update/review

The physics of phaco: A review

Mark Packer, MD, William J. Fishkind, MD, I. Howard Fine, MD, Barry S. Seibel, MD,
Richard S. Hoffman, MD

Despite its unparalleled success in the field of surgery, the precise mechanism of
ultrasonic phacoemulsification cataract extraction remains controversial. We review
the relevant peer-reviewed literature on the subject of power generation and
tip–tissue interactions to clarify the current status of our knowledge. We conclude
that phacoemulsification most likely operates by a combination of mechanisms,
including direct action of the vibrating tip against tissue and indirect cavitational
effects. Surgeons will benefit from understanding the physical principles underlying
phacoemulsification because they will be better able to evaluate the performance of
various parameters and different machine settings.
J Cataract Refract Surg 2005; 31:424–431 ª 2005 ASCRS and ESCRS

U nited States patent 3 589 363, filed July 25, 1967,

lists Anton Banko and Charles D. Kelman as
inventors of ‘‘an instrument for breaking apart and
ciency,’’ Ophthalmology Times, April 15, 2003, pages
62–64).2,3 Although definitive answers may prove
elusive, it behooves surgeons to understand the language
removal of unwanted material, especially suitable for of physics and engineering, not only to analytically
surgical operations such (as) cataract removal, including evaluate marketing claims but also to ‘‘promote the
a handheld instrument having an operative tip vibrating performance of a surgical procedure that is more gentle
at a frequency in the ultrasonic range with an amplitude and efficient, thus improving outcomes and minimizing
controllable up to several thousandths of an inch.’’1 complications.’’3
Now, 37 years later, the fundamental mechanisms
by which the system known as phacoemulsification Basic Principles of Power Generation
operates remain controversial. While some authors
The prerequisite for the removal of a cataract
describe the surgical advantages of a unique type of
through a small incision is a technique to break up the
cavitational energy, others deny any role for cavitational
hard nucleus into emulsate for aspiration. Inspired by
energy in phacoemulsification (C. Guttman, MD, et al.,
the dentistry technique to remove tarter with a metal
‘‘Microbursts of Ultrasound Increase Safety, Effi-
tip that oscillates longitudinally at frequencies in the
ultrasonic range, Kelman ingeniously adopted this
Accepted for publication November 8, 2004. principle and combined the oscillating tip and the
From a private practice, Eugene, Oregon, USA. evacuation tube into a hollow needle.1 A special
Dr. Packer is a consultant to Advanced Medical Optics, Inc., and
titanium alloy is the material of choice for such
Bausch & Lomb, Inc., and has received travel support and honoraria applications because of a favorable strength-to-weight
from Alcon Laboratories, Inc., and Staar Surgical, Inc. Dr. Fishkind is ratio as well as biocompatibility and resistance to
a consultant to Advanced Medical Optics, Inc. Dr. Fine is a consultant fragmentation.
to Advanced Medical Optics, Inc. and Bausch & Lomb, Inc. Dr. Seibel
is a consultant to Bausch & Lomb, Inc. Dr. Hoffman has no financial The phaco handpiece incorporates a transducer for
interest in any product mentioned. converting high-frequency, alternating current into me-
Reprint requests to Mark Packer, MD, 1550 Oak Street, Suite 5, chanical vibrations. Magnetostrictive transducers are
Eugene, Oregon 97401, USA. based on packs of ferromagnetic lamellae, surrounded

2005 ASCRS and ESCRS 0886-3350/05/$-see front matter
Published by Elsevier Inc. doi:10.1016/j.jcrs.2004.11.027
 UPDATE/REVIEW: PHYSICS OF PHACO

