Eyeworld

EW SECONDARY FEATURE 130 Phaco turns 50 • April 2017 by Liz Hillman EyeWorld Staff Writer Remembering its development, critical reception, and evolution into the gold standard of cataract surgery I t was 1967, a Saturday morn- ing. A shade was pulled down on the window that looked into the operating room from the hallway. On the door were signs: "Do Not Enter," "Infected," and a picture of a skull and cross- bones. Jack M. Dodick, MD, then a se- nior resident at Manhattan Eye, Ear, and Throat Hospital in New York, wasn't allowed in the room but was at the hospital when the procedure was taking place. "I desperately wanted to see what was going on," Dr. Dodick, clinical professor, Department of Ophthalmology, New York Lan- gone Medical Center, New York, recalled of his interest in the novel procedure taking place that, while controversial at the time and in the decades that followed, would go on to become the most commonly performed elective surgery among Medicare beneficiaries in the United States. 1 The operation taking place under such secretive conditions was performed by Charles D. Kelman, MD (1930–2004), 50 years ago. It was the first phacoemulsification on a human patient. This first phaco took 76 min- utes in a hospital OR. 2 Today, the average phaco cataract surgery takes 18 minutes and is the most common diagnosis seen at ambulatory surgery centers. 3 What used to be a highly invasive procedure with a lengthy hospital stay, a long subsequent recuperation period, and poor visual outcomes now is an outpatient procedure with visual gains observed in just hours following surgery and added refractive potential with new technologies. Developing phaco The gold standard in the 1960s was intracapsular cataract surgery, which involved opening the eye 160–180 degrees and removing the cataract with the capsule and lens material intact. Postop, the patient required a week or more in the hospital and further recuperation at home. 3 Thick, "coke bottle" glasses were the standard for visual function after- ward, Dr. Dodick said. "Patients didn't undergo surgery until vision in not one but both of their eyes had deteriorated to the point where it was extremely difficult to function, and cataract surgery was therefore done in lenses that were very advanced," he added. In a paper published in 1994, Dr. Kelman recalled how decades earlier he questioned why the inci- sion for cataract removal had to be 180 degrees. 4 "Wouldn't a radical reduction in incision size benefit the patients enormously? Couldn't the recuperative period be effectively eliminated?" he asked. In the early 1960s, Dr. Kelman received a 3-year grant from the John A. Hartford Foundation, which supported, among other research, developing a technique that would reduce the incision in cataract sur- gery and require no hospitalization. In his paper, Dr. Kelman described how he first tried to identify a chem- ical or enzyme that could dissolve a cataractous lens. These compounds ultimately destroyed the corneal endothelium in the process. He then experimented with various surgical techniques and tools—encapsulation, drills, rotating devices, vibrators—which were also deemed unfit for the job. "At the end of 2 years, with most of my grant money spent, the solution to the problem of lens movement and denuding of the cor- neal endothelium had become more than a challenge: It was an obses- sion," Dr. Kelman wrote. "I realized that to be successful, the technique had to ensure that the lens remained stationary in the chamber." Dr. Kelman realized that proper acceleration of an instrument into the lens could achieve this stability. Giving the illustration of a knife and a punching bag, Dr. Kelman explained that if the knife is pushed slowly into the punching bag, the bag will move. If quickly stabbed, however, the punching bag will remain relatively still. For his purposes, "The required high acceleration could be achieved Phaco turns 50 T he heart and soul of ophthalmology is cataract surgery. Approaching 4 million surgeries a year, cataract surgery is the most common operation performed in the United States. It is also one of the most effective, safe, and life-changing procedures in all of medi- cine. Cataract surgery, in turn, has been dominated by a remarkable procedure for more than a generation: phacoemulsification. In this special section of EyeWorld, we cover the history of phacoemulsification and the people behind the innovation as we mark the 50th anniversary of phacoemulsification. Concomitantly, ASCRS will celebrate this milestone with a special Sunday Summit, multiple seminars, and an ASCRS Foundation phaco timeline at this year's ASCRS•ASOA Symposium & Congress in Los Angeles. Phacoemulsification is also a perfect example of how industry and clinicians can work together to benefit patients. The disruptive innovation was the use of ultrasound in the eye, but literally hundreds of subsequent incremental improvements in technology have improved the safety and efficacy of this procedure, bringing us to where we are today. Every ophthalmologist goes through a special rite of passage. Part of that trial by fire is performing their first phacoemulsification. As I read through this issue of EyeWorld, I enjoyed hearing from four of our most prominent cataract surgeons, David Chang, MD, Bob Cionni, MD, Bonnie An Henderson, MD, and Kerry Solomon, MD, as they described their introduction to cataract surgery. Their recollections took me back to my first experience. The gods of ophthalmology smiled upon me following my inaugural phacoemulsification and the procedure went flawlessly. My attending surgeon and mentor, Arnie Turtz, MD, recog- nized my euphoric grin and told me that if I could capture that feeling and reproduce it after every cataract surgery, I would have a great career. This remains the best advice I have ever received. I particularly enjoyed reading the article, "Phaco turns 50." Jack Dodick, MD, another pioneer in phacoemulsification and personal idol, recalls being a senior resident at Manhat- tan Eye, Ear, and Throat Hospital when Charlie Kelman, MD, performed his first procedure. Ann Kelman, Charlie Kelman's wife, shares information about the man behind the invention, and Charlie Kelman's biography provides insights into the man behind the legend. Finally, Richard Lindstrom, MD, and Doug Koch, MD, provide commentary, detailing the transition of phacoemulsification from a radical, risky procedure to the gold standard it has become today. The multiple luminaries in ophthalmology who created this pathway are quoted and their contributions recognized. This year we celebrate the 50 years since Charlie Kelman invented phacoemulsification and that makes this issue of EyeWorld and the upcoming events in Los Angeles very special indeed. Eric Donnenfeld, MD, EyeWorld Chief Medical Editor C e l eb r a t i n g 5 0 Y e a r s o f P h a c o e m u l s i c a ti o n 1967–2017

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