FocalPoints

Clinical Modules for Ophthalmologists

V O L U M E X X V I I I NUMBER 8

S E P T E M B E R 2 010 (2 of 3)

Basic Principles of
Phacoemulsification
and Fluid Dynamics
Uday Devgan, MD, FACS, FRCS (Glasg)

Reviewers and Contributing Editors Consultants

D. Michael Colvard, MD, FACS; Thomas L. Beardsley, MD, Editors for Cataract Surgery Barry S. Seibel, MD
James C. Bobrow, MD, Basic and Clinical Science, Course Faculty, Section 11 Donald N. Serafano, MD
Edward K. Isbey III, MD, Practicing Ophthalmologists Advisory Committee for Education

FPv28n08_0910.indd 1 7/23/10 1:30 PM

 Focal Points Editorial Review Board
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Editor in Chief; Cornea & External Disease
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to view and print your Academy transcript and report D. Michael Colvard, MD, FACS, Encino, CA
CME credit you have earned. You can claim up to two Cataract Surgery
AMA PRA Category 1 Credits™ per module. This will give
Bradley S. Foster, MD, Springfield, MA
you a maximum of 24 credits for the 2010 subscrip- Retina & Vitreous
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Oculoplastic, Lacrimal, & Orbital Surgery
Steven I. Rosenfeld, MD, FACS, Delray Beach, FL
Refractive Surgery, Optics & Refraction
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ii Focal Points : Module 8, 2010

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 Learning Objectives
Upon completion of this module,
the reader should be able to:
• Choose appropriate f luidic settings for
phacoemulsification (phaco) depending on the
surgical situation
• Select phaco power modulations to deliver less
ultrasonic phaco energy into the eye during
cataract surgery
• Describe the difference between peristaltic
and venturi f luid pumps and know the clinical
significance of changing parameters
• Perform safer, less traumatic, and more
efficient cataract surgery by tailoring the
phacoemulsification power and f luidic settings to
the surgical style and patients’ eyes
Financial Disclosures
The authors, reviewers, and consultants disclose the following
financial relationships. D. Michael Colvard, MD, FACS: (C) Abbott
Medical Optics, Bausch & Lomb; (P) OASIS Medical. Uday Devgan,
MD, FACS, FRCS (Glasg): (C) Bausch & Lomb Surgical, Hoya
Surgical Optics, Inspire, Ista Pharmaceuticals; (L) Accutome, Alcon
Laboratories, Bausch & Lomb Surgical, Carl Zeiss Meditec, Haag-
Streit, Hoya Surgical Optics, Ista Pharmaceuticals, Optos, SLACK;
(O) Alcon Laboratories, Bausch & Lomb Surgical, Inspire, Ista
Pharmaceuticals, Renaissance Surgical, Specialty Surgical, STAAR
Surgical; (P) Accutome; (C,L,O,S) Advanced Medical Optics, Allergan.
Steven I. Rosenfeld, MD, FACS: (C) Inspire Pharmaceuticals;
(L) Allergan. Barry S. Seibel, MD: (L) Alcon Laboratories, Bausch &
Lomb; (O) Calhoun Vision, OptiMedica; (P) Rhein Medical, SLACK.
Donald N. Serafano, MD: (C) Alcon Laboratories. C. Gail Summers,
MD: (C) McKesson; (L) BioMarin. Albert T. Vitale, MD: (C) Aciont,
Bausch & Lomb Surgical.
The following contributors state that they have no significant financial
interest or other relationship with the manufacturer of any commer-
cial product discussed in their contributions to this module or with
the manufacturer of any competing commercial product: Thomas
L. Beardsley, MD; William S. Clifford, MD; Bradley S. Foster, MD;
Edward K. Isbey III, MD; Susan R. Keller; Anil D. Patel; MD; Eric P.
Purdy, MD; George A. Stern, MD; Kim Torgerson.
C = Consultant fee, paid advisory boards or fees for attending a
meeting
L = Lecture fees (honoraria), travel fees or reimbursements when
speaking at the invitation of a commercial entity
O = Equity ownership/stock options of publicly or privately traded
firms (excluding mutual funds)
P = Patents and/or royalties that might be viewed as creating a
potential conflict of interest
S = Grant support
FPv28n08_0910.indd 1
Contents
Introduction 1
The Phacoemulsification Platform 2
• Foot Position 1: Irrigation 2
• Foot Position 2: Vacuum and Aspiration
of Fluid 2
• Foot Position 3: Ultrasound Energy 2
Basic Concepts of Fluidics 2
• Modulating Phacoemulsification
Fluid Flow: Poiseuille’s Equation 2
• Modulating Fluid Inflow 3
• Modulating Fluid Outflow 3
Flow Balance and Tubing Compliance 3
• Inflow Versus Outflow Tubing 3
• Phacoemulsification Needle Sizing 3
Peristaltic and Venturi Fluid Pumps 4
• Peristaltic Pump (Flow Based) 4
• Venturi Pump (Vacuum Based) 4
Optimizing Phacoemulsification
Fluidic Settings 5
Fundamentals of Ultrasonic
Phacoemulsification Power 6
• Continuous, Pulse, and Burst
Phacoemulsification Modes 7
• Hyper Settings for Power Modulation 7
• Variable Duty Cycle 8
Conclusion 9
Clinicians’ Corner 10
Introduction
Achievement of the best possible outcomes in phacoemul-
sification requires more than simply the mastery of the
techniques of the procedure. Optimization of outcomes
requires an understanding of the fundamental physics
of the device, and the ability of the surgeon to modify
basic power and f luidic parameters in order to improve
the performance of the device in challenging clinical set-
tings. A thorough understanding of phacodynamics and
Focal Points : Module 8, 2010 1
7/23/10 1:30 PM
 f luidics is necessary before the complete phacoemulsi-
fication surgeon can make these refinements in order
to perform phacoemulsification at the highest level of
proficiency and safety.
The Phacoemulsification
Platform
All phacoemulsification (phaco) platforms share the
same basic structure and concepts. The phaco machine
aims to balance f luidics within the eye, while delivering
ultrasonic energy and vacuum in order to emulsify and
aspirate the cataract through a small incision.
The main functions of the phaco machine are to pro-
vide irrigation into the eye; to create vacuum/aspiration
to remove the cataract; and to deliver ultrasound energy
in order to emulsify the nucleus. These functions corre-
spond to the machine’s 3 foot pedal positions (Figure 1).
