emulsify the nucleus. This leakage of infusion
solution provides sufficient cooling of any friction heat which may develop between the
tip and the surrounding tissue, making it possible to emulsify and aspirate the nucleus
485
without the occurrence of thermal burn and without resorting to Teflon-coated phaco tips
or ultrasonic wave-control technology (Fig. 33.3B). By implementing this technique,
thermal burn is less likely to occur when using a sleeveless tip than when using a tip
equipped with the infusion sleeve.
When we perform bimanual PEA, one of the main points in our surgical technique
involves the use of an incision which is 1 gauge larger than the outer diameter of the
phaco tip. This means that the incision for a 20 gauge phaco tip is made using a 19 gauge
(1.4 mm) MVR, and for a 21 gauge phaco tip we used a 20 gauge (1.2 mm) MVR. The
slight space between the phaco tip and the incision wall prevents deformation and injury
at the incision site due to movement of the phaco tip.
Tools for Successful Bimanual PEA: The 20 Gauge Irrigating Chopper
(Fig. 33.4)
The goal of bimanual PEA is to remove the nucleus through the smallest incision
possible. In addition, it is desirable to use only a single corneal side port,
FIGURES 33.3A AND B Flow

dynamics of infusion solution around
the phaco tip when the opening of the
tip was closed during occlusion mode.
(A left) Emulsification and aspiration
following insertion of a sleeved phaco
tip through a 3.0 mm incision. Because
the sleeve is deformed by contact with
the incision, leakage volume through
the incision is low. During phaco tip
fully occluded in PEA, the flow of
infusion solution around the phaco tip
within the infusion sleeve is also low.
When the phaco tip pressed against the
incision wall, friction heat develops
Phacoemulsification
484
between the tip and the sleeve.

Because there is insufficient infusion
solution flowing around the tip to
provide cooling, the heat is transmitted
to tissues at the incision site. Thermal
burn develops at the incision. (B right)
Emulsification and aspiration
following insertion of a sleeveless 20
gauge phaco tip through a 19 gauge
(1.4 mm) incision.
Because the phaco tip is not deformed
by passage through the incision, there
is space between the tip and the
incision. Thus, the maximum possible
volume of infusion solution is
available to flow around the tip,
providing cooling for any friction
between the tip and the incision tissue.
No thermal burn develops at the
incision site
and to make that port as small as possible also. Creating a third incision for the
nucleofractis hook would run counter to the objectives of this surgical technique. With
that in mind, we experimented with a bend in the tip of the infusion cannula. This
resulted in the production of hooked infusion cannulae having nearly the same shape as
conventional nucleofractis hooks. The Tsuneoka Irrigating Hook and the Tsuneoka
Irrigating Chopper are manufactured by American Surgical Instruments Corporation
(ASICO).
When using the infusion cannula as a hook or chopper, considerations of intraocular
operability dictate that instrument size not exceed 20 gauge. However, an ordinary
cannula having a 20 gauge outer diameter would have an inner diameter of only 0.6 mm,
making it difficult to guarantee
487
FIGURE 33.4 The 20 gauge irrigation

cannula with nucleofractis hook. A
cannula was prepared having an outer
diameter of 0.9 mm and an inner
diameter of 0.7 mm, with large
aperture at the tip. The cannula walls
were made thinner to ensure adequate
flow of infusion solution. This
cannula, manufactured by ASICO Co,
Ltd, is an essential tool for use in the
procedure described here
adequate infusion volume. With the infusion bottle at a height of 110 cm, an inner
diameter of 0.6 mm would permit a flow volume of only 38 mL/min. This is not enough
to sustain anterior chamber depth during surgery. We thus reduced the thickness of the
infusion cannula wall to yield an inner diameter of 0.70 mm. The modified cannula
provides a flow rate of 50 mL/min when the infusion bottle is raised to 110 cm.
The hook at the tip of this cannula is shaped to provide excellent operability during
emulsification and aspiration. Stable anterior chamber depth is maintained during PEA,
and the hook works well in a variety of nucleofractis procedures.
Equipment for Safer Bimanual PEA: The GFX Unit and VGFI Tubing
(Fig. 33.5)
In order to safely perform this surgery, it is important to increase the depth of the anterior
chamber during emulsification and aspiration. In cases where destabilization of anterior
chamber depth occurs during PEA even with the infusion bottle elevated to 110 cm or
higher, it is advisable to increase the flow rate by applying pressure to the infusion bottle.
During lens extraction we use a GFX fluid-gas exchanger, manufactured by Alcon
Laboratories, Inc, with vented gas forced infusion (VGFI) tubing. Applying a pressure of
10 mmHg
Phacoemulsification
486
FIGURES 33.5A AND B GFX (Gas

Fluid Exchange) equipment and VGFI
(Vented Gas Forced Infusion) tube an
air pump of GFX equipment (A)
creates pressurized air, and VGFI
tubing (B) delivers it to the infusion
bottle. Fluid from the infusion bottle
creates the same pressure and improves
anterior chamber stability of patient
eye. Infusion flow rate can be
automatically controlled with the GFX
air pump without raising or lowering
the bottle
to the infusion bottle has the same effect as raising the bottle an additional 13 cm, and
makes it possible for us to increase the infusion flow to the specific extent required.
Agarwal and colleagues5 also use the technique of applying pressure to the infusion bottle
in order to stabilize anterior chamber depth.
489
Clinical Results of Ultrasmall Incision Cataract Surgery Using PEA

Results from our experiments indicated that thermal burn could be prevented by
obtaining
FIGURE 33.6A A temporal corneal

incision is made using a 19 guage
MVR
sufficient leakage through the incision, and that a hooked infusion cannula (the Tsuneoka
Irrigating Hook, manufactured by ASICO) can be used to emulsify and aspirate nuclei by
bimanual nucleofractis while maintaining stable anterior chamber depth. In October 1999
we began applying these procedures to ultrasmall incision phaco surgery in human
patients.
Procedures for Ultrasmall Incision Bimanual Phaco Surgery6
After the eye is anesthetized, we make an incision from the temporal clear cornea into the
anterior chamber. We use a 19 gauge MVR blade for a 20 gauge small tip or a 20 gauge
blade for a 21 gauge microtip (Fig. 33.6A). The incision is approximately 0.9 mm in
length. We also create the infusion side port at a desirable location on the clear cornea,
using a 20 gauge MVR blade (Fig. 33.6B). Sitting at the patients head, the surgeon
positions the side port at eleven Oclock for the left eye or at one Oclock for the right
eye.
Injecting a viscoelastic material into the anterior chamber, we use a 26 gauge needle to
perform continuous curvilinear capsulorrhexis (CCC) with a diameter of approximately
5.0 mm, and then initiate hydrodissection. In order to prevent an abrupt rise in anterior
chamber pressure, it is important to press the base of the hydrodissection
Phacoemulsification
488
FIGURE 33.6B A side port for

irrigation is made at 1 Oclock in the
right eye using a 20 gauge MVR
needle firmly against the lower side of the incision so that excess fluid can leak out of the
incision while injection is in process.
We insert the Tsuneoka Irrigating Hook through the side port and the sleeveless phaco
tip through the temporal corneal incision, and emulsify and aspirate the lens while using
the tip of the cannula for nucleofractis (Fig. 33.6C). When we are working on the right
eye we hold the irrigating hook in the left hand and the ultrasound probe in the right
hand, and when working on the left eye we do the reverse, with the irrigating hook in the
right hand and the ultrasound probe in the left hand.
We use bimanual nucleofractis when emulsifying and aspirating the nucleus.
Depending on nucleus hardness, we use choose between the divide and conquer, quick
chop (karate chop), or crater divide and conquer methods (Fig. 33.6D). Safe PEA
requires that stable anterior chamber depth be maintained during surgery to prevent
collapse of the anterior chamber, and that scattering of nuclear fragments be avoided. In
order to maintain anterior chamber depth, a careful balance must be maintained between
the settings for side port infusion and for phaco tip aspiration. We adjust the height of the
infusion bottle to provide a side port infusion flow rate of at least 50 mL/min when using
a 20 gauge phaco tip, and an infusion flow rate of 40 mL/min for a 21 gauge phaco tip. It
is also important to set the parameters of the PEA
491
FIGURE 33.6C A 20 gauge sleeveless

phaco tip is inserted into the anterior
chamber through a 19 gauge incision
and a 20 gauge Tsuneoka irrigating
hook is inserted through a 20 gauge
side port
FIGURE 33.6D PEA is performed

using bimanual nucleofractis technique
machine appropriately, particularly the values for aspiration flow rate and maximum
aspiration pressure. The settings used at our institution are shown in Table 33.1.
Infusion flow may not keep up with aspiration flow if aspiration is continued when
there are no nuclear particles to be captured by the aspiration port on the phaco tip.
Surgery can be performed more safely if aspiration is turned off when it is not needed.
Prevention of nuclear fragment dispersion is an important point for improving PEA
safety. It is important to turn the ultrasound power as low as is feasible in order to reduce
the extent of endothelial injury from nucleus kick. Great care must also be taken when
using the nucleofractis hook to handle nuclear fragments.
Phacoemulsification
490
TABLE 33.1 Parameters used by phaco machine

type
Size of phaco
tip
Legacy 20000
(Alcon)
Sovereign
(Allergan)
24000 (Nidek)
20 gauge
Pulser (Optikon)
21 gauge
20 gauge
20 gauge
Flow
rate
Maximum aspiration
pressure
25
ml/min
28
ml/min
23
ml/min
30
ml/min
Height of irrigation
bottle
250 mmHg
120 cm
280 mmHg
100 cm
200 mmHg
100 cm
300 mmHg
90 cm
FIGURE 33.6E Residual cortex is

aspirated using a sleeveless I/A tip or
23 gauge bimanual I/A tip through the
side port
FIGURE 33.6
Ultrasmall incision (1.4 mm) bimanual
phaco surgery
Aspiration of the residual cortex through an ultra-small incision can be performed
using a sleeveless I/A tip or a 23 gauge aspiration cannula through the side port (Fig.
33.6E). In cases where it is difficult to remove endothelial fragments below the incision
line, the positions of the infusion cannula and the aspiration tube can be reversed so that
this procedure can be performed safely and effectively.
493
Perioperative and Postoperative Results

Results of Surgery
Since October 1999, ultrasmall incision PEA surgery has been performed at the Jikei
University School of Medicine Hospital by 3 surgeons on 757 eyes. Mean operating time
is 8 minutes 42 seconds, comparable to the time required for conventional cataract IOL
surgery by PEA. Approximately 90 mL of infusion solution is required per surgery,
slightly more than that for conventional procedures. Both operating time and amount of
infusion solution increase with greater nucleus hardness.
Incidence of Perioperative Complications
Among the patients studied, posterior capsular rupture occurred without vitreous prolapse
in 3 eyes (0.4%), and with vitreous prolapse in 6 eyes (0.8%). However, none of these
incidents of posterior capsular rupture were caused by use of this technology, and all
were treated successfully with uneventful recovery.
Nuclei having a hardness of grade 4 or above (Emery-Little classification) were
encountered in 37 eyes. No thermal burn developed in any of these cases, even though
the use of ultrasound was prolonged.
Postoperative Course
Slight iris injury developed in 6 eyes (0.8%) which showed preoperative shallow anterior
chamber and in 6 eyes (0.8%) with small pupils. There were no other notable
postoperative complications.
Postoperative follow-up was continued for at least 3 months in 312 eyes. Greater
nuclear hardness was associated with higher rates of reduction in endothelial cell density
(4.112.3% for nuclei of hardness grade 1 or 2, 10.816.0% for grade 3, and 16.812.6%
for grade 4 and above). However, none of these results differed greatly from those for
conventional techniques.
IOL Insertion through an Ultrasmall Incision
New IOLs for Use with Ultrasmall Incisions
In current cataract surgery even though the cataract can be removed through an incision
of 1.2 to 1.4 mm, there are no commercially available IOLs which can be inserted
through such a small incision, so at present the incision must be enlarged to 2.8 to 4.1
mm before the IOL can be inserted. However, several companies are developing acrylic
soft lenses which are thinner than the current commercially available foldable IOLs, and
in the near future we can expect to see the marketing of IOLs which can be inserted
through an incision of 1.4 mm or less.
At present Kanellopoulos and colleagues have reported the insertion through a 1.6 mm
incision of a dehydrated acrylic IOL manufactured by Acri Tec GmbH (Germany), and
Phacoemulsification
492
Agarwal and colleagues have reported insertion through a 0.9 mm incision of a

hydrophilic acrylic IOL manufactured by ThinOptX, Inc (USA). I have also
experimented with the ThinOptX IOL, but the lens is difficult to roll, and we believe that
an insertion system needs to be developed in order to enable the routine insertion of this
lens through incisions of predetermined size. Also, it remains to be seen whether these
new ultrasmall incision IOLs will provide satisfactory visual performance, and whether
they will maintain satisfactory long-term stability within the eye.
Techniques for Inserting Currently Available IOLs through Smaller
Incisions (Fig, 33.7)
By modifying the commercially available Alcon injector and cartridge (Monarch IIC), we
have succeeded in inserting Alcon acrylic soft lenses having an optic diameter of 5.5 mm
(the AcrySof
FIGURE 33.7A The initial corneal

incision is widened to 2.2. mm
FIGURE 33.7B AcrySof SA30AL is

inserted through a 2.2 mm incision
495
SA30AL and MA30BA) through a 2.2 mm incision (Fig. 33.7A).

