Chapter 14 Phacoemulsification has evolved to become the most efficient method to remove cataracts. Many recent improvements have been made in the computerization of the procedure. This has resulted in improvement in power delivery and the fluidics of the procedure. With modern fluidics occlusion of the phaco tip allows for the achievement of the most efficiency. Several methods that have evolved to attain occlusion of the tip include disassembly techniques such as divide and conquer, stop and chop, phaco chop and its variations, and phaco flip. The phaco flip technique is well suited to total occlusion of the phaco tip with the least amount of manipulation in the eye. In addition, the phaco flip procedure and its variants are performed in the center of the pupillary space and in the deepest part of the anterior chamber. By elevating the nucleus to the plane of the iris, phaco is performed far from the lens equator and posterior capsule, thus greatly minimizing the risk of the posterior capsule tearing during the procedure. This procedure is performed predominantly in the deep anterior chamber at the level of the iris plane. This technique requires movement of the nucleus nearer the cornea than emulsification, which is performed more posteriorly. Endothelial contact and damage is possible especially in certain situations enumerated below. Viscoelastic selection is therefore important. A surgeon with experience in this technique will find any viscoelastic suitable. The choice may be altered due to variations in ocular anatomy or access. For a surgeon transitioning to this technique, the flipping and phaco maneuvers may initially seem unusual. Therefore, a retentive dispersive viscoelastic such as Viscoat, a soft shell technique, or a visco-adaptive viscoelastic such as Healon5 should be selected. The phaco flip procedure is performed through a clear corneal incision. A paracentesis incision (or “functional incision”) is executed followed by a phaco incision of 2.5 to 2.8 mm made with a diamond keratome. A capsulorrhexis is performed under viscoelastic with a bent 23-gauge needle or forceps. The size of the capsulorrhexis is between 5.5 and 6.0 mm. The rhexis must be large enough to flip the nucleus but not so large that the insertion of the anterior zonules is encountered. In addition there must be adequate anterior capsular rim to ensure postoperative intraoperative lens (IOL) centration. All capsulorrhexis techniques require the surgeon to regrasp the torn edge of the capsule frequently to prevent inadvertent loss of control of the rhexis. With a large rhexis, regrasping is more important as the tear does not have as far to go to tear into the equator. Hydrodissection is next performed with an olive-tipped cannula (Storz E4414WS or equivalent) placed under the edge of the capsulorrhexis. The cannula tip is lifted to create slight upward tenting of the anterior capsule. This will ensure that the tip is not in the cortex. BSS is slowly injected and directed posteriorly while watching for the classic fluid wave over the red reflex. It is important to hydrodissect deliberately and slowly with the BSS so as to adequately lyse cortical-bag connections. Hydrodelineation is not necessary given that with the phaco flip technique keeping the nucleus and epinucleus intact as a single unit makes the emulsification more efficient. Next, it is imperative to ensure that the nucleus is completely free to rotate. To do this, the olive-tipped cannula is positioned on top of the nucleus and the nucleus is slowly rocked in the plane of the capsular bag two to three clock hours in each direction. If incomplete lysis of cortical attachments is noted, further hydrodissection is essential. Once the nucleus is unquestionably established to be completely free, the olive-tipped cannula is positioned toward the equator of the lens. The lens is simultaneously pressed inferiorly while rotating three to four clock hours (Fig. 14–1). With a gentle push, the lens will now flip on its edge with the depressed (subincisional) edge going deep into the capsular bag toward the opposite equator. The olive tip is then used to gently elevate the new distal pole of the nucleus, to complete the flip (Fig. 14–2). The former distal pole of the nucleus must simultaneously flip up, through the rhexis, into the anterior chamber. The entire lens nucleus will now be located vertical, on its side, or on its “back.” It is readily accessible to the phaco tip. At the completion of flipping the nucleus should rest about 45 degrees from the horizontal plane with the “new” uppermost pole toward the incision (Figs. 14–3 and 14–4
PHACO FLIP AND TILT
AND TUMBLE
PHACO FLIP TECHNIQUE1
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
