Eyeworld

135 EW SECONDARY FEATURE April 2017 • Phaco turns 50 The objectivity of the successful phacoemulsification surgeon has thus been impaired to such a great extent that he cannot bring himself to recognize the continuing value of intracapsular surgery. 8" "Finally, I should like to make a plea for the patient," Dr. Trout- man continued. "He is, after all, a frightened and highly suggestible human being, afflicted with one of mankind's oldest and most dreaded blinding diseases. He requires more than our surgical skill whether we perform on him a microsurgical intracapsular cataract extraction or a phacoemulsification. He must not be another eyeball impaled on a probe, observed through the objective of a microscope, and discharged into the world at the earliest possible moment after his surgical procedure, to find himself in an increasingly complex and hostile environment. If we, as physicians, do not respect our traditions and become merely technicians, surrogates of our ma- chines, we will lose our dignity and our purpose." Slow road to acceptance and adoption Dr. Koch trained under Dr. Emery, who had taken Dr. Kelman's course in 1972. During this transitional period for phacoemulsification (1978–81 in Koch's case), Dr. Koch said he learned phaco technique as well as intracapsular and extracapsu- lar cataract surgery. "We had this wonderful expo- sure to a brilliant surgeon and teach- er in Dr. Emery. We tended to do phaco on the younger patients with soft nuclei and, for the more dense nuclei, we would either use extracap or intracap. I was really fortunate to get that exposure," Dr. Koch said, adding that he didn't start per- forming phaco on the majority of patients until 1987. In the first few years following Dr. Kelman's invention of phaco cataract surgery and the adoption and adaptation of the technique by other notable surgeons—Richard Kratz, MD (1920–2015), Robert Sinskey, MD (1924–2015), and Dr. Emery, among others—Dr. Koch said criticism against it continued. "No comparative series of cases done by the same surgeons or surgeons of equal skill demonstrat- ed that the Kelman phacoemulsi- fication procedure is accompanied by fewer retinal detachments, Irvine-Gass syndrome, or oth- er postoperative complications. The Kelman phacoemulsification method should be an adjunct to, not a replacement for, the current intracapsular cataract extraction," Charles Iliff, MD (1911–1997), wrote in 1977. 9 Even in this atmosphere, Dr. Kelman didn't give up on this idea. In fact, he found his own way to get the word out. Dr. Kelman did an "unusual thing," Dr. Dodick said. He hired a publicist and took to the air- waves, promoting the new approach on "The Tonight Show Starring Johnny Carson" in 1975 and "The Dick Cavett Show," to name a cou- ple of examples. "He made America aware of this new technology," Dr. Dodick said. "Many docs were forced to take the course and buy the machine, so they could tell patients, yes, they have the technology. Though, many bought the unit and put it in the closet in the operating room." continued on page 136 Robert Cionni: My first phacoemulsification W hen I was a resident at the Uni- versity of Louisville, in Kentucky, between 1987 and 1989, my first cataract surgery was an extracapsu- lar procedure. It was a nightmare: The patient had asthma and tiny pupils, and every time she breathed her whole body moved up and down. It took me 3 hours to do this one case. When I was a third-year resident, the veterans hospital received its first phaco machine: a Storz Daisy unit. I had watched Bob Osher's videos on how to do phaco, and that's where most of my training came from, just from watch- ing those videos. There were a few staff members who were well-versed in phaco and doing it routinely, but you weren't always guaranteed that one of those staff members would be with you. At that point, I had done maybe 60 extracaps and never lost vitreous. Then I did about 40 to 50 phacos and in one out of three I broke the capsular bag, lost vitreous, or damaged the iris; you name it, it happened. Part of it was this lack of someone there knowing how to train you, but part of it was also the machines available. The technology back then was far more primitive. Although the phaco tip was designed to eat the lens, to me it seemed that its favorite food was vitreous and iris. I was so horrified by my experience with phaco, that I decided I was not going to be a surgeon. I decided I was going to go into neu- roophthalmology. After I told this to Bob Osher—I had been a friend of his when I was a medical student—he said, "Come up here, and do a fellowship with me. I guarantee you you'll be good at phaco." That's what changed the direction of my career. Fellowship with Bobby was quite an interesting thing. For the first 2 weeks, all that I was really allowed to do was observe, position, and then drape the patient. Once I graduated from those tasks, I was able to make the incision and eventually do the capsulotomy. To this day, when I'm not using a femtosecond laser, I use his technique for a capsulorhexis using a bent, 22-guage needle. I also phaco with my left foot, despite being right-handed and right-footed. Bobby always used the phaco pedal with his left foot, so when I was starting cases for him, he insisted I put the phaco pedal on my left foot. I had to retrain my feet as to which was dominant. I was probably 6 months into it when I started feeling com- fortable with phaco. After a year, I thought I could tackle anything. When I look at the surgery I did 1 year after my fellowship, maybe fast forward 10 years, I'm horrified how awful I was 1 year into it. I think we all get better with experience, and that's certainly true in my case. EW Contact information Cionni: rcionni@theeyeinstitute.com Robert Cionni, MD The Eye Institute, Salt Lake City ASCRS Immediate Past President Source: Family of Charles Kelman 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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