We set the AcrySof SA30AL (Fig. 33.7B) or MA30BA (Fig. 33.7C) in the Monarch
IIC cartridge, place the cartridge loaded with the IOL into the injector, and press the
plunger forward while ensuring that the pressure is applied to the optic portion of the
lens.
During insertion, the front tip of the cartridge is inserted into the corneal incision so
that it presses against the incision wall. The cartridge tip does not enter the anterior
chamber. Immediately before inserting the lens, we instruct the patient to look steadily in
the direction of the incision. With the
FIGURE 33.7C AcrySof MA30BA

is inserted through a 2.2 mm incision
FIGURE 33.7D The final incision size

is measured using Tsuneoka ultrasmall
inner caliper
cartridge tip elevating the inner edge of the corneal incision and pressing down on the
outer edge, we slowly press the injector plunger forward. With a hook inserted through
the side port, and making sure that the eye is not turned inward toward the nose, we
continue to press the plunger forward without decreasing the downward pressure of the
Phacoemulsification
494
cartridge on the incision, until the entire optic is within the anterior chamber. When using
the single piece SA30AL lens, we insert the trailing loop into the eye along with the
optic, but when using the three-piece MA30B A lens we leave the trailing loop outside
the eye when we withdraw the cartridge,
FIGURE 33.7E The incision self-seals

easily
FIGURE 33.7
The acrylic foldable IOL of which
optic diameter is 5.5 mm (AcrySof
SA30AL or MA30BA) is inserted
using the injector
FIGURE 33.8 5.5 mm optic acrylic

IOL is implanted through 2.2 mm
incision
and then use an instrument such as a hook to insert the trailing loop into the capsular bag.
After verifying the final incision width with a Tsuneoka micro incision inner caliper
(Fig. 33.7D), we aspirate the viscoelastic material and allow the incision to self seal.
497
The AcrySof MA30BA and SA30AL lenses, currently the most widely used
hydrophobic acrylic lenses in the world, are normally inserted through an incision of 3.0
mm or above. Our method makes it possible to insert these lenses through a 2.2 mm
incision (Fig. 33.8), which increases the significance of ultrasmall incisions for lens
removal. In our experience this lens removal surgery can be most effectively performed
by bimanual PEA using a sleeveless phaco tip.
References
1. Kanellopoulos AJ, Dodick JM, Brrauweiler P: Dodick photolysis for cataract surgery.
Ophthalmology 106:21972202, 1999.
2. Tsuneoka H, Shiba T, Takahashi Y: Feasibility of ultrasound cataract surgery with a 1.4 mm
incision. J Cataract Refractive Surg 27:93440, 2001.
3. Hara T, Hara T: Clinical results of phacoemulsification and complete in-the-bag fixation. J
Cataract Refractive Surg 13: 27986, 1987.
4. Agarwal A, Agarwal A, Agarwal S et al: Phakonit: Lens removal through a 0.9 mm corneal
incision. J Cataract Refractive Surg 27:154852, 2001.
5. Agarwal S, Agarwal A, Sachdev MS, et al: Air pump to prevent surge. In: Agarwal Set al (Eds):
Phacoemulsification, Laser Cataract Surgery and Foldable IOLs (2nd ed). Jaypee Brothers:
New Delhi, 2000.
6. Tsuneoka H, Shiba T, Takahashi Y: Ultrasonic phacoemulsification using a 1.4 mm incision:
Clinical results. J Cataract Refractive Surg 28:8186, 2002.
34
Corneal Topography in Phakonit with a 5
mm Optic Reliable IOL
Amar Agarwal, Soosan Jacob
Introduction
Cataract surgery and intraocular lenses (IOL) have evolved greatly since the time of
intracapsular cataract extraction and the first IOL implantation by Sir Harold Ridley1.
The size of the cataract incision has constantly been decreasing from the extremely large
ones used for ICCE to the slightly smaller ones used in ECCE to the present day small
incisions used in phacoemulsification. Phacoemulsification and foldable IOLs are a major
milestone in the history of cataract surgery. Large postoperative against-the-rule
astigmatism were an invariable consequence of ICCE and ECCE. This was minimized to
a great extent with the 3.2 mm clear corneal incision used for phacoemulsification but
nevertheless some amount of residual postoperative astigmatism was a common outcome.
The size of the corneal incision was further decreased by Phakonit24 a technique
introduced for the first time by one of us (Am.A), which separates the infusion from the
aspiration ports by utilizing a sleeveless phaco probe and an irrigating chopper. The only
limitation to thus realizing the goal of astigmatism neutral cataract surgery was the size of
the foldable IOL as the wound nevertheless had to be extended for implantation of the
conventional foldable IOLs.
Rollable IOL
With the availability of the ThinOptX reliable IOL (Abingdon, VA, USA), that can be
inserted through sub-1.4 mm incision, the full potential of Phakonit could be realized. A
special ultrathin 5 mm optic rellable IOL was designed by one of us (Am.A) to make the
incision size smaller.
Surgical Technique
Five eyes of 5 patients underwent Phakonit with implantation of an ultrathin 5 mm optic
reliable IOL at Dr Agarwals Eye Hospital and Eye Research Center, Chennai, India.
The name PHAKONIT has been given because it shows phacoemulsification
(PHAKO) being done with a needle (N) opening via an incision (I) and with the phaco tip
(T). A specially designed keratome, an irrigating chopper, a straight blunt rod and a 15
Corneal topography in phakonit
499
degree standard phaco tip without an infusion sleeve form the main prerequisites of the
surgery. Viscoelastic is injected with a 26 gauge needle through the presumed site of side
port entry This inflates the chamber and prevents its collapse when the chamber is
entered with the keratome. A straight rod is passed through this site to achieve akinesia
and a clear corneal temporal valve is made with the keratome (Fig. 34.1A). A continuous
curvilinear capsulorhexis (CCC) is performed followed by hydrodissection and rotation
of the nucleus. After enlarging the side port a 20 gauge irrigating chopper connected to
the infusion line of the phaco machine is introduced with foot pedal on position 1. The
phaco probe is connected to the aspiration line and the phaco tip without an
FIGURE 34.1A Clear corneal incision

made with a specialized keratome.
Note the left hand has a straight rod to
stabilize the eye
FIGURE 34.1B Agarwals Phakonit

irrigating chopper and sleeveless phaco
probe inside the eye
infusion sleeve is introduced through the main port (Fig. 34.1B). Using the phaco tip with
moderate ultrasound power, the center of the nucleus is directly embedded starting from
the superior edge of rhexis with the phaco probe directed obliquely downwards towards
Phacoemulsification
498
the vitreous. The settings at this stage are 50 percent phaco power, flow rate 24 ml/min
and 110 mm Hg vacuum. When nearly half of the center of nucleus is embedded, the foot
pedal is moved to position 2 as it helps to hold the nucleus due to vacuum rise. To avoid
undue pressure on the posterior capsule the nucleus is lifted slightly and with the
irrigating chopper in the left hand the nucleus chopped. This is done with a straight
downward motion from the inner edge of the rhexis to the center of the nucleus and then
to the left in the form of an inverted L shape. Once the crack is created, the nucleus is
split till the center. The nucleus is then rotated 180 and cracked again so that the nucleus
is completely split into two halves. With the previously described technique, 3 pie-shaped
quadrants are created in each half of the nucleus. With a short burst of energy at pulse
mode, each pie-shaped fragment is lifted and brought at the level of iris where it is further
emulsified and aspirated sequentially in pulse mode. Thus the whole nucleus is removed.
Cortical wash-up is then done with the bimanual irrigation aspiration technique.
FIGURE 34.1C The reliable iol

inserted through the incision
FIGURE 34.1D viscoelastic removed

probes
501
The lens is taken out from the bottle and placed in a bowl of BSS solution of
approximately body temperature to make the lens pliable. It is then rolled with the gloved
hand holding it between the index finger and the thumb. The lens is then inserted through
the incision carefully (Fig. 34.1C). The teardrop on the haptic should be pointing in a
clockwise direction so that the smooth optic lenticular surface faces posteriorly. The
natural warmth of the eye causes the lens to open gradually. Viscoelastic is then removed
with the bimanual irrigation aspiration probes (Fig. 34.1D). Figure 34.1 shows different
steps of the surgery.
FIGURE 34.2 Comparison of pre- and

postoperative BCVA
FIGURE 34.3 Mean astigmatism over

time
Topographic Analysis and Astigmatism
The preoperative best corrected visual acuity (BCVA) ranged from 20/60 to 20/200. The
mean preoperative astigmatism as detected by topographic analysis was 0.98 D0.62 D
(range 0.5 to 1.8 D).
The postoperative course was uneventful in all cases. The IOL was well-centered in
the capsular bag. There were no corneal burns in any of the cases.
Four eyes had a best-corrected visual acuity of 20/30 or better. One eye that had dry
ARMD showed an improvement in BCVA from 20/200 to 20/60. Figure 34.2 shows a
comparison of the pre-and postoperative BCVA. The mean astigmatism on postoperative
day 1 on topographic analysis was 1.10.61 D (range 0.6 to 1.9 D) as compared to 0.98
D0.62 D (range 0.5 to 1.8 D) preoperatively. The mean astigmatism was 1.020.64 D
(range 0.3 to 1.7 D) by 3 months postoperatively. Figures 34.3 and 34.4 shows mean
astigmatism over time. Figures 34.5A and B show a comparison of the astigmatism over
the pre- and postsurgical period.
Phacoemulsification
500
Discussion
Cataract surgery has witnessed great advancements in surgical technique, foldable IOLs
and phaco
TIME EYES MEAN Std. Dev. MINIMUM MAXIMUM
PREOP. 5
POD 1 5
POD 7 5
POD 30 5
POD 90 5
0.98
11
1.12
1.08
1.02
0.62
0.61
0.58
0.62
0.64
0.5
0.6
0.5
0.5
0.3
1.8
1.9
1.7
1.8
1.7
FIGURE 34.4 Table showing pre- and

postoperative mean astigmatism
FIGURE 34.5A Comparison of preand postoperative day 1 cylinder
FIGURE 34.5B Comparison of 1 day

postoperative and 3 months
postoperative astigmatism
technology. This has made possible easier and safer cataract extraction utilizing smaller
incision. With the advent of the latest IOL technology which enables implantation
through ultrasmall incisions, it is clear that this will soon replace routine
phacoemulsification through the standard 3.2 mm incisions. The ThinOptX IOL design
is based on the Fresnel principle. Flexibility and good memory are important
characteristics of the lens. It is manufactured from hydrophilic acrylic materials and is
available in a range from 25 to +30 with the lens thickness ranging from 30 m up to
350 m. One of the authors (Am.A) has modified the lens further by reducing the optic
size to 5 mm to go through a smaller incision. The lens is now undergoing clinical-trials
in Europe and the USA.
In this study, no intraoperative complications were encountered during CCC,
phacoemulsification, cortical aspiration or IOL lens insertion in any of the cases. The
503
mean phacoemulsification time was 0.66 minutes. Previous series by the same authors
showed more than 300 eyes where cataract surgery was successfully performed using the
sub-1 mm incision.3 Our experience and that of several other surgeons suggests that with
existing phacoemulsification technology, it is possible to perform phacoemulsification
through ultrasmall incisions without significant complications.26 In a recent study from
Japan, Tsuneoka and associates6 used a sleeveless phaco tip to perform bimanual
phacoemulsification in 637 cataractous eyes. All cataracts were safely removed by these
authors through an incision of 1.4 mm or smaller that was widened for IOL insertion,
without a case of thermal burn and with few intraoperative complications. Furthermore,
ongoing research for the development of laser probes7,8 cold phaco, and microphaco
confirms the interest of leading ophthalmologists and manufacturers in the direction of
ultrasmall incisional cataract surgery (Fine IN, Olson RJ, Osher RH, Steinert RF.
Cataract technology makes strides. Ophthalmology Times, December 1, 2001, 1215).
The postoperative course was uneventful in all the cases. The IOL was well-centered
in the capsular bag. There were no significant corneal burns in any of the cases. Final
visual outcome was satisfactory with 4 of the eyes having a BCVA of 20/30 or better.
One eye that had dry ARMD showed an improvement in BCVA from 20/200 to 20/60.
Thus the lens was found to have satisfactory optical performance within the eye. In our
study, the mean astigmatism on topographical analysis was 0.98 0.62 D (range 0.5 to
1.8 D) preoperatively, 1.10.61 D (range 0.6 to 1.9 D) on postoperative day 1 and 1.02
0.64 D (range 0.3 to 1.7 D) by 3 months postoperatively. Figures 34.5A and B showing a
comparison of the pre- and postoperative astigmatism indicate clearly that Phakonit with
an ultra-thin 5 mm reliable IOL is virtually astigmatically neutral. Figures 34.6A and B
depicting the topography comparison in different surgical periods show clearly the virtual
astigmatic neutrality of the procedure and stability throughout the postoperative course.
There is an active ongoing attempt to develop newer IOLs that can go through smaller
and smaller incisions. Phakonit ThinOptX modified ultrathin rollable IOL is the first
prototype IOL which can go through sub-1.4 mm incisions. Research is also in progress
to manufacture this IOL using hydrophobic acrylic biomaterials combined with squareedged optics to minimize posterior capsule opacification.
Phacoemulsification
502
FIGURES 34.6A AND B