Foot Position 1: Irrigation
The irrigation function of the phacoemulsification
machine provides a source of f luid infusion into the eye
during the surgery. Depressing the foot pedal to posi-
tion 1 turns on the infusion. There is no linear control
of the infusion—the infusion is either turned on or
turned off. The height of the infusion bottle determines
the relative infusion pressure and f low rate during the
surgery. To keep the eye inf lated during surgery, the
surgeon needs to make sure that the f luid inf low rate
is at least as great as the f luid outf low rate, because
any excess inf low will pressurize the eye and leak from
Figure 1  Position of the phaco system foot pedal controls
the 3 basic functions of the device. Position 1 delivers irriga-
tion alone, position 2 provides irrigation plus aspiration, and
position 3 adds phaco energy to irrigation and aspiration.
2 Focal Points : Module 8, 2010
FPv28n08_0910.indd 2
the incisions until equilibrium is achieved. An optional
switch for continuous f low is available and is useful in
avoiding inadvertent release of position 1 and potential
collapse of the anterior chamber.
Foot Position 2: Vacuum
and Aspiration of Fluid
Position 2 controls the vacuum and the relative aspira-
tion rate of the f luid from the eye. There may be a linear
control of vacuum and f low, so that the top of position 2
provides less vacuum or f low than the middle or bottom
range of the pedal. This is similar to the gas pedal in a
car, where the car’s throttle opens more as the gas pedal
is further depressed. The vacuum and aspiration levels
created during surgery draw the f luid out of the eye and
into a waste f luid collection via the outf low tubing.
Foot Position 3: Ultrasound Energy
Position  3 controls the delivery of ultrasound energy.
There is linear control of the ultrasound energy level so
that further pedal depression results in more ultrasound
energy. Note that if the pedal is in position 3, the sur-
geon is already engaging the full function of both posi-
tions 1 and 2. The irrigation is on, and the vacuum and
aspiration level is at its highest preset level. Ultrasound
energy should only be applied once the tip of the phaco
probe is in contact with part of the cataract.
Basic Concepts
of Fluidics
Due to the small volume of the anterior and posterior
chambers, the control of f luidics during phacoemulsifi-
cation surgery is critical. By keeping a constant infusion
pressure and by carefully controlling the outf low, the
surgeon can ensure that the eye stays inf lated and stable
during surgery. If the surgeon allows outf low to exceed
inf low, even for a fraction of a second, the chamber is at
risk of collapse.
Modulating Phacoemulsification
Fluid Flow: Poiseuille’s Equation
The basic equation that governs all f luid f low during
phacoemulsification surgery is Poiseuille’s equation:
F = ΔP π r 4/8 η L
In this equation, F = f low, ΔP = pressure gradient,
r = radius of the tube, η = viscosity of fluid, and L = length
7/23/10 1:30 PM
 of the tube (meters). The relative relationship is of more
concern than the exact values. The viscosity of the f luid
is relatively constant, as is the length of the tubing; in
addition, the values of π and 8 are constant. This leaves
a simpler equation:
F ~ ΔP r 4
Flow is proportional to the difference in pressure times
the radius of the tubing to the fourth power. Because the
value for tubing size is exponential, a small change to
the radius results in a large change in the relative f low.
A common-­sense situation clearly illustrates this. When
one drinks through a straw of narrow internal diameter,
more vacuum is required to move fluid than when drink-
ing through a straw of wider diameter (Figure 2).
Modulating Fluid Inflow
The source of f luid inf low is the bottle of balanced salt
solution. The factors that determine the rate of inf low
are pressure and the radius of the inf low tubing. To
modulate the pressure, the surgeon raises or lowers the
height of the bottle relative to the patient’s eye. The
inf low tubing has a large radius in order to maximize
the f low.
Modulating Fluid Outflow
The sources of f luid outf low are (1) the f luid removed
via the phacoemulsification probe due to the vacuum
level generated by the f luid pump, and (2) f luid leakage
Figure 2  Poiseuille’s equation shows that smaller-­bore tub-
ing (a) requires higher vacuum and results in a lower flow,
as compared to larger-­bore tubing (b), which can achieve a
high flow with less vacuum. The change in flow is exponen-
tially related to the radius of the tubing.
FPv28n08_0910.indd 3
from the incisions. The rate of the f luid outf low loss via
the incisions depends on the relative fit of the phaco tip
within the incision.
Some degree of f luid leakage from the incisions is
helpful to allow cooling of the phaco needle and to pre-
vent thermal injury during surgery. With the use of
advanced phaco power modulations, more experienced
phaco surgeons tend to move towards tighter incisions,
which can give more stable f luidics.
Flow Balance and
Tubing Compliance
Inflow Versus Outflow Tubing
The inf low tubing has a large bore and thin walls, and
the tubing is very f lexible. The purpose of this tubing is
to provide a high f low of f luid under low-­pressure sit-
uations. The maximum pressure achieved within this
inf low tubing is determined by the height of the infu-
sion bottle, and this level is not very high.
The outf low tubing has a smaller bore and thick walls,
and the tubing is very rigid and relatively noncompliant.
Because the f low varies exponentially with the radius
of the tubing, the smaller-­bore outf low tubing can help
ensure that the outf low does not exceed the inf low. The
outf low tubing has rigid, thick walls in order for it to
have a low compliance, which helps to prevent surge. The
f luid pump of the phacoemulsification machine deter-
mines the maximum pressure achieved within the out-
f low tubing and can easily exceed 500 mm of mercury.
This high vacuum level can cause collapse of the
outf low tubing if its walls are too thin and compliant.
When the outf low tubing collapses, and then rebounds
back to its normal state after the vacuum level drops,
this energy release causes an immediate and dangerous
surge of f luid out of the eye. This occurs most commonly
after occlusion of the phaco probe, when the occlusion
suddenly breaks and the tubing rebounds, causing the
surge. This is called postocclusion surge and is one of the
main causes of posterior capsule rupture during cataract
surgery (Figure 3).
