Patent Publication Number: US-6217543-B1

Title: Removal of tissue

Description:
RELATED CASE 
     This application is a divisional of U.S. Pat. No. 6,007,513, U.S. patent application Ser. No. 08/926,241, filed Sep. 5, 1997, which is a continuation-in-part of U.S. Pat. No. 5,911,699, U.S. patent application Ser. No. 08/828,928 filed Mar. 28, 1997, which is a continuation-in-part of U.S. patent application Ser. No. 08/625,909 filed Apr. 1, 1996, now U.S. Pat. No. 5,722,945, which is a continuation-in-part of U.S. patent application Ser. No. 08/372,866 filed Jan. 13, 1995, now abandoned, which is a continuation of U.S. patent application Ser. No. 08/035,985 filed Mar. 22, 1993, now abandoned, which is a continuation-in-part of U.S. patent application Ser. No. 07/759,937 filed Sep. 16, 1991, now abandoned, which is a continuation of U.S. patent application Ser. No. 07/680,292 filed Apr. 4, 1991, now abandoned, which is a continuation-in-part of U.S. patent application Ser. No. 07/553,975 filed in the name of Aziz Y. Anis on Jul. 17, 1990, now U.S. Pat. No. 5,222,959 for REMOVAL OF TISSUE. 
    
    
     BACKGROUND OF THE INVENTION 
     This invention relates to the removal of tissue from the body such as for example removal of cataracts from the eye. 
     It is known to remove diseased tissue from the body by fragmenting, crushing or otherwise making the tissue flowable while in the body and then aspirating it. In one known class of surgical techniques of this type specifically intended for the removal of cataracts: (1) an incision is made along the superior corneal margin from about 10 to 2 o&#39;clock (12 o&#39;clock is the location closest to the top of the head of the patient) approximately 10 mm in chord length; (2) an incision is made in the capsular wall; and (3) the cataract is removed. The anterior chamber is maintained substantially formed during the operation by means of a continuous inflow of irrigating solution. 
     In one prior art technique of this class for removing a cataract, the nucleus is expressed out of the eye and the cortex is removed by a process of irrigation and aspiration. In another prior art technique of this class for removing the cataract, the nucleus is removed with a vectis and about 0.1 milliliter of viscoelastic compound or irrigating fluid is introduced into the capsular bag to separate the capsular walls. With the capsular walls separated, a wedge of the cortex is engaged in the aspiration port of a cannula and peeled toward the center and then aspirated to remove it. This process is repeated so that the layers of the cortex are peeled and then aspirated inwardly through the cannula, layer by layer, until the intact capsular bag (except for the horizontal incision) is completely empty and clean. 
     This technique of removing the cataract is disclosed by Anis, Aziz Y., “Illustrated Step-by-Step Description of the Anis Dry Extra Capsular Cataract Extraction Technique With In-the-Bag Lens Implementation”;  Seminars in Opthalmology,  v. 1, N. 2 (June), 1986, pp. 113-129 and the technique is compared with other such techniques of this class. 
     Two prior art types of instruments which aid in the fragmentation and aspiration of the lens nucleus to permit extraction through a small incision are machines disclosed in U.S. Pat. No. 3,589,363 to Anton Banko et al.; U.S. Pat. No. 3,902,495 to Steven N. Weiss; U.S. Pat. No. 3,693,613 to Charles Kelman et al.; and U.S. Pat. No. 4,041,947 to Steven N. Weiss et al. These machines are intended in the prior art to fragment a lens nucleus using ultrasonic vibrations to aid the irrigation/aspiration of the lens. The ultrasonic vibrations laterally reciprocate the tip of an instrument to fracture the cataract after which it can be aspirated. 
     A further type of machine is disclosed in U.S. Pat. No. 4,908,015 issued to Anis on Mar. 13, 1990. This patent describes a machine that rotates a solid member having blades extending from it to grind the lens. 
     These tissue removal techniques have several disadvantages, such as: (1) the machines used in the techniques risk tearing the capsular wall with the reciprocating ultrasonic vibration tools or with the rotating blades; (2) under some circumstances, they require large incisions in or removal of parts of the capsular wall; and (3) they may require the use of several different instruments and/or machines. 
     Still another type of prior art technique for removing cataracts uses a machine disclosed in U.S. Pat. No. 3,996,935 to Banko issued Dec. 14, 1976. This type of machine has cooperating jaw-like members, one of which rotates inside the other to break up the lens by shearing sections of it. It aspirates fragments through the instrument. This type of instrument has a disadvantage in that it can break the capsular wall and is relatively complex. Part of the disadvantage comes from the teaching that it may be rotated manually or mechanically without a corresponding teaching of the rate of rotation required for efficient use. 
     Still another prior art instrument includes a small rotary magnetic cutter that is injected through the capsular wall and a means for applying magnetic fields that control the magnetic cutter in position. The small magnetic cutter is rotated as it moves from position to position in the capsular bag and to abrade or cut the lens that is to be removed. 
     This instrument has several disadvantages, such as: (1) it is relatively complicated and expensive because of the need to remotely control the small cutter; and (2) does not incorporate any mechanism for aspirating the lens particles as they are abraded from the lens. 
     In still another prior art device disclosed in U.S. Pat. No. 4,002,169, small retractable wires are rotated in a range of 5 rpm to 16,000 rpm. There is no teaching of selecting the speed for surface discrimination and the device relies on blunt surfaces to avoid damage to the capsular wall instead. This device has the disadvantages of: (1) providing a relatively slow cutting velocity range with blades not shaped for cavitation or turbulance; (2) not providing a range of velocities sufficient to form small particles that can be aspirated through a small hole; and (3) not providing for aspiration during fragmenting, thus blocking visibility with particles. 
     Each of these prior art types of instruments includes a handpiece and a console. The handpiece is held by the surgeon and includes an operative tip that, at one point in time, enters the capsular sac to fragment and remove the cataract. The console includes controls for the handpiece such as those that control the direction of movement and speed of movement of the tip, rate of flow of liquids, the suction or aspiration pressure and the drivers that apply power to the hand-piece at the appropriate values. Generally, the consoles are designed together with a particular type of hand-piece used in a specialized technique of ocular surgery. 
     A still further type of instrument is disclosed in U.S. Pat. No. 4,504,264 to Kelman issued Mar. 12, 1985. This patent discloses an instrument that reciprocates a cutting tip ultrasonically and oscillates it rotationally about its longitudinal axis at a rate of one hertz through an angle of between five degrees to 60 degrees. 
     A similar United States patent, U.S. Pat. No. 5,176,677 to Wuchinich describes oscillation through a larger arc and states that the rotational motion is not limited as to direction or speed. It describes a device in which rotation of a beveled tip cuts tissue with reversal accommodating asymmetrical morphology to cut tissue that is more easily separated from one side than the other. This patent teaches that rotation from 61 to 360 degrees is sufficient for most purposes but rotation through any arc is possible through appropriate control but does not teach any mechanism or range that is preferable other than the motor being capable of operating from zero to 200 r.p.m. but as much as 3,000 r.p.m. with an appropriate bearing. 
     Because of dwell time at each change of rotational direction, the repeated changes of direction and speed limitations inherent in the direction changes, these two instruments do not provide the advantage of positive breaking of the tissue into particles small enough to not cause plugging of the tip nor impede visibility. 
     The prior art arrangement has several disadvantages, such as for example: (1) it is difficult for the surgeon to use the most modern techniques without investing substantial amounts of money in purchasing additional consoles for the newer instruments; (2) for each new handpiece designed for a particular technique, the surgeon must adapt to different controls in the console itsseff rather than relying upon controls with which he is already familiar; (3) the handpieces are subject to plugging, poor visibility into the eye and excessive pressure on the capsular wall from movement of large particles; (4) different equipment is necessary to remove vitreous liquids; (5) the aspirating force pulls large masses of tissue when the tip is normal to the tissue, thus occluding the opening; (6) deep coring is not possible to break the tissue into particles; and (7) vitreous liquids and semisolids are not absorbed but pull back when aspirating pressure is released. 
     SUMMARY OF THE INVENTION 
     Accordingly, it is an object of the invention to provide a novel technique for tissue removal. 
     It is a further object of the invention to provide a novel instrument for fragmenting and removing a cataract during cataract removal surgery with low risk of damage to the capsular wall. 