Topographical comparison during
different surgical periods
505
Conclusion
Phakonit with an ultrathin 5 mm optic reliable IOL implantation is a safe and effective
technique of cataract extraction, the greatest advantage of this technique being virtual
astigmatic neutrality.
References
1. Apple DJ, Auffarth GU, Peng Q, et al: Foldable intraocular lenses: Evolution, clinicopathologic
correlations, complications. Thorofare, NJ, Slack, Inc., 2000.
2. Agarwal A, Agarwal A, Agarwal S et al: Phakonit: Phacoemulsification through a 0.9 mm
corneal incision. J Cataract Refract Surg 27:154852, 2001.
3. Agarwal A, Agarwal A, Agarwal A et al: Phakonit: Lens removal through a 0.9 mm incision.
(Letter). J Cataract Refract Surg 27:153132, 2001.
4. Agarwal A, Agarwal S, Agarwal A: Phakonit and laser phakonit: Lens removal through a 0.9
mm incision. In: Agarwal S, Agarwal A, Sachdev MS, et al: (Eds): Phacoemulsification, Laser
Cataract Surgery and Foldable IOLs. New Delhi, India: Jaypee Brothers Medical Publishers (P)
Ltd, 20416, 2000.
5. Tsuneoka H, Shiba T, Takahashi Y: Feasibility of ultrasound cataract surgery with a 1.4 mm
incision. J Cataract Refract Surg 27:93440, 2001.
6. Tsuneoka H, Shiba T, Takahashi Y: Ultrasonic phacoemulsification using a 1.4 mm incision:
Clinical results. J Cataract Refract Surg 28:8186, 2002.
7. Kanellpoupolos AJ: A prospective clinical evaluation of 100 consecutive laser cataract
procedures using the Dodick photolysis neodymium: Yittrium-aluminum garnet system.
35
Phakonit with the Acritec IOL
Amar Agarwal
History
On August 15th 1998 the authors (Amar Agarwal) performed the first 1 mm cataract
surgery by a technique called PHAKONIT.1,2 Today companies have started
manufacturing IOLs that can pass through ultra-small incisions of 1.5 mm or less. One
such IOL is the Acri. Lyc IOL made by the Acritec company (Berlin, Germany).
Terminology
The name PHAKONIT has been given because it shows phaco (PHAKO) being done
with a needle (N) opening via an incision (I) and with the phako tip (T). This shows
phaco done with Needle Incision Technology.
Incision
In the first step a needle with viscoelastic is taken and pierced in the eye in the area where
the side port has to be made (Fig. 35.1). A special keratome (Micro Surgical Technology,
USA) is then used to create an incision of 1.2 mm (Fig. 35.2). The viscoelastic is then
injected inside the eye.
Rhexis
The rhexis is then performed. This is done with a needle (Fig. 35.3). In the left hand a
straight rod is held to stabilize the eye. The advantage of this is that the movements of the
eye can get controlled as one is working without any anesthesia. Hydrodissection is
performed and the fluid wave passing under the nucleus checked.
Phakonit with the acritec IOL
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FIGURE 35.1 A 26 gauge needle with

viscoelastic making an entry in the
area where the side port is. This is for
entry of the irrigating chopper

made with the keratome. Note the left
hand has a rod to stabilize the eye as
the case is done without any
anesthesia. These instruments are made
by Katena (USA)
Phacoemulsification
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FIGURE 35.3 Rhexis started with a

needle
Phakonit
After enlarging the side port a 20 gauge irrigating chopper connected to the infusion line
of the phaco machine is introduced with foot pedal on position 1. The phaco probe is
connected to the aspiration line and the phaco tip without an infusion sleeve is introduced
through the incision (Fig. 35.4). Using the phaco tip with moderate ultrasound power,
chopping of the nucleus is done (Fig. 35.5). The whole nucleus is finally removed (Fig.
35.6). Note in Figure 35.6 no corneal burns are present. Cortical wash-up is done with the
bimanual irrigation aspiration technique (Figs 35.7 and 35.8).
Acritec IOL
The Acry.Lyc IOL is manufactured by the Acri.Tec company in Berlin, Germany. This
lens is a sterile foldable intraocular lens made of hydrophobic acry late. The intraocular
lens consists of highly purified biocompatible hydrophobic acrylate with chemically
bonded UV-absorber. It is a single piece foldable IOL like a plate-haptic IOL. The lens is
509
FIGURE 35.4 Phakonit irrigating

chopper and phako probe without the
sleeve inside the eye
FIGURE 35.5 Phakonit started. Note

the phako needle in the right hand and
an irrigating chopper in the left hand.
Phakonit being performed. Note the
crack created by karate chopping. The
assistant continuously irrigates the
Phacoemulsification
508
phaco probe area from outside to

prevent corneal burns
FIGURE 35.6 Phakonit completed.

Note the nucleus has been removed
and there are no corneal burns

aspiration started
511
sterilized by autoclaving. The lens comes in a sterile vial, filled with water and wrapped
in a sterile pouch.

Lens Loading Technique
To remove the IOL one should open the Medipeel pouch at the defined spot. The lens
vial or bottle (Fig. 35.9) is then taken out and placed on the sterile tray. The lens is like a
plate haptic IOL (Fig. 35.10). The next step is to prepare the injector (Fig. 35.11). First of
all the injector tip is fitted with a sponge tip (Figs 35.12 and 35.13) which comes with the
cartridge. This will prevent the injector tip from damaging the lens while inserting it
inside the eye. The lens is then taken out from the bottle/vial. The lens is then held with a
forceps. The lens is then placed in the cartridge (Fig. 35.14). Viscoelastic is injected in
the cartridge and once the flanges of the IOL are in the groove of the cartridge the
cartridge is closed and then inserted in the injector (Fig. 35.15). Once the cartridge is
fixed onto the injector the injection of the lens is done by the spongy tip (Fig. 35.16) till
one can see the lens coming into the nozzle of the cartridge (Fig. 35.17).
Lens Insertion Technique
After the Phakonit procedure is completed, the incision is increased to 1.5 mm. Then the
tip of the
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510
FIGURE 35.9 The Acri. Lyc foldable

IOL in the sterile vial
FIGURE 35.10 The Acri. Lyc

foldable IOL
cartridge is kept at the site of the incision (Fig. 35.18). Remember the cartridge is not
inserted inside the anterior chamber. Now, the lens is gradually inserted through the
incision (Fig. 35.19).
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FIGURE 35.11 The Acri. Tec injector
FIGURE 35.12 The soft spongy tip

being fixed onto the tip of the Acri.
Tec injector
Phacoemulsification
512
FIGURE 35.13 Tip of the injector

with the spongy tip. This will prevent
any damage to the lens when inserting
the lens
FIGURE 35.14 The Acri. Lyc IOL

placed in the cartridge
515
FIGURE 35.15 The cartridge fixed

onto the injector
FIGURE 35.16 The tip of the injector

with the spongy tip ready in place to
push the IOL
FIGURE 35.17 The IOL coming out

into the nozzle of the cartridge
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514
FIGURE 35.18 The tip of the nozzle

of the cartridge is at the incision site
but not inside the anterior chamber
FIGURE 35.19 The IOL inserted

through a 1.5 mm incision
517
FIGURE 35.20 The IOL being

inserted inside the bag
One can watch the lens unfolding inside the capsular bag. The inferior haptic goes into
the bag (Fig. 35.20) and the superior haptic is gradually tucked inside the capsular bag.
Viscoelastic is then removed with the Bimanual irrigation aspiration probes (Fig. 35.21).
FIGURE 35.21 Viscoelastic removed

probes
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Summary
With the advent of Phakonit the size of the incision has drastically reduced. Now with
more companies moving into manufacturing ultra-small incision IOLs which can pass
through 1.5 mm incisions or less the advantage of Phakonit becomes even more. With
time more surgeons will move into this technology thus benefiting more patients.
References
1. Agarwal S, Agarwal A, Sachdev MS, et al: Phacoemulsification, Laser Cataract Surgery and
Foldable IOLs (2nd edn) New Delhi: Jaypee Brothers, 2000.
2. Boyd BF, Agarwal S, Agarwal A, et al: Lasik and Beyond Lasik; Highlights of Ophthalmology;
Panama, 2000.
Section VII
Laser Cataract Surgery
36. Laser Phaco Cataract Surgery
37. Erbium-YAG Laser Cataract Surgery
38. Cataract Surgery with Dodick Laser Photolysis
36
Laser Phaco Cataract Surgery
Sunita Agarwal
J Agarwal, T Agarwal
Introduction
From the time of its inception in 1949 with Meyer Schwickerath in Germany the concept
of lasers has caught the imagination of child and adult alike, scientist and the public in
general. Science fiction movies are made with the concept of the laser as the ultimate
weapon against all evil. Little wonder then as eye surgeons we are always trying to better
the techniques of cataract removal over the years, thus today with lasers we find
ourselves equipped with one more wonderful tool in the armamentarium of the operating
room.
We are in the midst of a paradigm shift in cataract surgery today. We must either
become a part of the shift or we will be blind-sided by it. Today, one of the latest
developments in ophthalmology is the laser cataract surgical system. The laser cataract
surgery system would entail less trauma and better rehabilitation of the patient.
History
Cataract the bane of old age has been known as a disease process to human civilization
for many years. Earliest records of its treatment were carried out by Sushruta 500 BC the
famous Indian surgeon who practiced a form of medicine called Dhanvantri. He used a
needle with no anesthesia, through a bloodless route entered the eye through the cornea
and dislodged the cataract. The needle would stick into the cataract like a lollipop and
small movement of the cataract to and fro would break its zonular attachments. Then the
cataract would be made to fall into the deep vitreous. This saved many a eye in that era
and times, however many fell prey to the adversities of the posterior segment. Yet today
we have come a full circle by bringing in the concept of no anesthesia, bloodless,
painless, laser phaconit (needle surgery) cataract surgery.
This idea of couching traveled the silk route into the Arab world and reached the far
corners of Europe. However somewhere along the 11th century an Arabian scientist
Ammar came up with the methodology of removing the cataract enbloc out of the eye.
Thus, started the road of intracapsular cataract and extracapsular cataract extraction. For
many years the cataract would need to be rippend before the surgeon would go to remove
it.
Somewhere along the last two centuries sutures came into being and cataract surgery
became more and more safe where the eye and life were concerned. However it was the
Phacoemulsification
520
remarkable discovery by Sir Harold Ridley of PMMA pieces of plastic broken from the
windshield of planes, lying insert in the eyes of pilots of the Royal Air Force during the
Second World War. This led him to believe and rightly so that pieces of plastic could be
permanently placed in the eye to replace the lost condensing power of the eye. Thus
started the saga of intraocular lens in 1949.
However it was the conception of the ultrasound power by Charles Kelman in 1970
that made it really possible to make cataract surgery as atraumatic experience as we see it
today. It was also this ideology, which made industry look around and give us the
foldable intraocular lens.
With the last two decades research into the idea of lasers removing cataracts grew
stronger and stronger. We had some surgeons carrying out Nd: YAG laser capsulotomy
preoperatively over a slit lamp delivery and then taking the patient immediately to the
operation theater to remove the cataract and replace with an intraocular lens.
Around the latter part of the 80s a few patent applications were accepted for laser
cataract surgery per se. Here Dr. Eichenbaum created history by teaming up with
Paradigm Laser Photon and bringing out the first commercially available laser cataract
surgery system.
FIGURE 36.1 Laser photon machine

from paradigm (USA)
It was the authors (SA) good fortune to acquire such a machine way back in 1995 and
with continuous efforts from the parent principal company and the experience handed
over through patients, evolution of this methodology for cataract surgery has increased
ever more.
Laser Cataract Surgery
At the time when I first got the laser photon machine from Paradigm (Fig. 36.1) all I
could see was it was a powerful machine. The laser fiber optic actually could burn a hole
in steel, thus I wondered if such a machine can make a hole in steel a cataract tissue
would be childs play for it.
Laser phaco cataract surgery
523
However, there were many barriers to this thinking and soon I realized that evolution
of a better system was needed. The fluidics which make such an important part of
cataract surgery today was in its infantile phase. We were actually holding vacuum levels
at less than 100 mm of Hg and this was not fast enough to remove cataract tissue.
The major problem that all high-energy source have is, even though they may
disintegrate the tissue instantaneously they also have the repulsion to push away the piece
from the aspirating porthole. Combating this element with another physical capacity of
the laser being heat was another ball game altogether.
Nd: YAG laser was carried to the tip of the probe through a fiberoptic and instilled
inside the suction arena with a sleeve outside bringing in the fluids. The laser has the
capacity to ablate solid tissue on coming into contact, to about 20 microns tissue space.
However a small part of the tissue around this area of action would get caseated due to
the high protein content, slow aspiration rate and high temperatures. This caseating mass
would then plug the aspirating porthole and the surgery would have to wait till the mass
was deluged.
This kind of method continued for sometime until I realized this was not going to be
effective enough. Another aspect of laser cataract surgery is due to the probe fashioned in
the manner of a spoon. With the aspiration in the deep part of the spoon, occlusion was
next to impossible.
We had learned till then the cataract was to be divided and conquered, if occlusion
was not possible then divide and conquer was not possible. So started our road of
incorporating the laser with the ultrasound. The patents for this probe were filed that
same year, because we had understood this was the wonderful link between ultrasound
and lasers.
This became the method of choice for tackling hard and soft cataracts alike. Today we
are slowly moving away and away from ultrasound because we understand the
endothelial damage in an already compromised cornea. Thus the increased interest in the
laser that can remove the cataract with the ease of an irrigation aspiration handpiece yet
the power of the ultrasound vibrating needle.
We have much better fluidic control, our aspiration rates can touch 350 to 400 mm of
Hg, and this allows the cataract to get sucked in before it has time to caseate on the tip.
The laser is much better centered in the probe allowing all the laser energy to be targeted
along the cataractous tissue.
We have developed newer technologies for cataract removal without having to subject
the cataract into a divide and conquer routine we are able to remove the cataract with a
carouselling technique
Like each temple to its own deity and each monastery to its own monk so is each
technique to its own master. From the words of Jackie Chan, this relates so to in our
advanced laser phaco techniques, where each surgeon has their own techniques.
Pioneers
For decades now we have known benefits of the ultrasound energy. Incorporated with Dr
Kelmans path breaking in roads of using this energy for the removal of cataracts has
indeed reduced rehabilitation of the cataract patient.17
Phacoemulsification
522
Four top ophthalmologists have been working independently on the system of