by an electric coil. The magnetic field induced by the among the multiple layers of crystals that are needed to
high-frequency electric current flowing through the coil provide adequate stroke amplitudes, and the structural
excites the oscillation. The advantages of magnetostric- brittleness of the crystal itself. These properties limit the
tive transducers include contact-free excitation, which longevity of the transducers. They are delicate and
prevents deterioration at the junction of the current and deteriorate from accidental mechanical injury and the
the transducer. These transducers, coupling elements, oscillation they produce.
and the entire handpiece are rugged, withstanding Every material has an inherent frequency at which it
mechanical injury, and have a long lifespan. Their vibrates naturally. This is called its resonant frequency. If
primary disadvantage is a relative low grade of excited to vibrate at this frequency, the transformation
efficiency. Only a small part of the energy input is into mechanical amplitude will be optimal and the
transformed into mechanical action; most becomes creation of other forms of energy, principally heat, will
heat. Heating not only carries the risk for tissue burn but be minimized. The creation of balanced crystals, their
also makes the transducer lose efficiency with rising attachment to the horn, and the weight of the titanium
temperatures. Also, in the original design, the concen- phaco needle must therefore be carefully controlled
tric aspiration line had to be brought out in front of during manufacturing.
the lamellar stack, necessitating 2 sharp bends that fre- The phaco procedure is less controlled. In the
quently clogged. course of phaco, the needle is passed through and inside
Recent improvements include increased efficiency material of inconsistent resistance. The aqueous is less
through sophisticated ferromagnetic metal alloys with resistant than a soft nucleus, and a soft nucleus less
rare earth elements and engineering modifications that resistant than a mature one. Thus, for example, as the
allow the irrigation and aspiration lines to be concen- phaco needle travels through balanced salt solution into
trically brought straight through the track to the tip. a hard nucleus, the resonant frequency must be adjusted
This not only avoids the clog-prone bends but also to prevent inefficient emulsification. The result of
provides a double stream of constantly flowing cooling inefficient emulsification is prolonged phaco time,
fluid through all elements of the vibrating system, higher power, and increased heat generation. Therefore,
obviating the need for a separate cooling system, as modern phaco systems now have a built-in feedback
found on the older handpiece. loop that constantly adjusts or tunes the oscillating
Piezoelectric transducers are based on the reversals frequency to an optimal resonance. This is a function of
of the piezoelectric phenomenon. Upon compression, the central processing unit (CPU) of the machine. It will
certain crystals produce electric current. In reverse, read the change in resistance of the phaco needle and
electric current causes the crystal to contract. Applying make minute adjustments in the stroke length or fre-
current to a crystal at high frequency will cause it to quency. The greater the frequency of the corrections,
oscillate at that frequency. the more effective the emulsification will be.
The crystal is mounted on the ultrasonic horn, Power is the product of oscillatory frequency (hertz,
a piece of tubing of narrowing diameter, eventually cycles per second, secÿ1) and the work associated with
ending with the attachment of the phaco needle. The a given stroke length. Frequency is defined as the speed
narrowing diameter tube acts as an amplifier to generate of the needle movement. It is determined by the manu-
adequate power for emulsification. facturer of the machine. Currently, most machines
The advantages of piezoelectric crystals include operate at a frequency of between 35 000 cycles per
a high grade of efficiency and therefore little inherent second (hertz) and 45 000 cycles per second. This
heat generation, with no need for extra cooling. The frequency range is the most efficient for nuclear emulsi-
crystals’ low mass allows rapid movement and precise fication. Lower frequencies appear to be less efficient,
control. Many new handpieces use multiple crystals and higher frequencies create excess heat.
(usually 2 to 4 sets) to maximize responsiveness and Frequency is held constant by tuning circuitry
provide adequate power to emulsify the mature hard designed into the machine’s CPU. Stroke length is
nucleus. Disadvantages include the connection points defined as the length of the needle movement. This
between crystal and electric current, the connections length is generally 2 to 6 mil (thousandths of an inch).

