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Innovations | Jan 2014

Out With the Old, In With the New

Surgeons have an unbridled desire to improve ophthalmic surgery.

I am fortunate to have seen and experienced many major innovations in IOL surgery throughout my career. Beginning my residency in ophthalmology and completing my subsequent fellowship training in cornea and ocular surface disease in Omaha, Nebraska, I became well versed in the then-modern methods of cataract surgery; this was, however, prior to many advances that are now commonplace.

My first cataract surgery (Figure 1) was performed with an intracapsular technique, using surgical loupes without the aid of an ophthalmic viscosurgical device (OVD) and without placement of an IOL. The surgery, considered elegant at the time, took much longer than current methods—typically around 30 minutes. A von Graefe knife was used to create an incision that, many times, was as large as 5 clock hours. The cataractous lens would be removed with a cryoprobe, and the incision would be closed with 8-0 silk sutures. Vitreous loss was common, and visual recovery was slow. Patients would commonly remain in the hospital for days, with sandbags around their heads to prevent head movement. The medical and public perception was that cataract surgery was a medical procedure, not a refractive one.

INNOVATIONS AND INFLUENCES

Before, during, and after my residency and fellowship, a slew of innovations helped make the field of ophthalmology what it is today. Surgical microscopes, available in some form since the early 20th century and used for otolaryngology, became more widespread in ophthalmology. Also, the introduction of 10-0 nylon improved the closure of surgical wounds and lessened the eye’s inflammatory response.

With these improvements available during my fellowship, I was trained in extracapsular cataract surgery. I used the most modern lens, the Worst Medallion implant (Medical Workshop), which was sutured to the iris. Toward the end of my fellowship, I also began my training in phacoemulsification.

My success as an ophthalmologist stems from the influence of my fellowship mentor, Jack Filkins, MD. It is because of him that I became an early adopter of technology and innovations that I feel have scientific merit. I remember being summoned to the 1978 American Academy of Ophthalmology (AAO) exhibit hall 15 minutes prior to its opening. As I soon discovered, Dr. Filkins had purchased all the available IOL models on the US market. My role as fellow was to carry them back to the hotel and, ultimately, to Omaha. Our center subsequently became the regional leader in intraocular surgery.

After my fellowship, two more innovations, OVDs and the capsulorrhexis technique, further improved cataract surgery. In 1981, Healon (sodium hyaluronate; American Medical Optics Inc.; now Abbott Medical Optics Inc.) came to market. Coupled with the greater availability of IOLs, improved sutures, and phacoemulsification and extracapsular techniques, we had the tools required to perform outpatient cataract surgery. Although it was already being performed in Europe, in 1982, I became the first in the Omaha area to perform outpatient cataract surgery. As a result, I was nearly removed from the medical staff of our hospital. Many other surgeons continued to adopt outpatient surgery, especially after Howard V. Gimbel, MD, MPH, developed the continuous curvilinear capsulorrhexis in 1983.

CHANGES IN PUBLIC PERCEPTION

From 1983 to 2009, the modifications surrounding cataract surgery were refinements of existing techniques and technologies. However, there was another kind of change tied to these improvements: public perception. The public went from viewing cataract surgery as a major medical procedure to a refractive procedure. With the advent of radial keratotomy in 1974 and excimer laser surgery in the mid-1990s, this perception changed more rapidly.

When intraoperative aberrometry and femtosecond lasers became available in 2009 and 2010, respectively, I knew that this 26-year period of an almost status quo in cataract surgery was coming to an end. Cataract surgery was now almost fully considered a refractive procedure by the public, and more innovations were coming to market.

I am in full agreement with that perception. By the age of 63, I had yet to develop a cataract by the traditional definition, but I had lost my accommodation and noticed slight changes in my visual quality. BCVA was 20/25 in my nondominant eye and 20/20 in my dominant eye, not qualifying me for traditional cataract surgery. Therefore, in 2012, I asked my partner, Jason E. Stahl, MD, to perform refractive lens exchange in my nondominant eye (Figures 2 and 3), requesting a target spherical equivalent of -0.87 D. Through his skill, the use of the femtosecond laser, and intraoperative aberrometry, this was exactly my outcome.

CONCLUSION

I have seen the surgical management of crystalline lens-based complaints change fully over my career. It has been exciting to see firsthand my colleagues’ unbridled desire to improve ophthalmic surgery. In my practice, I feel comfortable recommending lens surgery for patients who experience presbyopia and more subtle visual complaints. I am excited for the future, as I feel that cataract surgery techniques will continue to improve.

Daniel S. Durrie, MD, is the president of Durrie Vision in Overland Park, Kansas, and a Professor of Clinical Ophthalmology and Director of Refractive Surgery at the University of Kansas. Dr. Durrie states that he is a paid consultant to and shareholder in Alcon and is a paid consultant to, is a shareholder in, and has patent ownership in WaveTec Vision. He may be reached at tel: +1 913 491 3330; e-mail: ddurrie@durrievision.com.

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