developing a laser to help in cataract removal. The first has been Dr Daniel Eichenbaum
from USA. It has been basically due to Dr Daniel Eichenbaum and Paradigm that the
laser cataract removal system could be started. They have developed a machine called the
Laser Photon. This laser photon uses the Yag laser for cataract removal.
The second ophthalmologist Dr Jack Dodick introduced the use of the Yag: YLF laser
for surgical cataract removal. A laser beam is a fiber-optically directed toward a titanium
mirror target. The reflection produces waves of optical breakdown power, resulting in
photoablation of the surface down to any depth desired. Succeeding generations of
instrumentation for this technique have been modified and refined. The probes are getting
thinner and thinner compared to a phacoemulsification tip.
The third ophthalmologist is Dr Michael Colvard. The Erbium laser is being used by
Michael Colvard to ablate ocular tissue and its advantage is that it has maximal
absorption in water. When properly directed and mirrored, as in Dodicks approach, the
laser beam is kept away from the posterior pole and the retina. Safety seems to be built
into reflected laser ablation, allowing ablation without thermal injury. In Colvards
technique, the laser beam is placed directly in contact with the nucleus of the cataract for
nonpercusssive cutting. By directing the beam much as one would use an eraser to wipe
over the surface, the tip of the beam is directed over the ablation zone, causing optical
breakdown just at the beams tip. The nuclear material is then removed with irrigation
and an IOL is implanted.
FIGURE 36.2 Sunita Agarwals laser

phaco probe
The fourth ophthalmologist was from IndiaDr Sunita Agarwal who designed a new
probe which incorporates laser and ultrasound in the same pico second (Fig. 36.2).
In 1995 we acquired our first laser machine for cataract surgery. Soon we realized the
potential of capitalizing on both the energy sources together, something not thought of by
any cataract surgeon at that time. And we developed a probe now capable of utilizing at
the same pico second laser and ultrasound energies.
525
Instrumentation
An ordinary phaco unit would contain three functional elements, the phaco power
delivered through a vibrating titanium needle of 900 microns diameter, aspiration through
the needle, and irrigating fluid pump into the eye through a silicon sleeve.
The laser unit consists of a key switch screwed into the laser head unit that allows the
laser light to pass through a glass fiberoptic delivery and the aiming beam is also passed
through the same system. This fiber is of 380 microns in diameter.
The laser phaco probe developed by Sunita Agarwal is patent pending as the idea of
incorporating laser with ultrasound in the removal of cataracts was first developed by us
and after going through many experimentations and variations we
FIGURE 36.3 Comparison between a

phaco probe and the laser phaco probe
FIGURE 36.4 Comparison between

other companies and Sunita
Agarwals laser phaco probe
now plough the laser fiberoptic through the phaco probe making any phaco probe into a
SA (Sunita Agarwal) laser phaco probe (Fig. 36.3).
Phacoemulsification
524
The instrumentation is thus in two parts. One is the Phaco part that most of us are
accustomed too, and the second is the laser part. These may come from the same machine
or from two different machines.
The Sunita Agarwal Laser Phaco Probe
All probes used before this (Fig. 36.4) were thus designed that used laser or ultrasound in
the innermost circumferential ring, with aspiration and irrigation flowing on the outer
ring. This was modified by special intermediary equipment that would allow that
phacoemulsification machine to still function with a laser fiberoptic delivery system in its
midst. Around this is the ultrasound waves pounding along with irrigation and aspiration
flowing on the outside. Thus the whole system consists of a four-function probe. The use
and utilization of both energy sources makes it easier for the cataract to be blasted out of
the eye in shorter time span, with less energy sources used in the eye. The machine we
used was the laser photon machine.
Anatomy of Dr Sunita Agarwal Laser Phacoemulsification Probe
The author has designed this patent pending SA laser phaco probe and it utilizes both, the
laser to a maximum extent and ultrasound to a lesser extent for cataract removal. This
probe can be developed by passing the laser fiberoptic through the aspiration end of a
regular phaco probe. This version of the laser phaco probe gives the advantage of using
the laser, ultrasound, irrigation and aspiration. Based on the ablation power of the laser of
water containing tissues four main have been evaluated of which Nd: YAG has the lowest
capacity for water absorption. It has been further qualified with being near perfect in
effect and holds its place in the industry for over two decades. The laser beam is focused
onto grades of high tensile glass fiberoptic which carry the same and release it on the
cataractous tissue on contact and hence the name contact laser. The laser photoablates 20
microns of cataractous tissue on contact and liquefies a further 200 microns cataractous
tissue around it.
Comparison
Let us compare the phaco probe with the laser phaco probe. There is a slight
embarrassment to outflow using the laser fiberoptic (Fig. 36.6) in comparison with a
phaco probe. This is because the phaco probe is of 900 microns. The laser probe is 380
microns. This is placed inside the phaco
527
FIGURE 36.5 Phaco incision
FIGURE 36.6 Laser phaco incision

probe. So we get only 520 microns of space left. Still the cataract is removed faster and
much more safely.
The laser has the capacity to photoablate 20 microns of tissue space in contact and
another 200 microns is liquefied reducing the solid cataract into liquid and gas. The
incision size is thus reduced as the phaco handpiece gets hot and can burn the corneal
tissue (Fig. 36.5). We are able to perfom laser phaco in an incision of 2 mm (Fig. 36.6).
The phaco incision in the cornea can get ragged with corneal burns. This rarely occurs in
laser phaco as the phaco energy used is comparatively very small (Fig. 36.7).
As the needle held in the hand is not vibrating anymore it can reach further into the
eye without any complications of iris capture or posterior capsule capture. Moreover, the
laser is ineffective
Phacoemulsification
526
FIGURE 36.7 Comparison of incision

between phaco and laser phaco
FIGURE 36.8 Laser phaco probe

500 microns away from the posterior capsule and can be used very close to the capsule.
The laser used is an ND: YAG with fiberoptic delivery and only the cataractous tissue
needs to be removed thus leaving behind an epinucleus and cortex that can be easily
aspirated.
Laser Photon
In the Laser Photon (Fig. 36.8) pulsed laser energy is used to vaporize and aspirate the
lens material out of the eye (Table 36.1). The most important feature of the Laser Photon
is its containment of laser energy. The probe is so designed that energy used to emulsify
the cataract is contained in a photovaporization chamber. The energy used to remove the
cataract does not expose the contents
TABLE 36.1 Paradigm photon laser phaco system

specifications
Laser system
Type
Specification
Nd: Yag q-switched
Wavelength
Mode structure
Pulse duration
Burst mode
Pulse interval
Energy (max)
Energy selector
Cone angle
Aiming beam
Ultrasonic system
Ultrasonic capsule probefrequency
Ultrasonic phaco probefrequency
Ultrasonic phaco probe-stroke
General system
Fluidics
Smartpac reusable cassette
system
Vitrectomy cutter
Bipolar diathermy
Programmable
Display and indicators
Cooling
Weight
Overall dimensions
Power requirements
529
1064 nanometers
Fundamental temoo
Less than 4 nano seconds
One, two or three pulses per burst
20 microseconds
20 ml per pulse
0.5 to 20 ml variable
16 degrees
HENEintensity variable to 5 mw
Specification
40 KHz
40 KHz
5 to 90 micron linear variable
Specification
Peristaltic paraflow vacuum system
Automated, programmable Irrigation pole
Pneumatic guillotine5070 cuts per minute
On demand
100 surgeon case programs
Video crt and computer touch panel. Audio prompts for all
surgical operations
Air quiet laminar flow base
175 lbs (79.4 kg)
21w-26d-53h inches
100240 vac 20 a 50/60 Hz
of the eye to this energy. This gives the laser cataract removal system an advantage over
conventional phacoemulsification systems, with which the ultrasonic energy can vibrate
throughout the anterior chamber and involve other ocular tissues.
The laser cataract surgery entails this specially designed probe that combines fluid
handling and systems controls of ultrasonic cataract systems, now fortified with the laser
energy from a solid state pulsed laser. All three major features of the system irrigation,
aspiration and laser are simultaneously transmitted through a precise location in the eye
through a single small incision.
The laser is capable of ablating high water containing tissues without pigmented
chromophore. This is done causing thermal injury. Its capability of performing these
functions through smooth cutting makes utilization inside the eye very favorable. Most
ocular tissues are very high in their water content and the laser acts best in these
surroundings. Also its high absorption by the cataractous lens makes its unwanted
transmission and scatter of laser energy to adjacent and underlying tissues more
controlled and precise.
The laser energy is generated through a solid state crystal and its care and service
come down to a minimum. The laser is air cooled and does not require any special
Phacoemulsification
528
installation practices. Hence it can be transported easily to the end user facility with no
untoward engineering practices.
In-built
The laser photon machine has an in-built:
1. Laser,
2. Phacoemulsification system,
3. Vitrectomy system and
4. Diathermy.
Uses
The laser cataract system is used for many purposes:
1. To do a capsulorhexis: This can be done with the help of the laser. One can get a neat
round rhexis even in cases of mature cataracts.
2. To remove the nucleus: A combination of laser and aspiration helps remove the
nucleus. This is aided by the technique of nuclear chopping. If the cataract is very hard
a combination of laser followed by emulsification can be done to make the cataract
removal through a 3 mm incision.
3. To remove cyclitic membranes: In such cases even a vitrectomy is difficult as the
membrane does not get removed with the help of the vitrectomy probe. But with the
help of the laser one can create a central opening in these membranes.
4. To create an opening in glaucoma cases. This is less traumatizing than other routine
anti-glaucoma surgeries.
5. To make an inferior iridectomy in cases when vitrectomy is completed and one has to
inject silicone oil. In such cases, we normally make the iridectomy with the vitrectomy
probe which can by mistake convert a small iridectomy to a complete iridectomy. But
with the laser photon one good controlled iridectomy can be created.
Surgical Procedure
The technique is basically the same as in normal phacoemulsification proceduresthe
only difference being that here instead of ultrasound power one uses the laser energy and
very rarely the ultrasound energy also. In the first step a needle with viscoelastic is
injected inside the eye to distend the eye. Then a clear corneal incision is done with a
diamond knife The rhexis can be done with the laser also. We prefer to do it with a
needle. After hydrodissection, the laser phaco probe is passed through the incision, with
the phaco chopper in the other hand through the side port opening. The nucleus is
circumferentially removed and gradually aspirated out, followed by cortical aspiration,
implantation of a foldable IOL and stromal hydration. In stromal hydration the BSS or
531
saline is injected at the lips of the clear corneal wound hydrating the cornea and making it
white. This helps make a better wound closure.
Advantages
There is no corneal burns or ragged edges at site of the incision as only minimal
ultrasound is used in laser phaco as compared to phacoemulsification.
A smaller incision is enough than that used for Phacoemulsification for cataract
removal.
The titanium needle has a diameter of 900 microns. After threading the laser fiberoptic
of 380 microns through the phaco probe, only 520 microns of space is left inside the
titanium needle for the rest of the lens material to be removed. But inspite of this
embarrassment in space the cataract extraction takes less time than a regular
The laser is ineffective 500 microns away from the posterior capsule and can hence be
relied upon while working close to the posterior capsule.
Capsulorhexis can be safely and neatly performed with the laser.
This laser has been used in performing laser sclerotomy in cases suffering from
glaucoma, to remove cyclitic membranes and to perform iridectomy.
How Small Will Our Incisions Go

Today, with more and more new technology, the Laser Photon will get better and better.
It will make the incision size smaller and smaller so that the astigmatism amount
becomes much less. By 2000 AD lasers will have become a major force in cataract
removal. Foldable IOLs have definitely come to stay and they will improve day by day.
Today with the Reliable IOLs the lenses are going through 1 mm incisions.
Any ophthalmologist who wants to put large lenses in large incisions is bucking the
tide of history. Small incisions offer the best chance for most rapid, stable visual
rehabilitation of the cataract patient at the least cost, including time of impaired vision
following surgery, the need for follow-up care, the attendance of relatives to take care of
them to the doctor and the like.
It is unclear as to how small will our incisions goperhaps down to 0.1 mm. With
laser phakonit the size has gone to the sub 1 mm incision level. In laser phaconit the laser
probe is passed through the titanium tip and the sleeve of the phaco probe is removed.
Increasingly, sophisticated laser equipment is capable of giving us better utilization of
energy. With the advent of the lasers, the size of the incisions will decrease.
Conclusion
Lasers would revolutionize cataract surgery. This is the modality by which one can go
real small in the incision. With this, new techniques and instruments will allow us to put
IOLs through these small incisions.
Phacoemulsification
530
What the human mind can achieve as it marshals the basic and clinical sciences will
continue to amaze us. Look how far we have come regarding IOLs and just imagine how
far we will go and can go.
References
1. Thornton SP: IOLs, knives and lasers: A new commitment to the cataract patient. Proceedings
of Ocular Surgery News Symposium, 15:3, 1994.
2. Daniel Eichenbaum: Phaco is easier to do with the new laser system. Ophthalmology Times,
19(13), 1994.
3. Daniel Eichenbaum: New laser phaco. Eye Care Technology, 1994.
4. Jack M Dodick: New laser phaco. Eye Care Technology, 1994.
5. Vance M Thompson: A perspective on balancing the knife with the laser. Ocular Surgery News,
11(13):1993.
6. Daniel Eichenbaum: Laser probes for cataract surgery. Ophthalmology World News, 1995.
7. Daniel Eichenbaum: First computer-aided laser cataract removal system ready for clinical trials.
Ocular Surgery News, 13(9): 1995.
37
Erbium-YAG Laser Cataract Surgery
Demetrio Pita-Salorio
Guillermo L Simon Castellvi
Jess Costa-Vila, Marc Canals-lmhor
JR Fontenla, J Laiseca
Introduction
Most North American and European surgeons agree today that ultrasonic cataract
surgery, when possible is the safest and the one with the shortest visual recovery.
Very soon ocular surgeons worldwide will be able to use the upmost of laser
technology for cataract surgery. In the authors hands the first European erbium-yttrium
aluminum garnet (Er-YAG) laser prototypes have shown to be effective, and, as they
have been developing the first European prototypes, they have found that Er-YAG laser
surgical approach to cataracts slightly differs from that of classical ultrasonic phacos.
Brief History of European Laser Cataract Surgery
The idea of substituting ultrasounds for another kind of energy is not new. Many have
been the lasers under research for cataract surgery. Some are still under development,
otherslike ultraviolet laserswere abandoned years ago due to their mutagenic and
carcinogenic side effects. Alternatives to ultrasonic emulsifiers for cataract surgery
include various instruments and lasers, with different wavelengths of laser energy. The
wavelengths currently under investigation for opacified crystalline lens removal include
the following (Table 37.1).
To date, the pursuit of the appropriate wavelength has centered around the
neodymium: yttrium aluminum garnet (Nd: YAG) and the Erbium: YAG.
TABLE 37.1 Wavelengths under investigation for

