Cataracts are a significant cause of vision impairment worldwide, particularly among the ageing population. With the advancement of medical technology, cataract surgery has transformed significantly over the past few decades. One of the most commonly performed and highly effective procedures today is phacoemulsification cataract surgery, often referred to simply as Phaco surgery. 

This comprehensive guide aims to provide a deeper understanding of the procedure, its advantages, step-by-step process, and post-operative care, making it an essential read for patients and aspiring ophthalmic professionals.

What Is Phacoemulsification Cataract Surgery?

Phacoemulsification is a modern, micro-incision technique used to remove a cataract-affected lens from the eye. A cataract occurs when the eye’s natural lens becomes clouded, leading to blurred vision, glare sensitivity, and difficulty seeing at night. 

In phacoemulsification, the surgeon uses a hand-held ultrasonic device that emulsifies or breaks the cloudy lens into microscopic fragments.  These fragments are then aspirated out of the eye through a small incision. 

Once the cataract is removed, an artificial intraocular lens (IOL) is implanted into the eye to restore vision. This procedure, typically performed under local anaesthesia, takes 8 to 10 minutes per eye. Its minimally invasive nature, along with rapid recovery times and low complication rates, has made phacoemulsification the gold standard for cataract treatment globally.

What Makes Phacoemulsification the Best Choice for Cataract Surgery?

Phacoemulsification offers several advantages over traditional cataract surgery techniques, such as extracapsular or intracapsular cataract extraction. These benefits contribute to its widespread preference among eye surgeons and patients:

• Smaller Incisions: The incisions are about 2-3 mm in length, self-sealing, and typically do not require stitches.
• Minimal Trauma: The ultrasonic probe emulsifies the lens precisely, causing less trauma to surrounding tissues.
• Quick Recovery: Because the ocular tissues are minimally disrupted, most patients experience rapid visual recovery and minimal postoperative discomfort.
• Reduced Risk of Infection: The smaller incision size and shorter surgery duration significantly reduce the risk of postoperative infections such as endophthalmitis.

Technology advancements have made the procedure even more efficient and safer, making it accessible to a broader patient demographic.

Step-by-Step Phacoemulsification Procedure

Let’s dive into the surgical process and understand each phase of phacoemulsification cataract surgery:

1. Anaesthesia

Local anaesthesia, typically administered via eye drops or gel, ensures that the patient feels no pain during the procedure while remaining conscious. Peribulbar or general anaesthesia may be considered in uncooperative patients or complex cases.

2. Patient Preparation and Draping

The eye and surrounding area are sterilised using a povidone-iodine solution. The eyelashes are taped away, and sterile drapes isolate the eye. A lid speculum is inserted to keep the eyelids open during surgery.

3. Making the Incision

A precise corneal incision is made using a microkeratome or diamond blade, usually on the temporal side. The size and location of the incision are carefully planned to ensure a self-sealing, watertight closure, which enhances postoperative stability and reduces infection risk.

4. Capsulorhexis

The surgeon creates a circular opening in the anterior lens capsule called a capsulorhexis. This step is crucial because a well-centred and appropriately sized capsulorhexis ensures proper IOL positioning and long-term visual stability. Techniques like the continuous curvilinear capsulorhexis (CCC) are used for precision.

5. Hydrodissection and Hydrodelineation

Fluid is injected into the lens capsule to separate the lens nucleus from the cortex and the capsule, allowing easier rotation and emulsification. Hydrodelineation helps isolate the nucleus from the epinucleus, reducing the amount of ultrasound energy needed.

6. Phacoemulsification (Nuclear Disassembly)

The phaco handpiece delivers ultrasonic energy to emulsify the dense nucleus. Various techniques like divide-and-conquer, stop-and-chop, or phaco-chop are employed depending on the cataract grade and the surgeon’s preference. The emulsified fragments are aspirated through the same probe.

7. Cortical Aspiration

The softer cortical material is aspirated using a bimanual or coaxial irrigation/aspiration (I/A) probe. Complete cortical cleanup reduces postoperative inflammation and prevents posterior capsule opacification (PCO).

8. Intraocular Lens Implantation

An injector system inserts a foldable IOL through the same small incision. The lens unfolds inside the capsular bag and is carefully positioned to ensure centration and stability.

9. Wound Closure

Thanks to the small, self-sealing incision, sutures are rarely required. The anterior chamber is formed with balanced salt solution, and the incision is hydrated to ensure proper sealing. A drop of antibiotic may be instilled before completing the procedure.

Meticulous planning and execution at The Vision Surgeon align with these advanced surgical techniques to ensure optimal outcomes.

