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ESCRS Heritage Lecture

Prof Thomas Neuhann reflects on a landmark moment in cataract surgery

Dermot McGrath

Posted: Monday, September 24, 2018

Prof Thomas Neuhann receiving his ESCRS Heritage Lecture Trophy from Professor Beatrice Cochener, President of the ESCRS

The renowned German surgeon and past ESCRS President Thomas Neuhann delivered the inaugural ESCRS Heritage Lecture at the 36th Congress of the ESCRS in Vienna in September.

Prof Neuhann’s lecture focused on the invention and evolution of the capsulorhexis, a key step in modern cataract surgery, and one which represented a significant advance on previous methods used to open the anterior capsule in order to access the lens material.

The invention of the capsulorhexis, and more precisely the continuous curvilinear capsulorhexis (CCC), is credited to both Prof Neuhann and Howard Gimbel MD, who both independently applied the same circular concept albeit using slightly different techniques.

Prof Neuhann told EuroTimes that he was honoured to have been asked to deliver the inaugural ESCRS Heritage Lecture at the invitation of Béatrice Cochener, current President of the ESCRS.

“I would like to thank Béatrice and the ESCRS for this singular honour. I was told that the lecture is being introduced as a means of highlighting important landmark moments and developments in the history of cataract and refractive surgery. I suppose it can be considered a bonus if the inventor of the technique is still alive to give the lecture!” joked Prof Neuhann.

While the capsulorhexis has become part and parcel of modern cataract operations, it is easy to forget that the technique was not always the preferred means of creating an opening in the anterior capsule. From Vogt’s technique using toothed forceps, Charles Kelman’s “Christmas tree” approach in the late 1960s, through to the popular “can-opener” technique in the 1970s and 1980s, surgeons had long searched for the optimal means of sculpting an aperture in the anterior capsule.

“In the early 1980s there was a bit of controversy around the question of whether we should go into the capsular bag with our lenses or should remain in the sulcus,” recalled Prof Neuhann.

“While the capsular bag was clearly the best place for the lens, the can-opener technique meant that the lenses were frequently decentred and there was a tendency for the haptics to pop out postoperatively. When it happened to me, I said to myself either I find a solution to this or I stay in the sulcus. I thought it better to be old-fashioned but effective rather than going with the trend and putting in decentred lenses with the risk of haptic displacement,” he said.

Prof Neuhann’s eureka moment came in the autumn of 1984 when he was faced with a female patient with retinitis pigmentosa and loose zonules.

“I simply could not get this can-opener technique to work. Every time I tried to nick the capsule the whole lens would move and I was afraid of ripping out the zonules. In my despair, I stuck a blade in and cut the capsule and inserted some Healon viscoelastic, which was not widely available at the time. I then took my tying-forceps and tried to tear the capsule – and miracle of miracles, the tearing was much less strenuous on the capsule than trying to nick it with the capsulotome. This was how my first capsulorhexis was performed – it was a mixture of relief and elation that it actually worked,” he said.

To more accurately describe the new technique and differentiate it from preceding techniques, Prof Neuhann coined the term “capsulorhexis”, which uses the Greek suffix “rhexis” meaning “to tear”.

At around the same time, Howard Gimbel was also experimenting with tearing out the capsule in arc-like sections while leaving small bridges to stabilise the flap until the circle was mostly formed.

“The basic principle of tearing was the same but my version ultimately stood the test of time because it proved to be a little bit more practical,” explained Prof Neuhann. “I had only one opening in the capsule from where I tore out 360-degrees, whereas Howard created two, three or four openings in the capsule and then united those by tearing,” he said.

Recognising that they had both arrived at the same basic concept independently and around the same time, Drs Gimbel and Neuhann decided to put aside any question of priority by publishing a joint paper in 1990 that explained their respective contributions to the capsulorhexis breakthrough.

“It was the right thing to do. My mentor Dick Kratz told me at the time: ‘I have seen so many bitter fights over priority. I think that is about the nicest way to handle such a thing that I have ever come across.’”

 

This story was published on Saturday September 22nd and updated on Monday September 24th