opacified crystalline lens removal
1,064 nm neodymium: yttrium aluminum garnet (Nd: YAG)
1,047 nm neodymium: yttrium lithium fluoride (ND: YLF)
1,053 nm with picosecond pulses
2,940 nm (Er: YAG)
193 nm, 248 nm, 308 nm, and 351 nm ultraviolet laser wavelengths (excimer lasers)
Phacoemulsification
532
FIGURE 37.1 Aesculap Laser. Picture

shows the first prototype of Erbium:
YAG laser for cataract surgery we
developed in the early nineties. It was
made by the German AesculapMeditec in Heroldsberg, according
to our first specifications. This first
prototype did notand still does not in
1998incorporate an
irrigating/aspirating system in the same
instrument. An external I/A system has
to be purchased separately to perform
cataract surgery
The development of the European Er: YAG phaco laser started in 1992, when Professor
Pita-Salorio suggested the use of this kind of laser for cataract surgery to AesculapMeditec (Fig. 37.1). Aesculap-Meditec owned an Er: YAG used for glaucoma
surgery (for ab externo fistulizing surgerylaser sclerostomy). Months later, the first
prototype of laser built to our specificationswith the obvious first technical
limitationswas given to us, and we started the development of laser that was due to be
a new tool for cataract surgery.
We performed some in vitro studies, with human cataractous lenses (eye bank lenses),
to study the tissular effects of this kind of laser on human crystalline lens.
The first prototype did not have I/A system, only a fiberoptic and different tips for
laser
Erbium-YAG Laser cataract surgery
535
FIGURES 37.2A AND B Pictures

show the first generation of tips at high
magnificationsome were straight,
others bent, with different diameters.
The fiberoptic core had also different
diameters, and slightly protruded from
the metal sleeve, easing the contact
with the lens material (arrow)
application on the eye (Figs 37.2A and B). This laser forced two-handed surgery, with the
laser tip in one hand and the I/A system in the other (through a paracentesis).
After checking the usefulness of the laser to ablate cataracts, we started the first in
vivo studies with human volunteers. The fiberoptics proved to be extremely fragile, and
the tips bulky, uncomfortable to manage and not perfectly designed. Aesculap-Meditec
protected and improved the fiberoptics and made the second generation of tips (Fig. 37.3)
to design (with I/A, through an external I/A system, we used the Storz Premiere phaco
I/A system).
We soon found new problemswe observed an energy loss throughout the fiber. Day
after day, the energy loss increased inside the fiberoptic, until the
Phacoemulsification
534
FIGURE 37.3 Picture shows the first

and second generation of laser tips for
the early Aesculap-Meditec Er: YAG
MCL-29 Phacolase. The first
generation (top) did not incorporate
I/A system in the handpiece, while the
second generation (bottom) handpiece
incorporated the possibility of using an
external I/A system the way we are
used to with ultrasonic phacos.
Nevertheless, a separated I/A system
had to be purchased
fiber became useless. New fibers had to be designed. At this time, we suggested to make
a new instrument combining the laser and the I/A systemnobody would buy a laser
without an I/A system! But Aesculap-Meditec did not manufacture it, and they still
have not achieved.
When Aesculap-Meditec relocated to the former East Germany in 1996, employees
who decided to remain in the West formed Wavelight Laser Technology. Following
the split, Wavelight focussed on developing a new laser phaco system with the benefit
of incorporating past experience.
Wavelight engineers came up with the Adagio, that produces pulse energy of 100
mJ and 100 Hz. It incorporates a conventional I/A system in the same instrument. This
system provides the possibility to work with smaller tips.
Why Er: YAG? The Reason to Choose the Er: YAG
Unlike other wavelengths, the Er: YAG boasts the highest absorption of energy in water
of any laser
537
FIGURE 37.4 Graph depicting Er:

YAG as the highest absorber of energy
in water of any laser
(Fig. 37.4). This means maximum protection for the high water content ocular tissues
energy is absorbed by the water of crystalline lens, and there is a reduced thermal effect
on other ocular tissues.
But Er: YAG is not only under investigation for ophthalmic usemany are the fields
in medicine where Er: YAG is being investigated (Table 37.2). FDA approval is a reality
for cosmetic skin surgery.
Pulsed laser energy is used to vaporize and photofragment (emulsify) high water
contents lens material out of the eye. Every pulse caused rapid localized heating and
vaporization, and creates a bubble at the tip of the fiber. The size of the bubble depends
on the pulse energy and is about 1 mm at 1 mJ. The shape of the bubble has multiple
lobes.
In other words, tissular water contents absorb this laser wavelength as heatwhen
temperatures
TABLE 37.2 Current other investigational uses of

Er: YAG lasers
Dentistrycosmetic dentine destruction, cavity preparation, caries removal, pits and fissures
Trauma/orthopedicsosteolysis of bone tumors
Digestive surgery*destruction of gallstones
Cosmetic surgeryphotodermolysis, dermabrasion
Dermatologydestruction of superficial skin tumors
Vascular surgeryangioplasty
ORLtympanoplasty
* FDA approved
Phacoemulsification
536
FIGURE 37.5 Mechanism of tissular

damage
are higher than 100C, vaporization of tissue water occurs. The liquid water changes into
gas (vapor), with a dramatic volume expansion that leads to tissular damage because of
the formation and collapse of vapor cavitiesit is what we call vaporization (Fig. 37.5).
This laser-induced vaporization is accompanied by the formation of acoustic transients
(pressure waves) that also produce mechanical damage to the tissue.
Unwillingly, at the same time, the proteins of the lens coagulate, progressively
increasing lens hardness, and making tissular lens photoemulsification more difficult as
surgery progresses.
One of the vital points to lessen this problem is to use the laser in a pulsed mode.
Every pulsed mode has an effective energy (at the beginning of the pulse) and an
uneffective energy at the end of the pulse, i.e. wasted as a thermic increase without
tissular damage. The higher the frequency, the more effective will be the laser. But too
much frequency leads to an enormous energy amount that dehydrates and cooks lens
tissues. Correctly balancing energy and frequency are extremely important.
Tissular Effects
In 1995, to evaluate the tissular effects of the new experimental European erbium: YAG
(Er: YAG) phaco laser on the human cataractous crystalline lens, we ruled a first in vitro
trial with a limited number of human eye bank crystalline lenses, to determine the
mechanism of damage and the utility of the European Er: YAG phaco laser to emulsify
cataractous lens cortex and nucleus. We show and discuss the tissular effects of this laser,
as observed through electron scanning microscope, at increasing energy levels, both in
aerial medium and underwater (like in real surgery).
Twenty human eye bank cataractous crystalline lenses underwent laser effect in two
groups (in aerial medium and underwater), at different increasing energy levels. After
perpendicular laser irradiation, each lens was preserved in a glutaraldehyde solution and
sent to our ocular morphology investigation unit to be processed and examined under
electronic scanning microscope.
Laser application time was set in all cases to 3 seconds, frequency was set in all cases
to 10 pulses per second (10 Hertz). Laser application was directly perpendicular to the
lens, at its center.
539
Results
We briefly show and discuss the tissular effects of this laser, as observed through electron
scanning microscope, at increasing energy levels, both in aerial medium (Figs 37.6A to
E) and underwater {(Figs 37.6F and G) in real surgery}.
Group A: Eye Bank Lenses, in Aerial Medium
1. Energy level: 10 mJ (10 Hz, 3 seconds) (Fig. 37.6A)
2. Energy level: 20 mJ (10 Hz, 3 seconds) (Fig. 37.6B)
3. Energy level: 30 mJ (10 Hz, 3 seconds) (Fig. 37.6C)
4. Energy level: 80 mJ (10 Hz, 3 seconds) (Fig. 37.6D)
5. Energy level: 100 mJ (10 Hz, 3 seconds) (Fig. 37.6E)
Group B: Eye Bank Lenses, Underwater (Under BSS, Like in Real
Surgical Conditions)
The scanning electron micrographs show an Er: YAG crater at 20 mJ (3 seconds of
irradiation at 10 pulses per second), with the European Er: YAG laser (Fig. 37.6F).
Observe that the borders of the crater show clear exfoliative tissular disruption (similar
to Nd: YAG laser effect), while deep smooth crater walls are due to tissular ablation
(similar to excimer laser effect).
1. Energy level: 10 mJ {(10 Hz, 3 seconds) (Fig. 37.6A)}
FIGURE 37.6A Lens anterior capsule

has been disrupted, and only
superficial lens cortex has been
damaged. This picture confirms2325
that, in air, Er: YAG laser has a very
short penetrating effect over crystalline
lens at this energy level, and may be
used for anterior circular continuous
capsulotomy
Phacoemulsification
538
2. Energy level: 20 mJ {(10 Hz, 3 seconds) (Fig. 37.6B)}
FIGURE 37.6B Anterior capsule and

cortex have been damaged. The central
round crater shows the point where
laser tip contacted the lens. Its walls
are razor sharp. Laser tissular damage
has spread far (12 mm) from the
contact point, showing that in aerial
conditions laser collateral effects may
not be so circumscribed as postulated
by other authors. The linear cotton
fiber is an undesired artifact from the
operating room
3. Energy level: 30 mJ {(10 Hz, 3 seconds) (Fig. 37.6C)}
FIGURE 37.6C Er: YAG laser

disruptive effect can be clearly
observedit seems as if a group of
small explosions (the different pulses)
had occurred inside the lens. The
image is similar to that obtained by
541
Nd: YAG laser irradiation over a

human crystalline lens. The picture on
the right shows laser effects at greater
magnification
We also observe a localized thermal effect (protein coagulation).
Our phaco laser system easily emulsifies lens cortex and nucleusthe higher the
energy, the better the effects. We were the first to notice that Er: YAG laser tissular
effects were different in air than underwater. Tissular destructive mechanism varies
according to the medium where it actsin
4. Energy level: 80 mJ {(10 Hz, 3 seconds) (Fig. 37.6D)}
FIGURE 37.6D Tissular disruption

has destroyed superficial lens cortex
and anterior capsule. Tissular damage
is greater than before. It seems as if
laser destruction was due to the first
laser pulseother pulses have
damaged in depth
5. Energy level: 100 mJ {(10 Hz, 3 seconds) (Fig. 37.6E)}
FIGURE 37.6F Underwater, like in

real surgical conditions, the crater is
Phacoemulsification
540
much deeper than the obtained in aerial

medium. Mass loss is much higher
underwater than in airthe European
Er: YAG works much better with a
film of water between lens and cataract
tip
FIGURE 37.6E Er: YAG laser

disruptive effect can be observed in
superficial lens layersobserve that
the borders of the crater show clear
exfoliative tissular disruption. In deep,
smooth crater walls are due to tissular
ablation. The deepness of the crater
increases with energy level. In 3
seconds, at 100 mJ we reach one-third
of lens thickness
aerial medium, disruption prevails over ablation. Underwater, in surgical conditions,
ablation prevails over disruption.
In vitro Er: YAG ablation does not confirm to a linear modelthe European Er: YAG
laser mass loss versus fluence curve is still to be stated. The penetrating effects over
crystalline lens increase with energy levels, either in air or underwater. Under certain
conditions (high energy levels, in aerial conditions), the extent of surrounding tissue
damaged may not be as
543
FIGURE 37.6G Note the smooth

walls of the crater, showing no tissular
disruption, though clear-cut tissular
ablation
limited as previously stated. Fortunately, this seems less important under real surgical
conditions (underwater).
To obtain the best result with this laser, there must be a small quantity of aqueous
humor (or irrigating balanced solution) between the laser tip and lens surfacethe laser
energy is better absorbed, and destroys lens tissue, because of vaporization and acoustic
effects. If laser acts on a dry crystalline lens, there is more thermal damage with
coagulation and necrosis of the target (tissular disruption). Er: YAG thermal damage
depends on the tissular absorption coefficient, which varies with water contents of the
tissue, and the presence or not of a small quantity of water between laser tip and the lens.
The lens tissue absorption coefficient of Er: YAG increases from 439+/151 cm1 in
ambient air to 12.800+/400 cm1 in waterfor this last value, cavitation phenomena
with bubble formation are added to heat production, producing more tissular damage.
Adagio by Wavelight Laser Technology GmbH
Today, we use the Adagio, a laser final prototype made in Erlangen-Tennenlohe, in
Germany by Wavelight Laser technology GmbH (Figs 37.7A to C and Table 37.3). In
our clinical research, we use the serial number 10021009. This phaco laser integrates
in one instrument an erbium: YAG laser system, a peristaltic vacuum system, and a
diathermy unit. A special tip allows circular continuous laser capsulotomy The same
instrument, with different tips allows cataract surgery, iridectomy, vitrectomy (?) and
antiglaucomatous ab externo laser sclerostomy.
With the Adagio, pulsed laser energy is used to vaporize and photofragment
(emulsify) high water contents lens material out of the eye. With the newly designed
probes, irrigation, aspiration and laser are simultaneously transmitted to a precise location
in the eye through a single small incision. Adagio has an integrated water cooling and
does not require any special installation practices.
Phacoemulsification
542
Fiberoptic Design
Because Er: YAG can be transmitted by fiberoptics, it has a great potential for intraocular
procedures. The best kept secret of this laser is the material, the fiberoptic and the tip
fiber are made of. As laser energy is being absorbed by water, we could not use quartz
because it has too high a water content. Instead, we use a fluoride/zirconium based
fiberoptic (Figs 37.8 and 37.9). The first fibers were extremely fragile (and expensive):
new fibers are more resistant, though not cheaper.
FIGURES 37.7A TO C Pictures show

the handpieces we are currently using
for cataract surgery with the
545
Wavelight Adagio phaco laser

systemthe handpiece incorporates a
laser fiber (see detail, in red), an
irrigating port through the silicone
sleeve and an aspirating port parallel to
the fiberoptic
FIGURE 37.8 Figure shows a

continuous long-term test of the
durability of NIR fibers made of
zirconium fluoride. It proved that these
fibers, which fail easily when
transmitting 800 mJ of input energy,1
survive much longer at a lower energy
level of 600 mJ2. To do this test, the
free-running laser produced pulses of
500 microseconds at 10 Hz (picture
taken from improved Erbium Laser
Parameters by Klaus Vogler and Max
Reindl, in Biophotonics InternationalNovember/December 1996. Page 41)
FIGURE 37.9 Close examination of

the distal end face of a 600
Phacoemulsification
544
micrometer-core zirconium fluoride

fiber reveals significant damage at the
surface. The utility and resistance of
these fibers have improved in the last
few years. (Picture taken from
Improved Erbium Laser Parameters
by Klaus Vogler and Max Reindl, in
Biophotonics InternationalNovember/December 1996. Page 41)
Cataract Surgical Procedure
The initial approach to cataract surgery is much similar to classical ultrasonic phaco
technique. The main difference is that instead of mechanical ultrasonic energy, laser
energy is used. Surgery can be performed under local (retro or peribulbar, topical or
intraocular) or general anesthesia. Wide
TABLE 37.3 Wavelight Laser Technology GmbH

