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Innovations | Jan 2014

From Aphakic Glasses to Modern-Day IOLs

Charting the evolution of cataract techniques in India.

Cataract surgery with IOL implantation has become the most common and successful ophthalmologic procedure in the world. Growing up, my first exposure to ophthalmology was watching my grandfather perform intracapsular cataract extraction (ICCE) using a von Graefe cataract knife. He was trained in cataract surgery by a British ophthalmologist when India was under British rule. Playing with aphakic glasses under his watchful eye was the beginning of my desire to become an ophthalmologist.


After medical school, I was fortunate to get an ophthalmology residency in India’s premier training institute in Chandigarh. It was here, in 1995, that I performed my first cataract surgery procedure using an extracapsular cataract extraction (ECCE) technique, followed by implantation of a rigid monofocal PMMA IOL with a 6.0-mm optic and dialing hole. Even though this was less than 2 decades ago, it seems like more than an era has passed since then.

I had seen and assisted many surgeries by that time, and, like all trainee assistants, I was itching to get my first chance; it all seemed so simple when done by the consultants. When my time came, the patient was a 55-year-old man with a mature white cataract in his left eye. It seems bizarre now, but, in those days, most ophthalmology residents would start their training with mature white cataracts, as the majority of patients who turned up for surgery in teaching institutes presented with advanced cataracts. At the time, ICCE camps were just being phased out in India, but the mindset lingered that white mature cataracts were ripe and therefore easily plucked from the eye. Most residents were happy, as no matter what happened during surgery the patient’s postoperative vision would surely be better than light perception.

On the day of my first surgery, I scrubbed with a lot of anxiety as well as excitement. After prep and drape, I placed a superior rectus bridle suture, performed conjunctival peritomy, and cauterized the bleeders. Using a blade-breaker handle, I created a 6.0- to 7.0-mm limbal incision, and I used 2% methylcellulose (as an ophthalmic viscosurgical device [OVD]) to form the anterior chamber. Because trypan blue and indocyanine green dyes were not available for staining the anterior capsule, an envelope or can-opener anterior capsulotomy was used for these white cataracts. I removed the nucleus by applying slight pressure at the inferior limbus and depressing the posterior scleral lip with an irrigating vectis. I then performed cortical aspiration (of the negligible cortical material) with a Simcoe cannula.

Grasping the PMMA IOL with lens-holding forceps, I implanted the IOL into the capsular bag through the envelope capsulotomy. We were taught to dial the trailing haptic into the bag with McPherson forceps, which was the trickiest part, and after I achieved placement I removed the remaining capsule with Utrata forceps. After a good anterior chamber wash, I placed six interrupted 10-0 nylon sutures.

The change from the white cataract to the clear, red glow of the eye’s new optical system was dramatic and thrilling. I performed the surgery under peribulbar block, and yet the patient was uncooperative by the end— understandable, considering I had taken a little more than 1 hour to complete the procedure.

On the first postoperative day, after removing the mandatory bandage that was placed over the eye, the patient’s UCVA was 6/36, improving to 6/12 with pinhole. The patient and I were both thrilled, as the result was almost better than we both expected.


My first experience with small-incision ECCE was also with a white mature cataract. The patient presented with preoperative vision of hand movements close to the face. After performing a conjunctival peritomy, I carefully created a scleral pocket incision, followed by an anterior capsulorrhexis with the aid of trypan blue dye. I used hydrodissection to prolapse the nucleus out of the bag; removed it via a small, self-sealing incision using a fishhook technique; performed cortical clean-up with a Simcoe cannula; and implanted a rigid PMMA IOL in the capsular bag. Postoperatively, the patient’s UCVA was 6/12, improving to 6/6 with pinhole. A video of the procedure can be viewed at eyetube.net/?v=sidop.


During the time of my residency training, from 1995 to 1998, it was standard for patients to be admitted 1 to 2 days before surgery and kept overnight after surgery. Postoperative care included antibiotics and steroid drops administered 4 to 6 times a day and tapered over a period of 6 to 8 weeks. Only at this time were patients prescribed final spectacles.

It was not uncommon to see a postoperative refraction that required a correction of against-the-rule astigmatism of 1.00 to 3.00 D. Intraocular pressure (IOP) spikes were also common, as residents were hesitant to go beneath the IOL to remove the OVD. Suture removal was not done routinely for 2 to 3 months, unless a patient experienced suture-related discomfort such as foreign-body sensation or there was a loose suture or exposed knot.