J CATARACT REFRACT SURG—VOL 31, FEBRUARY 2005 425

 UPDATE/REVIEW: PHYSICS OF PHACO

Most machines operate in the 2 to 4 mil range. Longer horn–tip impact and other mechanical forces, operating
stroke lengths are prone to generate excess heat. The in combination with hydrodynamic forces applied to
longer the stroke length, the greater the physical impact the tissue on the forward stroke in each cycle. No
on the nucleus. Stroke length is determined by foot evidence of cavitation in tissue was observed.’’ Using an
pedal excursion in position 3 during linear control of ultrasonic unit similar to the CUSA (Valleylab) set at
phaco. Although the frequency is unchanged, the ampli- 23 kHz with peak amplitude of about 330 mm, they
tude of the sine wave is increased in direct proportion to measured the transmitted waveform in water with
the depression of the foot pedal.3 calibrated hydrophones. While they observed both
acoustic streaming and cavitation in water, they did not
find evidence of cavitation in tissue interactions. They
Effects at the Phaco Tip note that ‘‘the interaction of acoustic energy with tissue
can be expected to be very different from the case of the
The action of phacoemulsification can include
interaction with water.’’5 In water, they found a power
several mechanisms including direct mechanical cut-
threshold above which a pattern of stable cavitation
ting, termed the jackhammer effect, and implosion of
bubbles developed. Using high-speed photography,
microcavitation bubbles, producing extreme yet brief
they described a model of tip–tissue interaction for
instances of heat and pressure.4 Cavitation can be
efficient fragmentation that relies on forward stroke
described simply as growth, oscillation, and collapse of
mechanical force and suction. Bond and Cimino found
micron-sized bubbles in liquids under the influence of
a ‘‘loss of contact’’ with tissue during the back stroke,
an acoustic field. Cavitational effects may be created as
‘‘which limits the fragmentation process to the forward
the phaco needle moves through the liquid medium of
(downward) stroke.’’5 ‘‘Given the absence of the
the aqueous at ultrasonic speeds, creating intense zones
negative part of the pressure cycle, it does not appear
of high and low pressure. Low pressure, created with
that it is possible that cavitation can be a significant
backward movement of the tip, may pull dissolved gas
fragmentation mechanism for the conditions of ‘good
out of solution or vaporize the aqueous solution itself,
fragementation.’’’5
giving rise to microbubbles. Forward tip movement
A more recent study investigated the specific issues
then creates an equally intense zone of high pressure.
of the mechanisms of phacoemulsification with a com-
This produces compression of the microbubbles until
mercially available unit, using straight, 45-degree
they implode.
beveled tips in both continuous and pulse modes (L.J.
However, Boukhny2 has stated that ‘‘all cutting
Bond, et al., ‘‘Physics of Phacoemulsification,’’ pre-
occurs due to mechanical cutting, much like during
sented at the 5th World Congress on Ultrasonics, Paris,
jackhammer action.. cavitation plays no useful role in
France, September 2003). Various ultrasonic measure-
phaco or other cutting ultrasound applications.’’ The
ments were made with 3 types of samples: hard and soft
jackhammer effect is the direct mechanical impact of
tissue phantoms and fresh porcine eyes. A hydrophone
the physical striking of the needle against the nucleus.3
wide-band receiver with effective bandwidth from
The efficiency of this mechanism depends on 2 main
10 kHz to 2.25 MHz was used to record the ultrasonic
prerequisites:
signals. The ultrasonic waves produced by the tip
1. Rapid forward acceleration of the phaco tip. This (horn)–sample impact (at 40 kHz) and any acoustic
overcomes the inertia of the nucleus, penetrating it emissions propagated through the test sample to the
rather than driving it away. receiver were measured in the configuration (Figure 1).
2. Close mechanical contact between the tip and the The unit was operated with all types of samples with and
nucleus. Engineers call this force coupling. It is without irrigation and suction. In all cases, material was
obtained by pressing the tip against the nucleus or fragmented and no significant cavitation was detected.
by pressing the nucleus to the tip. Both time domain and spectral measurements were
made, and no evidence of transient cavitation was
Bond and Cimino5 state that ‘‘the primary recorded. Under some conditions, very low level
mechanism for tissue fragmentation is shown to be cavitation events were recorded (Figure 2).

426 J CATARACT REFRACT SURG—VOL 31, FEBRUARY 2005

 UPDATE/REVIEW: PHYSICS OF PHACO

Figure 1. Left: Phacoemul-

sification tip, sample, and wide-
band receiver. Right: Example
of transmitted 40 kHz pulse.

