Phaco Pioneers

Last year marked 50 years since the dawn of phacoemulsification, the operation that changed the face of cataract surgery. Speaking to Paul Rosen FRCS, FRCOphth, at the XXXV ESCRS Congress in Lisbon, Mr Patrick Condon from Waterford, Ireland, detailed his early meetings with Dr Charles Kelman, who developed phaco in 1967. “He flew out from Manhattan in his own helicopter, from his private practice in the top of the Empire State Building. I met him at the operating room, having gone out to his hospital by train from my hotel, and saw him do this wonderful surgery.” Dr Condon recalls that once the surgical list was complete, Dr Kelman went to each patient one by one asking how they were feeling and making sure they had their appointments within him the following day. “It was really a new way of looking after patients immediately postoperatively.” Dr Kelman then brought Dr Condon back to Manhattan in his helicopter, but on the way overflying several golf clubs to check which course would be playable the following day. The Waterford surgeon was also Mr Eric Arnott’s first surgical assistant, when he worked at the Royal Eye Hospital group in London. Eric Arnott was an Anglo-Irish ophthalmic surgeon who spearheaded the introduction of phaco in Europe. The first live surgery phaco was carried out by Eric in the New Charing Cross Hospital, London. Following a succession of attending courses internationally, in 1984 Condon brought phaco to Ireland, where he ran his own courses as a consultant in University Hospital Waterford, bringing over eminent guests such as Kelman and Arnott, as well as Dermot Pierse, Peter Choyce and Bill Maloney and many other well-known surgeons involving live surgery. At first, many surgeons in Europe were extremely sceptical of phaco, having heard horrific stories involving damage to the endothelium and dislocation of nuclear fragments into the vitreous: so much so, that a motion put forward at one of the UK Implant Society meetings by Dr Condon recommending “phaco be taught to junior doctors as part of their training”, generated heated discussion but was finally passed by just one vote. “We didn't have social media at that stage, but if we did, I think it could have upset the uptake of phaco significantly!” Needless to say, the change over from extra-capsular to phaco, was not easy in that: “The pump systems were not sophisticated enough, one of the big problems being anterior chamber collapse – if you hit a very hard piece of nucleus, the build-up of the suction in the tubing was so great that when it released itself you had a sudden collapse.” Inspired by the late Dr Michael Blumenthal, Dr Condon made use of an anterior chamber maintainer to avoid this side-effect. This involved the use of a double infusion, one for the irrigation- aspiration line and one for the anterior chamber maintainer. “I still continued to use Blumenthal’s anterior chamber even after viscoelastics became the norm.” Another major step towards the widespread acceptance of the procedure was the development of foldable intraocular lenses. “It wasn't until we had a foldable silicon lens that could be put through a small incision that phaco really took off, and it was after that, that things started to happen.” Looking to the future, Dr Condon wondered what, if anything, might overtake phaco. He himself had his cataracts removed with femtosecond laser-assisted surgery. Despite it being his personal choice, he doesn’t see it taking over completely at this moment in time. “Looking at the ESCRS studies, and being very friendly with the late Peter Barry, who was involved in looking at it statistically through EUREQUO, the mechanics of it – [femto] is far too complicated, especially when phaco is so good, and the operation itself has become so cheap to do. The technique is relatively easy now, so I think it's going to be very difficult for femto to take over.” As an early adopter of such other special surgical methods as Automated Lamellar Keratoplasty (ALK) and subsequently LASIK, which was started by him in Dublin in conjunction with Professor Michael O’Keeffe in 1993, Dr Condon was always keen to learn new technology. At the ESCRS conference in Lisbon recently, he mentioned a discussion he overheard regarding “nano-phaco” which is a different form of energy in which there is no heat release and no ultrasound involved, and which may be a possible replacement for phaco in the future. “I say ‘Let us know about this, let's hear some more! That's why we come to these meetings, because it generates people with brilliant ideas and excitement about new products.” His great hope for the future is that ophthalmologists continue to work hand in hand with pharma companies, as they have done to date, so that these companies can develop more sophisticated gadgets and machines to make life easier for the patient at the end of the day. • This article is based on an EuroTimes Eye Contact interview. See here.

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