     It is a still further object of the invention to provide a novel instrument designed to fragment tissue without damage to the nearby tissue such as for example not damaging the capsular wall while removing the lens during cataract removal surgery or not damaging artery or vein walls while removing cancerous tissue near the vein or artery. 
     It is a still further object of the invention to provide a novel instrument and method for removing tissue that reduces the size of the tissue and aspirates them while maintaining good visibility. 
     It is a still further object of the invention to provide a novel surgical instrument that reduces the size of particles of tissue sufficiently to avoid occlusion of an aspirating device. 
     It is a still further object of the invention to provide a novel interface that permits the connection of a phacotmesis handpiece to consoles designed specifically for other ocular surgery such as consoles designed originally to cooperate with a phacoemulsification handpiece. 
     It is a still further object of the invention to provide an instrument capable of vitrectomy and removal of cateracts with the same handpiece. 
     It is a still further object of the invention to provide an instrument for removing the tissue that relies upon multiple mechanisms for fragmenting tissue including cavitation of hydrated tissue and torsional twisting of fiberous material to failure of the fibers. 
     It is a still further object of the invention to provide an instrument for removing tissue that does not depend on vacuum pressure to break smaller parts of tissue away from larger parts. 
     In accordance with the above and further objects of the invention, an incision is made for the insertion of a surface-discriminating, fragmenting tool. The surface-discriminating, fragmenting tool fragments and permits aspiration of high mass, rough-surface, rigid tissue without damaging nearby smooth, flexible, low mass walls. The tool fragments some tissue but avoids fragmenting other tissue by discriminating between tissues. This discrimination is based on one or more of several factors including: (1) the rigidity of the tissue; (2) the amount of mass of the tissue; (3) the angle of the tissue to the direction of movement of the tool; (4) the roughness of the surface of the tissue; and (5) the size and shape of the surface of the tissue to the extent the size and shape affect the tendency of the negative pressure created by aspiration and/or irrigation to move the tissue toward the surface-discriminating, fragmenting tool. 
     The surface discrimination of the tool is controlled by moving surfaces which fragment diseased tissue on impact, referred to as phacotmesis, and cause cavitation forces that further fragment and mix fragments of tissue, and provide a twisting section that breaks fibers to avoid pulling unbroken large particles into the tip to occlude it. The surfaces move at a rate of speed slow enough so that the more integrated, more flexible, lower mass and smoother tissue is moved away without fragmenting. The tissue is not constrained by opposed shear forces of the tool as in some prior art rotating tools nor is the higher mass, rigid tissue moved significantly as a bulk. 
     The surfaces of the instrument fragment tissue that: (1) is stiffer and has a higher modulus of rigidity; and (2) is at an angle to the cutting edge closer to 90 degrees and receives less force moving it away. Thus, the surgeon removing a cataract adjusts the speed of movement of the tool surfaces, the aspirating and irrigation forces, the rake angle of the tip and the cavitation level as controlled by the position of the tool surface, the velocity and the shape of the moving surface. The adjustment is made to fragment the cortex because of its higher mass, modulus of elasticity and projections in the path of the tool surfaces but to move the capsular wall because of its lower mass, lower modulus and fewer projections closer to 90 degrees and not fragment it. 
     In one embodiment, a moving, fragmenting surface moves at an angle with the normal to a cataract surface, which angle is obtuse and generally close to being perpendicular to the normal in such a manner as to mix particles and to cause or aid ultrasonic motion normal to the tissue in causing cavitation and torsional twisting forces that fragment and mix the cataract particles while maintaining the direct force on the cataract that could accelerate tissue against the capsular wall relatively low. In a preferred embodiment, the fragmenting surface is moved ultrasonically along the normal while it is moving at an angle to the normal such as by rotating continuously at least through several 360 degree rotations in one direction. Its effective range for cavitation and twisting is in the range of 1,400 r.p.m. and 10,000 r.p.m. and optimally 4,000 r.p.m. 
     The aspiration pressure is more effective within the moving surfaces of the rotating tip. It is low enough to pull the fragmented tissue and tissue to be fragmented but it does not hold the smooth flexible capsular wall against movement away from the moving surfaces of the tool. The rotating surfaces move the smooth wall outwardly and provide some counter pressure to the aspirating pressure inside the fragmenting zone. The vibrating speed and rotational speed can be adjusted to powder the cateract so as to maintain good visibility and ease of aspiration and can be adjusted for vitrectomy. 
     In the case of cataract removal surgery, a small incision of two to seven millimeters and preferably three millimeters is made in the sclera along the corneal border at 12 o&#39;clock and another incision of similar dimension or a round hole is made in the anterior capsular wall. The instrument is inserted and fragments the lens matter without fragmenting the capsular wall. The factors useful in surface-discriminatory, fragmenting differ from eye to eye or tissue to tissue and may be selected in accordance with the surgeon&#39;s observations. 
     These factors are the speed of the moving surfaces with respect to the tissue, the holding pressure from aspirating vacuum and irrigating liquid, the location and position of the moving surfaces, the rake angle of the cutting edge of the moving surfaces and the shape of the portions of the moving surfaces most related to cavitation. These factors are established by the surgeon as a function of the mass of the capsular wall and the mass of the tissue to be fragmented, the stiffness and smoothness of the capsular wall or other healthy smooth tissue and the hardness and flexibility of the tissue. 
     In one embodiment, moving surfaces of the fragmenting tool hit the cells at a substantially tangential angle and distort them or cut them with their leading edges while the trailing edges create cavitation that further breaks and mixes the tissue without imparting such force to the tissue in a direction that may injure the capsular wall. For large and rigid or for rough surfaces, the shear force and cavitation is sufficient for fragmentation whereas for more flexible, lower mass and smoother surfaces, the leading edges and the cavitation tend to move the surface away and thus avoid fragmentation. The aspirating port or ports tend to pull the fragmented material into the interior of the tool. 
     In a preferred embodiment, a tubular member has a central, aspirating channel along its longitudinal axis with one end having a fragmenting tip and the other end being adapted to rotate the tube. In one embodiment, the cavitation is at low frequency below the ultrasonic frequency range. In a preferred embodiment, the tip is rotated continuously in one direction for more than one 360 degree cycle and at the same time ultrasonically reciprocated. 
     In the preferred embodiment, a blunt tip with a central opening is rotated and reciprocated with aspirating pressure being applied to the central opening to remove particles. The ultrasonic reciprocating or near ultrasonic reciprocating combined with rotation causes cavitation and powders some of the cataract, particularly the hydrated cataract tissue. However, it also impacts tissue with the annular edge around the central opening, catches tissue so that the rotation twists the fiberous material. The speed of rotation is maintained at a value that twists the fibers to torsional failure so that those portions of the fiberous material not fragmented by cavitation are nonetheless maintained sufficiently small as to not occlude the central opening. Indeed, unlike prior art instruments, the preferred embodiment may be used normal to the cataract and inserted to considerable depth without occluding although with only ultrasonic vibration, the tip would be occluded and fail to aspirate particles efficiently. Thus, it would be necessary to use lollipopping with two instruments whereas with the preferred embodiment the extra cutting tool is not needed. 
     Vitreous material is broken up and aspirated easily unlike the prior art instruments which only pulled the vitreous material without separating it from the mass so that it pulled back and could not be aspirated or only aspirated with difficultly. The instrument of this invention twists the vitreous free from the mass and aspirates the vitreous material faster than a refractory cannula which only slowly severs pieces in shearing between two surfaces and aspirates them. 
     As can be understood from the above description, the technique and instrument of this invention have several advantages, such as: (1) they selectively fragment some tissue without damaging other nearby tissue; (2) they are able to fragment, mix and aspirate tissue, and in the case of cataract removal, while maintaining good visibility; and (3) the same handpiece can perform vitrectomy. 