Bond also conducted measurements to determine cavities, or bubbles, in a liquid medium.’’ He dis-
the source of the ‘‘cavitational hiss’’ heard during tinguishes gaseous cavitation, a low intensity release of
phacoemulsification. He noted that without irrigation, dissolved gas, from vaporous cavitation, a high intensity
no hiss was audible. The unit was then operated with vaporization of the liquid medium. Vaporous cavitation
irrigation and no sleeve. The shoulder at the top of the is associated with very high pressure and temperature,
tip was noted to be the source of a fine atomized mist up to 10 000 atmospheres and 3000  C.7 ‘‘At the same
(Figure 3). Bond reported that the hiss only occurred time, free chemical radicals are produced, and even very
when the shoulder of the horn was immersed in fluid tough metals are eroded.’’7
or the sleeve, which entrains irrigation, was attached. Pacifico notes that ‘‘most surgeons view phacoe-
Further investigation showed that some low level cavi- mulsification as a single energy that emulsifies the
tation events occurred near the tip when the irrigation cataractous lens with an action similar to that of
fluid had transported microbubbles down the sleeve. a miniature jackhammer, ignoring the possibility that
Bond therefore concluded that the cavitational hiss was the procedure’s ultrasound energy may have other
produced at the shoulder of the tip and was not relevant dimensions and uses in ophthalmology.’’8 By ‘‘other
to tissue interaction. Based on these findings, it is dimensions,’’ Pacifico means cavitation. He schemati-
reasonable to conclude that ultrasonic cavitation occurs cally describes the creation of a cavity in lens material by
in fluid but not during tip–tissue interaction per se. means of energy release secondary to bubble implosion:
Ensminger,6 however, has noted that ‘‘many of the ‘‘[P]erhaps the cavitation effect is most easily visible
useful effects of ultrasonic energy are associated with when the phaco cuts clearly go deeper and beyond where
cavitation, a term used to describe the formation of mechanical cutting would have stopped.’’8 Davis echoes

Figure 2. Procedure in a porcine eye (left) with an example of

a low-level, random cavitation event recorded during the procedure
(right).

J CATARACT REFRACT SURG—VOL 31, FEBRUARY 2005 427

 UPDATE/REVIEW: PHYSICS OF PHACO

Cavitational Effects in Phacoemulsification,’’ presented

at the ASCRS Symposium on Cataract, IOL and
Refractive Surgery, San Francisco, California, USA,
April 2003). By taking acoustic measurements from an
ultrasonic tip immersed in a water tank, Schafer
demonstrates the production of cavitational effects
(Figure 4). He also suggests that micropulses of US
give rise to a phenomenon known as transient, as
opposed to stable, cavitation. Stable cavitation involves
volume oscillations of gas bubbles in a continuous
sound field, while the more violent transient cavitation
is associated with collapse of the gas bubbles during
a single US cycle or after a small number of cycles.10 In
the final phase of collapse, pressure and temperature
inside the bubble can reach thousands of millimeters of
mercury and Celsius degrees. These high temperatures
Figure 3. Atomization of irrigation fluid at tip (horn) shoulder.
lead to the emission of light (sonoluminescence) and
can cause bond dissociation in molecules, producing
free radicals able to react with biomedical species in the
same way as those produced by ionizing radiation.11
Immediately after the bubble rebound, the high-
pressure shock wave emanates from the bubble location
and causes mechanical damage to the surrounding
fluid.12 Hence, the greatest destruction of tissue by
ultrasonic cavitational energy is mediated by violently
collapsing bubbles.
Several authors cite the formation of free radicals as
evidence of cavitation during phacoemulsification.
These species are thought to be generated when the
Figure 4. Ultrasonic tip in water bath showing wave propagation heat from the implosion of cavitation bubbles causes the
and presence of presumed cavitation bubbles. decomposition of water.13–15 Holst et al.16 used a single
photon counting apparatus and luminol in rabbit eyes
this observation: ‘‘Phaco surgeons often notice cataract to demonstrate chemoluminescence secondary to the
tissue breakdown anterior to their phaco needles with- production of free radicals during phacoemulsification.
out the tip touching the cataract. This is because the They also obtained data correlating the amount of free
shock waves are focused in front of the phaco needle as radicals produced with the amount of ultrasonic power
shown by Schlieren imaging.’’9 He cites Fishkind’s used. Topaz et al.17 demonstrated sonoluminescence
video presentation of shock waves in vitro to support under simulated phacoemulsification in aqueous me-
this concept (W.J. Fishkind, MD, ‘‘Pop Goes the Micro dium using electron paramagnetic resonance spec-
Bubbles,’’ video presented at the ASCRS Symposium troscopy and photon detection. They also noted
on Cataract, IOL and Refractive Surgery, Seattle, modification of acoustic cavitation and elimination of
Washington, USA, June 1996). sonoluminescence by saturation of the solution with
Schafer reported an in vitro assessment of cavitation carbon dioxide. The release of cavitational energy
generation and cavitational effects associated with during phacoemulsification has also been confirmed
phacoemulsification, specifically contrasting micropulse in vitro by experiments performed by Reinhert Teizel at
applications of ultrasound (US) with continuous power the Physikalisches Institut, University of Erlangen,
(M.E. Schafer, MD, ‘‘Cavitation Generation and Germany (personal communication, William J. Fish-

