added margin of safety. When the epinucleus is emulsified, the posterior capsule is exposed to the phaco tip and may move toward it due to surge. Activation of pulse phaco, or micro pulse phaco, will create a deeper anterior chamber to work within. This occurs because, as noted previously, each period of phaco energy is followed by an interval of no energy. During the interval of the absence of energy, the epinucleus is drawn toward the phaco tip, producing partial occlusion, and interrupting outflow. This allows inflow to deepen the anterior chamber immediately prior to the onset of another pulse of phaco energy. The surgeon will recognize the outcome as operating in a deeper, more stable anterior chamber.

Pulse Shaping

This is a modification of varying power duration. By changing the morphology of the power burst in hyperpulse phaco, the power can be delivered with greater effectiveness. Different manufactures have developed different burst morphology.

AMO (Whitestar/Signature) use ICE (increased control and efficiency). A 1-ms punch of power with amplitude of 7% of the preset power maximum is delivered at the beginning of each burst (Fig. 3.4). This “kicker” has two consequences. First, it drives the nucleus away from the phaco tip sufficiently to augment partial occlusion phaco. Second, it allows the phaco tip to accelerate to the preset velocity almost

Fig. 3.4 AMO ICE. A 1-ms burst of power at the beginning of the power portion of the duty cycle

Fig. 3.5 B&L Millennium Pulse Shaping brings power up to preset slowly to decrease the repulsive effect of ultrasonic energy

instantly. The result is more effective phaco of the fragments.

B&L (Milennium/Stellaris) has taken a different approach. They bring the power up to maximum more slowly (Fig. 3.5). They believe that the slow increase in power enhances partial occlusion by not pushing the fragment away from the phaco tip.

3.3.3 Alteration of Emission

The emission of phaco energy is modified by tip selection. Phaco tips can be modified to accentuate:

(1) power, (2) flow, or (3) a combination of both.

1.Power is modified by altering bevel tip angle. 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 bend 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. Additionally, at the point where the wider end of the tip narrows additional cavitational energy is created, thus further emulsifying the lens material as it passes into the shaft of the needle.

2.Power 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. Additionally it is easier to occlude the tip due to the ease of applanation of the tip to the lens material. Small diameter tips, such as 21 gauge