    
    
     SUMMARY OF THE DRAWINGS 
     The above noted and other features of the invention will be better understood from the following detailed description when considered with reference to the accompanying drawings, in which: 
     FIG. 1 is a simplified, elevational view of a handpiece and control console for fragmenting and removing cataracts in accordance with an embodiment of the invention; 
     FIG. 2 is an enlarged, perspective view of a portion of the embodiment of FIG. 1; 
     FIG. 3 is a fragmentary, sectional view of another portion of the embodiment of FIG. 1; 
     FIG. 4 is a fragmentary, perspective view of another embodiment of blade portion usable as a replacement for the blade portion in the embodiment of FIG. 1; 
     FIG. 5 is a plan view of the embodiment of FIG. 4; 
     FIG. 6 is a fragmentary, elevational view, partly sectioned and partly diagramatic of another embodiment of handpiece; 
     FIG. 7 is a fragmentary, elevational view of another embodiment of tool portion; 
     FIG. 8 is a top view of the embodiment of FIG. 7; 
     FIG. 9 is an elevational, right hand view of the embodiment of FIG. 7; 
     FIG. 10 is a fragmentary, elevational view of a tool tip which represents a variation of the tool tip of FIGS. 7-9; 
     FIG. 11 is a diagramatic, top view of a tool tip illustrating a first step useful in making the embodiment of FIGS. 7-9; 
     FIG. 12 is a fragmentary, elevational view of the tool tip shown in FIG. 11; 
     FIG. 13 is an elevational view of a tool tip illustrating a second step in preparing the embodiment of FIGS. 7-9; .pa 
     FIG. 14 is a top view of the tool tip shown in FIG. 13; 
     FIG. 15 is a fragmentary, perspective view illustrating an additional step in preparing the embodiment of FIGS. 7-9; 
     FIG. 16 is a perspective view illustrating still another possible step in preparing a tool tip similar to the embodiments of FIGS. 7-9; 
     FIG. 17 is a block diagram of a process for using the instrument of FIGS. 1-6 to remove a cataract; 
     FIG. 18 is a simplified, cross-sectional view of an eye and cataract removal handpiece tip illustrating a portion of the technique of this invention; 
     FIG. 19 is a fragmentary, elevational view, partly sectioned and partly diagramatic of still another embodiment of handpiece; 
     FIG. 20 is a sectional view of another embodiment of handpiece; 
     FIG. 21 is a sectional view of a tip usable in the embodiment of FIG. 20; 
     FIG. 22 is a block diagram of a console interface for connecting any of several different consoles to a phacotmesis handpiece and a phacotmesis handpiece; 
     FIG. 23 is a schematic circuit diagram of an interface circuit; and 
     FIG. 24 is a block diagram of an ultrasonic driver circuit. 
    
    
     DETAILED DESCRIPTION 
     In FIG. 1, there is shown an elevational view of a surface-discriminating, fragmenting handpiece  10 , connecting tubing  23  and a console  21 . The handpiece  10  includes a drive portion  11 , a blade portion  14  and a tubular sleeve portion  12 . The tubular sleeve portion  12  includes a tubular casing  13  and an inner tubular aspirating drive shaft or sleeve  18 . The drive portion  11  houses the motor, an on-off switch  20  and connectors for irrigating fluid and aspirating vacuum pressure. 
     The blade portion  14  includes blades  17 A and  17 B each of which is fastened to the rotatable tubular shaft  18  at diametrically opposite locations on the shaft  18  and each of which has a corresponding one of blunt tips  15 A and  15 B turned inwardly to avoid cutting. The outer tubular casing  13  includes within it a movable sleeve  19 A so that upon longitudinal movement of a button  19  with respect to the outer casing  13  of the tubular sleeve portion  12 , the blades  17 A and  17 B move apart in a fragmenting position in response to one direction of movement of the button  19  and are forced within the movable sleeve  19 A within the tubular sleeve portion  12  against the pressure of the spring-like blades  17 A and  17 B upon movement in the other direction of the button  19  to fit within a smaller incision such as a 2 millimeter opening. The blades  17 A and  17 B are narrower in the direction of rotation and blunt on the trailing edge to cause cavitation. 
     With this arrangement, the blades  17 A and  17 B may be moved together for insertion of the handpiece  10  into a capsular sac through a relatively small aperture and then permitted to expand outwardly so that upon rotation of the blade portion  14 , the cortex and nucleus are fragmented within the capsular sac. In the embodiment of FIG. 1, the handpiece  10  includes a motor for rotating the shaft and a connecting tubing  23  for aspirating fragments. The console  21  may include for cooperation with the handpiece  10 , a standard source of electrical power, a vacuum source, a source of irrigating liquid and a pump for irrigating liquid. These elements are conventional and are not part of the invention except insofar as they cooperate with the handpiece  10 . 
     In FIG. 2, there is shown an enlarged, fragmentary perspective view of the blade portion  14  of the tool assembly having first and second blades  17 A and  17 B with corresponding blunt ends  15 A and  15 B. The blades  17 A and  17 B are sufficiently flexible in the embodiment of FIG. 2 to expand until they form outwardly, curved, cutting surfaces extending beyond the surfaces of the outer casing or shaft  13  (FIG. 1) and have sharpened edges  32  and  34  tangentially to or pointing inwardly from the circles of rotation formed as they rotate. When the blades  17 A and  17 B are pulled inwardly by movement of the sleeve  19 A upwardly, they fit within a cylinder having a diameter of less than two millimeters. 
     While the embodiment of FIGS. 1 and 2 have blades with sharpened edges pointing tangentially to or inwardly from the direction of rotation, sharpened edges are not necessary and the angle of attack or rake angle of the sharpened edges may vary. However, the angle of attack may be tangential to the path of rotation or any larger or smaller angle. For this purpose, any one of several multiple blade portions  14  with their attached inner drive shaft  18  may be inserted into the sleeve portion  12  and drive portion  11 . The blade portion is selected by the physician and one fact in such selection is the angle of attack of the blades. 
     To permit compressing of the blades  17 A and  17 B into a protective sleeve, the tubular sleeve portion  12  includes the three coaxial sleeves  18 ,  19 A and  13  (FIG. 1) in that order outwardly from the central axis. The blades  17 A and  17 B are mounted to the inner tubular drive sleeve  18  for rotation therewith and there is a space between the sleeves  18  and  19 A for irrigating fluid to flow. The movable sleeve  19 A is affixed to the button  19  (FIG. 1) and is movable axially with respect to inner drive sleeve  13  to engage the blades  17 A and  17 B and to compress them inwardly. 
     In FIG. 3, there is shown a fragmentary longitudinal sectional view of the tubular sleeve portion  12  and the drive portion  11 : (1) having within the sleeve portion  12 , the inner rotatable tubular aspirating drive shaft or sleeve  18 , the movable tubular protective sleeve  19 A and the outer sleeve  13 ; and (2) having within the drive portion  11 , a motor  40  for rotating the inner aspirating drive shaft  18  to turn the blades  17 A and  17 B (FIG.  1 ), a hollow aspirating tube  27  to apply vacuum pressure to the interior of the inner shaft  18 , an irrigating tube  17  communicating with the movable sleeve  19 A to apply irrigating fluid through the sleeve  19 A and through electrical wires  25  to control the motor  40 . The inner shaft  18  is coupled at one end  42  to the output shaft  44  of the motor  40  for rotation therewith and to a tubular connection  45  for aspiration. 
     As shown in this view, the outer sleeve  13  supports within it the movable sleeve  19 A with the button  19  extending through a slot in the outer sleeve  13  by which the movable sleeve  19 A may be moved upwardly and downwardly to bend the blades  17 A and  17 B inwardly for retraction or to permit them to expand outwardly in the cutting position to their normal position for rotating and in some embodiments still further under centifugal force when rotating. However, the moment of inertia of the blades  17 A and  17 B is sufficient so that the centrifugal force does not force the points to point outwardly and only the bent flat surface is presented to the outer sleeve  13  during rotation. It is spaced from the movable tube  19 A to permit irrigating fluid to flow therebetween and contains in its center, an opening  15  which extends downwardly for aspiration of tissues. 
     To provide irrigating fluids, the irrigating tube  17  is connected through a cable  23  to the console  21  (FIG. 1) from which irrigating liquid is pumped through the tube  17  around the motor  40  and to the space between the movable tube  19 A and the inner shaft  18  to supply irrigating fluid to the capsular sac. To aspirate tissue, the central opening  15  in the inner shaft  18  passes through an opening  29  in the wall of the inner shaft  18  and communicates through a sealed circular ring  31  with the aspirating conduit  25 . The connection  45  passes around the motor  40  and through the cable  23  to the console  21  (FIG. 1) which applies slight negative pressure to aspirate tissue. The cable  23  also carries electrical conductors for the motor  40  which are connected in series between the switch  20 , and a source of electrical power in the console  21  and the motor  40 . 