428 J CATARACT REFRACT SURG—VOL 31, FEBRUARY 2005

 UPDATE/REVIEW: PHYSICS OF PHACO

kind, MD, December 3, 2003). Using laser photogra-

phy techniques, the cavitation wave was photographed
at 2 to 5 nanosecond intervals (Figure 5).
Taken as a whole, the experimental evidence
suggests the interplay of mechanical and cavitational
forces operating at the phaco tip. While mechanical
forces emulsify tissue directly on contact with each
forward stroke of the phaco tip, the activation and
implosion of cavitation bubbles in the aqueous
environment of the anterior chamber may also disrupt
lens material. Transient cavitation will, however, only
occur above a certain threshold of US power. For
example, the American Institute of Ultrasound in
Medicine has accepted the mechanical index (MI),
which is a dimensionless quantity proportional to the
US rarefaction pressure and inversely proportional to Figure 5. Transient cavitation during micropulse
phacoemulsification.
the square root of the frequency of the US wave, as
a predictor of possible biological responses to transient
cavitation.18 Although more generally related to safety The advent of bimanual microincision phaco,
parameters for diagnostic US, an MI less than 0.7 which uses power modulations such as micropulse
indicates a low probability for transient cavitation technology to minimize US power, has eclipsed the
effects.19 This theoretical prediction may be incorrect if early promise of laser phaco systems to deliver non-
the medium through which the ultrasonic waves pass thermal cataract extraction (A. Franchini, MD, ‘‘From
behaves as a viscoelastic fluid. Based on the fact that MI Laser Phaco to Cold Ultrasound: 10 Years of Micro-
depends directly on elasticity, Allen and Roy20 have insision Cataract Surgery,’’ presented at the ASCRS
reformulated the MI criteria. This reformulation may Symposium on Cataract, IOL and Refractive Surgery,
have implications for the intraocular environment in San Diego, California, USA, May 2004).25 Micropulse
which viscoelastic substances have been specifically technology may not only reduce US use but also
introduced for the protection of tissues. have fluidic advantages, as Steinert and Schafer
demonstrated with high-resolution, color, digital US
imaging (R.F. Steinert, MD, M.E. Schafer, MD,
Current Research Directions ‘‘Thermal Energy and Turbulence with WhiteStar and
Ironically, as controversy over the mechanism of Conventional Phacoemulsification,’’ presented at the
US continues to swirl and bubble, reduction in the use ASCRS Symposium on Cataract, IOL and Refractive
of US energy itself as an extractive modality in cataract Surgery, San Francisco, California, USA, June 2003).
surgery has become a primary surgical goal. Innovations They showed that micropulse power modulation
in fluid management including low-compliance tub- decreases fluid turbulence around the phaco tip and
ing and cassettes, microprocessor control of pumps, thereby improves followability (Figure 6).
aspiration-bypass and flow-restriction systems, high- Other alternative extractive technologies, such as
resistance down-sized phaco tips, modification of pulsed warm water, may ultimately find wider accep-
parameters during tip occlusion, and irrigation pressur- tance.26 As patients come to cataract surgery earlier in
ization have allowed safe use of high flow rates and very the course of their disease21 or opt for refractive lens
high vacuum levels, permitting extraction of moderately exchange before the development of visually significant
dense cataracts with minimal to no use of US.21–23 cataract,27 minimization of surgical morbidity and
Evidence is continuing to mount that the reduction in rapid achievement of excellent uncorrected visual
US use correlates with faster visual rehabilitation and acuity have become more important goals (R.H.
improved outcomes.24 Osher, MD, ‘‘Early Uncorrected Vision: An Important

