Phacodynamics
Phacodynamics
Phacodynamics
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128 PHACODYNAMICS: STEP BY STEP<br />
15 <strong>Phacodynamics</strong><br />
A clear understanding of the physical and mechanical<br />
principles that govern phacoemulsification can facilitate<br />
usage of this technique for effective and efficient cataract<br />
removal<br />
It is essential to understand the basic principle of<br />
phacodynamics. This is even more relevant to bimanual<br />
microphaco and is mandatory for the evolution of this<br />
technique.<br />
<strong>Phacodynamics</strong> is defined as the study of the fundamental<br />
principles of inflow rates, outflow rates, vacuum,<br />
phaco power modulation along with microsurgical<br />
maneuvers with different types and grade of cataract.<br />
A true understanding of this will help in logical setting<br />
of the machine parameters in adaptation to different<br />
surgical techniques.<br />
Even the most modern machine will not give adequate<br />
results as compared to an older machine if the principles<br />
of phacodinamics are not well understood.<br />
Most of the surgeons use their equipment without<br />
really understanding their machines or the basic values<br />
which allow them to operate in great safety.<br />
The most important parameters in microphacoemulsification,<br />
in order to be performed well requires a<br />
good understanding of fluid mechanics.<br />
Basically the dynamics of phaco in both conventional<br />
and microphaco remain the same In microphaco<br />
irrigation is through the side port rather than through<br />
the irrigation slevees (Fig. 15.1).<br />
JEROME JEAN BOVET (SWITZERLAND)<br />
With this one of the major problems encountered is<br />
that not enough fluid is going into the eye through the<br />
side port irrigating chopper. In conventional phaco the<br />
silicon sleeve delivers up to 65 cc/min into the eye<br />
whereas the best irrigating choppers of 20 G cannot<br />
deliver more than 45 cc/min. keeping this basic fact in<br />
mind one has to work around it in term of surgical<br />
manoeuvers, fluid management, ultrasonics and type and<br />
grade of cataract.<br />
Some of the obvious advantages of bimanual microphaco<br />
are decreased incision size, less astigmatism, good<br />
anterior chamber maintenance if we understand the logic<br />
of phacodynamic.<br />
Because irrigation is separated from aspiration the<br />
added advantage theoretically is that all fluids comes in<br />
through one incision and exit through the other.We have<br />
always to take in account some leak from the irrigation<br />
sideport and from the aspiration sideport that’s we<br />
demonstrate in our experimental set-up.<br />
The irrigation fluid in conventional phaco has a<br />
tendency to push the fragments away from the aspiration<br />
tip.<br />
With bimanual microphaco we are improved<br />
followability, we are able to manipulate tissue with the<br />
incoming stream of fluid and we have a much more stable<br />
chamber because all of the fluid is entering through one<br />
side of the eye and leaving through the other side so we<br />
do not have competing currents of fluid aroud the phaco
FIGURE 15.1: Phaco overview<br />
needle. Of course bimanual irrigation and aspiration<br />
systeme of the cortex has been known for a long time to<br />
be advantageous.<br />
The fundamental principle of every cataract operation<br />
is to improve the vision of the patient after surgery of<br />
the cataract and not to diminish it.<br />
The purpose of the stability of the anterior chamber<br />
is to distance the endothelium and the posterior capsule<br />
from the tip of the probe.<br />
Consequently, in order to avoid any lesion of the<br />
corneal endothelium, the consequence of which is<br />
considerable corneal oedema with a risk of the need to<br />
perform a graft, it is imperative to control the stability<br />
and depth of the anterior chamber.<br />
We must always bear in mind that the principal cause<br />
of corneal grafts is the cataract operation.<br />
The most important heading in phacodynamic that<br />
will be discuss below are:<br />
• Fluidic<br />
• Surge<br />
Phacoemulsification is a cataract surgery in a close<br />
chamber, in a such close chamber ,one must monitor the<br />
inflow (irrigation), the outflow (aspiration) and the leak.<br />
There are three components of fluidics.<br />
Irrigation<br />
PHACODYNAMICS 129<br />
For most machines irrigation is passive, i.e. it is determined<br />
by the height of the perfusion and the diameter of<br />
the tube. Most of these machines do not possess a<br />
pressure control or a control of the flow rate of the liquid<br />
entering the eye. Such a control would make it possible<br />
to prevent the collapse of the anterior chamber. This is<br />
the weak point of all of the phacoemulsification machines<br />
and the bimanual microphaco technique.<br />
There are two ways of increasing the flow rate of the<br />
liquid in the anterior chamber:<br />
• By increasing the pressure<br />
Many authors have described theirs own methods to<br />
increase the flow by increasing the pressure everybody<br />
have forget the Poiseuilles law increasing the pressure<br />
increase also the pressure inside the eye and affect the<br />
endothelium<br />
• By increasing the diameter of the perfusion probe<br />
utilising a Duet handpieces design by Larry.Lacks of<br />
Microsurgical technology in which the chopping<br />
lumen of a 19 G tip deliver at least 60cc/min with a<br />
pressure of 33 mm Hg<br />
• An other way to increase inflow volume is to add an<br />
anterior chamber maintener as has been described
130 PHACODYNAMICS: STEP BY STEP<br />
by Michael Blumenthal, this device may be use in<br />
addition to or instead of an irrigating second instrument,altough<br />
it involves a third incision for access<br />
to the anterior chamber.<br />
Aspiration<br />
outflow Rate<br />
Outflow rate is defined as the volume of fluid by unit<br />
that exit the anterior chamber that governs the speed of<br />
the procedure and the danger to aspirated the iris or the<br />
posterior capsule<br />
Vacuum is what grips the nucleus which is occluding<br />
the phacotip, this grip allow to decrease ultrasound and<br />
aids chopping<br />
Leak<br />
In a conventional phaco the leak is a composant of the<br />
surge and the instability of the anterior chamber. In a<br />
bimanual microphaco with 19 G irrigation needle (that<br />
mean at least a 60 cc/min of irrigation). The controled<br />
leak is to cool done the phacotip without induce an<br />
instability of the anterior chamber (Fig. 15.2).<br />
The inflow rate has to be higher than the outflow<br />
rate even with the maximum of vacuum with every type<br />
of pump to avoid the surge.<br />
FIGURE 15.2: Aspiration-irrigation leak: Microbimanual 19 G<br />
FIGURE 15.3: Surge: Vacuum with a peristaltic pump<br />
Surge<br />
This phenomenon is produced when the phaco tip is<br />
occluded by nuclear masses. The increase in the negative<br />
pressure occurs up to the limit values that have been<br />
predetermined. The greater the negative pressure and the<br />
longer the time it is maintained, the larger will be the<br />
volume of liquid to be replaced along the length of the<br />
tubes at the time of the decompression. The vacuum will<br />
be propagated up to the anterior chamber leading to its<br />
collapse (Fig. 15.3).<br />
The best way to avoid the problem is to increase the<br />
flow rate upstream of the anterior chamber. In the case<br />
of bimanual surgery, it is necessary to increase the<br />
diameter of the irrigation probe to 19 G tip.<br />
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PHACODYNAMICS 131<br />
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