     To use the embodiment of FIGS. 1-3, an incision is made for the insertion of the surface-discriminating, fragmenting handpiece  10 . The surface-discriminating, fragmenting handpiece  10  fragments and permits aspiration of the tissue but avoids damaging nearby smooth, flexible walls. Instead, it fragments rougher, more rigid surfaces of higher masses. This surface discrimination is controlled by the moving surface of the blades  17 A and  17 B, which permit the diseased tissue to be strained or cut by the blades  17 A and  17 B and further fragmented by the forces of cavitation within their fragmenting zone but which move at a rate of speed and have openings between them of such a size that the more integrated, lower mass or more flexible and smoother tissue does not fall within their fragmenting zone but is moved away from the moving surfaces. The aspirating pressure, cavitation and turbulence is counteracted or attenuated within the sphere of the rotating ring to avoid damage to the flat surface tissue. 
     In the case of cataract removal surgery, a small incision of two to seven millimeters and preferably three millimeters is made in the schlera along the corneal border at 12 o&#39;clock and another incision of similar dimensions is made in the capsular wall. The instrument is inserted and fragments the higher mass, more rigid, rougher lens without fragmenting the capsular wall. 
     The actual time that the fragmenting zone must be open to fragment diseased tissue without injuring smooth walls differs from eye to eye or tissue to tissue and may be selected in accordance with the surgeon&#39;s observations prior to use. It is a function of: (1) the rigidity of the tissue; (2) the mass of the tissue; (3) the angle of the tissue to the direction of movement of the tool; (4) the roughness of the surface; and (5) the effect of the negative pressure pulling the tissue inwardly such as the aspiration vacuum pressure which may vary in its effect depending on the size and shape of the tissue. 
     The surface discrimination of the tool is controlled by moving surfaces which cause the diseased tissue to fragment under impact, referred to as phacotmesis, and cavitation forces, referred to as phacocoelosis, but which move at a rate of speed slow enough so that the more integrated, more flexible, lower mass and smoother tissue is moved away without fragmenting. The surfaces of the instrument fragment tissue that: (1) is stiff; (2) has a high mass and large inertia; and (3) is at an angle to the cutting edge close to 90 degrees. 
     To take advantage of the differences between the tissue to be fragmented and the lower, more flexible tissue, the surgeon removing a cataract adjusts the speed of movement of the tool surfaces, the aspirating and irrigation rates, the rake angle of the leading edge of the blade surfaces and the cavitation level as controlled by the position of the blade surfaces, the velocity and the shape of the moving surfaces, especially the trailing edge of the blades. The adjustments are made to fragment the cortex because of its higher mass, modulus of elasticity and projections in the path of the tool surfaces and to move the capsular wall away from the blades because of its lower mass, lower modulus and fewer projections closer to 90 degrees. Tips are replaced to change the rake angle and cavitation surfaces. 
     The aspiration pressure is more effective within the moving surfaces of the rotating tip. It is low enough to pull the fragmented tissue and tissue to be fragmented but does not hold the smooth wall against movement nor pull it inwardly. The rotating surfaces move the smooth wall outwardly and provide some counter pressure to the aspirating pressure inside the fragmenting zone. In one embodiment, radially, inwardly, extending edges further pull and mix tissue within the fragmenting zone. 
     To better describe this and other embodiments, some special terminology is useful. For purposes of this description, the words, “low power” mean less than one horsepower (1.341 kilowatts). In this description, the words, “motion resistance” mean the resistance of a portion of tissue to movement when impacted by a moving tool surface caused by the inertia of the tissue and the effect of the inertia of other tissue connected to it taking into consideration the flexibility of the connecting tissue. 
     In this description, the words, “fragmenting velocity” mean the minimum velocity of a moving surface of a tool with respect to predetermined stationary tissue that the moving surface of the tool impacts that is sufficient to cause strain in the tissue of at least ten percent of the distance moved by the entire tissue mass and to break the tissue by combined strain, cutting and cavitation effects. This value is specific for a predetermined stationary tissue having a predetermined motion resistance. It assumes that the tool surface has sufficient kinetic energy to maintain its velocity constant in spite of the impact. The fragmenting velocity is affected by: (1) the angle the motion of the moving surface makes with the surface of the tissue; and (2) the momentum of the moving surface. 
     In the embodiments of FIGS. 1-3, a ring or partial ring having a diameter of two millimeters in the widest distance perpendicular to the axis of revolution forms a surface of revolution when rotated having at any one time open spaces and a solid cutting ring. The ring is rotated at approximately 120,000 rpm (revolutions per minute). The solid ring is approximately 0.50 millimeter wide along the surface of revolution, leaving an open area in the surface of slightly less than nine square millimeters and more precisely, 8.9 square millimeters with a length of 2.4 millimeters at the longest circle of a segment. 
     The time between portions of the solid ring sweeping across any surface of revolution is approximately every 250 microseconds and should be no longer than once every three milliseconds (1,000 rpm) but may be as short as 0.75 of a microsecond (400,000 rpm). With this arrangement and with parameters adjustable for the particular circumstance, the capsular wall does not enter into the fragmenting zone within and near the surface of revolution and is not cut and yet the ring is able to fragment the lens for easy aspiration. 
     In FIG. 4, there is shown a second embodiment of blade portion  14 A, having a shaft  18 A connected to a blade  17 C formed as a partial zone of a circle or an arc extending from the shaft  18 A and having a pear-shaped, blade portion  14 A with: (1) blunt trailing edges  20 ; (2) sharpened leading edges  22 ; (3) a wide base attached to the shaft  18 A that is narrower along the axis of the shaft  18 A so that there is at the wide portion, a blunt trailing edge  20  and a sharpened leading edge  22  as the cutting blade  17 C rotates about the shaft  18 A; and (4) an axis of rotation along the shaft  18 A between the base and the narrower upper portion. The apex is generally blunt, but in some embodiments has a drill shape at the apex  24 . 
     It has been found that the sharpened leading edges  22  strain and elongate the cells of higher-mass, rigid material but push away flexible and low-mass material. The leading edges  22 , under some circumstances, cut or scrape fine particles from the harder material that might otherwise plug the aspirating channel but the cavitation effect fragments the particles into small particles that can easily be aspirated. The blades  17 C are shaped to maximize cavitation that liquifies and stresses lens matter and any viscous fluids and causes fragmentation and mixing of the higher-mass more rigid material. In the embodiment of FIG. 4, the blades have two blunt sides, a top blunt portion  24  and a blunt portion at the mounting base to the tube  18 A for strength at the bottom and to form a non cutting surface at the top. 
     In FIG. 5, there is shown a top view of the embodiment of FIG. 4, having the blade portion  14 A with the blade  17 C shaped with a thicker portion having a blunting surface  24  at its upper end facing away from the direction of the tubular shaft  18 A and rotating thereabout. However, in some embodiments, it has a cutting edge to permit it to provide an abrading center area in the forward direction for positioning at a point to be fragmented. This embodiment operates substantially the same as the prior embodiments except that its unique shape enables careful placement for special purposes. Instead of a cutting edge, the top portion  24  may be bent inwardly or may be blunt to avoid cutting at its top. 
     In FIG. 6, there is shown a fragmentary, partly diagramatic and partly longitudinally sectioned view of another embodiment of hand piece  10 A which is operated by a similar dental drill motor  40  and adapted to receive a tool by having inserted therein an aspirating drive sleeve  18 B of a tubular sleeve portion  12 C substantially identical to that of the embodiments of FIGS. 1-5 except that the blade portion is constructed in a different manner on the end of the inner shaft  18  (FIGS. 1-3) as will be described hereinafter. 
     The hand piece  10 A includes, in addition to the aforementioned motor  40  and the aspirating drive sleeve  18 B, an outer housing  60  and a motor-tool sleeve coupling  62  with: (1) the motor  40  being connected to the drive sleeve  18 B through the coupling  62  and being located within the outer housing  60 ; (2) the sleeve  18 B extending outwardly thereof for rotation by the motor  40  through the coupling  62  during operation of the handpiece. 
     To enclose and provide the necessary liquid and vacuum connections to the operative tool, the outer housing  60  includes a motor housing portion  70  and a tool and coupling housing portion  72  integrally formed together with a tubular connector  74  for irrigating fluid, a tubular connector  76  for aspirating negative pressure and a hole  78  being provided through the housing  60  for venting air. The air vent port  78  is an opening extending into and communicating with the interior of the motor housing portion  70  to provide cooling to the motor  40 . The irrigating fluid connector  74  is an opening communicating with the interior of the housing portion  72  to apply fluid therethrough for eventual passage through a protective sleeve  13 A on the outside of the drive sleeve  18 B and to the operating point in a manner to be described more fully hereinafter. 
