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Today's Practice | Jan 2014

From ECCE in Goat Eyes to Modern Phaco

Practicing extracapsular surgery on animal eyes led this surgeon to ophthalmology residency.

When I was young, my family lived in an apartment attached to the clinic of my father, Keiki Mehta. I would saunter in and out of the clinic, trying my hand at the slit lamp and playing with the ophthalmoscope and discarded cryoprobes that still had enough juice to produce a small iceball. Along with “Tom and Jerry” cartoons, my dad sometimes played videos of his surgeries on our old 8-mm projector. Names like Fyodorov, Kelman, Arnott, and Rosen were mentioned often at the dinner table.

My father was at the forefront of the IOL revolution in India. I remember people waiting by the staircase of his clinic as late as midnight with their dinner in hand. As you can imagine, being one of three or four lens implant surgeons in a country of 1.5 billion had its advantages, as well as its challenges. He would operate on 20 patients every morning and see 100 more in the afternoon, doing lens measurements and a great bulk of the refractions by himself.

By the late 1990s, my father was traveling every weekend, teaching phaco and IOL implantation techniques to fellow eye surgeons, many of whom had never before seen an IOL or a phaco machine. The eye surgery I saw in the operating room looked like fun, and the patients seemed grateful, so in third grade I decided that I, too, would be an eye surgeon.

PRACTICE MAKES PERFECT

My first cataract patient did not need anesthesia; it was a goat eye. Every Saturday in the mid 1990s, I would operate on three or four goat eyes, practicing the extracapsular cataract surgery (ECCE) can-opener style technique that I often watched my father perform. I used my father’s discarded Konan microscope and bits of leftover 10-0 nylon suture.

A few years later, during residency, I performed plenty of ECCE procedures and implanted one-piece PMMA IOLs in human eyes. Because these cataracts were so mature, a quick pass with the Simcoe cannula washed out the negligible cortex. The day after surgery, we residents would check to see which surgeon had produced the least corneal striae and whose patients could identify fingers at 6 m. All patients were admitted to the hospital for 5 days and left wearing dark glasses. They were all given intravenous antibiotics and steroids during their stay at the hospital.

Because the A-scan did not always work, typically the IOL power was determined from preoperative refraction and intraoperative funduscopy after removal of the mature cataract. As one can imagine, this was far from optimal.

PHACO NEWBIE

In 1997, I took a 20-hour train ride to an eye hospital in Chitrakoot in northern India. The surgeons there were doing nearly 150 to 200 cataracts per day, but, like me, none had experience with phacoemulsification.

I carted along an old Optikon phaco machine and the phaco trainer—my father—and joined the ranks of the phaco newbies in Chitrakoot. One week and more than 100 cases later, I felt confident enough to begin my own practice.

Armed with a masters degree, I went to the United States for 3 months in March 2000. While visiting I. Howard Fine, MD, and his colleagues in Oregon, I witnessed my first multifocal IOL (Array; no longer available; Abbott Medical Optics Inc.) and accommodating IOL (AT-45; now known as the Crystalens; Bausch + Lomb) implantations.

In 2002, I started implanting 5.5-mm PMMA lenses that required me to enlarge my 3.2-mm phaco incision. At the time, I was using a Legacy Series 20000 phacoemulsification system (Alcon) and an old Leica microscope. I made my phaco incisions with a diamond blade, as the boss declared metal blades “fit only for the kitchen” and created the rhexis with forceps because needles were only “for giving injections.” I was also informed to steer clear of small-incision nonphaco cataract surgery—the “endothelial holocaust,” as he called it. I never did understand how 7.0 to 8.0 mm was a small incision, and I still have no experience with those techniques.

I remember it took more than 20 cases before the capsulorrhexis would actually go around by itself, and hard cataracts usually ended in conversion to ECCE.

