50 years of phaco - Richard Packard

To mark 50 years since the birth of phacoemulsification, EuroTimes spoke to Richard Packard, who got in at the ground floor of phaco in the 1970s. Starting at Charing Cross Hospital in London, he observed a course in phaco and lens implantation, and he describes this as his “road to Damascus” moment. “Before that I had been planning to do ocular oncology, I’d done my MD thesis on choroidal melanoma, and that went out the window straight away.” By the following month he had performed his first phaco surgery. Machinery in those days was both crude and expensive. Dr Packard said that back then, a phaco handpiece had something attached to it that was called the grey lead. This was sterilised in a disinfectant called Cydex, not in an autoclave. “It was left there for 15 minutes and you had to remember to stick the rubber bung in the end, because if the Cydex got inside the grey lead then that was basically the end of that particular handpiece. And they were £3,000 pounds apiece.” That was on top of the roughly £25,000 each machine cost, which is a much higher relative cost than machines in use today. The early machines had no linearity of power delivery - this meant that as you passed into foot pedal position 3 the full power came on. The machines did not tune the handpieces for you either. “The nurse stood there listening to the device until you got to the right pitch, and you’d say ‘Oh! that's it!’” The arrival of linear-phaco power with the Coopervision 9001 machine was, in Dr Packard’s words, “a revelation”. While he missed the very beginning of phaco itself, Dr Packard was right there for the advent of foldable lenses. He worked with Dr Eric Arnott, the European phaco pioneer, undertaking a study on implanting these lenses in rabbits. “We wrote that up and sent it off to the American Intraocular Implant Society journal, who rejected it, because they said that even though the professor of pathology at the Institute of Ophthalmology was doing the pathology it wasn't adequate. It was accepted by the British Journal of Ophthalmology unchanged and immediately published.” He had been advised against working with Dr Arnott, his bosses at Moorfields High Holborn saying he would “ruin his career” in doing so. “Being young and foolish I decided to carry on, and we were proved right!” Along with foldable lenses, Dr Packard feels that the enthusiasm of younger doctors was vital for the success of phaco. “The senior registrar grade could see what was happening elsewhere and they were pushing their bosses to do this.” These doctors would take their newly acquired skills and then train their superiors in the procedure, leading to broader uptake. Asked about what he saw in the future for cataract surgery, Dr Packard believes capsulotomy is key. “Having an accurately placed capsulotomy combined with a lens that makes use of the capsulotomy will get us much closer to predicting the effective lens position. Because with all the wonderful formulae that we have and Warren Hill's big data and so on, we're still not getting as good as we could in terms of predicting the outcome.” Further, he believes that advances in microelectronics will eventually lead to the production of a lens that will be able to mimic accommodation. While cataracts may eventually be prevented, in some way or another, presbyopia will not go away, and so people will need still need some sort of accommodative lens. No matter how advanced the technology gets, however, he doesn’t believe that robotics will replace the surgeon in the operating room. “Patients are patients, and you can't necessarily predict the way that their tissues are going to behave. The other issue is that if there is a problem during surgery, even if you're a robot, your ability to adapt to the situation that you find yourself in is going to be quite difficult.” The job of the surgeon is safe, for now, he believes. In other words: “A very long time after I retire.” • This article is based on a EuroTimes Eye Contact interview. See here.

Tags: phaco