     The aspirating connector  76  is adapted to receive tubing for applying negative pressure through the motor-tool sleeve coupling  62  to the interior of the drive sleeve  18 B to withdraw material during use of the handpiece  10 A. The forward end of the tool and coupling housing portion  72  includes external threads  82  which engage internal teeth  112  on the protective sleeve  13 A and a shoulder with an O-ring  80  positioned in it so that the protective sleeve  13 A can be threaded onto the outer housing  60  to enclose a portion of it sealingly and extend it through its outer end in a manner to be described hereinafter. 
     To connect the motor  40  to the sleeve portion  12 C, the motor-tool sleeve coupling  62  includes a motor output shaft  90 , a cylindrical boss  92 , a cylindrical support member  94 , an annular groove  96  within the support member  94 , two counterbores  98  through the support member  94  at the bottom of the annular groove  96 , an opening  100  communicating with the aspirating connector  76  and extending through the cylindrical support member  94 , a cylindrical opening  95  sized to receive the sleeve  18 B and a brazed connection  102  more firmly fastening the support member  94  to the sleeve  18 B. A support  101  receives the motor shaft  90  and the boss  92  which rotate within it and are supported by it. The groove  96  communicates with the opening  100  as it rotates because of its annular shape and receives vacuum pressure which it transmits through the counterbores  98  into the sleeve  18 B to create negative pressure in the working tip through this elongated sleeve. 
     With this arrangement, the sleeve  18 B is rotated and carries vacuum pressure with it to the tip. The brazed connection  102  aids in transmitting force from the output shaft  90  to the drive sleeve  18 B through the boss  92  by increasing the firmness of the connection between the drive sleeve  18 B and the shaft  90 . 
     To mount and support the drive sleeve  18 B, the protective sleeve  13 A in the embodiment of FIG. 6 includes a cylindrical base member  110  having internal teeth  112  adapted to engage the external teeth  82  of the housing portion  72  and is sealed against the flow of fluid therethrough by the O-rings  80  compressed between the enlarged cylinder base member  110  and the housing portion  72 . A narrower outer sheath portion  114  is integrally formed with the cylindrical base member  110  and receives a cylindrical passageway formed between the inner drive sleeve  18 B and its outer tubular surface to permit the flow of irrigating liquid between the outer protective sleeve  13 A and the inner drive sleeve  18 B into the capsular bag. 
     With this arrangement, the drive sleeve  18 B can be rotated by the motor  40  and at the same time: (1) irrigating fluid can be applied between it and the protective outer sleeve  13 A; and (2) aspirating negative pressure can be applied to pull fragments along its longitudinal axis. At its outer end, the fragmenting tip or blades are formed in a manner to be described hereinafter. 
     In FIG. 7, there is shown a front, elevational view of one embodiment of a tool having a sleeve portion  12 A and a blade portion  14 B with two blade members formed in its outer end and separated by an opening  123  longitudinally passing along the longitudinal axis of the tool to form the blade portion  14 B at the end of the same cylinder forming the sleeve portion  12 A. Both the blade portion  14 A and the sleeve portion  12 A are formed on a single, integrally formed cylinder that serves as an aspirating drive shaft  18 B. Aspirating holes extend through the tip of the blade portion  14 B orthogonal to the longitudinal axis and a slot  120  (FIGS.  8  and  9 ). To receive some material for aspirating, apertures  122  and  123  (FIGS. 8-10) are approximately 0.04 inch from the tip  24  (FIG. 10) of the blade portion  14 B and the diameter of the aspirating drive shaft  18 B is approximately 0.042 inch. The diameter of the aspirating apertures  122  and  123  are 0.018 inch and should not be larger than seven millimeters. 
     In FIGS. 8 and 9, there are shown a plan view and a right elevational view of the embodiment of FIG. 7, respectively, showing the slot  120  having a width of 0.008 inch and extending downwardly approximately 0.07 inch. As best shown in FIG. 8, the edges of the walls of the tube or sleeve  18 B along the slot  120  have a larger or blunter trailing edge shown at  126  and a sharper leading edge shown at  124  in one embodiment as well as a blunter edge shown at  130  and a sharper edge shown at  128  so that the sharper edges  124  and  128  as the item rotates counter-clockwise as shown in FIG. 8 looking into the surface of the drawing elongate or cut the tissue within the eye and create cavitation at the blunter edges  130  and  126 . 
     In FIG. 10, there is shown a fragmentary, front elevational view of another embodiment showing the tip  24  along the slot  120 A brought together, welded and offset to provide a sharper and a blunter edge by offsetting the edges along the slot  120 A to a greater degree but without the need for changing the thickness of the tube walls. This embodiment forms a rake angle of 90 degrees and two cutting edges, but slots at three locations in the wall of sleeve  18 B can also be formed instead of two slots 180 degrees apart, providing a 60 degree rake angle and three cutting edges, or four slots can be formed to provide a 45 degree rake angle and four cutting edges. Moreover, the tips can be brought together as in FIG. 10 to form a smooth protective dome or can include a cutting edge or be open. The tip can also be twisted, which will change the rake angle along the slot and provide a cyclone fan pulling effect. 
     To form the embodiments of FIGS. 7-10, a tubular sleeve  18 B is slotted at  120  as shown best in FIGS. 11 and 12 and pinched together. The two sides are then offset in space laterally in a direction along a plane passing through the center of the slots and the longitudinal axis of the sleeve as shown in FIGS. 13 and 14 and the tips pinched together and brazed together to form a tip such as that shown in FIG.  10 . Prior to closing the tips  24 , the narrower and blunter edges may be further shaped by cutting one wall at a more acute angle than the other wall and then removing the other sides of the slot with a reverse cut to form flat ends and sharpened ends. 
     To form other raking angles and/or shape the blade to pull viscous fluid, the ends are offset, twisted and brazed as shown in FIGS. 15 and 16, first offset along a line or plane aligned with the two slots and longitudinal axis and then twisted at a slightly different angle to form a different rake angle and to create a cyclone pump effect. The tip is normally smooth at the very tip  24  but has a cutting effect as it moves radially outwardly. 
     In one version of the preferred embodiment, the tube  18 B has an outer diameter of 42 thousandths (0.042) inch with two diametrically opposed slots. The ends are moved together in a curvature leaving a slot about eight thousandths inch wide at its widest point and extend from the top approximately 70 thousandths inch (70 thousandths long). Ninety degrees removed from the two slots are central aspirating apertures having a diameter of 18 thousandths of an inch and being circular in cross section. They are located with their bottom edge generally adjacent to the end of the slots. 
     The tube usually rotates at approximately 1600 hertz when fragmenting the nucleus in a preferred embodiment having two cutting edges and the wedged surfaces of the slots have one edge that is in a range of one thousandths of an inch to 20 thousandths of an inch thick and a trailing edge that is in the range of ten thousandths of an inch to 50 thousandths of an inch thick. Preferably, it should be in the range of 300 hertz to 4000 hertz but may be slower or faster when at a location in the capsular sac not near tissue to be preserved or which may be moved to change other tissue. The slots and rate of rotation are selected to provide, in the preferred embodiment, a surface moving 200 centimeters a second at the fastest point on the curved moving surfaces and preferably to provide a surface moving at the fastest point within a range of five meters a second to 40 centimeters per second at the fastest point but may move slower or faster under some circumstances. 
     Since it is a rotating surface which curves inwardly toward the center, the speed is very low at the center and, under some circumstances, does little fragmenting at the center and more and more fragmenting as the rotating radius increases to the sleeve radius. The slot is next to tissue for a very short time such as between 10 milliseconds and 1 millisecond. Each cutting edge sweeps past a point about once every 625 microseconds, preferably, or in the normal range of once every 3 milliseconds to once every 400 microseconds. 
     In addition to zones of a sphere and sections of a cylinder intended for use within an eye, other shapes of moving surfaces may be used and the tool has uses other than for cataract removal, such as in vascular operations. For example, multiple zones of a sphere may be spaced from each other at a shorter distance so that the item need not be rotated as fast and motion other than rotational motion may be used to prevent entrance of the tissue into the fragmenting zone. A convenient embodiment for removing structures around veins or arteries during vascular operations is dumbbell shaped so that a recess fits around the vein while spherical cutting zones are positioned on either side of the vein. 