I eventually upgraded to the Infiniti phaco machine (Alcon). Used to older technologies, I could not believe how stable the anterior chamber was, and my incision size dropped to 2.8 mm from the 3.2-mm incisions we had been using. The first foldable IOLs I used were three-piece silicone lenses with a holder-folder (Allergan, Inc.). The lens popped open as soon as it entered the anterior chamber. The only ophthalmic viscosurgical device (OVD) available at the time was hydroxypropylmethylcellulose, which was filled into a syringe from autoclaved glass bottles. A patient within ±1.00 D of intended correction was a great refractive result.

AVAILABILITY OF PREMIUM LENSES

I started using the ReZoom IOL (Abbott Medical Optics Inc.) soon after it became available in India. At the time, in 2004, the trend was toward multifocal lenses; reading glasses were passé.

After I found out about the German company Acritec (later purchased by Carl Zeiss Meditec), I began implanting many of its multifocal lenses, as well as foldable and refractive multifocal IOLs from Rayner Intraocular Lenses, Ltd. I also tried the tripod lens from then-manufacturer IOLTech (now a part of Carl Zeiss Meditec) and the Torpedo Lens (Acqua; Figure 1), the latter of which was implanted through a 4.0-mm tunnel but swelled to 5.5 mm once implanted; a great idea, I thought.

I also implanted nearly 100 Ultra Choice 1.0 IOLs (ThinoptX; Figure 2), the first thin IOL. After dipping the lens in saline warmed to 40º C, I would roll it in my fingers and push it into the eye through a 1.0-mm incision.

CONTRIBUTING TO OPHTHALMOLOGY

I also tried my hand at designing modified choppers. One variation, the triprong chopper (Figure 3), fixates the nucleus similar to the tines on a pitchfork. We also developed the Mehta Accommodative IOL (Figure 4A), which consisted of an anterior ring (Figure 4B) and a posterior dioptric carrier (Figure 4C) that were implanted separately in the capsular bag and then dovetailed together. A few prototypes provided up to 2.00 D of accommodation.

In 2009, I introduced a new technique, the bag-to-the-wall, in which a one-piece acrylic lens is sutured through a subluxated capsular bag (as in Marfan syndrome) to the sclera without a Cionni ring (Morcher GmbH).

CURRENT PRACTICES

In 2004, I boarded the sleeveless phaco bandwagon but quickly realized that coaxial phaco with a 2.2-mm incision was safer, as it was less likely to burn the cornea, and also faster. The availability of IOL injectors also enhanced surgical safety, and the original screw-type injectors slowly made way for the push-type, as surgeons could not properly stabilize the eye, hold the injector, and turn the screw at the same time.

Lately, I have been using the AT LISA trifocal lens (Carl Zeiss Meditec), and my patients are happy with their intermediate, near, and far vision. Also, use of Ozil transversal phaco technology (Alcon), and new pulse-shaping software from Carl Zeiss Meditec and Optikon make short work of India’s brownest lenses, which just 15 years ago would end in conversion to ECCE in most instances. Now I perform most cases through a 1.8-mm tunnel incision.

I started using immersion biometry in 2001 after seeing Dr. Fine’s success with it, and I recently acquired the IOLMaster 500 (Carl Zeiss Meditec). This tool has made the refractive inaccuracies of the past a rarity.

CONCLUSION

I believe that laser-assisted cataract surgery can have a great future in the developing world—if industry can bring down costs, as occurred with the introduction of reusable tubing for phacoemulsification.

I am still waiting for some bright spark among the industry to figure out that surgeons need one integrated unit that can make LASIK flaps and incisions, apply excimer laser treatments, and remove a cataract, all at the same workstation.

Cyres Keiki Mehta, MS(Ophth), MCH(Ophth), is the Surgical Director and Chief of Dr. Cyres K. Mehta’s International Eye Centre, Mumbai, India. Dr. Mehta can be reached at tel: +9819850971; e-mail: cyresmehta@yahoo.com.

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