Adagio phaco laser system specifications
Laser system
Specifications
Type
Wavelength
Pulse duration
Pulse energy
Pulse frequency
Usual working
parameters
Maximum output
Radiation
transmission
Laser class
Aiming beam
Safety standard
Solid state/Erbium: YAG

2940 nm
50150 microseconds
up to 100 mJ (panel or linear, pedal controlled)
up to 100 Hz (panel or linear, pedal controlled)
2060 mJ and 2050 Hz
Power
Handpiece
General system
Fluidics
Diathermy
2W (100 mJ)
Fluoride based fiber
4
diode laser (635 nm), continuous wave, 1 mW max
IEC 601/IEC 825, Medical device law
EU conformity declaration 93/42/EEC
Foots witch (4 positions: rest, irrigation alone, I/A, I/A+laser)
combined laser-I/A, autoclavable different fiber tips (anterior capsulotomy,
vitrectomy, sclerostomy)
Specifications
Peristaltic paraflow vacuum system
Premiere DPX 100 (Storz Instrument Co. St. Louis, USA)
Aspiration range: 040 ml/min
Vacuum range: 0500 mn Hg (linear)
Yes
547
Display and indicators Video CRT and Computer touch panel

Power connection
100/230 V, 50/60 Hz
max. 3.2 kW
Cooling
Integrated water cooling
Weight
65 kg
Dimensions
1024075 cm3
FIGURE 37.10 Wide mydriasis is

preferable, though not essential. It
allows better surgical view. We have
noticed that pupil tends to contract as
laser progresses
mydriasis is preferable, though not essential (Fig. 37.10).
We prefer a slightly side-incision (temporal) approach to ease surgical maneuvers with
the laser tip. A clear corneal single plane 2.5-mm incision is made, being the gateway for
laser phacoemulsification and for foldable IOL implantation. Smaller incisions will soon
be able with new phaco laser tips.
After the incision has been completed, viscoelastic (any of the currently used
substances) is injected to fill the anterior chamber, and thus protect corneal endothelium
from shockwave damage. Performing a clear-cornea paracentesis in the opposite side is
preferable for better rotation and positioning of nuclear fragments.
Capsulorhexis may be performed either using a cystitome (30 G bent needle, the
classical way), the
Phacoemulsification
546
FIGURE 37.11 When capsulorhexis is

performed with the special
capsulorhexis laser tip, it is less regular
than mechanical capsulorhexis with the
cystitome or the Utrata forceps
FIGURE 37.12 A special

capsulorhexis laser tip has been
designed to allow continuous circular
laser anterior capsulotomy
Utratas forceps, or a specially designed laser capsulorhexis tip (Fig. 37.11). This laser tip
allows circular continuous laser capsulotomy (capsulorhexis) even in cataracts without
red reflex (Fig. 37.12). One important point to ease surgery is performing a wide
capsulorhexisthis will allow luxation of the superior pole of the dissected nucleus and
cortex to better and faster fragment it with the Er: YAG laser. The goal is to use the
lowest possible energy levels, to make phaco laser a safe technique.
Hydrodissection and hydrodemarcation of the cortex and nucleus follow, with
balanced salt solution (BSS) and a 27 gauge anterior chamber cannula. Up to now there
are no surgical differences with ultrasonic phacoemulsification technique. Whatever
technique you are using, good nuclear rotation is essential.
549
In soft cataracts, where Er: YAG laser works at its best, you can proceed the same way
you do in ultrasonic phacoemulsificationa divide and conquer technique may be used,
with very high aspiration levels to attract the cortex and nuclear masses to the tip.
Nevertheless we prefer performing complete nuclear phacofragmentation-aspiration,
starting at high frequency (5060 Hz) and low-energy levels (2030 mJ)superior
cortex is ablated and aspirated, and nucleus fragmented and aspirated by the laser energy.
We direct the laser beam over the cortex and nucleus as we would use an eraser to wipe
over a surface. The laser tip is directed as perpendicular as possible over the ablation
zone, producing optical breakdown at the beams tip. As a result, we obtain a tough
posterior cortical shell, that can be luxated to the pupillary area with the manipulator, cut,
fragmented and aspirated with the laser, at lower frequency (2030 Hz) and higher
energy (4050 mJ). Working in the pupillary area, never in the anterior chamber, far from
the posterior capsule, we avoid posterior capsule breaks. Sometimes, it will be advisable
to inject some viscoelastic under the corticonuclear shell, to lift it and allow easier and
safer laser manipulation. Touching the tip of the laser with the manipulator is not
dangerous for the tip.
Our in vitro trials showed that laser energy (thermal and acoustic laser effect) is not
only limited to the end of the tip as we first thought, but can go 1 to 2 mm away from it,
endangering the posterior capsule. Nevertheless, posterior capsule break arises when the
capsule is directly touched by the laser at work. We suggest you to work as far away as
possible of the posterior capsulethis is not difficult with a sealed incision and good
intraocular pressure (25 mmHg) obtained by the I/A system that pushes the capsule
backwards.
Due to hydrodemarcation, nuclear mobility may make removal difficult because of the
tendency to move away from the laser phaco tip. To avoid this, a nuclear manipulator
may be used through the
FIGURE 37.13 Superior pole luxation

eases emulsification, since laser better
attacks the cortex from the equator of
the lens
paracentesis, to stabilize the masses. Do not forget that this laser is not effective without a
close contact of the mass to be ablated and the laser phaco tip. Without this contact, laser
energy is wasted as undesirable heat and Shockwaves in the anterior chamber.
Phacoemulsification
548
For all kind of cataracts, specially when the nucleus is hard, laser phaco chopping may
be specially difficult if the rhexis line is not clearly seen. That is why we perform a wide
capsulorhexis, as wide as possible. After good rotation of the nucleus, we perform
luxation of the superior pole of the lens contents (Fig. 37.13). The superior pole may be
cut with the laser through an equatorial approach, in the pupillary area. If necessary, you
can inject some viscoelastic under the cortex to ease this luxation (viscoexpression). The
nucleus is split into small pie-shaped pieces and gradually aspirated out. We prefer a twohanded technique, which makes surgery easier and faster, though one-handed is also
possible if you are not stressed by time.
Luxating the superior pole to pupillary area avoids nuclear movement and zonular
stress, making surgery easier.
FIGURE 37.14 Picture shows Adagio

Er: YAG laser at worknotice that the
early tips had a metal sleeve instead of
the todays blue silicone sleeve
FIGURE 37.15 IOL lens insertion

does not differ from ultrasonics
Wide capsulorhexis allows safe rotation of the nucleus (by reducing the effects of
friction), allows superior pole luxation, and has the advantage of less future capsular bag
retraction, though it has the disadvantage of slightly more unstable IOL positioning.
551
Cortex remnants are aspirated using a standard I/A probe, followed in the end with the
insertion of a posterior IOL, preferably foldable IOL. We either use silicone lenses,
acrylics or hema with polymethyl-methacrylate (PMMA) rigid haptics (Fig. 37.14). The
ideal foldable or injectable, and stable IOL has yet to be invented.
Even with a complete rhexis and whatever method is used to remove the nucleus, a
break may result. Even so, using Adagio phaco laser we find that rhexis breaks enlarge
less in proportion to what happens with ultrasonic phaco in similar cases (Fig. 37.15).
Frequency and Energy: Vital Parameters
A no vice will experiment some difficulty in balancing frequency and energy levels. The
correct management of both parameters is essential to avoid cooking lens proteins and
dehydrating lens material. In summary, we can say that hard nucleus need low frequency
and high energy soft cataracts need high frequencies and low energy levels. Personal
experience allows better balancing of both parameters.
Both can be controlled on the computer touch panel. If the laser mode (energy and
frequency) is set to panel control, the full preset power will be reached as soon as the
pedal reaches the laser position (I/A+laser).
Adagio laser can also be set to linear control, which gives progressively more laser
energy and/ or frequency as the pedal is progressively depressed.
The foot pedal has also reflux control that reverses flow, so that fluid (capsule or iris)
will flow out of the aspiration port.
The AdagioR Er: YAG laser seems well suited to cut the high water-content structures
of the eye, specially the cataractous soft crystalline lens. Nevertheless, far more research
is necessary until this laser might be widely used for intraocular cataract surgery.
Postoperative Evolution
Typical postoperative aspect and evolution does not differ from that of an ultrasonic
phacoemulsification for an uncomplicated surgery. Mild corneal edema at the incision is
seen if manipulation is excessive, the energy dissipation in the incision area being
negligible. Minimal postoperative inflammation and endothelial cell loss are the rule for
uncomplicated surgery The endothelial cell loss seems very similar to that of our first
ultrasonic phacos, and should improve as we get experienced with this new tool (Fig.
37.16). Complete results of our studies are still awaited.
Phacoemulsification
550
FIGURE 37.16 Postoperative aspect

of uncomplicated patients treated with
the Erbium: YAG Wavelight Adagio
system does not differ at all from that
of patients treated with ultrasounds.
Nevertheless, we have observed a mild
increase of the intraocular pressure the
first days after surgery. This IOP
increase was common in patients that
underwent the first ultrasonic cataract
surgeries
FIGURE 37.17 IOP rise

Mild to moderate intraocular pressure rise is common a couple of days after surgery (Fig.
37.17). Postoperative medication may be necessary in patients with advanced
glaucomatous optic nerve damage.
Short-term follow-up of our first patients has revealed no adverse effects or
extraordinary complications.
In our clinical study with volunteer patients, we also perform corneal topography,
before surgery and three months after surgery. Preliminary results seem to show that
553
there are no special topographic changes that might be attributable to Er: YAG. Corneal
topographic changes do not differ from that of ultrasonics.
Anterior Chamber Temperature
Since Er: YAG laser use in human eyes still raises some safety concerns, we are also
checking temperature rise in anterior chamber. For an uncomplicated surgery of about 10
to 15 minutes, temperature rise is lower than 10C, and should suppose no special danger
for endothelium, as it reverses after a few minutes. I/A system minimizes temperature
rise, as it permanently cleans and refreshes anterior chamber. At the energy levels we use
(2060 mJ), there is actually no need for cold BSS. As we are planning to increase energy
levels in a close future in order to be able to deal with harder nuclei, the use of cold BSS
will probably become necessary.
Conclusion
The Er: YAG phaco laser works at its best with soft and middle-soft cataracts, yet has
some important difficulty with middle hardness and hard nuclei (Table 37.4).
Nevertheless we are sure laser will soon be a major force in cataract removal. The
incision size is getting smaller and smaller, minimizing postoperative astigmatism. To
new small-incision surgeons, it has the advantage of a shorter learning curve.
Experienced surgeons will have to slightly modify their phaco technique, and will be
satisfied to use a modern new tool that may achieve cataract surgery in a safer and easier
way.
Initially dismissed as being unsafe and not effective enough, we believe that through
perseveration, Er: YAG phaco laser improvements will develop into a procedure that will
gain worldwide acceptance as a safe effective method of removing cataracts (see Chart
37.1). But there is still a long way to go, a lot of work to be done.
TABLE 37.4 Advantages and disadvantages of Er:

YAG
Advantages
Effectively removes cataractous lens
cortex and nucleus (in soft and middle
hardness nuclei)
Best absorption under water
Safe and easy to learn
does not directly damage adjacent
tissues
less thermal damage
endothelial cell loss not worse than
ultrasound
Many potential different ophthalmic
uses (cataract, glaucoma, retinal and
Phacoemulsification
552
vitreous surgery, cosmetic surgery)

Disadvantages
Slowablation mass smaller than
other techniques (ultrasound, Ho: YAG
laser?)
Not risk free (posterior capsule break,
IOP rise)
Fragile and perishable fiberoptics
Still some technical problems to be
solved
Expensive?
Does not work properly with hard
nuclei
Further Reading
1. Agarwal S: Laser can be used to ablate cataracts. Ocular Surgery News (International ed)
8(9):1997.
2. Bath PE: Laserphacoan introduction and review. Ophthalmic Laser Ther 3(2):7582, 1988.
3. Bath PE, Kar H, Apple DJ et al: Endocapsular excimer laser phakoablation through a 1-mm
incision. Ophthalmic Laser Ther 2(4):24548, 1987.
4. Bath PE, Mueller G, Apple DJ et al: Excimer laser lens ablation (letter). Arch Ophthalmol
105:116465, 1987.
5. Bonnie SR, Puliafito CA: Erbium: YAG and Holmium: YAG laser ablation of the lens. Lasers
Surg Med 15:7482, 1994.
6. Borkman RF: Cataracts and photochemical damage in the lens. Ciba Found Symp 106:88109,
1984.
7. Brown S: The multipurpose 1053 picosecond laser. Presented at the American Society of
Cataract and Refractive Surgery (ASCRS) Annual Meeting, 1990.
8. Cleary SF: Laser pulses and the generation of acoustic transients in biological material. In
Wolbarsht ML (Ed): Laser Applications in Medicine and Biology New York: Plenum Press,
3:175219, 1977.
9. Cleary SF, Hamrick PE: Laser induced transients in the mammalian eye. J Acoustic Soc Am
46:103744, 1969.
10. Colvard DM: Erbium: YAG laser removal of cataracts. Presented at the American Society of
Cataract and Refractive Surgery (ASCRS) Annual Meeting, 1993.
555
CHART 37.1 Wavelight Adagio:

