Eyeworld

EW NEWS & OPINION 14 "I was fortunate to be around at the right moment. It was very exciting. We did good things for patients and it was very satisfying to be part of it. It revolutionized cataract surgery." —Dr. Frank Hurite T he American Intra-Ocular Implant Society (AIOIS) was started in 1974. It evolved into the American Society of Cataract & Refractive Surgery in 1985. Its germination, development, and growth have been well documented by others. The 2014 meeting in Boston marks its 40th consecutive annual convoca- tion. Unlike the millions of New Yorkers who swore to have person- ally witnessed Bobby Thomson's "shot heard round the world" at the Polo Grounds, very few cataract sur- geons extant attended the AIOIS's initial meeting in Dallas; it coin- cided with the year's American Academy of Ophthalmology meeting. The average age of ophthalmol- ogists in this country is 51. This is not surprising since board certifica- tion is earned at a relatively wizened 32 years or older. The majority of the nation's eye surgeons entered practice after 1990, the year pha- coemulsification surpassed extra- capsular cataract extraction in popularity. I'd wager most ophthal- mologists have never witnessed an intracapsular cataract extraction. Those few, those happy few, that band of brothers led by Charles Kelman, MD, the progenitor of modern cataract surgery, saw to that. Let me digress. I was a first- year resident at the University of Pittsburgh's Eye and Ear Hospital in 1978 when I sat in the surgeon's saddle chair and adjusted the eye- pieces of the operating microscope. The latter was recently purchased by the Veterans Administration to sup- plant surgical loupes. Both a retrob- ulbar block and general anesthesia were administered. A semicircle of conjunctiva was dissected, a hand- held cautery staunched bleeding, and a limbal stab followed. Right- and left-handed Troutman scissors extended the incision to 3 and 9 o'clock; my heart rate responded autonomically with each clock hour's snip. Injection of alpha- chymotrypsin magically vanquished those pesky zonules later deemed priceless by future posterior chamber lens implant surgeons. Then … nothing. We waited; an operating room can be a very quiet place. Soon, the attending surgeon, Walter Baker, MD, gingerly lifted the hemispheric corneal flap by the 7-0 silk suture placed at 12 o'clock. If all went well, the cryoprobe, its application discovered contempora- neously by that same Dr. Kelman and Dr. Krawawica in Poland in the 1960s, would freeze to the catarac- tous lens' surface. After gentle side- to-side rocking, the cataract was coaxed from the eye. If fortunate, the ice ball had not adhered to the cornea's endothelium or iris surface and the vitreous face remained in- tact. Confidence in one's suturing dictated whether 8, 9, or 10 addi- tional silk ligatures were placed. A good assistant would cut them just short enough. The conjunctival flap was repositioned over the incision and sutured. My operative note reveals that the procedure started at 11:50 a.m. and was completed at 12:42 p.m. I saw the patient in the hospital for the next seven or eight days. Weeks later, an aphakic con- tact lens was fitted. On the other side of town, Frank Hurite, MD, had just com- pleted perhaps his 18th case of the morning. Most patients received a state-of-the-art two-loop Binkhorst lens, its posterior haptics placed under the pellucid leaflets of the residual capsule. Conducting his artistry with a Kelman-Cavitron 7007 phacoemulsifier introduced in 1975, he made a 3 mm incision into the eye of a lightly sedated patient. You know the rest of the story— the procedure hasn't changed that much. Surely, microscopes are light- years better; Healon's introduction was huge as was that of balanced salt solution, intraocular epineph- rine, and Tom Mazzocco, MD's foldable lens; the circular capsulo- tomy of Thomas Neuhann, MD, minimized the dreaded equatorial capsular tear; self-sealing corneal incisions obviated sutures. Cavitron became CooperVision then Alcon, now a cog of the phar- maceutical giant Novartis; the ma- chine's technology leapt forward. Surges of vacuum causing the anterior chamber to trampoline, a bane to early phaco surgeons, were negated. Ultrasonic power was in- creased. The threat of non-sterile cooling fluid mixing with sterile irri- gant because of faulty O-rings van- ished; Noble Prize winner Richard Feynman would later demonstrate faulty O-rings at the Challenger dis- aster inquiry. The phaco cord could be sterilized using ultrasound. Such are the tasks of trailblazers. The story is told that Murray McCaslin, MD, long-time chair of the Department of Ophthalmology at the Pittsburgh Eye and Ear Hospi- tal, attended a meeting in New York City where Dr. Kelman spoke of his innovation. It may have been at this same presentation that David Paton, MD, head of Baylor's pro- gram and another pathfinder, first heard of phacoemulsification. Ac- cording to Dr. Hurite, Dr. McCaslin, having trained before modern intra- capsular technology, conjured bene- fit in maintenance of the posterior capsule. Dr. Kelman's approach held intuitive appeal. Dr. McCaslin was gifted at de- veloping relationships. He arranged that five Pittsburgh ophthalmolo- gists journey to Manhattan Eye and Ear Infirmary to observe Dr. Kelman's wizardry. Several visits en- sued and the Carnegie Hall maestro himself visited Pittsburgh on occa- sion. Surgery was performed using the Kelman-Cavitron 7001 unit; it resembled a stainless steel hi-fi console, so très chic in the 60s. Sometime during 1971 or early 1972, Dr. McCaslin, ever the vision- ary, secured a donation to purchase a unit. One of the first beyond New York City, it cost $40,000 (approxi- mately $230,000 in today's inflated dollars). Five years out of his residency, Dr. Hurite witnessed Dr. Kelman's virtuosity; he never looked back. Quietly, he built one of the largest cataract surgery practices in the country. Patients came because of the atraumatic postoperative ap- pearance of the eye, the stunning advantages of the intraocular lens compared to aphakic glasses or con- tact lens correction, and the single overnight hospital stay. The elimina- tion of induced astigmatism, a rapid return to function, and the instant gratification from patients appealed to optometrists and other profes- sionals. April 2014 by J.C. Noreika, MD, MBA At the beginning, success had many fathers J.C. Noreika, MD, MBA continued on page 16 Insights

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