As the expected UCVA ranged from 6/24 to 6/18 and postoperative recovery was long, most patients were advised to undergo surgery only when their vision dropped significantly due to cataract. Operating on a 20/30 cataract for glare or a mild posterior subcapsular cataract for visual discomfort was less common during the 1990s in India, and it was considered a sacrilege in teaching institutions.

During my residency, emphasis was placed on minimizing surgically induced astigmatism. I learned how to carefully bury the knots, make equidistant sutures of equal and appropriate length, ensure proper IOL positioning in the capsular bag, and check that the anterior chamber was well formed at the end of surgery.


After residency, I had limited experience with phacoemulsification. It was introduced in India only in the 1990s, and most surgeons there were still mastering the technique, including my mentor, Jagat Ram, MD. I sought fellowships abroad to gain skills with this next generation of cataract surgery.

During fellowships at the Storm Eye Institute in Charleston, South Carolina, and the John A. Moran Eye Center in Salt Lake City, Utah, I practiced phaco chop in postmortem eyes using the Miyake-Apple posterior video technique. I was also involved in research using that video technique under the direction of the late David J. Apple, MD.1-6 I performed several experimental studies and learned about various newly available IOL biomaterials and designs and also analyzed pathology of explanted IOLs. In addition to several peer-reviewed publications,1-6 my work was also recognized during the American Society of Cataract and Refractive Surgery (ASCRS) conference (Figure 1). Afterward, I refined my surgical skills in phacoemulsification and performed complex phaco procedures under the guidance of Anthony Maloof, MD, and John Milverton, MD, at the Sydney Eye Hospital, University of Sydney, Australia.

During my stay in the United States, I interacted with many pioneers of IOL designs and phacoemulsification surgery, and I was inducted into the International Intraocular Implant Club (IIIC). It was my privilege to write biographies for Sir Harold Ridley;7 D. Peter Choye, MD;8 and Charles D. Kelman, MD.9


After 7 years abroad, I returned to India and, along with my wife, opened the SuVi Eye Institute & Lasik Laser Center in Kota, India. In addition to practicing ophthalmology, I shared my passion to teach phacoemulsification and IOL implantation by participating in various national and international conferences and by demonstrating these skills during the live surgery session (Figure 2). In our practice, we counsel cataract patients and offer them the most appropriate IOL, choosing from a broad range of options that includes toric, multifocal, multifocal toric, and accommodating lens models. The majority of our patients opt for small-incision phacoemulsification through a 2.2- to 2.8-mm incision with implantation of a premium IOL. Our pearls for toric and multifocal toric IOL implantation can be viewed at eyetube.net/?v=seleg and eyetube.net/?v=fleji.

We had the opportunity to perform India’s first Tecnis toric multifocal IOL (Abbott Medical Optics Inc.) implantation. The patient was a 55-year-old man with cataract and corneal astigmatism in his right eye and a preoperative BCVA of 20/60. The procedure can be viewed at eyetube.net/?v=getad.

I used the Whitestar Signature Phacoemulsification System with Ellips transversal ultrasound (Abbott Medical Optics Inc.) and bimanual irrigation-aspiration to remove the cortical material. The IOL was then implanted in the capsular bag using the Emerald Injector system (Abbott Medical Optics Inc). Immediately after surgery, the patient could read a newspaper with his 20/20 and N6 unaided vision. He was thrilled with the visual outcome (Figure 3).

Currently, our team probably spends more time on diagnostic investigations including topography, optical coherence tomography, and IOL power calculation and in patient counseling than the cataract surgery itself; what a long way I have come from that first 1-hour ECCE procedure I performed more than a decade ago.


Today, the advances in IOL designs have enabled us to give near-perfect results in situations that would have previously been considered as disasters. In our practice, we take a special interest in pediatric cataract surgery and IOL implantation,10 and we have operated on several patients with traumatic cataract, some of them with torn anterior capsules. IOLs with sticky surfaces enable in-the-bag implantation, even in the presence of a compromised capsular bag, and multifocal IOLs provide our patients with spectacle-free distance and near vision.

The increased availability of advanced IOL designs, especially from our Indian manufacturers, enables us to give excellent, uncompromised results to our patients, and we can even perform surgery for free for our economically deprived patients. A video on multifocal IOL implantation in pediatric traumatic cataract can be seen at eyetube.net/?v=mibop.