Er-YAG laser cataract surgery
Phacoemulsification
554
12. Dodick JM, Christiansen J: Experimental studies on the development and propagation of shock
waves created by the interaction of short Nd: YAG laser pulses with a titanium targetpossible
implications for a Nd: YAG laser phacolysis of the cataractous human lens. J Cataract Refract
Surg 17(6):79497, 1991.
13. Dodick JM, Sperber LTD, Lally JM et al: Laser phacolysis of the human cataractous lens. Arch
Ophthalmol 111:90304, 1993.
14. Ebran JM, Buisson JP, LHuillier JP et al: Absorption cristallinienne du laser Er: YAG (French
with English summary). Ophthalmology 3(9):26572, 1995.
15. Jean B, Kriegerowsky M, Bende T: Correction of myopia with Er: YAG laser fundamental
mode photorefractive keratectomy. J Ref Surg 5:392, 1995.
16. Kelman CD: Phacoemulsification and aspiration-a new technique of cataract removal, a
557
17. Kochevar IE: Cytotoxicity and mutagenicity of excimer laser radiation. Lasers Surg Med
9(5):44045, 1989.
18. Li Zhao-zhang, Code JE, Van de Merwe WP: Er: YAG laser ablation of enamel and dentin of
human teethdetermination of ablation rates at various fluences and pulse repetition rates.
Laser in Surg and Med 6(12):625, 1992.
19. Li Zhao-zhang, Reinisch L, Van de Merwe WP: Bone ablation with Er: YAG and CO2 laser
study of thermal and acoustic effects. Lasers in Surg and Med 1(12):79, 1992.
20. Maguen E, Martinez M, Grundfest W et al: Excimer laser ablation of the human lens at 308 nm
with the fiber delivery system. J Cataract Refract Surg 15:40914, 1989.
21. Margoli TI, Farnath DA, Destro M: Erbium-YAG laser surgery on experimental vitreous
membranes. Arch Ophthalmol 107:42428, 1989.
22. Marshall J, Sliney DH: Endoexcimer laser intraocular ablative photodecomposition (letter). Am
J Ophthalmol 101(1):13031, 1986.
23. Muller-Stolzenburg N, Muller GJ: Transmission of 308 nm excimer laser radiation for
ophthalmic microsurgerymedical, technical and safety aspects. Biomed Tech (Berlin)
34(6):13138, 1989.
24. Muller-Stolzenburg N, Stange N, Kar H et al: Endocapsular cataract surgery using the excimer
laser at 308 nm (in German with English abstract). Fortschr Ophthalmol 86(6):56165, 1989.
25. Nanevicz T, Prince MR, Gawande A A et al: Excimer laser ablation of the lens. Arch
Ophthalmol 104:182529, 1986.
26. Parel JM, Simon G and the members of the accommodation club: Phaco-Ersatz 2001update.
Anales del institute Barraquer 25:14351, 1955.
27. Pellin MJ, Williams GA, Young CE et al: Endoexcimer laser intraocular ablative
photodecomposition (letter). Am J Ophthalmol 104:11822, 1986.
28. Peyman GA, Katon N: Effects of an Erbium: YAG laser on ocular structures. Ophthalmol
10:24553, 1987.
29. Peyman GA, Kuszak JR, Weckstrom K et al: Effects of XeCl excimer laser on the eyelid and
anterior segment structures. Arch Ophthalmol 104:11822, 1986.
30. Pita-Salorio D, Simon G: Cirugia laser de la cataract. Course at the Faculty of Medecine. Spain,
Santiago de Compostela, 1996.
31. Pita-Salorio D, Simon-Castellvi G, Canals-Imhor M et al: Er: YAG laser tissular effects on
human cristalline lens. Proceedings of the XIth Congress of the European Society of
Ophthalmology, Budapest (Hungary), 1997.
32. Pita-Salorio D, Simon G: Chirurgie des cataractes au laser Er: YAGpremieres impressions
French with English summary. Ophthalmoloy 11:26467, 1997.
33. Pita-Salorio D, Simon G: Poster presented at the Aesculap-Meditec booth. American Academy
Meeting 1995.
34. Pita-Salorio D, Simon G: Er: YAG laser tested in ten eyes. Ocular Surgery News (International
ed) 7(2):1996.
35. Pita-Salorio D, Simon G et al: Erbium: YAG laser cataract surgery. Course. Presented at the
American Society of Cataract and Refractive Surgery (ASCRS) Annual Meeting 1998.
36. Puliafito CA, Steinert RF: Laser surgery of the lensexperimental studies. Ophthalmology
90(8):100712, 1983.
37. Puliafito CA, Steinert RF, Deutch TF et al: Excimer laser ablation of the cornea and lens
experimental studies. Ophthalmology 92:74148, 1985.
38. Trentacoste J, Thompson K, Parrish RK II et al: Mutagenic potential of a 193 nm excimer laser
on fibroblasts in tissue culture. Ophthalmology 94:12529, 1987.
39. Tsubota K: Application of Erbium: YAG laser in ocular ablation. Ophthalmologica
200(3):11722, 1990.
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40. Visuri SR, Pristowsky JB, Walsh JT: Er: YAG laser ablation of pairie dog gallbladder
epithelium for the prevention of gallstones. Laser Surg Med 4(15):358, 1994.
41. Wang Kang-sun, Li Qi, Lan Zhi-lin: Comparison of Er: YAG and excimer laser corneal
ablation in rabbits. Lasers Light Ophthalmol 2:69,1994.
42. Wetzel W, Hring G, Brinkmann R et al: Laser sclerostomy ab externo using the erbium: YAG
laser. German J Ophthalmol 2:14, 1993.
43. Wetzel W, Scheu M: A new application system for laser sclerostomy ab externo. Laser Light
Ophthalmol 5(4):19398, 1993.
44. Williamson WA, Aretz HT, Weng G: In vitro decalcification of aortic valve leaflets with the
Er: YAG laser, Ho: YAG laser, and the cavitron ultrasound surgical aspirator. Laser in Surg and
Med 4(13):421, 1993.
38
Cataract Surgery with Dodick Laser
Photolysis
Jorge L Alio
Valerio De Iorio
Introduction
The possibility of cataract removal using a laser system has been investigated in the last
15 years as an alternative to the present ultrasound phaco system introduced by Kelman
in 1967.1 The first presentation of the idea of laser cataract removal was done by Jack
Dodick at the American Academy of Ophthalmologys 1989 annual meeting2 and in 1991
he performed his first case using a pulsed 1064 nm Nd: YAG laser.3,4 The technique was
presented as an alternative of the ultrasound phacoemulsification. As a matter of fact,
even if the effectiveness of the ultrasound phacoemulsification with all degree of nuclear
density is well known, this technique is not free of drawbacks, complications such as
burns at the wound, the potential damages of the endothelial cells, of the iris, the
mechanical trauma due to the turbulence of the fluids and the nuclear fragments specially
of hard cataracts and the always present risk of posterior capsule breaks.5
Technical Fundamentals of Laser Photolysis System
Up to now only two solid-state laser system are available for cataract removal: The
neodymium: yttrium aluminum garnet (Nd: YAG) laser, and the erbium: YAG (Er:
YAG) laser.5
The systems using the Nd: YAG laser are divided in: (i) direct acting system
(Photon, Paradigm Medical Industries, Salt Lake City, UT), and (ii) indirect acting
system {(Dodick laser lens ablation device, ARC laser GmbH, Germany) Fig. 38.1}.
The Nd: YAG laser principle has been used for
Phacoemulsification
558
FIGURE 38.1 Dodicks ARC laser

system
FIGURE 38.2 View of the titanium

target inside the laser tip
many years in YAG capsulotomy and is based on the generation of plasma and shock
waves. Specifically the laser-pulsed energy is transmitted from the source by a Quartz
fiber of 300 m through the handpiece, stopping 1.3 mm in front of the Titanium target
inside the tip (Fig. 38.2). This target acts as a transducer converting light energy into
mechanical energy (shock waves). As soon as the light strikes the titanium target, an
optical breakdown (plasma formation) and shock waves result which disrupts the nuclear
material held at the mouth of the aspirating port. In this way there is no light leakage
potentially dangerous for the retina, corneal endothelium and for the eyes of the
surgeon.69
Cataract surgery with Dodick laser photolysis
561
FIGURE 38.3 Laser phaco lysis

handpiece and two port side irrigation
cannula
On the bases of recent studies, comparing the heat produced at the US phaco tip and at
the laser phaco lysis tip, it has been proved that the laser system produces no clinical
significant heat in respect to what happens in the US phaco system,10 for this reason there
is no need of a cooling system. The previous model of handpiece, that included besides
the Quartz fiber and aspiration line the infusion line, now is formed only by Quartz fiber
and aspiration (Fig. 38.3). In this way the purpose of reducing both the handpiece
dimensions and the diameter of the tip and obviously the incision size is reached.
Consequently, the surgical approach has been modified from unimanual to bimanual
configuration, in which the infusion connected with a conventional I/A phaco system,
better with Venturi-based pumps is introduced through a second paracentesis.11 Actually
the diameter of the tip is 1.2 mm and the wound size to implant a foldable IOL has to be
enlarged up to 3.4 mm.
Selection of Patients and Indications
Up to this moment the cataract density that we are able to treat range from +1 to +3.
The hard cataract of more than +3 or +4 and harder, for the moment remain treatable
in our hands, only with the US phacoemulsification. We found that an optimal elective
indication nowadays of Dodicks laser photolysis is for lens refractive surgery.
Considering the very delicate way of working of this device, other excellent
indications are subluxated cataractous lenses and post-traumatic cataracts of not high
density, zonular laxity and some congenital cataracts.
Anesthesia
Topical anesthesia: Generally, the laser photolysis, can be done using topical anesthesia
0.75 percent bupivacaine plus 2 percent lidocaine 2 drops every 5 minutes before
surgery, with supplemental intracameral preservative-free 1 percent lidocaine diluted
Phacoemulsification
560
1:1 in balanced salt solution (BSS). Additionally we can use to add sedation with 1 mg
of Dormicum and 0.5 mg of Limifen, upon patient needs.
However, we may prefer to use other anesthesia options in order to eliminate
intraoperative eye movements, especially in young anxious patients and according
to the surgeons preference.
Peribulbar anesthesia with 8 cc of 0.75 percent, bupivacaine and 2 percent lidocaine
plus Tiomucase to help the diffusion in the orbit: Special attention should be taken in
the anesthesia of high myopic eyes with posterior staphyloma. Mild venous sedation is
used when necessary, specially to decrease the pain sensation during the injection of
the anesthetic solution. In this case we use 1 mg per kg of Propofol EV.
Retrobulbar anesthesia has been abandoned in our hands, specially in the elongated
myopic eye, due to the risk of globe perforation.
General anesthesia is not necessary unless requested as in very young patients.
Sub-tenonian anesthesia with blunt Fukasaku cannula (Katena, products. Inc. Denville;
New Jersey, USA. Ref. K74002) of 1 percent lidocaine, provides an alternative
option specially with sclerocorneal approach in high myopes.
Then a light compression with the Honan balloon is applied for 5 minutes, 15 minutes
before surgery.
FIGURE 38.4 First paracentesis with

a 1.4 mm calibrated blade at 2 Oclock
position
Surgical Technique with Dodick Laser Phacolysis: Our Experience
We have operated 45 patients with this device with cataract density of +1/+3, and all
except the first five cases, under topical anesthesia. We perform first two watertight
paracentesis in clear cornea 90 apart, at 10 and 2 Oclock with 1.4 mm blade (V-Lance
Knife, Alcon Surgical, Fig. 38.4) followed by the injection of 1 percent lidocaine
preservative-free diluted 1:1 in BSS. Two different viscoelastic solutions are used in the
anterior chamber, first Viscoat (Alcon Cusi, Barcelona, Spain) to protect the
endothelium, then Celoftal (Alcon Cusi, Barcelona, Spain) to increase volume in the
563
anterior chamber (AC). A 5.5 mm continuous curvilinear capsulorhexis (CCC), is

performed with Condon capsulorhexis forceps (John Weiss, Milton Keynes, England.
Ref. 0101566), which is the only one that we have found effective through the watertight
incision (Fig. 38.5). After the hydrodissection of the cortex and nucleus with a flat
cannula, we introduce first the irrigation cannula with two-port side, at 2 Oclock
incision, then the phaco laser tip at 10 Oclock incision. The laser lysis of the cataract can
be described as touch, pulse, aspiration.11 In fact the ablation of the nucleus begins
applying
FIGURE 38.5 Continuous curvilinear