Phacoemulsification Needle Sizing
The size of the phacoemulsification needle lumen is
important for phaco f luidics because it affects the out-
f low rate. The important thing to remember from Poi-
seuille’s equation is that the f low is proportional to the
radius of the tube to the fourth power. This means that
Focal Points : Module 8, 2010 3
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Figure 3  Compliant outflow tubing can collapse and cause
surge during cataract surgery.
a small change in the size of the phaco needle can result
in a very large change in the f low. Comparing 2 common
size phaco needles, 0.9 mm (20 gauge) versus 1.1 mm
(19 gauge), with all other factors equal it is surprising to
see that the f low through the larger 1.1 mm needle is
more than twice that of the 0.9 mm needle. As the needle
size decreases, the f low drops exponentially.
Peristaltic and Venturi
Fluid Pumps
Two types of vacuum pumps are used in phacoemulsifi-
cation platforms: peristaltic and venturi. Although they
work in different ways, each has its advantages.
Peristaltic Pump (Flow Based)
The peristaltic pump uses rollers to compress the phaco-
emulsification outf low tubing in a peristaltic manner,
thereby creating f low and vacuum. The compression of
the rollers on the tubing with the rotation of the pump
physically moves f luid and creates a continuous “milk-
ing” action on the f luid column. The phaco machine can
directly control this f low level, hence the term flow based;
however, the preset vacuum level is only achieved once
there is occlusion of the outf low line, typically at the
phaco needle tip with cataract material.
As the occlusion happens, the vacuum builds, the roll-
ers slow down, and the outf low level decreases. Most
manufacturers preprogram how the rollers slow down
4 Focal Points : Module 8, 2010
FPv28n08_0910.indd 4
once an occlusion happens at the tip. However, some
machines also allow surgeons to program this speed
based on their technique. Thus, if the surgeon wants a
faster or slower “rise time” to the maximum value of
vacuum, this can be programmed into the system. On
complete occlusion, the rollers come to a stop, the out-
f low approaches zero, and the vacuum is at its highest
level (Figure 4).
Venturi Pump (Vacuum Based)
The venturi pump makes use of the venturi effect to cre-
ate a vacuum. The venturi effect creates a vacuum by the
f low of a f luid, typically air, over an opening. In many
phacoemulsification machines, this requires nitrogen
tanks or a self-­contained air compressor. The vacuum
level is created within a rigid drainage cassette, to which
the phaco aspiration tubing is connected. Since there is
no milking of the aspiration line, the phaco tubing can
be made rigid with low compliance (Figure 5).
The advantage of the venturi pump is that it is able
to create the preset vacuum level without occlusion of
the phaco needle tip. When the surgeon depresses the
foot pedal, the preset vacuum level is immediately cre-
ated, hence the term vacuum based. The venturi and other
vacuum-­based systems typically have the advantage of
much faster rise time, the time required to build up
the desired vacuum level with and without occlusion,
as well as the potential for much higher effective f low
rates within the eye. A disadvantage is that the outf low
rate is variable and is determined by the vacuum level
created; the surgeon cannot directly set it.
Figure 4 The peristaltic pump uses rollers to compress the
phaco outflow tubing in a peristaltic manner, thereby creat-
ing flow. The compression of the rollers on the tubing with
the rotation of the pump physically moves fluid and creates
a continuous “milking” action on the fluid column.
7/23/10 1:30 PM

Figure 5 The vacuum level is created within a rigid drainage
cassette, to which the phaco aspiration tubing is connected.
Since there is no milking of the aspiration line, the phaco
tubing can be made rigid with low compliance.
Optimizing
Phacoemulsification
Fluidic Settings
The function of the phacoemulsification f luidics is to
balance the inf low and outf low of f luid in order to main-
tain the working space, bring cataract material to the
phaco tip, and prevent collapse of the eye. Optimizing
the phaco f luidic settings is crucial to maximizing effi-
ciency and safety of phacoemulsification surgery.
In order to optimize the phaco f luidic settings, it is
important to match the machine parameters to the sur-
geon’s phaco technique. With a typical peristaltic phaco
machine platform, the most common type in the United
States, only a few parameters are adjustable. These
include needle size, bottle height, f low rate, and maxi-
mum vacuum level.
The selection of phaco needle size is of great impor-
tance. The most common sizes are the smaller-­bore
0.9‑mm needle and the larger-­bore 1.1-mm needle. If the
surgeon’s preference is a quicker procedure with rapid
nucleus removal, then the larger 1.1‑mm needle size
is desirable because it will give a significantly greater
f low rate. If the surgeon prefers a slower but more con-
trolled procedure, then the smaller-­bore 0.9-mm needle
is more suited to that technique. The holding power of
the phaco probe on to the cataract nucleus is related
to the vacuum level used as well as the surface area of
occlusion. Using a larger phaco needle allows for lower
FPv28n08_0910.indd 5
vacuum levels to achieve holding power as required in
phaco chop techniques.
The bottle height determines the inf low of f luid into
the eye. In order to help prevent surge, it is important to
keep the inf low of f luid at least as high as the outf low
of f luid at all times, because any excess inf low will pres-
surize the eye and leak from the incision until equilib-
rium is achieved. The inf low of f luid comes from only
1 source, the bottle of balanced salt solution, while the
outf low of f luid comes from 2 sources, the suction via
the phaco needle and the leakage from the incisions. If,
at any time, the outf low outstrips the inf low, the eye
will collapse and there is a high likelihood of posterior
capsule rupture. It is often advantageous to start with a
high bottle height to ensure a sufficient inf low of f luid,
and then to taper it downwards to minimize the poste-
rior displacement of the lens-­iris diaphragm due to the
infusion pressure.
For the “phaco chop” method, the holding power of
the needle tip is important in order to fixate the nucleus
securely while using the chopper to disassemble the
nucleus mechanically. This requires a relatively high vac-
uum, such as 200 to 250 mmHg with the 1.1 mm nee-
dle, or 300 to 400 mmHg with the 0.9 mm needle. Once
the nucleus has been broken into smaller fragments, the
peristaltic f low rate determines the speed at which the
fragments are attracted to the phaco tip, with a f low rate
of 20 cc/min being very slow and 50 cc/min being very
fast. During phaco chop, the surgeon can use the same
vacuum and f low rate settings for the entire nucleus
removal procedure.