J CATARACT REFRACT SURG—VOL 31, FEBRUARY 2005 429

 UPDATE/REVIEW: PHYSICS OF PHACO

Figure 6. Increased fluid velocity away from

the tip with continuous mode (left) as opposed to
micropulse (right) phaco suggests that continuous
phaco is more likely to push nuclear fragments
away from the tip.

Measurement in Contemporary Cataract Surgery,’’ pre- 2. Boukhny M. Phacoemulsification tips and sleeves. In:
sented at the Royal Hawaiian Eye Meeting, Kauai, Buratto L, Werner L, Zanini M, Apple D, eds, Phaco-
Hawaii, January 2004). Regardless of the specific direc- emulsification Principles and Techniques, 2nd ed.
Thorofare, NJ, Slack, 2003; 247–254
tion cataract extraction moves, the trend toward reduc- 3. Fishkind WJ, Neuhann TF, Steinert RF. The phaco ma-
tion of US energy will certainly continue because of its chine: the physical principles guiding its operation. In:
demonstrated correlation with improved outcomes.21 Steinert RD, ed, Cataract Surgery; Techniques, Com-
In this regard, 1 challenge for surgeons, particularly plications, and Management, 2nd ed. Philadelphia, PA,
those conducting research, has been the lack of objective Saunders, 2004; 61–77
comparative data among the phaco machines produced 4. Seibel BS. Phacodynamics: Mastering the Tools and
Techniques of Phacoemulsification Surgery, 3rd ed.
by the various manufacturers. Arbisser and Schafer Thorofare, NJ, Slack, 1999; 98
recently reported their attempt to compare the ultra- 5. Bond LJ, Cimino WW. Physics of ultrasonic surgery
sonic energy levels of 2 different machines and con- using tissue fragmentation: part II. Ultrasound Med
cluded that ‘‘the machine-provided data is extremely Biol 1996; 22:101–117
difficult to interpret and use for this purpose, and 6. Ensminger D. Ultrasonics; Fundamentals, Technology,
manufacturers should be encouraged to provide more Applications, 2nd ed. New York, NY, Marcel Dekker,
1988; 66
meaningful data in a simpler format’’ (L.B. Arbisser, 7. Ensminger D. Ultrasonics; Fundamentals,Technology,
MD, M.E. Schafer, MD, ‘‘Quantitative Investigation of Applications, 2nd ed. New York, NY, Marcel Dekker,
Ultrasonic Energy Levels Required During Cataract 1988; 394
Surgery,’’ presented at the ASCRS Symposium on 8. Pacifico RL. Ultrasonic energy in phacoemulsification:
Cataract, IOL and Refractive Surgery, San Francisco, mechanical cutting and cavitation. J Cataract Refract
California, USA, June 2004). Surg 1994; 20:338–341
9. Davis P. Cavitating microbubbles create shock waves that
emulsify cataract. In: Mehta KR, Alpar JJ, eds, The Art of
Phacoemulsification. New Delhi, Jaypee Brothers, 2001;
Conclusions 45–50
The evidence amassed thus far regarding the 10. Brennen CE. Cavitation and Bubble Dynamics. New
mechanism of ultrasonic phacoemulsification supports York, NY, Oxford University Press, 1995
11. Frizzell LA. Biological effects of acoustic cavitation. In:
a direct tip–tissue interaction. Indirect evidence, pri-
Suslick KS, ed, Ultrasound: Its Chemical, Physical, and
marily from in vitro studies, suggests a role for cavita- Biological Effects. New York, NY, VCH Publishers,
tional emulsification. 1988; 287–303
12. Ayme-Bellegarda EJ. Collapse and rebound of a gas-filled
spherical bubble immersed in a diagnostic ultrasonic
References field. J Acoust Soc Am 1990; 88:1054–1060
1. Banko A, Kelman CD, inventors; Cavitron Corporation 13. Augustin AJ, Dick HB. Oxidative tissue damage after
assignee. US patent 3 589 363. July 25, 1967 phacoemulsification: influence of ophthalmic viscosur-

