Phacoemulsification Step by Step Procedure
Phacoemulsification is the standard surgical technique for cataract removal that involves using ultrasonic energy to emulsify the lens nucleus through a small self-sealing incision of 2.2-2.8 mm, followed by aspiration and intraocular lens implantation. 1
Preoperative Assessment and Planning
- Thorough evaluation of cataract density and potential complications
- Selection of appropriate incision type, anesthesia, and surgical technique based on nuclear density
- Special consideration for dense or subluxated cataracts that may require modified approaches 2
Step-by-Step Phacoemulsification Procedure
1. Incision Creation
- Create a self-sealing clear corneal or limbal incision (typically 2.2-2.8 mm)
- Make a secondary side port incision for instrumentation
2. Viscoelastic Injection
- Inject viscoelastic material to maintain anterior chamber depth and protect corneal endothelium
3. Capsulorhexis
- Perform continuous curvilinear capsulorhexis (CCC) to create a circular opening in the anterior capsule
- Achieving an intact capsulorhexis is critical for successful in-the-bag IOL placement, particularly in subluxated cataracts 3
4. Hydrodissection and Hydrodelineation
- Inject fluid between lens capsule and cortex to separate them (hydrodissection)
- For dense cataracts, careful hydrodissection with nucleus rotation is essential for zonular protection 2
- Perform hydrodelineation to separate nucleus from epinucleus when needed
5. Nuclear Fragmentation and Emulsification
- Rotate the nucleus to ensure mobility
- Use appropriate phacoemulsification technique based on nuclear density:
- For standard cataracts: Divide nucleus into quadrants or use chopping techniques
- For dense cataracts: Consider specialized techniques like step-by-step chop, vertical chop, or stop-and-chop 2
- Apply ultrasonic energy to emulsify the lens fragments while aspirating them
6. Cortical Cleanup
- Remove remaining cortical material using irrigation and aspiration
7. IOL Insertion
- Inject viscoelastic material to expand the capsular bag
- Insert the intraocular lens into the capsular bag
- For dense cataracts, consider inserting the IOL before emulsifying the last quadrant to improve surgical safety and reduce posterior capsular rupture risk 4
8. Viscoelastic Removal
- Remove viscoelastic material using irrigation and aspiration
9. Wound Closure
- Ensure incision is watertight (may require hydration or suturing)
- Administer antibiotics if part of protocol
Special Considerations for Dense Cataracts
For rock-hard dense nuclear cataracts:
- Adjust machine settings with higher power, vacuum, and aspiration for optimal efficiency 5
- Consider reduced vacuum and flow rate to minimize complications 4
- Implement the technique of inserting IOL before emulsifying the last quadrant, which has been shown to significantly reduce posterior capsular rupture risk (from 6.7% to 0%) 4
- Use specialized nuclear dismantling techniques and fluidic/power modulations 2
Potential Complications and Management
- Posterior capsular rupture (PCR): If it occurs, complete emulsification after IOL insertion and clean prolapsed vitreous 4
- Endothelial cell loss: Monitor postoperatively; more common with traditional techniques in dense cataracts 4
- Corneal edema: Track central corneal thickness changes postoperatively 4