For divide-and-­conquer phaco, there are 2 distinct
stages of nucleus removal: sculpting of the nucleus and
quadrant removal. Different f luidic settings are required
for each. For grooving and sculpting of the nucleus, the
work is being done by the ultrasonic energy and thus the
f low and vacuum settings are quite low—just enough to
aspirate the nuclear material removed from each for-
ward stroke of the phaco probe. A vacuum level of less
than 100 mmHg and a f low rate of less than 30 cc/min
are sufficient for this purpose. For quadrant removal, a
moderate amount of holding power is required to bring
each quadrant into the phaco tip. Using a higher vac-
uum level of 200 to 300 mmHg and a f low rate of 30 to
50 cc/min, depending on the needle size, is typically suf-
ficient for this purpose.
With knowledge of the concepts behind the variables,
it is easy to tailor the f luidic settings to the surgeon
and technique. Understanding the concepts behind the
phaco f luidic settings is instrumental in optimizing the
parameters for increasing the efficiency and safety of the
surgeon’s phaco technique.
Focal Points : Module 8, 2010 5
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 Fundamentals
of Ultrasonic
Phacoemulsification
Power
The phacoemulsification ultrasound probe delivers
energy into the eye that is used to break up the cata-
ract to facilitate emulsification and aspiration. It accom-
plishes this by vibrating at a fixed frequency when
the foot pedal is depressed to position 3. To increase
the amount of ultrasound power, the machine simply
increases the stroke length of the probe.
Traditionally the probe delivers power only in a longi-
tudinal manner, with the phaco needle moving forward
and back. Recent innovations in phaco technology also
allow for the delivery of power through a lateral motion.
Delivering ultrasound power through lateral motion can
increase cutting efficiency by reducing repulsion of lens
material.
The 2  types of lateral motion in phacoemulsifica-
tion are torsional, in which the phaco tip oscillates in
a rotational manner along its primary axis, and trans-
versal, where the phaco tip moves in an elliptical path.
Because of their types of motion, torsional works best
with an angled phaco needle while transversal works
equally well with a straight or angled needle. Combin-
ing lateral motion phaco with traditional longitudinal
phacoemulsification can aid cutting efficiency, since the
cataract material is emulsified in more than one direc-
tion (Figure 6).
Figure 6 Longitudinal as well as rotational or elliptical move-
ment of the phaco needle may be used to emulsify cataract
material and facilitate aspiration.
6 Focal Points : Module 8, 2010
FPv28n08_0910.indd 6
The stroke of the phaco needle creates a mechani-
cal impact as the metal phaco needle hits the cataract
material. It also creates cavitation and implosion as a
microvoid is created just in front of the phaco needle.
A f luid and particle wave is propagated into the cata-
ract material and finally, heat is created as a by-­product.
It is important to avoid choosing phaco power settings
that cause excessive heat build-­up as this can burn the
cornea and damage the delicate ocular structures. Unre-
stricted f low through the surrounding irrigating sleeve
is also very important, as the constant cooling effect of
balanced salt solution moving around the phaco probe
helps to prevent heat build-up.
During surgery, the phaco machine keeps track of
the average phaco power, given as a percentage of maxi-
mum, as well as the total time during which phaco ultra-
sonic power was delivered. The machine displays these
settings as “U/S AVE,” which stands for “ultrasound aver-
age,” and “EPT,” which is “elapsed phaco time.” The total
energy delivered into the eye is the product of the phaco
power multiplied by the time the power is on, known as
the absolute phaco time (APT). The phaco machine will
automatically calculate the APT by multiplying the “U/S
AVE” by the “EPT,” so that the surgeon can compare the
total ultrasonic energy delivered in different cases.
Delivering 15  seconds of 100% power is the same
energy as delivering 30 seconds of 50% power, or 60 sec-
onds of 25% power. For each of the 3 examples in Fig-
ure 7, the APT is 15 seconds.
It is important to use as little ultrasonic phaco energy
as possible during the cataract surgery. The ultrasonic
energy can damage the corneal endothelial cells, with
excessive damage leading to corneal decompensation.
To decrease the APT maximally, the surgeon needs
to decrease the phaco time and/or the average phaco
power. The average phaco power can be decreased by
limiting the foot pedal depression in position  3 when
Figure 7 A maximal reduction in the absolute phaco time
requires a reduction in both phaco time and phaco power.
7/23/10 1:30 PM
 using a linear controlled power mode or by decreasing
the maximum phaco power level on the machine. The
phaco time can be decreased by applying the ultrasonic
power only when cataract pieces are at the phaco tip and
vacuum alone is insufficient to aspirate the piece. Addi-
tionally, phaco time can be reduced by delivering shorter
pulses or bursts of phaco power instead of continuous
ultrasound power or by decreasing the duty cycle (the
ratio of the on:off pulses). This method of breaking up
the ultrasonic power into smaller packets of pulses and
bursts is called phaco power modulation.
Continuous, Pulse, and Burst
Phacoemulsification Modes
The basic power settings are continuous, pulse, and
burst. In the continuous power setting, energy delivery
is continuous with variations in power, controlled by the
amount of foot pedal depression.
In the pulse mode, the pulse power increases linearly
by how far down the foot pedal is depressed. The far-
ther it is depressed, the greater the power will be of each
sequential pulse of energy. The defining feature of pulse
mode is that after each pulse of energy delivered, there is
a period of time in which no energy is delivered between
increasing pulses of energy, the “off” period. Alternating
between equal “on” and “off” pulse times reduces heat
and delivers half the energy into the eye.
In burst mode, each burst has the same power but the
interval between each burst decreases as the foot pedal
is depressed. The farther the foot pedal is depressed, the
shorter the “off” period will be between each burst. As a
result, at maximum foot pedal depression, the bursts of
energy will become continuous delivery of energy.
In referring to modulations of phacoemulsification
power, the terms burst and pulse may seem similar, but
they refer to entirely different concepts. Surgeons are
used to the concept of “continuous” phacoemulsifica-
tion power that is delivered in a linear fashion: as the
phacoemulsification foot pedal is depressed, the power
level increases. “Pulse” mode simply gives the same
linear control of phacoemulsification power; however,
the energy is always delivered in pulses. “Burst” mode
defines a specific and identical “burst” of phacoemulsifi-
cation energy. As the foot pedal is depressed, these iden-
tical bursts of energy are delivered more rapidly, until
the interval of time between bursts is infinitely small. A
key advantage of burst mode is that it allows the surgeon
to titrate the rate of delivery of these tiny bursts, which
can be as short as a few milliseconds.