     In some embodiments, the moving surface is formed of a curved member attached to a rotatable shaft having a sharpened edge at an angle of between 0 and 60 degrees but preferably 45 degrees with a surface of revolution, which surface has a center of rotation aligned with the rotating shaft. The sharpened edge of the curved member may face away from the center of rotation so that the cutting action of the sharpened surface is into the cortex and core material of a cataract. 
     In FIG. 17, there is shown a block diagram generally illustrating the steps in a cataract extraction and lens implantation technique  50  comprising: (1) the step  52  which includes the preliminary substeps of maintaining the anterior chamber and making the incision into the capsular wall; (2) the step  54  of removing the lens by fragmenting it and aspirating it with the rotating member; and (3) the step  56  which includes the substeps necessary for implanting the lens. 
     In performing this technique, the step  52  which includes the substeps required to make the incision and maintain the anterior chamber and the step  56 , which includes the substeps necessary for implanting the lens are not by themselves new and many of the steps are described in Anis, Aziz Y., “Illustrated Step-by-Step Description of the Anis Dry Extra Capsular Cataract Extraction Technique With In-the-Bag Lens Implementation”,  Seminars in Opthalmology,  v. 1, N. 2 (June), 1986, pp. 113-129. Moreover, the removal of the lens may not be followed by implantation but may be part of a treatment in which the aphakia is treated by contact lens or glasses. 
     The step  54  of removing the lens by fragmenting and aspirating it with the rotating member includes: (1) the step of inserting the handpiece; (2) the step of breaking and removing the hardened part of the nucleus; and (3) the step of aspirating particles of tissue. These steps are all performed through a small incision while the anterior chamber is maintained with a viscoelastic medium. Hydrodelineation may be performed as described in U.S. Pat. No. 4,908,015, if desired, but such hydrodelineation is not part of this invention. If necessary, vitreous fluids may be aspirated. 
     The step  52  which includes preliminary substeps of maintaining the anterior chamber and making the incision in the capsular wall includes the substep of making a small incision in the capsular bag, preferably no greater than three millimeters in length and in the range of one to two millimeters. This incision is made while the anterior chamber is maintained and is made as small as possible to maintain the structure of the capsular bag to the extent possible. Through this small incision, the step  54  of fragmenting and aspirating and the step  56  of implanting a lens are performed. Under some circumstances, the incision may be four or five millimeters but should always be less than 7 millimeters. 
     With the posterior capsule in focus in the focal plane of the microscope, the handpiece  10  is introduced through an incision shown at  220  in FIG. 18 in the wall of the capsular sac. The tip of a handpiece  10  is thrust through the incision in the wall of the capsular bag and into the lens therein. 
     The tip is rapidly rotated and linearly vibrated in a direction normal to the plane of rotation while slight negative pressure is applied to aspirate the fragments. The rotating tip is inserted gradually into the cortex and nucleus and, from time to time, a small amount of irrigating fluid is injected. Fragmented cortex or nucleus material is aspirated. The speed of rotation and vibration can cause the particles to be so fine as to be substantially invisible and not to interfere with visibility of the surgery. The rotation and aspiration mix the small particles and easily pull them into the instrument. The same handpiece can be used to remove vitreous fluids. After removal of the cataract and the handpiece with the capsular sac relatively intact, a lens implant is inserted through a relatively small opening as described in the above publication of Anis. 
     Generally, the nucleus is first removed then the cortex. The surface-discriminating, fragmenting handpiece fragments and permits aspiration of the cotex and nucleus without damaging nearby smooth walls of the capsular sac. It avoids fragmenting the smooth walls with its cutting edges but fragments rougher, stiffer higher-mass tissue, moving it into a negative pressure zone for aspiration. The smooth more flexible, lower mass surfaces are moved by the blades which hit it at an angle. The tissue being fragmented is hit at an angle and is subject to cavitation rapidly and repeatedly with a force each time that does not move the entire material to the extent that it may damage the capsular wall or other healthy tissue that is not to be fragmented but does fragment the cortex. 
     The surface discrimination of the instrument is controlled by moving surfaces which permit the diseased higher-mass tissue to be fragmented but which move at a rate of speed and have openings between them of such a size that the more integrated flexible, lower-mass and smoother tissue does not fall within their fragmenting zone. The tissue is not constrained by opposed shear forces of the instrument but are free to move and the cutting edge of the instrument cuts tissue that: (1) is stiffer and has a higher modulus of rigidity; and (2) is at an angle to the cutting edge closer to 90 degrees and receives less force moving it away. 
     Thus, the surgeon removing a cataract adjusts the speed of movement of the cutting edge to cut cortex with a higher-mass and modulus and more projections in the path of the cutting surface and not the capsular wall with a lower modulus and mass and fewer projections closer to 90 degrees so it is more readily moved away from the cutting edge. The aspirating pressure is low enough to pull the fragmented tissue but not the smooth wall. The rotating surfaces move the smooth wall outwardly and provide some counter pressure to the aspirating pressure inside the cutting zone. 
     In using this instrument, as the lens is reduced in mass and freed from its connection to the structure of the eye by fragmentation, its tendency to move away from the cutting edges is increased. One way of compensating for this effect may be by changing the speed, the location and the direction in which the cutting edges impact the lens sufficiently often to neutralize the tendency of the impact to move the lens in one direction. Another aid is to rotate the tip to mix the particles with fluid and pull the fluid and particles into the instrument. This is done by continuously rotating the tip in one direction while ultrasonically vibrating it. Continuous rotation in one direction means rotation in one direction for more than one 360 degree cycle of rotation. Without such rapid impact, the impacting may cause the lens to move, such as by causing rotation of the lens. 
     In FIG. 19, there is shown a fragmentary, partly diagramatic and partly longitudinally sectioned view of still another embodiment of handpiece  10 B especially useful after the lens has been reduced in size. Instead of being operated by a dental drill motor  40 , it is driven by a vibrator  40 A, which may be any conventional type of vibrator such as those used to operate the tip in the above-mentioned U.S. Pat. Nos. 3,589,363 to Anton Banko, et al., 3,902,495 to Steven N. Weiss, 3,693,613 to Charles Kelman, et al, and 4,041,947 to Steven N. Weiss, et al. Except for the drive mechanism, the handpiece  10 B is identical to the embodiment of FIG.  6  and the reference numbers for identical parts remain the same. 
     The handpiece  10 B includes, in addition to the aforementioned vibrator  40 A, an aspirating drive sleeve  18 B, an outer housing  60  and a motor-tool sleeve coupling  62  with: (1) the vibrator  40 A being connected to the drive sleeve  18 B through the coupling  62  and being located within the outer housing  60 ; (2) the sleeve  18 B extending outwardly thereof for vibrating curvalinear motion by the vibrator  40 A through the coupling  62  during operation of the handpiece  10 B. 
     The vibrator  40 A includes a conventional oscillator  130 , a source of dc power  132 , and a piezoelectric or electromagnetic vibrator  134  electrically connected in series with the switch  20  (FIG. 1) to be energized and vibrate the cutting edges (not shown in FIG. 19) connected to the sleeve portion  12 C as explained in connection with the embodiment of FIG. 6. A shaft  90 A is mounted for rotation in bearings  138  and includes a welded arm extending orthogonally and radially therefrom, biased into contact with or fastened to a movable portion of the vibrator  134  so that vibration of the vibrator imparts rotating motion to the shaft  90 A. 
     To connect the vibrator  40 A to the sleeve portion  12 C, the motor-tool sleeve coupling  62  includes the vibrator output shaft  90 A, a cylindrical boss  92 , a cylindrical support member  94 , an annular groove  96  within the support member  94 , two counterbores  98  through the support member  94  at the bottom of the annular groove  96 , an opening  100  communicating with the aspirating connector  76  and extending through the cylindrical support  94 , a cylindrical opening  95  sized to receive the sleeve  18 B and a brazed connection  102  more firmly fastening the support member  94  to the sleeve  18 B. 
     The bearing support  101  receives the vibrator shaft  90 A and the boss  92  which rotationally vibrate within it and are supported by it. The groove  96  communicates with the opening  100  as it moves because of its annular shape and receives vacuum pressure which it transmits through the counterbores  98  into the sleeve  18 B to create negative pressure in the working tip through this elongated sleeve. 
     With this arrangement, closing the switch  20  (FIG. 1) connects power from the power supply  132  to the oscillator  130 . The vibrator  134  then vibrates at the frequency to which the oscillator  130  has been tuned by the surgeon, which vibrator  134  being energized through conductors  139 . The vibrator  134  reciprocates a lever  136  turning the shaft  18 B repeatedly. This causes the lens to be impacted with the cutting edges at an angle and speed that avoids damage to the capsular wall, if it should be near, and fragments the lens. 
