Eyeworld

140 EW SECONDARY FEATURE Phaco turns 50 • April 2017 Phaco continued from page 138 Bonnie An Henderson: My first phacoemulsification W hen I started ophthalmology residency at Massachusetts Eye and Ear Infirmary in Boston in 1994, phacoemulsification had become the primary method of cataract surgery in the U.S. Yet many academic centers—in- cluding mine—were still going through the transition. At that time, all residents had to perform about 20 large-incision extracap- sular cataract extractions before learning phacoemulsification. I even performed a few intracapsular cataract extractions in patients with loose zonules—capsular sta- bilization devices hadn't been developed yet. The difficult part about the transi- tion was that most supervising surgeons in residency programs didn't have much experience with phacoemulsification, so if the trainee ran into complications, there was little guidance on how to manage the situation. My first phacoemulsification surgery was equally thrilling and terri- fying. It took about an hour to complete and by the end of the surgery, the scrub nurses had to pry my clenched fingers off the phaco probe. They say the president of the United States ages over his term; I believe the same could be said of attendings who supervise resident surger- ies, especially those teaching the first handful of cases. I'm certain the experience shaved 5 years off the life of my attending. Fortunately, the patient did well. While I was so drained afterward—I had to go home and take a nap—it was an incredible feeling to help restore sight in a patient. That's what keeps us coming back for more. Since my training, there have been many advances in technology and techniques. The machines have become safer and more efficient. While fluidics have become more complex, it's also more automated. Ultrasonic power is delivered differently now with altered movements to the phaco tip. Even irrigation tubing has been improved to increase stability. Besides the improvements in the phacoemulsification machines, there has been an explosion of advancements in IOLs and diagnostic tools for preoperative and intraoperative calculations. Cataract surgery has merged with refractive surgery, and now most cataract surgeons ac- tively consider the postoperative refractive outcome of the patient. The introduction of the femtosecond laser in cataract surgery is just another example of the rapid change in technology in ophthalmology. EW Contact information Henderson: bahenderson@eyeboston.com Bonnie An Henderson, MD Tufts University School of Medicine Private practice, Ophthalmic Consultants of Boston Boston ASCRS Vice President/ President Elect are slowed to soften the peripheral cortex gently without tearing the capsule." The ultimate goal, however, will be to find a way to prevent cataract development in the first place. Dr. Dodick called this the "holy grail of cataract surgery." "Ultimately, there will be drugs that will be developed that can cross the corneal barrier by just inserting eye drops in sufficient concentration in the eye…that would prevent cata- racts from forming," Dr. Dodick said. Reflecting on the 50th anniver- sary of the first phacoemulsification on a human and the evolution that has taken place since, Dr. Lindstrom called it one of the most extraordi- nary advances in cataract surgery. "When I was in training, there were 500,000 cataract surgeries a year in the U.S., and in those days, it was 2 hours in the operating room and then 1 week in the hospital. Now, we're doing 4 million a year in the U.S. Can you imagine the resources that would be required if we had to spend 2 hours in the operating room and a 1-week hospital stay?" Dr. Lindstrom said, noting that he has actually calcu- lated the numbers. "It would be about $50,000 per eye to do cataract surgery for a procedure that would give a poor outcome in terms of function and visual rehabilitation. Now, it's about $1,600 in Medicare reimbursement, a 20- to 30-minute outpatient surgical procedure with patients being functional and seeing well the next day." Dr. Dodick said the innovation's impact was monumental to the broader field of medicine as well. "When you think about it, Charlie Kelman was the very first surgeon who figured out how to remove unwanted tissue in the hu- man body through a small opening, therefore he became the father of small incision cataract surgery in the eye," Dr. Dodick said, adding that other medical specialties took note and applied a similar concept pioneered by Dr. Kelman to other procedures. "In my mind," he said, "Charlie Kelman is the grandfather of all least invasive, small-incision surgery in the human body, and that's huge." EW Editors' note: The sources interviewed for this story do not have any financial interests related to their comments. References 1. Schein OD, et al. Cataract surgery among Medicare beneficiaries. Ophthalmic Epidemiol. 2012;19:257–264 2. Kelman CD. The history and development of phacoemulsification. Int Ophthalmol Clin. 1994;34:1–12. 3. Cullen K, et al. Ambulatory surgery in the United States, 2006. National Health Statistics Report. Center for Disease Control and Pre- vention. 2009;11. Accessed Jan. 24, 2017. 4. Kelman CD. Phacoemulsification and aspiration: a new technique of cataract re- moval. A preliminary report. Am J Ophthalmol. 1967;64:23–35. 5. Arnott EJ. A New Beginning of Sight. Royal Society of Medicine Press Ltd. 2007. 122. 6. Goes FJ. The eye in history. Jaypee Broth- ers Medical Publishers, Inc. 2013. 411. 7. Kelman CD. Through my eyes: The story of a surgeon who dared to take on the medical world. Crown Publisher. 1985. 226–32. 8. Southern California Lions Eye Institute. Foundation for Ophthalmic Education. A transcript of the first international congress on phacoemulsification and cataract methodolo- gy. 1975. 69–70. 9. Iliff, CE. Phacoemulsification—why? Trans Sect Ophthalmol Am Acad Ophthalmol Otolar- yngol. 1977;83:213–5. 10. Francois J, et al. Springer Science & Busi- ness Media. First International Congress on Cataract Surgery Florence, 1978. 2012. 58. 11. Shearing SP. Mechanism of fixation of the Shearing posterior chamber intra-oc- ular lens. Contact Intraocular Lens Med J. 1979;5:74–77. 12. Gimbel HV, Neuhann T. Continuous curvi- linear capsulorhexis. J Cataract Refract Surg. 1991;17:110–1. Contact information Dodick: Jackdodick@aol.com Koch: dkoch@bcm.edu Kelman: gurarie@aol.com Lindstrom: rllindstrom@mneye.com 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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