capsulorhexis (CCC) with Condon
forceps through the 1.4 mm incision
lightly the probe on the anterior surface of the cataract then a pulse of laser is delivered at
the lower laser set power with vacuum level of 250 mm Hg using the Venturi pump of
the Accurus device (Alcon Ref. 8065740238): and the fragment is aspirated (Figs 38.6A
and B). We have found less effective the peristaltic pump used previously in our initial
cases. The nucleus is cracked after creating a deep initial groove, as soon as is possible.
When all the nucleus is aspirated, we insert at 10 Oclock position the aspiration cannula
decreasing the vacuum till 100 mmHg and we finish to clean the cortex remnants (Fig.
38.7). After the injection of a dispersive cohesive viscoelastic solution like
methylcellulose Celoftal (Alcon Cusi, Barcelona, Spain) in the capsular bag, we enlarge
the 10 Oclock incision up to 3.2 mm and we implant a foldable IOL (Figs 38.8A and B).
The procedure terminates with the aspiration of the viscoelastic solution using specific
I/A cannula (Geuder, GmbH, Heidelberg, Germany. Ref. G-32774; G-32769) in
continuous irrigation and hydrating the two wound with BSS (Figs 38.9 and 38.10).
The reason why we perform two watertight incisions is because this procedure utilizes
high vacuum, so it is necessary to work in a closed pressurized surrounding, the only
drawback is the needs to screw a bit the tips into the incision.
Phacoemulsification
562
FIGURE 38.6A Laser lysis and

aspiration of the nucleus
FIGURE 38.6B Aspiration of cortical

material
Usually with +1/+2 density cataracts, 40 to 100 pulses are sufficient to complete the
procedure, while with +3 density we use about 300 to 400 pulses. The bottle of BSS is
fixed 75 cm high from the patients head.
If placed at a higher level, the excessively high intraocular pressure (IOP), may induce
initial vagal response to the patient due to the induction of oculo-vagal reflex.
565
FIGURE 38.7 Cleaning of the cortical

cells with the aspiration cannula
FIGURE 38.8A Implantation of a

foldable IOL with Buratto IOL folder
forceps, after enlarging the incision up
to 3.2 mm
Transition from Phacoemulsification
The transition from the US phacoemulsification to the photolysis system is easy, the
surgeon has only to be customized on working in a pressurized anterior chamber.
Converting into Phacoemulsification
If for any reason the surgeon has to interrupt the photolysis technique, for instance when
the nucleus is harder than what he expected, before entering with the phaco tip, he has
first to enlarge the 10 Oclock incision up to 3.2 mm, then to avoid the anterior chamber
collapse due to the excessive
Phacoemulsification
564
FIGURE 38.8B Implantation of an

injectable acrylic IOL, after enlarging
the incision up to 3.2 mm
FIGURE 38.9 Aspiration of

viscoelastic solution with I/A cannulas
outflow of fluidics, has to stitch the 2 Oclock paracentesis. In this way, it is possible to
complete the operation as the usual phacoemulsification.
Cataract Surgery and Clear Lens Extraction in High Myopia with
Photolysis Laser System: Our Technique
In high myopic patients, in whom we implant a non-foldable IOL, the AL-3 (Domilens,
Chiron Vision, Lyon, France) we use a scleral approach.
567
FIGURE 38.10 Hydration of the two

incisions with BSS solution
This lens for its concavoconvex shape, seems to maintain better the anatomical relations
between the posterior capsule, the vitreous, and the retinal periphery, decreasing in this
way the risk of retinal detachments,12 more frequent after clear lens extraction, specially
in the high myopic patients, and the posterior capsular opacification (PCO).
After preparing the patients with topical anesthesia, we perform a superior limbal
conjunctival peritomy, and we insert the Fukasaku cannula (Katena, Products Inc.
Denville; New Jersey, USA. Ref. K74002) for a sub-Tenon anesthesia with 1 percent
lidocaine. A 7 mm Frown incision with a 45 blade is done 2 mm from the limbus (Fig.
38.11 A), then with a crescent knife we create a scleral tunnel 1 mm towards the cornea
in order to create an anastigmatic incision (Fig. 38.11B). The procedure continues as
usual creating two side ports of 1.4 mm at 10 and 2 Oclock, injection of viscoelastic
solutions, CCC with the Condon forceps, hydrodissection, laser photolysis, at that point
we open the anterior chamber with a 3.2 mm knife and widening the incision with a
crescent knife before IOL implantation (Figs 38.12A to C). Even if the sclerocorneal
incision should be self-sealing, because of the abnormal consistency of the high myopic
sclera, we prefer to use a continuous 100 nylon suture to avoid an against-the-rule
(ATR) postoperative astigmatism due to the dehiscence or disinsertion of the sclera,
finally we complete the procedure aspirating the viscoelastic solution, hydrating the
incisions and
FIGURE 38.11A Frown incision 2

mm from the limbus
Phacoemulsification
566
FIGURE 38.11B Creation of a

sclerocorneal tunnel, to introduce a
polymethylmethacrylate (PMMA) IOL
after Dodicks photolysis in a high
myope
closing the conjunctival peritomy with diathermy or with one drop of adhesive (ADAL-2
TM, Medical Inc., Alicante, Spain).
Postoperative Medication
Dexamethasone alcohol 0.1 percent (Maxitrol, Alcon Cusi, Barcelona, Spain),
prednisolone acetate 1 percent (Pred Forte, Allergan SA, Madrid, Spain) 3per day
per 3 weeks.
Tobramycin eyedrops are used for 3 days at postoperatively.
Diclofenac eyedrops are used for 1 month.
FIGURE 38.12A View of: aspiration

cannula, a new infusion cannula
provided of a hook for chopping the
569
harder nucleus and the two-port side

infusion cannula
FIGURE 38.12B Enlarged view of the

three cannulas
Complications
We can just aspect some generic complications in common with the US
phacoemulsification technique.
Endothelial Cell Count
Long-term specular microscopy follow-up of the endothelium preoperatively and
postoperatively will be required to document that the rate of endothelial cell loss does not
exceed that of
FIGURE 38.12C Enlarged view of the

tip of the new infusion cannula
Phacoemulsification
568
traditional ultrasound phacoemulsification. In this regard Dodick referred that in his last
series of cases, he found that the endothelial cell loss ranged from 0 to 6 percent, and no
change in corneal thickness following the procedure occurred.5
Posterior Capsule Rupture
In our experience we had only two cases of capsular breaks due to the use of the highlaser power setting used in soft cataracts. Generally no specific postoperative
complications happened to our cases, anyway we cannot refer any about other surgeons
experiences. No other complications were observed. Corneal edema, even minimal, was
never observed at the slit-lamp examination, even at the early postoperative period.
Advantages and Disadvantages
This system appears to be safer for the corneal endothelial cells, for the posterior capsule,
and the iris. Practically no heat production is produced and there are no corneal burns.
The ergonomic shape of the handpiece gives to the surgeon a more comfortable way of
working. Moreover we emphasize the low energy and the low fluidics used, the stability
of the anterior and posterior chamber during the procedure, the quietness if compared to
the traditional phacoemulsificator device and most important of all the minimal
incision surgery (less than 2 mm), VS the small incision surgery (more than 2 mm).
The procedure itself has low cost, considering the quartz fiber, the handpiece and the
disposable titanium target. For the moment only the laser system has high cost.
Technically the only limitation is the hard cataract.
Future Trends
The big target pursued by all the surgeons to perform a cataract operation with the
Minimal incision, seems finally to be catch, and the old dream of injecting a malleable,
clear polymer trough a small capsulotomy, capable of accommodation, brings to our
memory the Phacoersatz idea.13 Now the biggest effort has to be done by the company
interested on inert polymer that could really mimic the human lens and its characteristic
accommodation ability. We can imagine that the new kind of IOLs, could be liquid,
injectable and made of silicone, hydrogel or collagen.11
Summary
More than 20 years have passed since Kelman introduced the US phaco system,1 till
Dodick presented his first laser phacolysis cataract extraction.24 From that moment
different types of phaco lasers have been tried. Actually only two-laser system are used
for this purpose: (i) the Nd: YAG laser, and the Er: YAG laser. Our personal experience
is referred to the Dodick laser photolysis device. The undoubted advantages (Table 38.1)
of this technique are: the minimal incision, the safety for the endothelium, the very low
571
rate of posterior capsular rupture, no heat production at the tip and consequently no
corneal burns, the very delicate and controllable way of cataract removal, the minimal or
practically absent intra/postoperative complications and the safe and fast learning curve.
The main technical limitation is represented by the high-density cataracts. Today the
most important indication seems to be the surgical treatment of high degree of refractive
errors through clear-lens extraction and IOL implantation (phaco refractive cataract
surgery). Our experience with high myopic patients, seems to confirm the suitability of
this device in order to avoid any complications in treating this particular kind of eyes.12
Because of the safety of this technique, other indications could besubluxated lens,
zonular laxity, post-traumatic cataracts and congenital cataracts. Now, to make use
properly of the advantages brought by this Minimal incision surgery, we must wait for
the technical improvements in the development of new IOLs materials.
References
1. Kelman CD: Phacoemulsification and aspirationa new technique of cataract removal, a
preliminary report. Am J Ophthalmol 64:2335, 1967.
2. Use of Neodymium-YAG laser for removal of cataracts is reported. Ophthalmology Times
1:1989.
3. First Laser Phacolysis proves a success. Ophthalmology Times, 1991.
4. Dodick JM, Sperber LTD, Lally JM et al: Nd: YAG laser phacolysis of human cataractous
lensa case report. Arch Ophthalmol 111:90304, 1993.
5. Aasuri MK, Basti S: Laser cataract surgery. Current Opinion in Ophthalmology 10:5358, 1999.
TABLE 38.1 Dodicks photolysis laser system:

settings (Prof. Jorge L. Alio, Instituto
Oftalmologico de Alicante)
Cataract hardness from 0 to Soft clear
5+
lenses
1+
2+
3+
Frequency
Laser power
1sec
Low energy
1sec
Low energy
3sec
High energy
Vacuum power (Venturi pump) 250 mmHg

Vacuum
Mean number of pulses to finish 10 pulses
the cataract
250 mmHg
Vacuum
40 pulses
23sec
High>Low
energy
250 mmHg
Vacuum
100 pulses
400 mmHg
Vacuum
300400 pulses
7. Dodick JM, Lally JM, Sperber LTD: Lasers in cataract surgery. Current Opinion in
Ophthalmology 4(1):10709, 1993.
8. Dodick JM, Cristiansen J: Experimental studies on the developement and propagation of shock
waves created by the interaction of short Nd: YAG laser pulses with a titanum targetpossible
implications for Nd: YAG laser phacolysis of the cataractous human lens. J Cataract Refract
Surg 17:79497, 1991.
9. Lewin PA, Bhatia R, Zhang Q et al: Characterization of optoacoustic surgical devices. IEEE
Transaction on Ultrasonics, and Frequency Control 43(4):1996.
Phacoemulsification
570
10. Alzner E, Grabner G: Dodick laser phacolysis: termal effects. J Cataract Refract Surg 25:800
03, 1999.
11. Laser Lens Lysisa new approach to very small incision cataract surgery Cataract and
Refractive Surgery Euro Times, 6:1997.
12. Dorothy SP Fan, Dennis SC Lam, Kenneth KW Li: Retinal complications after cataract
extraction in patients with high myopia. Ophthalmology 106:68892, 1999.
13. Haefliger E, Parel JM, Fantes F et al: Accommodation of an endocapsular silicone lens
(phacoersatz) in non human primate. Ophthalmology 94:47177, 1987.

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Phacoemulsification

LONDON AND NEW YORK

1998, 2000, 2004 Sunita Agarwal, Athiya Agarwal, Amar Agarwal

First published in India in 2004 by

ISBN 1 84184 470 5 (Print Edition)

This two volume book on Phacoemulsification is dedicated to two wonderful people

I Howard Fine MD FACS

Foreword to the Third Edition

Foreword to the Second Edition

Foreword to the First Edition

Preface to the Third Edition

Preface to the Second Edition

With the Mediterranean influence of L Burrato we have a new chapter on the

Preface to the First Edition

Section I: Cataract and Preoperative Evaluation

Section II: Instrumentation and Medication

14. Anesthesia in Cataract Surgery

Section III: Phaco Steps

Section IV: Phaco Techniques

Section V: No Anesthesia Cataract Surgery

28. No Anesthesia Cataract Surgery

Section VI: Phakonit

Section VII: Laser Cataract Surgery

FIGURE 1.1 Mature senile cataract

2. Development and application of drug-related strategies to counteract the development

Congenital and Infantile Cataract

FIGURE 1.2 Anterior polar congenital

FIGURE 1.3 Congenital cortical

FIGURE 1.4 Congenital coronary

TABLE 1.1 Etiology of Infantile cataract

K. Inherited with systemic abnormalities

same pedigree. In an extended pedigree of 28 patients with autosomal dominant nuclear

newborns in the United States and 1:23,000 newborns in Ireland. A homozygous

Hankinson et al in a prospective study examined the association of BMI with cataract

Marital status is a measure of social support which is postulated to be an important

TABLE 1.2 Smoking and the risk of cataract

Relative risk 95%

Leske et al, 1991 1.68

was 1.09 (confidence interval, 1.041.16). The frequency of posterior subcapsular

FIGURE 1.5 Diabetic cataract

FIGURE 1.6 The lipid profile of the

TABLE 1.3 Age distribution of patients with

FIGURE 1.7 The prevalence of lens

FIGURE 1.8 Prevalence of lenticular

FIGURE 1.9 Physical signs associated

FIGURE 1.10 Acetylator status of

TABLE 1.4 Extent of light expoxure and the risk of

USA: NHANES Daily hours of sunlight

may have similar or greater antioxidant potential. In addition to -carotene, -carotene,

FIGURE 1.11 Anterior subcapsular

FIGURE 1.12 Vossius ring after

Epidemiologic studies have demonstrated cataract to be more prevalent in sunny

FIGURE 1.13 Progession of steroidinduced cataract

FIGURE 1.14 Posterior subcapsular

FIGURE 1.15 Tempo of lens

An unpublished study conducted at the University of Stellenbosch Medical School

Biochemistry of the lens

FIGURE 2.1 Human lens protein

FIGURE 2.2 Biochemistry of lens

Biochemistry of the lens

FIGURE 2.3 Chemical composition of

FIGURE 2.4 Active transport process

Biochemistry of the lens

FIGURE 2.5 Schematic diagram