Phacoemulsification: How do I set up and take down the phaco machine?

Authors: Charlene Tran, BS; Tyler S. Quist, MD; Karen Fitzgerald, ST; Jessica Shiner, RN; Justin Bloomberg, DO

Posted December 8, 2020

The purpose of this tutorial is to help young cataract surgeons understand the nuts and bolts of the Centurion Visual System. This review contains sufficient information to both set up, use, and take down the phaco machine. A better understanding of this process will help trainees not only feel more comfortable in the operating room, but also enable them to better trouble shoot technological issues that may arise during surgery.

How do I set up the phaco machine?

First, remove the protective covering. Then, remove the monitor and front utility tray protective coverings. Plug the power cable into an outlet located at the back of the machine. Pull the monitor up and rotate it clockwise. Push the power button located on the right side of the machine. Select the "Provider" and "Procedure" tabs on the touch screen monitor.

Pull the utility tray located at the front of the machine forward and let it slowly fall into position. Locate the remote control stored in a drawer on the right side of the machine.

Secure the remote control to the utility tray by nestling it within the metal bar configuration. Then, push the white knob down and rotate the utility tray located on the top of the machine simultaneously in a counter clockwise direction. Open the sliding door located on the top of the machine and insert a bag of basic salt solution (BSS). Then close the sliding door and wipe the gray top with an alcohol swab.

What is all that stuff on the back table?

The materials needed for the case are placed on the back table in a sterile fashion as shown here. These items include surgical towels (red), the phaco tubing and accessory kit (green), a phaco hand piece (blue), the Des Moines VA custom cataract kit (yellow), a bottle of BSS (purple), a keratome (orange), ophthalmic viscosurgical devices (golden brown), and an I/A tip (black). In addition, the cataract surgical instrument tray is also placed on the back table but is not shown in this photograph.

The phaco tubing and accessory kit includes a plastic drape for the utility tray, a cassette with tubing for irrigation and aspiration, and a small plastic package. The small plastic package is shown. It contains a phaco handpiece cannula (red), sleeve (yellow), and filling catheter (blue).

The Des Moines VA custom cataract kit is shown here.  The kit includes surgical gowns (blue), a surgical drape (yellow), 27-guage angled cannulas (red), a paracentesis blade (green), empty plastic BSS cups (purple), Weck-cel sponges (orange), 3-cc syringes for BSS and 1-cc syringes for intracameral solutions (green-brown), a surgical marking pen (black), a cystotome (gray), an eye shield and gauze (light blue).

The healon syringe is initially unassembled. Remove the white plunger from the tip of the cannula by pulling it off (red), push the cartridge forward (blue), place the white plunger onto the cartridge by screwing it in (red), and place a 27-guage cannula, or the cystotome, on the end of the syringe (yellow). The healon syringe is now assembled.

The Viscoat syringe also comes initially unassembled. Remove the grey cap (red) and place a 27-guage cannula on the syringe (yellow). The viscoat syringe is now assembled.

How to I set up the phaco handpiece?

After scrubbing in, place a surgical towel on the center of the utility tray and place the plastic drape over the utility tray. It is helpful to push the plastic drape through the metal ring at the front of the tray to make a place to hold your phaco handpiece during the case.  Insert the cassette into the front of the machine by inserting the lower part first and then rotating the piece forward to click it into place. Stick the tubing in the BSS bag on top of the machine. Pull the irrigation and aspiration tubing apart and attach the ends of the irrigation and aspiration tubing together. Select "Prime FMS" on the touch screen monitor or by pushing enter on the remote.

Next, plug in the phaco handpiece into the middle slot on the right side of the machine by matching up the two red dots. Attach the phaco cannula to the phaco handpiece by lightly screwing it in until resistance is reached and then just every so slightly past that point. Attach the phaco sleeve to the phaco cannula by threading it over the cannula and carefully screwing it into place while assuring that the tip comes out of the end and not accidentally out of one of the side ports. Connect the aspiration and irrigation tubing to the phaco handpiece. Insert the hand piece and the filling sleeve into an empty BSS cup. Select "Fill" on the bottom of the touch screen monitor or push enter on the remote and wait for this step to be completed. In the meantime, fill the filling sleeve for the next step and fill the BSS cup for future BSS syringes that may be needed. Next, insert the phaco handpiece into the catheter so that it is air tight and rotate the hand piece so the handpiece is pointed upward. Select "Test Handpiece" on the touch screen monitor or push enter on the remote. The phaco handpiece is now ready and the screen on the monitor will automatically go to procedure mode.

