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Maximize Phaco Efficiency Using Two Specialized Techniques
BY ROBERT WEINSTOCK, M.D.

Figure 1. Bevel points right.

Figure 2. Bevel turned to point up to maintain full occlusion at the tip.

In using a chopping or a divide-and-conquer technique for removing extremely dense nuclei, either with bimanual or coaxial phacoemulsification, one of the benefits of hyperpulse technology is the ability to keep the phaco needle cool, while still providing a tremendous amount of power for emulsifying the nucleus.

When we first learned to phaco, it was pedal to the metal. In training residents, I have noticed that, regardless of whether there are pieces on the tip, these new surgeons are hitting on the phaco power and hoping pieces of nucleus comes to the tip. Unfortunately, many surgeons continue this practice without a true understanding of what is actually happening at the phaco tip. Unless there is material on the tip, phacoemulsification power is useless. It is much more efficient and better for the eye to only activate phaco power if the tip is occluded with nuclear material. The key to efficient phaco is to utilize a technique with matching settings that allow nuclear material to constantly be moving toward the phaco tip — and only going into foot position three when the tip is occluded and vacuum is building. The phaco power is then applied only to break the occlusion. Finally, vacuum is used to remove the material from the eye.

Additionally, there are times when a piece of dense nucleus will be at your tip that is not really occluding the tip. In these instances, the nuclear material is just sitting there or chattering at the tip while you are applying phaco power, producing wasted energy. The reason this happens is that the orientation of the nuclear piece does not match well with the beveled orifice of the phaco needle.

So, how do you solve this problem? I have polished two particular techniques over the past few years that maximize the efficiency potential of this phaco system and help eliminate inefficient phaco and wasted power with the problems described above. These two techniques are effective with either coaxial or bimanual phaco. They work very well for reducing the amount of energy delivered to the eye and provide maximal efficiency of the phaco power. One of the phaco machines I like to use for these techniques is the Sovereign Compact with WhiteStar technology (Advanced Medical Optics [AMO], Santa Ana, Calif.). 

Double-Pulse Technique

With WhiteStar hyperpulse technology, the machine pulses so fast it is difficult to tell that you are even in a pulse mode. The machine is cycling phaco power on and off so fast that it cannot be heard or seen. In addition to this hyperpulse, you can tap your foot in and out of foot position three (phaco) on your own. Tapping back and forth between phaco and resting provides a rapid drop and rapid increase of vacuum and phaco in addition to the hyperpulse, essentially creating a pulse within a pulse. This "double pulse" changes the occlusion and the vacuum dynamics at the tip of phaco needle to instantaneously bounce the nuclear fragment off the phaco needle and re-occlude it. By using the double pulse, the orientation of the nuclear fragment on the tip is altered, creating better occlusion and a rise in vacuum. Better occlusion and rapid vacuum building facilitates removal of nuclear material. The double-pulse technique is highly efficient because it uses vacuum more than ultrasound to clear the tip.

Twist-and-Turn Technique

Figure 3. Bevel rotated to face left and keep material directly against its opened end.

Figure 4. Phaco handpiece is then twisted in the surgeon's hand to have the bevel pointing down, which matches up flat and flush against the nuclear material.

To further improve phaco efficiency, surgeons can utilize what I like to call the "twist-and-turn" technique simultaneously with double pulse. The twist-and-turn technique is helpful when emulsifying nuclear material that is architecturally challenging, such as one that is shell-like in shape, pointy or multifaceted. These types of nuclear material typically do not efface well with the tip of the phaco needle, leading to ineffective ultrasonic energy that is applied.

To address this situation, many surgeons might bring their second instrument in and use this to reposition the nucleus or chop it with the phaco needle. While this works, I believe that a more efficient method is the twist and turn technique, which uses a beveled phaco tip and a spinning or rotating motion to match up with the flat face of the nuclear material. As phaco is performed, the phaco needle is continually repositioned against different pieces and facets of the nuclear quadrant to optimize complete obstruction (Figures 1-4).

The twist-and-turn technique leads to better occlusion and more efficient use of ultrasonic energy. The vacuum builds faster, rising high enough to facilitate rapid removal of the nucleus as a pulse of phaco breaks the occlusion. The goal of the twist-and-turn technique is to achieve complete occlusion, break occlusion and then get occlusion again. This technique does require the surgeon to pulse with his or her foot in and out of position 3 (phaco) in concert with the clearing of material from the tip of the needle.

As I have honed my bimanual phaco skills, I have found that these two techniques have decreased my total phaco time and increased my efficiency. I use double-pulse and twist-and-turn techniques in conjunction with one another on a daily basis. The subtleties of just how efficient these techniques become more apparent as I practice and fine tune them.

These techniques have resulted in my being able to perform extremely fluid phaco — where the material stays right on the tip and the next piece follows immediately as the tip is cleared. Every surgeon has his or her own special technique and tricks for removing nuclei and these are just some of the methods I have developed when working with the bimanual instrumentation.

Robert Weinstock, M.D., is director of cataract and refractive Surgery at the Eye Institute of West Florida in Largo, Fla.