The march of history

Outgoing ESCRS President Prof David Spalton reflects on the past 50 years of phaco surgery

David Spalton

Posted: Monday, October 2, 2017

Prof David Spalton

The only certainty in ophthalmology is that progress is certain.

Apparently, Mao Tse Tong, when asked what he thought of the French Revolution, replied: “It’s too early to tell.” Fortunately, advances in cataract surgery move at a rather faster pace, and the past 50 years have seen the most remarkable advances where, in the western world, surgery has advanced from being a sight-saving operation to one to enhance the quality of vision. As a resident at Moorfields in the 1970s, cataract surgery was intracapsular with aphakic glasses, acuity had to be reduced to 6/60 or less to justify surgery and unilateral cataracts could only be corrected with contact lenses. The operation was performed under GA, there was a ceremonial first dressing the next day and patients were in hospital for a week, leaving with a temporary pair of +10D aphakic glasses until their refraction had stabilised three months later. It is not surprising that many of our elderly patients still remember the ordeal their parents went through.

As a resident, intraocular lenses were never discussed, which surprises many people, but in many ways, this was not surprising. Harold Ridley had little clinical judgement, his ideas were way before their time with a lack of understanding of ocular physiology, a lack of technical support, and the clinics were littered with patients with devastating complications and losing their sight. I well remember a 30-year-old lady with bilateral anterior chamber IOLs, corneal decompensation, peripheral anterior synechiae and glaucoma for which, in those days, there was no effective surgical treatment. Some years later, when I put up a plaque at St Thomas’ to commemorate the first implant, one of my senior colleagues remarked it should be accompanied by another to commemorate those patients who lost their sight in the process.

A few years ago, I found the old operating book for 1949 (see the ESCRS historical online archive) and it was a surprise to find Ridley’s first implant was done as a secondary procedure. The patient, a 49-year-old lady with a unilateral cataract, had surgery in November 1949 and then a secondary procedure to implant the lens in February 1949. This was something Ridley never admitted, it being highly controversial to subject a patient to what was in effect a second sight-threatening operation. Serendipity, though, was on his side, as four months later the posterior capsule had fibrosed sufficiently to support the weight of the heavy lens: if it had been done as a primary procedure, dislocation into the vitreous would have happened and ophthalmic history not been made.

Early Ridley Operation: Cataract extraction and Lens Implantation

The 1980s and 90s saw rapid advances. Healon arrived, and this transformed implant surgery from a virtuoso technique into something within the realm of all surgeons. It was so novel and expensive that I remember one syringe would be divided for three operations. Eric Arnott was a gifted and elegant surgeon who pioneered implants in the UK with flair, and his contribution, in my opinion, has never been fully acknowledged. Remarkably, he was to sue Alcon for infringement of his IOL patent, and in a winner-takes-all case and with nerves of steel he won a million-dollar settlement. The most important development, however, was the invention of the flexible J-loop posterior chamber lens by Shearing, making it possible to put the lens back to where it belonged. Advances in surgical technique followed in parallel. The early phaco machines had enormous post-occlusion surge, with devastating consequences. Phaco became safer with the advent of capsulorhexis, which at the time seemed the most sophisticated intraocular manoeuvre, and we all went on courses to learn it. Wound size decreased with foldable IOLs to single-stitch closure, then rapidly to no sutures and clear corneal incisions.

It has been an amazing voyage for me and at times I have wondered whether the operation could get any better, but the fertility of human imagination knows no bounds. As my Presidency of the ESCRS nears completion at the end of this year it is a time for reflection. Is FLACS here to stay? We have yet to show it is a better or safer operation for the patient; it certainly isn’t cheaper. Multifocal IOLs in their various forms get even better, EDOF lenses are a major advance, improving near vision with less dysphotopsia, with more designs to come, but for the present a truly accommodating IOL remains a distant project. More fundamentally, we are starting to enter an era of almost science-fiction, where medical treatment of cataracts is beginning to appear. Lanosterol can clear cataractous lenses in dogs, lens regeneration can be achieved in children and the topical drug from Encore Vision has the potential to reverse presbyopia. The only certainty is that progress is certain.

The Presidency of the ESCRS is an enormous privilege. It is an active, executive role and is an immensely enjoyable experience, and I am constantly surprised and pleased by the willingness of our colleagues to give up their time for the good of the Society. They make a tremendous and unacknowledged contribution to our success and this is an opportunity to express my gratitude. In January Béatrice Cochener takes over the Presidency. She is a lady with huge experience, enormous ability and a massive work ethic. Our future is in safe hands.