Phacoemulsification Step by Step: A Beginner's Guide

Last updated: October 2026

Every phaco surgeon was once a beginner with shaking hands. This page breaks phacoemulsification into its steps, explains the purpose of each one, and lists the most common beginner mistakes and how to avoid them.

Before you start

• Know your patient: pupil size after dilation, pseudoexfoliation, anterior chamber depth, nuclear density, and previous surgery.
• Check the biometry and the IOL in theatre before you begin.
• Position the patient and microscope so you are comfortable. A tense surgeon has tense hands.
• Apply povidone-iodine 5% and drape the lashes completely out of the field.

Step-by-step

1. Incisions: a side port (paracentesis) and a main clear corneal incision (typically 2.2–2.8 mm). A good main incision has a tunnel long enough to self-seal. Too short a tunnel leads to iris prolapse and leaks; too long a tunnel causes corneal striae and poor view.
2. Viscoelastic (OVD): fill the anterior chamber to flatten the anterior capsule and protect the endothelium. Dispersive OVDs coat the endothelium; cohesive OVDs maintain space. The "soft-shell" technique uses both.
3. Capsulorhexis: aim for a central, round, continuous tear of about 5–5.5 mm that overlaps the IOL optic edge. Re-grasp often and keep the flap close to the centre. In white cataracts, stain the capsule with trypan blue.
4. Hydrodissection: inject fluid gently under the capsule edge until you see a fluid wave, then confirm the nucleus rotates freely. Avoid forceful hydrodissection in posterior polar cataracts.
5. Nucleus removal: divide and conquer (sculpt grooves, crack, then emulsify quadrants) is the usual beginner technique. Chop techniques use less energy and become more useful with harder nuclei. See phaco chop techniques.
6. Cortex removal (I/A): engage cortex under the capsule edge, pull it towards the centre, then aspirate. Subincisional cortex is the hardest; a bimanual I/A or a curved tip helps.
7. IOL implantation: refill with OVD and inject the lens into the bag. Make sure both haptics are in the bag and the optic is centred.
8. OVD removal and closure: remove viscoelastic from behind and in front of the IOL to prevent a post-operative IOP spike. Hydrate the wounds and confirm they are watertight.

Understand your machine settings

• Power emulsifies the nucleus. Use it efficiently; excess energy damages the endothelium.
• Vacuum holds the nuclear fragment on the tip. Low vacuum for sculpting, high vacuum for chopping and quadrant removal.
• Aspiration flow controls how quickly fragments come to the tip and how lively the chamber feels.
• Bottle height or infusion pressure maintains the chamber. Too low and the chamber collapses (surge); too high and the chamber is deep and uncomfortable for the patient.

Common beginner problems

Building your skills

• Practise on a wet lab or simulator before and alongside live surgery.
• Record your operations and review them with a mentor. Every video teaches more than you think.
• Learn one technique well before learning many.
• Start with easy cases: good dilation, moderate nucleus, deep chamber, cooperative patient.

More reading: Phaco Tips & Tricks, IOL calculators, and a little philosophy in My Thoughts in Ophthalmology.