Eyeworld

P haco Fundamentals has been a long-standing symposium at the ASCRS Annual Meeting, giving attendees the latest information that they can incorporate in their surgical cataract practice for safe and effective outcomes. The 2026 symposium, sponsored by Alcon and Bausch + Lomb, moderated by Richard Tipperman, MD, and Yousuf Khalifa, MD, FACS, was broken into three main categories with several presentations in each section. Part 1a: Essential Phacodynamic Principles Lisa Park, MD, discussed when adjustments should be made to the vacuum or flow settings. "Essentially, it's all about anterior chamber stability," she said. "What goes into the eye should equal what comes out of the eye." This balance is important because, as Dr. Park pre- sented, an underpressurized eye can cause shallowing and chamber collapse, which can result in endothelial cell loss, iris damage, and posterior capsule rupture. An overpres- surized eye does the opposite, causing anterior chamber deepening, which can lead to zonular stress or misdirection of aqueous fluid. Modern phaco systems incorporate sophisticated fluidics technologies to help maintain chamber stability by balanc- ing inflow and outflow during surgery. Flow rate (the flow of fluid through the tubing) influences how quickly frag- ments flow to the phaco tip, while vacuum refers to how tightly the materials are held at the tip (occurring when the tip is occluded). Peristaltic pumps are flow based, creating vacuum upon occlusion with flow being constant until oc- clusion occurs. This pump type, Dr. Park said, is slower but considered safer. Venturi pumps are vacuum based, with the vacuum being created by the pump and flow varying based on the level of vacuum. Dr. Park said venturi pumps are fast- er, but they come with an increased risk of post-occlusion surge. This difference may be mitigated by advanced sensors in current phaco machines. PHACO FUNDAMENTALS 2026 Dr. Khandelwal spoke about how to recognize and handle post-occlusion surge. Source: Sumitra Khandelwal, MD "We should understand that when you adjust the settings on your machine, you are setting the maximum vacuum versus actual vacuum," Dr. Park said. "On a linear setting, the actual vacuum will depend on how much you are pressing down on the foot pedal. One should understand that achiev- ing maximum vacuum also requires tip occlusion." Dr. Park said there are different phaco tip angles, and physical adjustments may need to be made when touch- ing the tip to the nucleus to achieve full occlusion. She also discussed how fluidic imbalance can be caused, either through incorrect wound construction or oblique positioning of the handpiece in the wound. Conditions that may require adjustments in fluidic settings include floppy iris syndrome, zonulopathy or extreme myopia, floppy posterior capsule, and posterior capsule rupture, Dr. Park said. Sumitra Khandelwal, MD, dove deeper into the topic of post-occlusion surge, specifically recognizing and managing it. She shared a case of one of her fellows (the first time she had them sit superiorly) and before even pushing play, she noted a few pitfalls. "What you see here is we're pushing the eye down. We're going to have a lot of egress from the paracentesis there on the left, and it was well dilated when we started this case … but it's getting smaller, so we already have a stressor here because we're losing some of that visu- alization," she said. Dr. Khandelwal described surge as the sudden with- drawal of fluid after an occlusion break, resulting in shallowing or collapse of the anterior chamber. There are various ways to prevent surge, including decreasing vacuum or flow rate, using a short and stiffer tubing, constructing tighter wounds, raising the bottle height or IOP, and use of an aspiration bypass system. Dr. Khandelwal also discussed "pseudo-surge," which can occur due to leaking tubing, "It's all about anterior chamber stability. What goes into the eye should equal what comes out of the eye." —Lisa Park, MD

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