430 J CATARACT REFRACT SURG—VOL 31, FEBRUARY 2005

 UPDATE/REVIEW: PHYSICS OF PHACO

gical devices. J Cataract Refract Surg 2004; 30:424– 21. Fine IH, Packer M, Hoffman RS. Use of power modu-
427 lations in phacoemulsification: choo-choo chop and flip
14. Shimmura S, Tsubota K, Oguchi Y, et al. Oxiradical-de- phacoemulsification. J Cataract Refract Surg 2001; 27:
pendent photoemission induced by a phacoemulsification 188–197
probe. Invest Ophthalmol Vis Sci 1992; 33:2904–2907 22. Fine IH, Packer M, Hoffman RS. New phacoemulsifica-
15. Takahashi H, Sakamoto A, Takahashi R, et al. Free rad- tion technologies. J Cataract Refract Surg 2002; 28:
icals in phacoemulsification and aspiration procedures. 1054–1060
Arch Ophthalmol 2002; 120:1348–1352 23. Fine IH, Packer M, Hoffman RS. Power modulations
16. Holst A, Rolfsen W, Svensson B, et al. Formation of free in new phacoemulsification technology: improved out-
radicals during phacoemulsification. Curr Eye Res 1993; comes. J Cataract Refract Surg 2004; 30:1014–1019
12:359–365 24. Vasavada AR, Mamidipudi PR, Minj M. Relationship of
17. Topaz M, Motiei M, Assia E, et al. Acoustic cavitation in immediate intraocular pressure rise to phaco-tip ergo-
phacoemulsification: chemical effects, modes of action nomics and energy dissipation. J Cataract Refract Surg
and cavitation index. Ultrasound Med Biol 2002; 28: 2004; 30:137–143
775–784 25. Olson RJ. Clinical experience with 21-gauge manual
18. Apfel RE, Holland CK. Gauging the likelihood of cavi- microphacoemulsification using Sovereign WhiteStar
tation from short-pulse, low-duty cycle diagnostic ultra- Technology in eyes with dense cataract. J Cataract
sound. Ultrasound Med Biol 1991; 17:179–185 Refract Surg 2004; 30:168–172
19. Holland CK, Apfel RE. Fundamentals of the mechanical 26. Mackool RJ, Brint SF. AquaLase: a new technology for
index and caveats in its application [abstract]. J Acoust cataract extraction. Curr Opin Ophthalmol 2004; 15:
Soc Am 1999; 105:1324 40–43
20. Allen JS, Roy RS. Dynamics of gas bubbles in viscoelastic 27. Hoffman RS, Fine IH, Packer M. Refractive lens ex-
fluids. I. Linear viscoelasticity. J Acoust Soc Am 2000; change as a refractive surgery modality. Curr Opin
107:3167–3178 Ophthalmol 2004; 15:22–28

J CATARACT REFRACT SURG—VOL 31, FEBRUARY 2005 431