50 years of phaco

Fifty years ago, 1967 was a year of revolutionary ideas in culture, politics, science and medicine. That year saw the debut of the Beatles’ Sgt. Pepper’s album, the summer of love, the first pocket calculator and the first heart transplant. It was during this time of creative ferment that a struggling eye surgeon in New York had an epiphany in a dentist’s chair that would forever change the way cataract surgery would be performed. Charles Kelman MD was an American surgeon who had trained in Switzerland and, by his own account, was more interested in music than medicine in his residency years. He ultimately committed to ophthalmology and began developing ways to improve cataract surgery. At that time, cataract surgery was performed via a large incision, often under general anaesthesia, leaving patients aphakic and with a long period of convalescence. Patients would then be fitted with bulky glasses. “Charlie’s original idea for phaco was to have an operation that would allow patients to leave hospital in a short amount of time, not have them lying around with pillows around their head for weeks so the eyes didn’t fall apart,” noted Richard Packard MD in an interview with EuroTimes. Dr Kelman was convinced that cataract surgery could and should be done by way of small incision. He had initially developed a cryotherapy probe that showed some potential to improve intracapsular surgery, but then began looking for some other way to break up and remove the cataract through a small incision. He tried all manner of drills and cutters with no success and had reached an impasse. To clear his mind, he decided to get a haircut and visit his dentist for a teeth descaling. He describes his eureka moment in his lively memoir Through my Eyes, The Story of a Surgeon who Dared to Take on the Medical World. “I sat in his chair as he reached over and took a long silver instrument out of its cradle and turned it on. A fine mist came off the tip, but the tip didn’t seem to be moving.” He inquired about the device and learned that it was an ultrasonic probe that vibrated at 25K/sec, cleaning teeth via the principle of acceleration. This was exactly what he had been looking for, a way that would allow the cataractous lens to be broken up without moving the lens in the eye during surgery. He reports that he actually hugged and kissed his dentist and ran out of the office. His insight that the ultrasonic probe could be repurposed to break up a cataract safely through a small incision would completely revolutionise cataract surgery, yielding improved safety and efficiency, not to mention better visual outcomes. Dr Kelman did not have much success when he first tried to share his ideas with the ophthalmology world. Indeed, he says in the early years his ideas only met with “scepticism, laughter, rejection and professional jealousy, even sabotage”. PHACO IN EUROPE Dr Kelman persevered and began giving courses for surgeons interested in the controversial technique. It was at a Barraquer symposium in Spain that Eric Arnott, at the time a promising young surgeon from the UK, would first encounter Dr Kelman and his novel technique. Mr Arnott subsequently learned phaco from Dr Kelman. He performed the first phaco cataract surgery in Europe, in London, on October 27, 1973. Mr Arnott soon became an active proponent of the technique. He recounts in his own memoir A New Beginning in Sight that he too encountered strong opposition from the establishment. “I encountered dogma and abysmal ignorance regarding small incision surgery from so many peers when championing modern forms of cataract surgery.” At that time phaco was performed with a very basic machine, mostly under general anaesthesia without the benefit of viscoelastics. Patients usually went home the next day and were fitted with contact lenses. “The settings were very simple. There was no linear phaco power at all. The settings allowed a flow rate of 25cc/min and a vacuum of 47mmHg, that was it. Generally, you started with 100% power, until most of the nucleus was done, then you would finish and manually put it at 50% power,” said Mr Packard, who had a ringside seat at that time as a senior registrar working with Mr Arnott at the newly opened Charing Cross Hospital in London. Shortly thereafter, German surgeon Ulrich Dardenne MD became the first to do phaco on the continent. He encountered a storm of resistance from the German ophthalmology establishment and nearly lost his career when senior surgeons called for him to be struck off the rolls. Phaco was not an overnight success story in the US or Europe. Aside from institutional resistance, the machine was expensive and the surgeons needed to learn a whole new technique through training courses. But the tide turned eventually, notes Mr Packard. “Finally, what happened was that the senior residents (registrars) pushed to learn phaco. They actually ended up teaching many of the consultants how to do the procedure. It was an evolution from the bottom up.” The major change that persuaded more surgeons to get on board was foldable IOLs. Of course, there have been many innovations and improvements in phaco technology to make the surgery safer and faster. Added to this such developments as topical anaesthesia, viscoelastics, and advanced technology IOLs have made phaco become the standard of care for cataract surgery. Richard Packard: eyequack@vossnet.co.uk

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