holds the lens material close to the phaco tip without total occlusion, the partial occlusion environment of this system generates remarkable follow-ability and deep, stable, anterior chambers.

3.7Phacoemulsification Technique and Machine Technology

The patient will have the best visual result when the total phaco energy which is delivered to the anterior segment is minimized [4]. Additionally, phaco energy should be focused onto the nucleus. This will prevent damage to iris blood vessels, trabecular meshwork, 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.

Generally all phaco procedures have two phases. The first is the creation of fragments. This requires sculpting or chopping. The second phase is the removal of the fragments in a controlled approach. Occlusion is mandatory to move the fragments to the iris plane. Fragment removal is assisted by partial occlusion phaco.

All phaco techniques are preceded by capsulorhexis, cortical cleaving hydrodissection, and the removal of the superior cortex and the epinucleus to expose the endonucleus.

3.7.1 Micro-incisional Phaco

The development of micro-pulse and non-longitudinal phaco (“cold phaco”) has led to the performance of phaco through increasingly small incisions with tighter irrigation sleeves or no irrigation sleeves.

Fig. 3.13 Bimanual Phaco. Irrigating chopper on right. Unsleeved phaco tip on left

and incision size is essential. If the wound is too tight, it is difficult to manipulate the instruments. If the wound is too large, excessive outflow leads to chamber shallowing with an unstable anterior segment. In bimanual MICS the instruments can be moved only forward and backward through the incisions without creating corneal distortion. If the instruments are angled in the incision, sufficient corneal distortion occurs and the procedure becomes appreciably more difficult. The problem can be prevented by the construction of trapezoidal incisions where the needle has room to move at the external incision. The irrigating chopper should be parallel to the iris and above it. The inflow current thus created, tends to wash the fragments toward the unsleeved phaco tip. The small incisions cause less disruption of the blood aqueous barrier, and are more stable and secure.Then a new incision is created for IOL implantation. In the future, with the insertion of an intraocular lens (IOL) through the 1.4 mm incision, there should be less disruption of ocular integrity, immediate return to full activities, and less risk of postoperative wound complications (Fig. 3.13).

3.7.2 Bimanual Micro-Incisional Phaco

Two incisions are created 90° apart. Their size is dependant on the instrumentation. Instruments require 1.4–1.1 mm incisions. There is no irrigating sleeve on the phaco tip. The instrumentation for this procedure is important and the relationship between the instrument

3.7.3 Micro-Incisional Coaxial Phaco

A thin walled flared, 21-gauge phaco tip and thinner irrigation sleeve is available for both the Infiniti (Alcon) and Stellaris (Bosch and Lomb) machines, which permits phaco though a 2.2-mm incision with Infiniti and 1.8 mm. with Stellaris. Despite the smaller incision, inflow is adequate to maintain a deep anterior