Phacoemulsification

Phacoemulsification (or "phaco") is the gold standard for cataract surgery, using ultrasonic energy to break up and remove the cloudy lens through a tiny incision (2–3 mm). It allows for rapid recovery, minimal induced astigmatism, and excellent visual outcomes.

Key Steps in Phacoemulsification

1. Incision

  • Main corneal incision (2.2–2.8 mm, self-sealing).

  • Side-port incision (1 mm, for second instrument).

2. Capsulorhexis

  • Continuous curvilinear capsulorhexis (CCC) (~5–6 mm diameter) to access the lens.

3. Hydrodissection & Hydrodelineation

  • Fluid injection to separate the nucleus from the cortex and capsule.

4. Nucleus Emulsification

  • Phaco probe uses ultrasonic vibrations to break up the nucleus.

  • Common phaco techniques:

    • Divide & Conquer (groove and split nucleus into quadrants).

    • Stop & Chop (central groove + chopping).

    • Prechop (manual segmentation before phaco).

5. Cortex Aspiration

  • Irrigation/Aspiration (I/A) to remove remaining lens material.

6. Intraocular Lens (IOL) Implantation

  • Foldable IOL inserted through the small incision into the capsular bag.

  • Options: Monofocal, Toric, Multifocal, EDOF, or Accommodative IOLs.

7. Wound Hydration & Sealing

  • Self-sealing incisions (usually sutureless).

Advantages of Phacoemulsification

✔ Small incision (2–3 mm) → minimal induced astigmatism.
✔ Fast recovery (vision stabilizes within days).
✔ Sutureless (self-sealing wound).
✔ Precise IOL placement (better refractive outcomes).
✔ Lower risk of complications (vs. ECCE/SICS).

Disadvantages & Challenges

✖ High equipment cost (phaco machine required).
✖ Steeper learning curve (requires surgical skill).
✖ Risk of thermal injury (if improper phaco settings).
✖ Not ideal for very hard cataracts (may require SICS/ECCE).

Comparison: Phaco vs. SICS vs. ECCE

FeaturePhacoemulsificationSICSECCE
Incision Size2–3 mm (self-sealing)5–7 mm (tunnel)8–10 mm (sutured)
Energy UsedUltrasoundManualManual
Wound ClosureSuturelessSuturelessSutures needed
Recovery Time1–7 days1–2 weeks3–6 weeks
CostHighLowLow
Best ForMost cataractsHard cataracts, resource-limited settingsRarely used today

Complications & Management

  • Intraoperative:

    • Posterior capsule rupture → may require anterior vitrectomy.

    • Zonular dialysis → capsular tension ring (CTR) or alternative IOL placement.

    • Corneal burns (from phaco heat) → proper irrigation & technique.

  • Postoperative:

    • Endophthalmitis (rare, but serious → requires intravitreal antibiotics).

    • Cystoid macular edema (CME) → NSAIDs/steroids.

    • Posterior capsular opacification (PCO) → YAG laser capsulotomy.

Recent Advances in Phaco

  • Femtosecond laser-assisted cataract surgery (FLACS) (laser capsulotomy & fragmentation).

  • Torsional & Ellips FX phaco (reduced energy, safer for cornea).

  • Advanced IOLs (Toric for astigmatism, multifocal for presbyopia).

Conclusion

Phacoemulsification is the preferred method for cataract surgery due to its small incision, rapid recovery, and precision. While SICS/ECCE remain useful for hard cataracts or low-resource settings, phaco delivers the best visual outcomes in most cases.

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