How to Achieve a Stable Anterior Chamber in Phaco Surgery   

Phacoemulsification (phaco) surgery is a common and highly effective procedure for cataract removal. A key to successful phaco surgery is maintaining a stable anterior chamber throughout the procedure. A stable chamber ensures better visualization, reduces the risk of complications, and facilitates smoother surgical maneuvers. Here are essential tips and techniques to achieve a stable anterior chamber during phaco surgery.

1. Proper Incision Placement

    

   Location and Size:

   • Primary Incision: Place the primary incision in the clear cornea at the 10 or 2 o’clock position, depending on surgeon preference and hand dominance. Ensure the incision is self-sealing to prevent fluid leakage.
   • Side Ports: Create side port incisions at the 3 and 9 o’clock positions for better access and instrument manipulation. These incisions should be small and snug around the instruments to minimize fluid loss.

   Technique:

   • Use a sharp, precise blade to make the incisions. Avoid excessive tissue manipulation to reduce the risk of wound leaks.
2. Optimal Use of Viscoelastic Agents

   Types of Viscoelastics:

   • Dispersive Viscoelastics: Use these to coat and protect the corneal endothelium and maintain space during the initial steps of surgery.
   • Cohesive Viscoelastics: Utilize these to create and maintain space in the anterior chamber during critical steps such as capsulorhexis and intraocular lens (IOL) implantation.

   Application:

   • Inject an adequate amount of viscoelastic to deepen the anterior chamber and create a stable working environment. Replenish as needed throughout the procedure to maintain stability.
3. Efficient Fluidics Management

   Phaco Machine Settings:

   • Aspiration Flow Rate: Adjust to a level that provides sufficient fluid exchange without collapsing the chamber. Typically, a moderate flow rate is effective.
   • Vacuum Levels: Use appropriate vacuum levels based on the density of the cataract and the step of the procedure. Higher vacuum levels can help with emulsification but should be balanced to avoid chamber instability.
   • Infusion Pressure: Ensure the infusion bottle is positioned at the correct height to maintain constant pressure. Modern phaco machines offer adjustable infusion pressures to optimize chamber stability.

   Technique:

   • Use a slow and controlled approach to phacoemulsification, minimizing sudden movements that can destabilize the chamber.
4. Effective Use of Capsulorhexis Instruments

   Capsulorhexis Forceps vs. Cystotome:

   • Choose the instrument that offers the best control and comfort for the surgeon. Capsulorhexis forceps provide excellent precision, while an irrigating cystotome can help maintain chamber depth.

   Technique:

   • Create a continuous curvilinear capsulorhexis (CCC) of appropriate size, typically around 5.0 to 5.5 mm in diameter. A well-centered and correctly sized capsulorhexis helps in maintaining chamber stability throughout the surgery.
5. Controlled Phacoemulsification Technique

   Divide and Conquer vs. Chop Techniques:

   • Divide and Conquer: Suitable for beginners, involves creating grooves in the nucleus and breaking it into smaller pieces for easier removal.
   • Chop Techniques: Advanced methods like stop-and-chop or direct chop allow for quicker emulsification but require skill and experience.

   Technique:

   • Perform phacoemulsification in the central safe zone of the anterior chamber to avoid peripheral damage. Use low-energy settings and efficient chopping techniques to minimize turbulence and maintain stability.
6. Proper Intraocular Lens (IOL) Implantation

   Lens Injection:

   • Inject the IOL slowly and smoothly, ensuring it unfolds gradually within the capsular bag.

   Viscoelastic Removal:

   • Thoroughly remove viscoelastic from the anterior chamber and behind the IOL to prevent postoperative complications such as increased intraocular pressure. Use gentle aspiration techniques to avoid chamber collapse.
7. Postoperative Considerations

   Wound Sealing:

   • Ensure all incisions are securely sealed at the end of the procedure. Hydrate the wounds and check for leaks.

   Intraocular Pressure Management:

   • Monitor intraocular pressure (IOP) closely postoperatively and manage any spikes promptly to ensure patient comfort and safety.