Burst mode allows a true phaco-­assisted aspiration of
the lens nucleus. The surgeon uses the vacuum and f lu-
idics of the phaco machine to aspirate the cataract and
FPv28n08_0910.indd 7
then gives small bursts of phaco power only when nec-
essary. Because one can program these bursts of phaco
power to be very short (as quick as a few milliseconds),
one can effectively give hundreds of tiny bursts and still
total less than 1 second of total phaco time. Because the
phaco foot pedal now controls the rest interval between
identical bursts, one does not have linear control of the
phaco power level. For this reason, it is important to use
a lower phaco power setting when using burst mode as
compared to pulse or continuous modes. When the foot
pedal is maximally depressed, the rest interval between
bursts is zero and the phaco probe essentially delivers
continuous energy (Figure 8).
Hyper Settings for Power Modulation
The range of programmability of the pulse and burst
phacoemulsification settings has expanded consider-
ably. While previous generations of phaco platforms
had pulse rates of up to 20 pulses per second, the newer-­
generation machines have the ability to deliver up to
120 pulses per second. Similarly, the older machines had
burst widths as narrow as 30 milliseconds, while the new
platforms are able to deliver burst widths as fine as just
4 milliseconds.
The advantage of this upgraded range of programma-
bility is the smoothness and precision of power deliv-
ery. With the standard settings in pulse mode, where
each pulse is as long as each rest period, the pulse mode
can deliver good cutting power with half the energy of
Figure 8  “Continuous” phaco power is delivered in a linear
fashion. “Pulse” mode gives the same linear control of
phaco power, except that the power is delivered in pulses.
“Burst” mode defines a specific and identical “burst” of
phaco power. As the foot pedal is depressed, identical
bursts of power are delivered more rapidly, until the interval
of time between bursts is infinitely small.
Focal Points : Module 8, 2010 7
7/23/10 1:30 PM
 continuous phaco power. The more pulses per second
given, the smoother the power delivery will be—very
similar to serrations on a knife.
Power modulation using hyper settings also allows the
surgeon to reduce the total amount of energy released
in the eye. For example, simply changing from continu-
ous phaco power to a hyper pulse rate of 100 pulses per
second allows the surgeon to cut total energy delivery
in half. This halving of the ultrasound energy will result
in less endothelial cell damage, less heat production,
clearer corneas, and sharper vision immediately post‑op.
Surgeons who perform the divide-and-­conquer method
of nucleus phaco can switch to a hyper pulse mode and
immediately perform better surgery without a change
in technique.
Note, however, that simply changing the number of
pulses per second alone does not change the amount
of energy delivered into the eye. Whether the surgeon
gives 2 pulses per second or 8 pulses per second, the total
energy, as represented by the green blocks (Figure 8) is the
same. The same applies when comparing 10 pulses per
second to 100 pulses per second. Reduction in the energy
delivered is accomplished by decreasing the time that the
power is on by altering the ratio of the on:off pulses (Fig-
ure 9). The lower pulse rates tend to be better for emulsi-
fying nuclear fragments since there is a significant time
interval between pulses for the fluidics to keep the cata-
ract piece attracted to the phaco needle. The higher pulse
rates tend to work better for sculpting or grooving the
nucleus since the narrow time interval between pulses
produces a smoother delivery of ultrasonic energy.
Variable Duty Cycle
Ultrasound energy creates helpful cavitation and
mechanical forces that are used to break up the cataract
Figure 9 If the duty cycle is held constant, simply increas-
ing the pulses per second (PPS) does not decrease the total
phaco energy delivered.
8 Focal Points : Module 8, 2010
FPv28n08_0910.indd 8
nucleus; however, this energy also can create significant
heat. The jackhammer effect of ultrasound energy can
cause repulsion of the nuclear fragments from the phaco
tip. It is helpful to alternate periods of phacoemulsifica-
tion energy with rest periods that serve to achieve cool-
ing of the phaco needle and aspiration of the nuclear
fragments. If the surgeon changes the ratio of the on
period, when ultrasound energy is delivered, to a shorter
duration, then the surgeon can favor the aspiration and
cooling of the phaco needle over the heat generation and
jackhammer repulsion effects of the ultrasound.
With the choice of a mode such as pulse mode, which
alternates phaco power pulses with periods of rest, the
default ratio is 50:50. This is called a 50% duty cycle, as
each complete cycle is composed of power on for 50% of
the time, then power off for 50% of the time. This default
ratio can be changed to alter the ratio of ultrasound
energy to the rest interval. For example, 40% results in
40 msec on, 60 msec off giving a ratio of 40:60. The sur-
geon can then harness the benefits of a lower duty cycle,
which results in longer cooling time for the phaco nee-
dle, thus decreasing the amount of phaco energy deliv-
ered to the eye. In addition, during the extended “off”
time, no energy is delivered and nuclear fragments can
be easily aspirated (Figure 10).
When are higher or lower duty cycles preferred? The
answer depends on the phase of surgery. For sculpting
the nucleus, such as with the technique of divide-and-­
conquer, the surgeon needs to deliver sufficient energy
to be able to cut the grooves. This requires a duty cycle of
about 40% to 60%. Once the surgeon has placed grooves
in the nucleus and has achieved cracking that results
in quadrants, a lower duty cycle can be used during the
Figure 10 The total phaco energy delivered can be reduced
significantly by altering the “on-­off” duty cycle.
7/23/10 1:30 PM
 phaco-­assisted aspiration of the quadrants. For this quad-
rant removal, a lower duty cycle of 20% to 40% can be
used since the principal force for aspiration is the f luid-
ics and not the ultrasound.
Using the variable duty cycle programming allows the
surgeon to deliver just the right amount of ultrasound
energy during each phase of surgery. The concept to
remember is that a higher duty cycle results in better
cutting power but increased heat generation and more
energy-­related damage to the corneal endothelium.
Using the lower duty cycle allows more f luidic aspira-
tion of nuclear fragments while minimizing heat and
phaco power, resulting in clearer corneas immediately
after surgery. Clear corneas on postoperative day 1 make
for good visual acuity and very satisfied patients.
Conclusion
An understanding of phacoemulsification technology
is of fundamental importance to the modern phaco
surgeon. Advances in technology allow the surgeon to
FPv28n08_0910.indd 9
optimize phaco fluid settings and modulate phaco power,
especially with regard to pulse, burst and duty cycle, to
improve proficiency and safety. A thorough knowledge
of these features allows the surgeon to make refine-
ments in phaco parameters in order to enhance cutting
efficiency, reduce risks of thermal injury, improve “fol-
lowability,” or encourage better chamber maintenance,
depending on the specific techniques of the surgeon and
the clinical challenges of an individual case. All of this
helps to make surgery safer, gentler and more success-
ful for our patients.