Preoperative Planning for Phaco Surgery

Successful phacoemulsification begins long before the patient enters the operating room. Preoperative planning is crucial for optimal surgical outcomes and involves several detailed assessments and discussions:

• Comprehensive Eye Examination: Includes vision testing, slit-lamp examination, and dilated retinal examination to determine the severity and impact of the cataract.
• Corneal Health Assessment: Tests like pachymetry and specular microscopy help evaluate corneal thickness and endothelial cell count, which is especially important in patients with corneal guttae or Fuchs’ dystrophy.
• Biometry for IOL Calculation: Accurate measurement of axial length, anterior chamber depth, and corneal curvature using optical biometry devices (e.g., IOLMaster, Lenstar) is vital for selecting the correct power of the IOL.
• Macular OCT: A non-invasive imaging test that helps detect any underlying macular pathology that could affect visual outcomes.
• Discussion of IOL Options: Patients are briefed on the types of IOLs available, including monofocal, toric (for astigmatism), and multifocal lenses. Patient lifestyle, visual needs, and expectations are considered when choosing the best lens.
• Preoperative Medications: Includes prophylactic antibiotics and anti-inflammatory eye drops. Conditions like blepharitis or dry eyes are managed to reduce the risk of postoperative complications.

Also read: Pterygium Surgery Procedure and Recovery Guide

Postoperative Management and Recovery

Recovery after phacoemulsification is typically quick and uneventful. Most patients notice improved vision within 24 to 48 hours. However, complete visual stabilisation may take a few weeks.

Immediate Postoperative Instructions:

• Avoid rubbing or pressing on the operated eye
• Use prescribed eye drops as directed (antibiotics and steroids)
• Wear protective eyewear or an eye shield while sleeping
• Avoid swimming, heavy lifting, or dusty environments for at least one week

Follow-Up Visits:

Patients are usually scheduled for follow-up on Day 1, Week 1, and then after 4-6 weeks for a final refraction and assessment. The surgeon evaluates wound healing, IOL position, and intraocular pressure during these visits.

Risks and Complications of Phacoemulsification

Though phacoemulsification is highly safe, certain complications may arise. Some potential risks include:

• Posterior Capsule Rupture: May occur if the capsule is accidentally torn, leading to vitreous loss.
• Cystoid Macular Oedema (CME): Swelling in the central retina that can affect vision.
• Infection (Endophthalmitis): Rare but sight-threatening. Prompt antibiotic treatment is essential.
• Intraocular Pressure Spikes: Usually transient, but may need medical intervention.
• Corneal Oedema: Can occur due to excess ultrasonic energy or endothelial cell damage.

Most complications are rare and manageable when identified early and treated appropriately.

Who Is a Good Candidate for Phaco Surgery?

Ideal candidates for phacoemulsification include:

• Patients with visually significant cataracts interfering with daily activities
• Individuals in good general and ocular health
• Patients with controlled systemic conditions (e.g., diabetes, hypertension)
• Those with realistic expectations regarding visual outcomes

Patients with complex ocular conditions, such as pseudoexfoliation, zonular weakness, or dense brunescent cataracts, may still undergo phacoemulsification, but it requires advanced techniques and higher surgical expertise.

Advances and Innovations in Phacoemulsification

Phacoemulsification continues to evolve with cutting-edge innovations aimed at improving safety, precision, and outcomes:

• Femtosecond Laser-Assisted Cataract Surgery (FLACS): Offers computer-controlled precision in corneal incision, capsulotomy, and lens fragmentation.
• New-Generation Phaco Machines: Feature improved fluidics, reduced thermal energy, and enhanced safety features.
• Innovative IOLs: Options like extended depth-of-focus (EDOF), trifocal, and light-adjustable lenses revolutionise post-cataract visual quality.
• Artificial Intelligence in Planning: AI-powered platforms now assist in predicting optimal IOL power and customising surgery plans.

These advancements signify a promising future for cataract surgery, especially in delivering premium visual outcomes.

Conclusion

Phacoemulsification cataract surgery is a landmark in ophthalmology. It offers a minimally invasive, efficient, and highly successful solution for one of the most common causes of vision loss. By understanding each aspect of the procedure, from preoperative planning to recovery, patients can confidently make informed decisions and approach the surgery.

With the help of skilled ophthalmic surgeons and modern surgical tools, phacoemulsification has restored vision for millions and continues to transform lives globally. If you’re experiencing cataract symptoms, consult your eye care professional to discuss whether phacoemulsification is the right choice.

Don’t wait for your cataracts to worsen. Book a consultation with The Vision Surgeon today and take control of your vision health with a trusted expert.