There was almost no discussion about IOL selection during my ophthalmology residency days, but now a bewildering range of IOL options leaves most patients confused. It is our job as surgeons, as well as that of our colleagues who are counselors, to spend time gently guiding our patients to choose the most appropriate IOL. However, we must leave the final decision in the patient’s hands.

Cataract surgery has undergone significant advancement during the past few decades. The recent innovations in IOL technology have been some of the most exciting advances in ophthalmology to date, and we now have the ability to offer patients improved postoperative vision by not only removing their cataract, but also greatly reducing their spherical aberration with aspheric IOLs, astigmatism with toric and multifocal toric IOLs, and presbyopia with multifocal and accommodating IOLs. The level of patient satisfaction after cataract surgery is at an all-time high.

In my career, I have experienced too many advances to list them all here, but a few stand out in my mind as exceptional. The first was the progression from the large scleral tunnel incision to the small clear corneal incision. The second was the introduction of folding IOL technology, which has delivered a huge benefit to patients in the form of shortened postoperative recuperation. The third was the concept of eliminating preexisting corneal astigmatism as a postoperative goal, which gave birth to the concept of refractive cataract surgery. The fourth was IOL injection systems, which, from folding forceps to injectors to preloaded IOLs, have bred an entirely new field of discovery, experimentation, and triumph. The fifth, studies of the Light Adjustable Lens (Calhoun Vision), may provide surgeons with a tool to avoid IOL explantation as a result of refractive surprise during the postoperative period. Finally, laser-assisted cataract surgery represents another potential paradigm shift in cataract surgery.

All these advances will help surgeons experience the goal of 20/happy.

Suresh K. Pandey, MBBS, MS, is the Director of SuVi Eye Institute & Lasik Laser Centre, Kota, India, and a Visiting Assistant Professor at the John A. Moran Eye Center, University of Utah, and the Sydney Eye Hospital, Save Sight Institute, University of Sydney, Australia. Dr. Pandey states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +91 93514 12449; e-mail: suresh.pandey@gmail.com.

  1. Pandey SK, Werner L, Escobar-Gomez M, Visessook N, Peng Q, Apple DJ. Creating cataracts of varying hardness to practice extracapsular cataract extraction and phacoemulsification. J Cataract Refract Surg. 2000;26(3):322-329.
  2. Pandey SK, Werner L, Escobar-Gomez M, Roig-Melo EA, Apple DJ. Dye-enhanced cataract surgery. Part 1: anterior capsule staining for capsulorhexis in advanced/white cataract. J Cataract Refract Surg. 2000;26(7):1052-1059.
  3. Werner L, Pandey SK, Escobar-Gomez M, Hoddinott DS, Apple DJ. Dye-enhanced cataract surgery. Part 2: learning critical steps of phacoemulsification. J Cataract Refract Surg. 2000;26(7):1060-1065.
  4. Pandey SK, Werner L, Escobar-Gomez M, Werner LP, Apple DJ. Dye-enhanced cataract surgery. Part 3: posterior capsule staining to learn posterior continuous curvilinear capsulorhexis. J Cataract Refract Surg. 2000;26(7):1066-1071.
  5. Pandey SK, Snyder M, Werner L, Apple D, Trivedi RH, Macky T. Interlenticular opacification: clinical and pathologic lessons for management and prevention. Video presented at: the ASCRS annual meeting; May 2001; San Diego.
  6. Pandey SK, Werner L, Apple DJ, M. Kaskaloglu, Izak AM, Cionni RJ. Intraocular Lens Opacification, Opacification, Opacification. Presented at the AAO annual meeting; October 2002; Orlando, Florida.
  7. Pandey SK, Apple DJ. Sir Nicholas Harold Ridley: The Inventor of the Implant and a Pioneer in Quest to Eradicate World Blindness. In: Advances in Ophthalmology, Garg A, Pandey SK, Chang DF, (Eds). Jaypee Brothers, New Delhi, India; 2002;311-316.
  8. Pandey SK, Apple DJ. Professor Peter Choyce: An early pioneer of intraocular lenses and corneal/refractive surgery. Clin Experiment Ophthalmol. 2005;33(3):288-293.
  9. Pandey SK, Milverton EJ, Maloof AJ. A tribute to Charles David Kelman MD: Ophthalmologist, inventor and pioneer of phacoemulsification surgery.Clin Experiment Ophthalmol. 2004;32(5):529-533.
  10. Wilson MA, Trivedi RH, Pandey SK (Eds). Pediatric Cataract Surgery. Philadelphia: Lippincott Williams & Wilkins; 2005.