Uday Devgan, MD, FACS, FRCS (Glasg) is in private
practice at Devgan Eye Surgery in Los Angeles, Beverly
Hills, and Newport Beach, California. Dr. Devgan is also
the chief of ophthalmology at Olive View–UCLA Medical
Center and an associate clinical professor of ophthalmol-
ogy at the Jules Stein Eye Institute, UCLA School of Medi-
cine, Los Angeles, California.
Focal Points : Module 8, 2010 9
7/23/10 1:30 PM
 Clinicians’Corner
Clinicians’ Corner provides additional viewpoints on
the subject covered in this issue of Focal Points. Con-
sultants have been invited by the Editorial Review
Board to respond to questions posed by the Acade-
my’s Practicing Ophthalmologists Advisory Committee
for Education. While the advisory committee reviews
the modules, consultants respond without reading the
module or one another’s responses. – Ed.
10 Focal Points : Module 8, 2010
FPv28n08_0910.indd 10
1. Discuss the relative advantages and disadvantages
of venturi-­based and peristaltic phacoemulsifica-
tion (phaco) systems as they pertain to a surgeon’s
level of experience.
Dr. Seibel: In one perspective, vacuum-­based pumps,
such as a venturi system, are simpler than f low-­based
systems, such as peristaltic pumps, in that they have but
a single f luidic parameter for the surgeon to adjust. The
surgeon commands only vacuum (mmHg) in a venturi
pump and clinically produces f low to the extent that
the aspiration port is open, and grip to the extent that it
is occluded. The f low pump, by comparison, has at least
2  f luidic parameters (aspiration outf low in cc/minute
and vacuum limit in mmHg) as well as additional f low
modulations that may alter rates of pump speed change
with varying degrees of occlusion or vacuum load. This
relative difference in f luidic complexity would seem to
tip the scales in favor of a vacuum pump for less experi-
enced surgeons. However, vacuum pumps have a signif-
icant disadvantage of producing potentially dangerous
f low rates of 60  cc per minute or higher with typical
commanded vacuums of modern phaco techniques (250
to 450 mmHg). For this reason, a peristaltic pump may be
preferred by a less experienced surgeon (or a more expe-
rienced surgeon dealing with compromised anatomy) for
the ability to set a slower, gentler f low rate.
Dr. Serafano: The surgical requirements for successful
phacoemulsification are maintaining a stable anterior
chamber, attracting lens material to the tip, and holding
and emulsifying the lens material with minimum tur-
bulence. Technically this means minimum f luctuation
of IOP, minimizing f low while not occluded, and short
linear vacuum rise time.
Since venturi-­based systems are vacuum based and
cannot generally set f low separately, IOP f luctuations in
the range from unobstructed f low to occlusion break are
much greater than with peristaltic systems. This means
that surgeons preferring the venturi system need a high
7/23/10 1:30 PM
 level of experience in order to anticipate surge. Some
surgeons use a venturi patch (mesh to filter particles)
attached to the aspiration line to introduce resistance in
order to reduce surge. Peristaltic systems allow the sur-
geon to customize f low and vacuum separately to assure
consistent and predictable venting. This should allow a
safer procedure for surgeons of any level of experience.
2. Discuss in greater detail the relative advantages
and disadvantages of venturi and peristaltic phaco-
emulsification systems as they pertain to the
method of cataract removal (“divide and conquer”
versus “phaco chop”).
Dr. Seibel: Phaco chop methods involve higher vac-
uum levels and more occlusion of the aspiration port
as compared to the sculpting-­intensive divide-and-con-
quer methods. Vertical chop methods in particular may
require very high vacuum levels of 350 to 450 mmHg.
These higher vacuum levels can have f luidic liabilities in
both pump types upon abrupt occlusion breaks: peristal-
tic pumps can have more propensity for postocclusion
surge, and venturi pumps can produce dangerously high
associated f low rates. Many newer peristaltic machines
allow considerable sophistication of programming to
mitigate surge, including modulations to adjust pump
acceleration rate and venting protocols. High-­vacuum
tubing such as the Intrepid micro-­coaxial system (Alcon,
Fort Worth, TX) can also blunt postocclusion surge. Ven-
turi surgeons using phaco chop techniques may need to
consciously reduce vacuum prior to an anticipated occlu-
sion break, such as for carouselling phacoaspiration of
chopped fragments after using a higher vacuum level
for chopping. Such dynamic control can be facilitated by
dual linear pedal control (Bausch & Lomb, Rochester, NY;
Abbott Medical Optics [AMO], Santa Ana, CA).
Dr. Serafano: If a surgeon prefers sculpting and quadrant
management, then there are 2 considerations. First, dur-
ing the nonocclusive sculpt phase, peristaltic pump sys-
tems allow for setting lower aspiration f low rates (AFR).
This results in less turbulence, thereby allowing greater
retention of the ophthalmic viscosurgical device (OVD)
to protect the endothelium. Second, during the preoc-
clusive and occlusive quadrant management phase, the
peristaltic pump systems allow for setting a range of lin-
ear vacuum that should lead to safer anterior chamber
FPv28n08_0910.indd 11
stability. venturi systems require more irrigation inf low
to compensate for inability to separately adjust AFR.
Although this increased irrigation is necessary to main-
tain a stable chamber and minimize IOP f luctuations, it
may lead to increased turbulence.
If a surgeon prefers phaco chop, then the consid-
eration is vacuum. The venturi system is perceived as
faster than a peristaltic system because a chop technique
generally requires higher vacuum levels, and the ven-
turi system can access high vacuum levels very quickly.
A peristaltic system allows for the setting of operating
range of vacuum and rise time, which can be adjusted
to the surgeon’s personal preference. The key difference
at higher vacuum levels is the management of occlusion
break. The venturi user needs to anticipate the break and
thus modulate with the foot pedal, whereas the peristal-
tic user is not burdened with this process.
3. How are the settings adjusted to alter the “follow-
ability” of nuclear pieces?
