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byBonnieAnHenderson,MD

Supplementto
EyeWorld
August2014
Phaco
fundamentals:
Devicesettings
andbest
practicesfor
routineto
complexphaco
emulsification
ThisCME
supplementis
supportedby
unrestricted
educational
grantsfrom
AlconandBausch
+Lomb.

Understandingperistalticversusventuripumps

Whendifferentiatingbetweenperistalticandventuripumps,itis
importanttoreviewthegoalsofproperfluidicrelationships.The
objectiveistohavesufficientpowertoremovethecataractwhile
maintainingastableanteriorchamberandminimizingcorneal
damageandheatproduction.Anothercrucialconceptwhen
discussingphacoemulsificationpumpsisinflowandoutflow.
Usuallyinflowisdefinedbygravityandhence,bottleheight.The
higherthebottle,thegreaterthedifferencebetweentheheightof
thebottleandtheeye,leadingtoahigherinflow.Inflowis
accompaniedbyaprogrammablepump.Somenewer
BonnieAnHenderson,MD
phacoemulsificationmachineshavesubstitutedanactivepump
systemratherthanrelyingongravity.Outflowisdefinedby
vacuum,aspiration,tubingsize,andincisionarchitecture.
Aspirationflowratemayseemlikeanamorphousfactor,butit
actuallyreferstohowmuchandhowfastfluidisremoved.Itis
whatcausesnuclearpiecestobeattractedtothephacotip.In
turn,vacuumisthenegativepressurethatkeepsthenuclear
fragmentsonthephacotipthehigherthevacuum,thegreater
theholdingforce.Aperistalticpumpusesflexibletubing
compressedagainstarigidrotorbyaseriesofrollersonthepump
head.Thiscreatesarelativevacuumwhentheaspirationportis
occluded.Thereareseveraladvantagestoperistalticpumps.The
Venturipump
surgeoncansetvacuumlimitsindependentofflowandcanallowa
differentamountofflowbutagreateramountofvacuum.
Peristalticpumpsallowformoderateflowwithlowvacuumto
increasethermalsafetyduringsculpting.However,withperistaltic
pumps,youhavetohaveaclearunderstandingofhowflowand
vacuumwork,astheycanbechangedinappropriatelyinnovice
hands.Withtheventuripump,theflowandvacuummustwork
togethersothereisonlyonevariabletochange.Inaventuri
system,thetipdoesnothavetobeoccludedtocreatevacuum.
Themovementofthephacoportcanbeminimizedandwithout
needingtochasepieces.Thedisadvantageisthatyouhavetobe
morecautiousofwhatelseisaroundyourtipatthetime.When
PeristalticpumpSource:
thevacuumisengaged,notonlywillthenuclearfragmentbe
attractedtothetip,thecapsulewillalsobeattracted.Withtodays Bausch+Lomb
efficient,advancedsystems,youwillnoticetherapidmovementofthepiecestowardthetip.
Preventingsurge
Surgeoccurswhenafragmentthatisoccludingtheportissuddenlyaspirated.Whenthefragment
isoccludingthephacotip,thetubingcollapsesduetonegativepressure.Whenthefragment
clears,thereisasuddenexpansionofthetubingcausingarapidrushoffluidintothetubingand
subsequentflatteningoftheanteriorchamber.Surgeisoftenassociatedwiththerigidityofthe
tubing.Themorepliantthetubing,thehigherthelikelihoodofcreatingsurge.Tohelpcontrol
surge,thesurgeoncanincreasetheinflowintotheeyewithahigherbottleheight,loweraspiration
flowrate,andlowervacuumpreset.Todaysphacotechnologyoftenwillhavebuiltinaidstohelp
avoidsurge.Theseincludedigitallycontrolledandautomatedinfusionsystems,rigidtubing,anda
bypassporttoallowsomeflowevenwhenthetipisoccluded.
Phacodevicesettingsavoidingwoundburn
Alteringthefluidicsforthedensityofthecataractcanbeadvantageous.Foraventuripump
system,atypicalsettingforamoderatecataractisabottleheightof135cm,powerof40,vacuum
of275,dutycycleof40%,and30pulsespersecond(pps).Incontrast,withadenselens,the
bottleheightremainsat135cm,butthepowercanbeincreasedto60,vacuumincreasedto290,
dutycycleincreasedto70%,with70pps.Ifthepatienthasweakzonules,Iadjustmysettingstoa
bottleheightof50to75cm,apowerof40,avacuumof35,50to70ppsdependingondensity,
andadutycycleof50%.Withweakzonules,theentirediaphragmofthecapsularbagtendsto
trampolineupanddown,sothegoalistostabilizethechamber.Bydoingso,thiscanpreventthe

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10/8/2015

TheBestofOphthalmology.....EyeWorldNewsMagazine
vitreousfromprolapsinganteriorlyandhopefullypreventtheneedforavitrectomy.Asinflow
decreaseswithalowerbottleheight,Idecreasethevacuumanddecreasepowertoabout40.
Althoughwoundburnislesscommonwithtodaysadvancedphacotechnology,itstillissomething
everysurgeontriestoavoid.Afewsurgicalpearlstopreventawoundburnaretoaspiratesome
oftheviscoelasticmaterialbeforebeginningtosculptorvacuumthelensandtoensureproper
incisionarchitecture.Makesuretheincisionsizeisappropriate,theentryintotheanteriorchamber
issquare,andavoidtorquingthewoundwhenusingthephacohandpiece.Payingcloseattentionto
thesetypesofsmalldetailsarethebasicsofphacofundamentals.
Dr.HendersonisinprivatepracticeatOphthalmicConsultantsofBoston,andclinicalprofessorof
ophthalmologyatTuftsUniversitySchoolofMedicine.Shecanbecontactedat
bahenderson@eyeboston.com.

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