Eyeworld

EW SECONDARY FEATURE 134 Phaco turns 50 • April 2017 Phaco continued from page 132 Jared Emery, MD, performs phaco in 1979 with an early phaco unit. Source: Douglas Koch, MD David Chang: My first phacoemulsification A s the son of an anesthesiolo- gist, I went to medical school planning to be a general surgeon. My third-year general surgery rotation in 1978 at the Peter Bent Brigham Hospital, Bos- ton, burst that bubble, however, and I was suddenly without direction. After a sleepless night on call I was forced to at- tend mandatory Saturday grand rounds, during which an ophthalmologist pre- sented a 35 mm film of a new method of cataract surgery. It was of Charlie Kelman performing phacoemulsification. That was my light bulb moment, and I imme- diately signed up for an ophthalmology rotation at the Massachusetts Eye and Ear Infirmary, Boston. I read Kelman's textbook on phaco from cover to cover and excitedly arranged to observe my at- tending perform cataract surgery one Sat- urday morning. Imagine the emotional letdown when I watched him and his assistant perform an intracapsular cataract extraction (ICCE) with loupes! Where were the microscope and the phaco machine? My first cataract operation as a resident at the University of Cal- ifornia, San Francisco, was an ICCE in 1982. Nothing in my surgical career ever since has quite matched the tachycardia, tremor, and terror of my first time maneuvering a cryoprobe while trying not to freeze the cornea or iris. After a dozen ICCEs, I advanced to extra- capsular cataract extractions (ECCEs) with posterior chamber IOLs, before finally getting to try phaco—at long last—during my second year. None of our attendings did phaco but the chief at our VA, John Stanley, was either curious or fearless enough to let us try. I didn't re- ally have any strategy other than to keep sculpting, and after I broke the posterior capsule on my second, fourth, and seventh cases I was ready to abandon phaco altogether. In a conversation I'll never forget, my senior resident, Carl Minatoya, confided that he had also started similarly, and it wasn't until after 12 cases that it started to click and he understood what to do. Thanks to his encouragement, I kept going and finished my residency in 1984 with a program record of 70 phaco cases. We learned the Kratz technique of prolapsing the nucleus by watching unnarrated VHS tapes of Tom Mazzocco operating. I'm one of the rare ophthalmologists who got to perform ICCE, ECCE, and phaco as a second-year resident. I still remember my first time seeing Charlie Kelman lecturing live at one of my first meetings, and the even greater thrill when he invited me to lecture in his ASCRS phaco course. He didn't know my name, but I had just presented a video at an ASCRS free paper session that he was moderating, and he needed a last-minute replacement for his course. Out of this grew our friendship, and he wrote the foreword to my first phaco textbook shortly before he died in 2004. I was hon- ored to be a consultant for the 2010 documentary on Charlie Kelman, Through My Eyes, and to give the American Academy of Ophthalmolo- gy Kelman Lecture in 2011. But my charmed life as a cataract surgeon might never have happened had I not been forced to attend that surgical grand rounds in 1978. EW Contact information Chang: dceye@earthlink.net David F. Chang, MD University of California, San Francisco Private practice Los Altos, California Co-chair of ASCRS Foundation ASCRS past president (2012–13) In the epilogue of his autobiog- raphy, Through My Eyes, Dr. Kel- man wrote there was a time when "doctors would literally spit on the floor in front of me as I walked the exhibit floors." 7 Later, some of these same doctors would become devoted supporters. In addition to having to learn something new—such as using an operating microscope and phacoemulsification technique— phacoemulsification in the 1970s was a significant added expense, it still required opening the wound to 6 mm to accommodate a non-fold- able IOL, and complications such as corneal edema and iris damage were higher, recalled Richard Lindstrom, MD, private practice, Minnesota Eye Consultants, Minneapolis. "It was still very controversial at the time. I would say the number of cataract surgeons doing phaco was maybe 1%. There were maybe 100 surgeons in the entire U.S. doing phaco," Dr. Lindstrom said. Given the buzz about it though, the American Academy of Oph- thalmology (AAO) commissioned a study to compare traditional intra- capsular cataract surgery to phaco outcomes. Douglas Koch, MD, professor and the Allen, Mosbacher, and Law Chair in Ophthalmology, Baylor College of Medicine, Hous- ton, recalled that Jared Emery, MD, was to present the findings at AAO's 1974 annual meeting, but an individual—who Dr. Koch didn't name—saw the data were favorable for phacoemulsification surgery and allegedly tried to suppress the talk, Dr. Koch said. "Emery persisted. He gave the talk and that enabled phaco to get a standing as a procedure of com- parable safety. Those against phaco could no longer claim that outcomes were inferior to other contemporary methods," he added. "Phacoemulsification is, in all probability, as effective in restoring vision after cataract as our currently practiced techniques, but certainly no more so," the Academy's com- mittee chairperson, Richard C. Troutman, MD, said in a recording of the 1974 meeting, aired as part of the Through My Eyes documentary. "This decision is only a draw. The currently practiced cataract oper- ation is, in many cases, not only the preferred method but the only method to be used." Even with this conclusion by AAO's committee about phaco, Dr. Koch said it was a "critical turning point in the acceptance of technique into mainstream ophthalmology." Though, it didn't mean a lot of peo- ple started to adopt it right away. The first International Congress on Phacoemulsification and Cataract Methodology in 1975 sponsored by the Foundation for Ophthalmic Education delved into various topics pertaining to cataract surgery at the time. While the pros and cons of phaco, IOLs, and other techniques were discussed, midway through the meeting, Dr. Troutman shared his critical view of phaco at this meet- ing. "At the present time, an oph- thalmologist trained and equipped to do phacoemulsification, especially when this fact has been widely pub- licized in the local or general press, feels compelled to attempt this pro- cedure on any cataract patient who presents himself," Dr. Troutman said. "He is often further corrupt- ed by being able to command, or demand, a greater economic reward.

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