Dr. Seibel: Distal followability brings a fragment to the
phaco tip and is a function of pump f low into the aspi-
ration port; it is adjusted directly on a f low pump (aspir­
ation outf low parameter in cc/min) and indirectly on a
vacuum pump by commanding a vacuum level in mmHg
when the aspiration port is not occluded. Proximal fol-
lowability refers to the efficiency with which carou-
selling phaco aspiration takes place, with poor function
manifest by chattering of the cataract fragment on the
tip. Poor proximal followability is an indication of insuf-
ficient attractive f luidic parameters (f low and vacuum)
and/or excessive repulsive forces (traditional longitudi-
nal ultrasound).
In addition to decreasing ultrasound power level,
other modifications include various ultrasound modula-
tions such as hyperpulse, which differs from continuous
ultrasound by having varying amounts of “off” cycles
between “on” cycles in order to increase efficiency of
followability by allowing nuclear fragments to re‑engage
the aspiration port during “off “ cycles. Another modifi-
cation of traditional ultrasound is to augment or replace
the traditional longitudinal vibration of the phaco nee-
dle with a rotational (Alcon Ozil) or ellipsoidal (AMO
Signature) vibration that is less likely to repel a nuclear
fragment. Fluidic modifications to enhance proximal
Focal Points : ModulE 8, 2010 11
7/23/10 1:30 PM
 Clinicians’Corner

followability include increasing f low rate (f low pump), Torsional movement allows emulsification to take place
increasing vacuum limit (f low pump), or increasing com- when the tip moves in each cutting direction, or 100%
manded vacuum level (vacuum pump). of the time, whereas longitudinal ultrasonic cuts only in
the forward stroke, or only 50% of the time.
Dr. Serafano: “Followability” is the surgeon’s term for
The advantage of torsional over transverse is that the
how readily the nuclear fragments are attracted to the
tip can be controlled separately in the x and y axis as
ultrasound tip. In peristaltic systems, this can be opti-
2 distinct motions (ie, longitudinal and torsional). The
mized by adjusting the AFR setting. AFR is the rate at
limitation of the transverse motion is that its movement
which f luid is removed from the anterior chamber. It
is along 1 plane only (cannot mix the x with the y axis
is expressed in milliliters per minute. Irrigation inf low
movements of the tip).
must be equal to, and potentially greater than, the sum
of the AFR plus incisional outf low to maintain a steady
5. Discuss settings for patients with a relatively soft
IOP and therefore a stable anterior chamber. In coax-
cataract, such as those with primarily a posterior
ial phaco, inf low entering through the infusion sleeve
subcapsular cataract in a younger patient.
ports creates a f luid current that helps bring nuclear
fragments into the phaco tip if the AFR is balanced for Dr. Seibel: Using phacodynamic principles (Phacodynam-
the surgeon’s technique. The peristaltic system allows ics, 4th ed, Thorofare, NJ: Slack; 2005), the surgeon ascer-
for the direct adjustments of the AFR, whereas most ven- tains the clinical task for each parameter for a given type
turi systems cannot accomplish this. Some venturi sys- of cataract at a given moment in surgery. Ultrasound
tems have introduced “pitch and yaw” to the foot pedal functions to mechanically disrupt lens material that
in order to allow for more control of vacuum and power. would otherwise be too rigid to deform sufficiently for
aspiration under a given vacuum load alone. Therefore,
4. Does either torsional or transverse movement offer in a soft cataract, only minimal amounts of ultrasound
advantage over the other for cataract surgery? energy are required in order to moderately reduce the
amount of f luidics required; 15% to 20% might be a
Dr. Seibel: Controversy exists concerning a blanket supe-
starting point, realizing that there is no industry stan-
riority of one modality over another, and whether either
dardization for phaco power. Vacuum is titrated to allow
is absolutely superior to traditional longitudinal ultra-
deformation and aspiration of the material. In these
sound that is modulated with hyperpulse. Using ultra-­
cases, a value of about 150 mmHg is typically sufficient,
highspeed videography, Teruyuki Miyoshi elegantly
assuming augmentation by mild levels of ultrasound.
illustrated the enhanced proximal followability afforded
Flow functions to pull nuclear material into the tip and
by hyperpulsed longitudinal phaco. The best statement
aspirate out of the eye, and for softer nuclei, settings of
for this question would be the recommendation to avoid
20 cc to 25 cc per minute will often suffice. Given these
traditional longitudinal continuous ultrasound in virtu-
relatively moderate f luidic settings, a bottle height of
ally all applications in favor of ellipsoidal, torsional, or
95 cm should provide adequate chamber stability. Such
longitudinal ultrasound with hyperpulse.
settings are starting points, with adjustments made
Dr. Serafano: There are currently 3 movements avail- according to phacodynamic principles based on surgeon
able with phaco tips. First is the traditional longitudinal observations.
movement along one line (x axis) that all machines have
Dr. Serafano: Soft cataracts require less ultrasonic power.
available. Second is torsional movement, which is “side
This allows for “vacuum-­assisted phaco.” Once hydrodis-
to side” (y axis). Third is transverse movement, which
section and hydrodelineation have been completed, vac-
closely resembles the longitudinal line motion, but it is
uum levels and aspiration f low rates can be increased
delivered at an angle to the tip shaft (x and z axis).
from normal levels. In order to maintain a steady IOP,
Torsional and transverse are meant to improve effi-
bottle height may have to be increased to balance the
ciency by eliminating or minimizing the repulsive force
increased AFR. Divide and quadrant management or
inherent in the forward stroke of longitudinal phaco.

12 Focal Points : Module 8, 2010

FPv28n08_0910.indd 12 7/23/10 1:30 PM

 chop techniques are seldom effective in soft cataracts.
The soft cataract technique is essentially irrigation and
aspiration using the large bore of a phaco tip.
6. Discuss the advantages and disadvantages and fluid
dynamics for microincisional phacoemulsification.
Dr. Seibel: Advantages include a lower amplitude of
induced incisional astigmatism, as well as a more stable
anterior chamber due to less incisional leakage, all other
things being equal (eg, rigidity of the infusion sleeve).
Originally, microincisional phaco involved a bimanual
approach that had the disadvantage of requiring a modi-
fication of technique and at least some learning curve.