How do I set up my instruments for cataract surgery?

A cataract surgery tray contains all instruments needed for cataract surgery including the I/A hand piece. For a complete list of instruments, please click on the following link: https://eyerounds.org/tutorials/instruments/Phaco/index.htm. These instruments are removed from the surgical tray and are placed on the utility table in the order that they will be used for the case. A hemostat or surgical tape can also be used to secure the irrigation and aspiration tubing to the side of the utility tray.

How do I set up the I/A handpiece?

The I/A handpiece is located within the lower level of the cataract surgery tray. Attach the I/A cannula to the I/A handpiece by lightly screwing it in until resistance is reached and then just every so slightly past that point similar to the phaco handpiece. Attach the I/A sleeve to the phaco cannula by threading it over the cannula and carefully screwing it into place while assuring that the tip comes out of the end and not accidentally out of one of the side ports, similar to the phaco handpiece. Remove the irrigation and aspiration tubing from the phaco handpiece and insert them onto the I/A handpiece. Go to position 1 to run fluid through the I/A handpiece. The I/A handpiece is now ready.

How do I set up for an anterior vitrectomy?

Select "Ant Vit" in the bottom right of the screen. This has to be done manually and cannot be done with the remote. The Vitrectomy Setup screen will automatically come up. Open the vitrectomy kit, which contains the vitrector, irrigation cannula, and tubing.  Remove the aspiration and irrigation tubes from the phaco hand piece. Connect the irrigation and aspiration tubing to the console vitrectomy port then click next on the monitor. These pieces are connected by first pushing into place and then slightly rotating clockwise to click them into place. Connect the aspiration tubing to the vitrector and click next on the monitor. Connect the irrigation tubing to the irrigation cannula and click next on the monitor. Stick the vitrector tip and the irrigating cannula in a cup filled with BSS and click "Fill" on the monitor then click "Test" on the monitor. Select the red X button on the monitor once these steps are completed. Select the green button in the middle of the screen labeled "Anterior Vit" to select either Anterior Vit or I/A cut settings. Of note, Cut I/A settings are identical to Anterior Vit settings.

What do I need to know about the remote?

The remote is located in the small drawer on the right side of the machine and is placed on the utility tray at the front of the machine beneath the plastic tray drape during the case. The remote can be used to toggle through phaco settings to avoid needing to touch the screen when you are sterile. Clicking buttons A through F allows you to change rows (red). The corresponding rows for buttons A through F are depicted in different colors on the phaco screen. Clicking the right and left arrows allows you to change your selection within a given row (yellow). Clicking the up, down, right, and left arrows allows you to change your selection within a given row or to change rows completely (purple). Clicking plus and minus buttons increase or decrease the selected setting (e.g. IOP) (blue). The enter button is used select items on the screen (green). Of note, the "Coag" and "Ant Vit" settings must be clicked manually and are not part of the A through F rows. 

What do I need to know about the foot pedal?

The foot pedal is located on the back of the phaco machine where it is hung. The foot pedal charges by simply resting in place against the phaco machine. A green light located on the right lower portion of the foot pedal indicates that it is being charged and is properly placed. Make sure the foot pedal is not tilted and that the power cable does not interfere with its placement. In the rare event that the foot pedal is out of battery and will not charge, there is a spare cable located in the same drawer as the remote on the right side of the machine. This cord can be used when you're in a pinch and connects the foot pedal into the phaco machine directly. It is important to know that a given foot pedal works as a set with only one phaco machine. It is not interchangeable with other machines. 

The foot pedal has multiple features. Pushing down on the main foot pedal to position 1 is irrigation, down to position 2 is aspiration, and down to position 3 is ultrasound (red arrows). The foot pedal can be programed as desired for additional maneuvers. At the Des Moines VA, clicking down on the large black button on the right will advance you forward through your phaco settings and clicking on the large black button on the left will advance you backward through your phaco settings (blue arrows). Kicking to the right will turn on and off continuous irrigation and kicking to the left will reflux aspirated contents (green arrows).

How do I turn off the phaco machine?

After removing all instruments, tubing, and draping from the phaco machine it is ready to be turned off. Select the Tool icon on the touch screen and select "Shutdown System". You do not push the power button on the right side of the machine that you push to turn on the machine. Place a cover on the front utility tray and monitor and then rotate these back into place. Place the foot pedal to its original position, wrap the power cord around the back, and finally place the drape over the machine.

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