     In FIG. 20, there is shown a partly longitudinally sectioned, fragmentary, simplified view of a handpiece  10 C, having as its principal parts an ultrasonic vibrator  40 C, an electrical rotational motor  40 D and a aspirating tube  18 C all in line with each other along a common longitudinal axis. The motor  40 D is coupled to the ultrasonic vibrator  40 C, which in turn is coupled to the aspirating tube  18 C to impart a combined rotary and longitudinal ultrasonic reciprocating motion to the aspirating tube  18 C. 
     With this mechanism, the aspirating tube  18 C moves the fragmenting tip  14 C (not shown in FIG. 20) so that it rotates rapidly, and while rotating, ultrasonically vibrates in and out of the tissue once for each small, angular increment of rotational motion, such as for example, every one degree or less. Thus, it combines the rotational movement and ultrasonic movement of prior embodiments. While the motor  40 D is intended to continuously rotate the aspirating tube  18 C in a single direction, such as clockwise or counterclockwise, it can alternate rotations, between clockwise and counterclockwise in the manner of the embodiment of FIG.  19 . In this manner, the time of impact is primarily determined by the frequency of the ultrasonic, reciprocal motion and the location and direction are primarily controlled for a stationary handpiece by the rotational speed. By selecting the optimum or near optimum values of rotational speed and reciprocating frequency, movement of the mass of tissue with respect to fragmenting speed may be controlled. 
     The embodiment  10 C of FIG. 20 is similar to prior embodiments in that it includes a tubular aspirating connector  76  and an irrigating connector  74  to aspirate through the center of the aspirating tube  18 C and irrigate between the protective sleeve  12 D and the aspirating tube  18 C in the manner described in previous embodiments. In the embodiment of FIG. 20, the outer housing  60 C encloses both an ultrasonic vibrator  134  (FIG. 19) adapted for reciprocally vibrating the aspirating tube  18 C to which the fragmenting tip is connected in a direction aligned with the longitudinal axis of the handpiece  10 B and the tip and the rotational motor  40 D coupled through a coupled mechanism  150 . The necessary electrical connections are supplied through an opening in a rear bulkhead  152 . 
     In FIG. 21, there is shown a fragmentary, sectional view of another embodiment of fragmenting tip  14 C having tubular, cylindrical walls  164  enclosing an aspirating section  162 , which communicates with the interior of the aspirating tube  18 C (FIG.  20 ). The end of the tip  14 C is rounded at  158  and in one embodiment, may be roughened. An opening  156 , communicates with the aspirating section  162  and provides a slight, inward pull of tissue. 
     To fragment tissue, the opening  156  is blunt and able to grip tissue and rotate it as tissue is pulled inwardly. Reciprocating ultrasonic vibration of the tip causes cavitation and rotation causes twisting. The rotation may also cause small particles to be formed and a central plug to be twisted free and mixed with liquid and aspirated. 
     In operation, the tube  18 C is rotated while ultrasonic vibrations are applied along its rotational axis so that it reciprocates in and out of tissue a large number of times for each rotation. For example, the rotation may be between 100 and 15,000 revolutions per minute and preferably between 4,000 and 5,000 revolutions per minute while the ultrasound vibtrations may be applied within a range of 10 kilohertz to 500 kilohertz and preferably 40 kilohertz. The exact frequency of reciprocating vibration and rotational speed may be selected by the surgeon and may even extend to lower speeds and frequencies or higher speeds and frequencies depending on the nature of the cataract being fragmented. The tip of the tube should be symmetrical rather than chisel shaped so as to be visible when rotating and reciprocating and may have a continuous distal edge but must be shaped to remove tissue by cavitation. 
     The frequency of vibration and the speed of rotation are selected so that the tip moves inwardly into the tissue at every small fraction of rotation, such as at every degree of rotation to not impart excessive motion to the mass of the tissue but to cause removal of the tissue as a fine powder. 
     The combined integrated technology of this surgical tool provides added convenience and functions normally in separate available surgical handpieces. Size reduction due to advancing technology, in conjunction with the physician&#39;s desire for smaller surgical wound sites and precision tissue removal, allow this handpiece to incorporate both rotary action and ultrasonic fragmentation. It permits vitrectomy and removal of fragmented cateract with the same handpiece tip. When operating at 40 kHz (which is the most commonly effective frequency for ultrasonic systems), this handpiece delivers 0.012 inch of stroke displacement. The constant stroke feature provides consistent power through any hardness of tissue. 
     The rotary action assists the ultrasonic fragmentation of the tissue, by tumbling the fractured particles at the distal end of the ultrasonic tip. This allows the tip to acquire a new surface of tissue without the need for a second manipulation instrument. This allows smaller “bites” and reduces propensity for “coring” or “plunging” and subsequent particles are aspirated through the ultrasonic tip. The inner plug of tissue is twisted free of larger bodies and aspirated. 
     The added fluid action from the rotation enhances a “capture zone” forming a larger funnel shaped suction pattern that enhances flow to the tip. Just outside this region is a turbulent zone that rejects (protects) tissue. The speed of rotation increases or decreases this action. Working in conjunction with the aspiration and infusion, the rotation enhances the ultrasonic action. 
     In FIG. 22, there is shown a block diagram of an interface  170  between a phacotmesis handpiece  10 C and any one of a plurality of incompatible consoles  21 A which consoles may be electrically incompatible with the phacotmesis handpiece  10 C. The consoles  21 A may be of the type used for a hydrosonic type of ocular operation or phacoemulsification type of ocular operation. 
     For this purpose, the interface  170  includes a handpiece simulator  174 , a power supply  176 , an ultrasonic driver  178 , and a motor driver  180 . The power supply  176  and the motor driver  180  are conventional. The power supply  176  is adapted to be connected through conductors  172  to conventional power mains. It supplies DC power to the handpiece simulator  174 , the ultrasonic driver  178  and the motor driver  180  through the conductor  182 . 
     The handpiece simulator  174  is electrically directly connected to the console  21 A and matches the output impedance of the console to the imput impedance of the handpiece to obtain efficient power transfer of the control signal from the console to the drivers. The fluidic connections are connected directly from the console  21 A to the phacotmesis handpiece  10 C since they are generally compatible. The console  21 A and the handpiece simulator  174  together provide the appropriate signal to determine at least the amplitude of ultrasonic vibration by the ultrasonic driver  178 . The frequency of the ultrasonic vibrations and the rate of rotation by the motor driver  180  may be set on the handpiece  10 C or by the synergist and may or may not be varied by signals from the console  21 A depending on the design of the instrument and console. 
     To enable the connection of a plurality of different consoles to a phacotmesis handpiece  10 C, the handpiece simulator  174  includes a rotary switch that is adapted to interconnect any other of a plurality of different impedances to the input connectors leading to the console  21 A, with the input impedances being selected to match the output impedances of the different consoles. Instead of utilizing control signals from the console  21 A, the interface  170  may include individual, manually, adjustable attenuation devices or amplifiers to control the ultrasonic driver  178  and the motor driver  180  individually to set rates of ultrasonic vibration of the tip and corresponding rates of rotation of the tip or a combination of the two from a single switch. 
     In FIG. 23, there is shown a schematic circuit diagram of the handpiece simulator  174  having an input transformer  190 , lumped parameter impedances  192 , a selector switch  194 , and output terminals  196 . The transformer  190  is adapted to have its primary electrically connected to a console  21 A (FIG. 22) and the output terminals  196  are adapted to be electrically connected to the ultrasonic driver  178  (FIG. 22) and to the motor driver  180  (FIG.  22 ). The lumped parameter impedances  192  and the selector switch  194  are adapted to be electrically connected in circuit with each other and between the transformer  190  and the output terminals  196 . The switch  194  may be open to disconnect the console, closed to a first terminal to connect one value of impedance or to a second terminal to electrically connect in circuit a second impedance so that the handpiece simulator  174  may provide an input impedance which matches the output impedance of a console to which the handpiece is intended to be connected. 