The smaller incisions (typically 1.4 mm wide) required
smaller-gauge instruments (20 to 23 gauge), and these
often had difficulty in supplying sufficient infusion
inf low to mitigate against postocclusion surge with
higher vacuum levels. Newer coaxial microincisional
systems essentially eliminate the learning curve associ-
ated with bimanual methodology but increase incisions
up to 1.8 to 2.2 mm, depending on the platform, reduc-
ing induced astigmatism (as compared to traditional
19‑gauge phaco) to around 0.25 diopters. Adequate cham-
ber stability is achieved in these systems by restricting
outf low, such as with small-­bore aspiration line tubing
in the Intrepid system (Alcon), or a vacuum surge sup-
pressor used in the Stellaris (Bausch & Lomb) platform.
Dr. Serafano: I would like to define microincisional phaco
as a phaco incision of 2.4 mm or less. Since the total area
for f luid exchange is reduced with smaller incisions, irri-
gation may be reduced depending on the tip and sleeve
chosen by the surgeon. Therefore, a knowledgeable and
matching selection of the aspiration and infusion com-
ponents is mandatory. Depending on component selec-
tion, to compensate for decreased irrigation, AFR and
vacuum levels may have to be reduced to balance f luidics
and prevent surge and IOP f luctuations. Some microin-
cisional ultrasound tips have been modified by slightly
f laring the port of the tip to maintain holding power and
decreasing the outer diameter of the shaft to allow for
more irrigation to f low between the tip and sleeve into
the anterior chamber. The main advantages of micro-
coaxial phacoemulsification are the improved patient
outcomes, which include lower postoperative surgically
FPv28n08_0910.indd 13
induced astigmatism as compared to standard incision;
more secure incision closure; and lower intraoperative
f luid consumption due to improved f luid dynamics.
7. What adjustments to the surgeon’s usual setting
should be made in patients with pre-­existing cor-
neal disease such as Fuchs corneal dystrophy?
Dr. Seibel: Parameters should be adjusted to mini-
mize further trauma to already compromised corneal
endothelial cells. Ultrasound usage can be minimized
through more efficient modulations such as hyperpulse,
and by using more efficient occlusion type methods such
as chopping, and of course ultrasound should not be
engaged when the tip is anterior to the iris plane. With
regard to f luidics, anterior chamber turbulence should
be minimized by decreasing the f low rate (either directly
with a f low pump or indirectly with a vacuum pump)
and by minimizing chamber f luctuations by reducing
postocclusion surges, by either raising bottle height,
reducing vacuum parameter, or dynamically reducing
the commanded vacuum level (with dual linear pedal
control) just prior to an occlusion break. Attempts can
also be made to keep the irrigation ports oriented in the
iris plane so as not to direct f luid f low with correspond-
ing shear force directly against the corneal endothelium.
Dr. Serafano: Protection of the endothelium is the goal
in this situation. This is best achieved by low f low and
low turbulence. Decreasing these parameters will assist
in the retention of OVD and therefore endothelial protec-
tion. Low f low means to lower the bottle height, lower
aspiration f low rate and lower vacuum. Consider replac-
ing OVD as needed and try to remove as much nucleus
as possible below the iris plane.
8. Are there any adjustments to be made in a patient
with eyes that have long or extremely long axial
lengths?
Dr. Seibel: These patients have a greater likelihood of
having weak zonules and/or an excessively deep ante-
rior chamber, setting these patients up for lens-­iris dia-
phragm retropulsion syndrome in which the complete
pupil perimeter seals against the anterior lens capsule.
Surgeons would historically have to compensate by low-
ering the infusion bottle, which would compromise
Focal Points : ModulE 8, 2010 13
7/23/10 1:30 PM
 Clinicians’Corner
surge control in an already unbalanced anterior cham-
ber. Robert Cionni reported on a novel technique to dis-
rupt this syndrome and restore normal anterior chamber
depth and architecture by mechanically separating the
iris from the lens, with the phaco/irrigation/aspiration
tip (in pedal position 1) or a second instrument. These
longer eyes often have large anterior segments, and sur-
geons must be particularly vigilant about appropriate
sizing of the capsulorrhexis; direct measuring is advised,
such as with the Rhexis Ruler (MST, Redmond, WA).
Dr. Serafano: Eyes with long axial lengths and postvit-
rectomized eyes do not have normal intracameral resis-
tance to support the lens/iris diaphragm when irrigation
increases pressure in the anterior chamber. Eyes with
normal axial lengths and formed vitreous exert a resis-
tance to support the lens/iris diaphragm and help keep
the anterior chamber stable with standard phaco set-
tings. If this support is missing or low, normal fluid phaco
parameters in the anterior chamber can push the lens/
iris diaphragm posterior and cause large f luctuations
in IOP and anterior chamber depth. Another situation
Suggested Reading
Benjamin L, Little BC, Packard R, Packer M. Phacoemulsifica-
tion 1. Basic techniques. In: The Video Atlas of Eye Surgery.
Surrey, UK: Eye Movies Ltd; 2005.
Packard R. Understanding phacodynamics. J Cataract Refract
Surg. 2010;36:876–877.
Seibel BS. Phacodynamics: Mastering the Tools and Techniques of
Phacoemulsification Surgery, 4th ed, Thorofare, NJ: Slack; 2005.
14 Focal Points : Module 8, 2010
FPv28n08_0910.indd 14
with large f luctuations in anterior chamber depth is an
eye having an IOP of 5 mmHg or less after glaucoma fil-
ter surgery. In eyes with excessive filters, the anterior
chamber will not react predictably with normal phaco
f luidics. In all of these situations, lower the initial f low
parameters in order to decrease anterior chamber f luctu-
ations. After the initial entry into the anterior chamber
and establishment of f low, the parameters may be slowly
increased to find the proper f luidic balance.
Barry S. Seibel, MD, is a practicing ophthalmologist at
Seibel Vision Surgery in Los Angeles, California. He is
also a clinical assistant professor of ophthalmology at
the University of California, Los Angeles, Geffen School
of Medicine.
Donald N. Serafano, MD, is a practicing ophthalmolo-
gist at Complete Eye Care Association Incorporated in
Los Alamitos, California. He is also an associate clinical
professor at the University of Southern California.
Related Academy Materials
Surgery for cataract. In: Lens and Cataract. Basic and Clinical
Science Course, Section 11, 2010–2011. Chapter 8 includes
discussion of phacoemulsification, including ultrasonics
terminology, vacuum terminology, phaco instrumentation,
phaco power delivery, irrigation, aspiration, and advances in
energy delivery; full discussion of a basic phaco procedure;
and advances in energy delivery.
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