Cataract surgery advancements continue unabated

The first commercial phacoemulsification procedure with Charles Kelman, MD, as the inventor and surgeon occurred in 1967 in the United States.

The first IOL implant was 18 years earlier in 1949 by Sir Harold Ridley in England. The Zeiss OPMI 1 operating microscope was developed in Germany and launched in 1953.

The evolution and continuous improvement of these three devices and the ophthalmic surgeons who use them combined to create the modern-day miracle of today’s cataract surgery with IOL implantation, which benefits 5 million Americans and nearly 30 million patients globally every year. In my opinion, the history of the development and refinement of IOLs, phacoemulsification and operating microscopes is a virtuous example of the great progress that can be made when surgeons from around the world collaborate with each other and industry to benefit millions of patients.

I first employed phacoemulsification with posterior chamber IOL implantation for cataract/IOL surgery as a fellow in microsurgery at the Mary Shiels Eye Hospital under the direction of the late William S. Harris, MD, in 1977. The first phacoemulsification instrument I used was the Cavitron 7007, and a year later the 7007A featured improved power modulation and a safer tip cooling. CooperVision acquired Cavitron, and then Alcon, after being capitalized by Nestlé in 1977, acquired the surgical business of CooperVision. Since that time, Alcon has been a leader in phacoemulsification innovation, following with phacoemulsification models 8000, 9000, 10000, 20000, Infiniti, Centurion and now Unity. That is nine major advances and new launches of phacoemulsification equipment by one company in 50 years, or one every 5 to 6 years. Simultaneously, major leaders and innovators in ophthalmic surgery, including Advanced/Abbott Medical Optics (now Johnson & Johnson Vision), Storz, Iolab and Chiron (now Bausch + Lomb Surgical), Carl Zeiss Meditec and others also committed to continuously innovate and advance phacoemulsification equipment.

The safety, efficacy and reproducible outcomes of phacoemulsification have been continuously enhanced by advances in surgical technique and improvements in ultrasound power modulation, fluid dynamics, enhanced chamber stability and automated surge control. Today, phacoemulsification with the newest machines can be performed at a constant and physiologic anterior chamber pressure level and with ever less ultrasound power. There is a trend toward “phacoaspiration” rather than “phacoemulsification” as patients seek surgery at a younger age with softer lens nuclei.

Yet, phacoemulsification cataract removal and IOL implantation remain highly dependent on surgeon skill and experience. In an attempt to enhance the outcomes, efficiency and safety of cataract surgery, surgeon-assisted robotic devices are being employed. The first of these are the computer- and AI-driven lasers utilized by femtosecond laser-assisted cataract surgery designed to create precise and customized corneal incisions, anterior capsulorrhexis and nuclear fragmentation. I project we will see as a next stage robot assistance in the critical nuclear and cortical lens removal step, further enhancing safety and efficiency and allowing more reproducible outcomes from one patient and one surgeon to another. Combined with improved visualization systems in a robotics-enhanced surgical workstation with heads-up visualization and template displays along with ever better IOLs, cataract/IOL surgery will continue to evolve and improve.

When I entered residency training at the University of Minnesota and affiliated hospitals in 1973, we scheduled one intracapsular cataract extraction with retrobulbar anesthesia and no IOL implant every 2 hours and then admitted the patient to the hospital for 4 to 7 days. Today, outpatient topical anesthesia cataract/IOL procedures with two to three cases per hour in a single OR and four to six cases an hour with two ORs are possible around the world. The patient journey and outcomes achieved were unimaginable in 1973 when I started my ophthalmology training. The potential outcomes achievable in the future with continuing collaboration between surgeons and industry worldwide will likewise surprise and amaze today’s cataract surgeon and their patients. The innovation cycle will continue to generate extraordinary advances as long as properly supported by the investment of human and financial capital.

• For more information:
• Richard L. Lindstrom, MD, can be reached at rllindstrom@mneye.com.

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Source:
Expert Submission

Disclosures:
Lindstrom reports having disclosures for Alcon, Bausch + Lomb Surgical, Horizon Surgical Systems, Iantech, Johnson & Johnson Vision and Zeiss.

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