     In FIG. 24, there is shown a block diagram of an ultrasonic driver  178  having input terminals  200 , a high voltage power supply  202 , a variable power supply  204 , a tuning module  208 , a power amplifier  206 , an impedance matching network  210  and output terminals  212 . The input terminals  200  are electrically connected to the handpiece simulator  174  (FIG. 22) to receive control signals. These control signals are applied to drive the DC motor driver  180  (FIG. 22) and are applied to the power amplifier  206  and the variable supply  204 . The variable power supply  204  receives power from the high voltage supply  202  and supplies a selected voltage to the power amplifier  206  under the control of the control signal through input terminals  200 . This signal determines the amplitude of the signal applied to the impedance matching network  210 . The frequency of that signal is adjusted by the tuning module  208  under the control of a computer or the direct control of a surgeon. The output from the matching network  210  drives the ultrasonic vibrator and the handpiece  10 C (FIG.  22 ). 
     In use, the interface is connected to a console and to the phacotmesis handpiece and the rotary switch is switched to the appropriately labeled console to provide efficient power transfer by impedance matching. In the preferred embodiment, the control signal from the console is used to control both the rotational speed and the vibration speed. 
     After preparation for phacotmesis, the lens is preferably grooved to form three delineated sections. This may be done by a first groove made in the lens of the eye which is then bifurcated by two grooves, using the phacotmesis instrument described above with the ultrasonically vibrating and rotating tip extending slightly, such as zero to two millimeters beyond the distal end of the irrigating sleeve. After the first groove is made, the nucleus is fractured such as by cracking forceps, then the second groove is made in the larger fragment and that fragment is fractured. 
     The phacotmesis tip is then retracted slightly until it is level with the irrigation sleeve. It may extend slightly for very hard lens material and may be retracted slightly for soft lens material but is approximately level. The tip is then positioned on a surface of one of the fragments and held by oclusion. The phacotmesis tip is activated and the resulting fragments are one-by-one aspirated. More specifically, the instrument includes a blunt zero degree tip configuration with a central opening of 0.6 mm caliber and a sophisticated micro motor that provides the tip with rotary capability simultaneously with its ultrasonic activity at speeds reaching up to 5,000 or 6,000 rpms and 40 Khz vibration. The optimum rotational speed has been found to be 4,000 rpm. The combination of the two movements (the linear ultrasound and high speed rotary), give the blunt tip a sufficient cutting capability to cut a groove in the nucleus with apparently no resistance at all as demonstrated by the lack of any movement and the complete stability of the nucleus during the cutting. One can therefore create short, very deep grooves at an obtuse or nearly obtuse angle of the tip to the nuclear surface without fear of clogging or lollipopping the nucleus. By contrast, with the standard Phaco tip one needs a longer runway and many more passes since it is imperative to avoid complete occlusion during sculpting. 
     An incision is made with a 2.65 mm diamond Keratone even though a 2.50 mm incision is quite enough. The sharp side of the Keratome is pressed (without any slicing motion), over the temporal limbus just outside the clear cornea to create the external incision line and the Keratome introduced through this line to enter the anterior chamber, forming a 2×2.6 corneal valve. A paracentesis incision is made with a diamond lance at six o&#39;clock in the left eye or twelve o&#39;clock in the right eye. 
     A 0.12 mL volume of Xylocaine 1% without preservation is injected into the anterior chamber and the chamber is filled with Viscoelastic. A 25 gauge needle is used, (straight, without bending the tip), to puncture the anterior capsule at the center and moved sideways cutting the capsule with its sharp bevel until the position of the desired circumference of the capsulorhexis. The tip of the needle is now used to pick the cut edge of the capsular membrane forwards to create a dog-ear. A microforceps is now used to complete the Capsularhexis. 
     Careful attention to this step is of paramount importance, and when performed properly, can save the surgeon the step of aspirating the cortex. A canula is used to perform manual hydrodissection. This canula is a 29 gauge canula with the port to the side of the very tip, which is blunt and rounded. Keeping the port posterior, the configuration of the tip permits it to be threaded underneath the cut edge of the capsularhexis, gently lifting the anterior capsule from the cortex without picking any of the cortical fibrils. The canula is then advanced peripherally very gently until resistance is felt and the cut edge of the capsulorhexis moves with very gently nudges of the canula. This insures that the tip of the canula is now at the capsular equator with the port facing backwards. Injection of BSS at this point almost invariably cleaves the whole capsular membrane from the cortex. 
     To make a dividing groove in the lens the following parameters are used: (1) simultaneous ultrasound rotation; (2) ultrasound ceiling: 40%; (3) rotational speed: 3,000 rpm; (4) vacuum: 10 mm Hg; (5) aspiration flow rate: 20 mL/min; (6) infusion bottle: height 85 cm; (7) continuous flow; and (8) surgeon control. 
     The tip is now introduced in the anterior chamber with the irrigation sleeve retracted just enough for the desired groove depth. A deep short groove along the diameter of the nucleus is now made with 2-4 one directional deep passes. This is significantly different from the multiple to and fro shallow passes with standard Phaco. 
     A cracking forceps is used to divide the nucleus into two halves along the groove. Then with the cracking forceps still inside the anterior chamber, it is used as a manipulating instrument to rotate the nucleus so that the fracture line lies 90 degrees to the axis of the tmesis instrument, one half of the nucleus now is nasal and othe other half is temporal. 
     To aspirate the nuclear halves, the following parameters are used: (1) simultaneous ultrasound and rotation; (2) ultrasound ceiling; 40%; (3) rotation speed: 3,000 rpm; (4) vacuum: 120 to 150 mm HG; (5) aspiration flow rate: 25-30 mL/min; (6) infusion bottle height: 85 cm; (7) continuous flow; and (8) surgeon control. 
     With these parameters the tip is now introduced into the anterior chamber and the central bulk of the nasal fragment is removed using short radial strokes, or better still, a side to side wiping motion of the tip. The nasal nuclear half now looks more less like a quartered orange peel. The silent tip is now used to gentle nudge it towards the equator and forwards. This maneuver almost invariably tumbles the nuclear half backside forwards, delivering its equatorial margin into the center of the pupil. The fragment is now attached at its equator. The most productive way of using tmesis to aspirate the nuclear fragment is to apply the silent tip to it&#39;s surface so that the axis of the tip is 9 degrees to the plane of the surface in order to occlude the zero degree tip and engage with aspiration. 
     The fragment is held in mid-pupil just posterior to the iris plane and the foot control is used to initiate rotary and reciprocation power. A big chunk of the nucleus will be gulped. By repeating this step once or twice the remains of the nasal nucleus and cortical half is eliminated. Aspiration requires initial occlusion of the tip prior to applying ultrasound and rotation so that the fragment does not chatter. However, because tmesis does not permit coring and filling up or blocking of the lumens of the tip, negative pressure inside the tip, or time to build up, there is no surge and the anterior chamber remains remarkably stable. 
     During the aspiration of the nasal nuclear half the tmesis tip is supported over the temporal half, which protects the posterior capsule from coming forwards at any time. Now the temporal half is rotated to occupy the nasal half of the capsular bag and a nuclear manipulator is introduced through the paracentesis incision and held steadily posterior to the tmesis tip to keep the posterior capsule from coming forwards during the aspiration of the remaining nuclear fragment. This is the only function that uses the second instrument. 
     The tip is now applied to the center of the anterior edge of the fractured surface of the nuclear half. Aspiration is applied to engage it and the tmesis tip eats into the remaining nuclear half. The second nuclear half almost always rotates spontaneously tumbling itself to deliver its equatorial margin within the pupil area. At the same time it becomes constricted in the center so that it assumes an hour glass like shape. The steps of occlusion and then tmesis are applied until it is completely eliminated. As mentioned before, if hydrodissection was efficiently performed there is no cortex remaining. If there is any residual cortex remaining with the tmesis tip sill inside the anterior chamber, the mode is changed to aspiration/irrigationonly and the cortex is aspirated. 
     The incision is now enlarged to the desired size with proper sized Keratome. The viscoelastic of choice is injected to inflate the capsular bag and the foldable IOL of choice is implanted into the capsular bag. The tip in aspiration/irrigation mode is used to aspirate the Viscoelastic from the anterior chamber. 
     As can be understood from the above description, the technique and equipment of this invention has several advantages, such as: (1) they selectively fragment some tissue without damaging other nearby tissue; and (2) they are able to fragment, mix and aspirate tissue, and in the case of cataract removal, also scrub the capsular wall without damaging it, all with one instrument. 
     Although a preferred embodiment of the invention has been described with some particularity, many modifications and variations are possible in the preferred embodiment without deviating from the invention. Therefore, it is to be understood that within the scope of the appended claims, the invention may be practiced other than as specifically described.