My Phaco Odyssey in London: 27 Years and Going Strong!

My phaco journey began on December 4, 1978 — my first day as senior registrar at Charing Cross Hospital, in London. (Until that day, I had been senior resident at Moorfields Eye Hospital, in London, and I had only seen intracapsular cataract extraction [ICCE] and no lens implantation.) On this, my first day at Charing Cross, there was a phaco course in progress, and IOLs were being implanted. It was a startling revelation, and I felt a bit as I suspect Saint Paul may have felt on the road to Damascus. My life was never the same again!

The operating surgeons were Bob Azar, of the United States, and my new boss, Eric Arnott. Emulsification of the lens nucleus in the anterior chamber followed a Christmas tree capsulotomy and nuclear prolapse in front of the iris (Figure 1). The cystotome was reusable and very large, just like a billhook. Dr. Azar used the Cavitron 8000V (Cavitron Corporation, acquired by Coopervision [Lake Forest, California] followed by Alcon Laboratories [Fort Worth, Texas]) phaco machine (Figure 2). He then inserted a rigid tripod anterior chamber lens, of his own design (Figure 3), through a 6.5-mm incision. The nonautoclavable magneto restrictive handpiece was attached to a long lead called the grey lead. A 15-minute disinfectant bath sterilized the items between cases. There was no linear control of phaco power; 100% was used at the beginning to core out the center of the nucleus, and then the power was reduced to 50%. The machine came with an aspiration flow rate setting of 25 mL/minute and a vacuum setting of 47 mm Hg, which did not seem to change. The machine was not very efficient.

I was overwhelmed with excitement and anxious to try my hand at phaco. Eric Arnott (Figure 4) insisted that I watch several cases so that he could demonstrate how it was done properly. He, more than anybody else, was the greatest influence on my career. First because of his surgical skill and second because he taught me to question everything. At the end of January 1979, I used a phacoemulsifier for the first time. It felt very odd! I quickly learned how to do the capsulotomy, but I found the nuclear prolapse into the anterior chamber difficult. The first lens I implanted was the Fyodorov Mark 1 (Rayner Company, East Sussex, UK), in the iris clip design.

EUROPEAN PIONEER
I was lucky to work with Dr. Arnott, the European pioneer of phaco, because I got to meet and operate with most of the top surgeons in the world. Later in 1979, I met Charles D. Kelman (Figure 5) when he took part in a phaco course at Charing Cross. I gave a presentation on the learning curve for a new phaco surgeon; we hit it off immediately, and he became a good friend with whom I would meet in exotic locations around the world. He was always thinking of new ideas and was happy to discuss mine with genuine interest and lots of humor. That same year, Eric Arnott asked me to investigate the use of a soft implant material, poly-HEMA, as a possible folding implant. I implanted the lens into rabbits after phaco. The rabbits were then sacrificed at 3 months to study the effect of the lens material on surrounding tissues (Figure 6). We published the research in 1981, however, we did not think to patent the idea. This was done by Tom Mazzocco, who filed for the patent in February 1982. His became the STAAR silicone lens (STAAR Surgical Company, Monrovia, California).

In 1980, Charing Cross Hospital hosted an international congress that showed various cataract removal techniques and lens implant styles. As senior registrar, I assisted the visiting surgeons who included Charles Kelman, Bob Sinskey, Cornelius Binkhorst, Jan Worst, Jim Little, Peter Choyce and John Pearce. I had not been happy with the Kelman anterior chamber technique, and I was intrigued to see Bob Sinskey using a one-handed posterior, or at least an iris-plane technique. I decided to emulate this approach, which involved a can-opener capsulotomy and allowing the nucleus to come forward into the iris plane by letting the eye decompress. The phaco tip then pushed the nucleus away and lifted the proximal pole. The nucleus was then removed in the iris plane.

Toward the end of 1980, flexible loop posterior chamber lenses made their first appearance in the United Kingdom. I implanted my first under the expert tutelage of Henry Clayman during live surgery. After that, I stopped implanting the Little Arnott iris-clip posterior chamber lenses.

In 1981, Leo Amar organized a major cataract and IOL meeting, in Cannes, France. It seemed as if everyone who had a lens named after them was there. I met Eddie Epstein, an early IOL pioneer. At this meeting, one of the most important cataract surgery advances of the decade was reported by Bob Stegmann. He described sodium hyoluronate (Healon; Advanced Medical Optics [AMO], Santa Ana, California). Before Healon, lenses were implanted under air, putting the corneal endothelium at risk of touch and damage.

Eric Arnott, in cooperation with CilCo Inc (Sanford, North Carolina), developed a lens from a single piece of PMMA with loops that encircled the optic. In 1982, I tried the lens. The loops were lengthy, complex and difficult to handle. Once the correct technique was developed, however, they were stable in the eye. The disadvantage of this lens was that it needed a larger incision versus other IOLs with polypropylene loops. Thus, my preferred IOL was Richard Kratz's modified J-loop lens (Coopervision).

TWO-HANDED TECHNIQUE
In 1983, I visited Henry Clayman, in Florida. He was using Healon not only for lens implantation, but also for capsulotomy, which I immediately adopted as well as his two-handed technique for phaco, which seemed easier than my one-handed approach. He also designed an oval optic IOL that reduced incision size. A good idea in theory, the lens caused glare from the optic's edge. The other big change in 1983 was the YAG laser, which was used instead of a needle for posterior capsulotomies. YAG lasers resulted from the work of Daniéle Aron-Rosa and Franz Fankhauser. In my practice, we still use a Coopervision 2500 YAG laser that was made in 1983. It is simply superb; it was built to a standard and not a price. We now had a noninvasive means to deal with posterior capsular opacity, which as Harold Ridley noted in an early paper, would be a problem.

In 1985, I gave a phaco course at the Krasnov Institute, in Moscow, and my partner in crime on the faculty was Larry Leiske. I used the Leiske anterior chamber lens for secondary implantation; my patients did not seem to suffer from the problems that gave this lens its later poor reputation. The same year, Leo Amar organized another meeting in Cannes. I met Bill Maloney, Philippe Crozafon, Hans Reinhard Koch, Rene Trau and many others who would be the leaders of the second wave of phacoholics. Over the ensuing decades, we gave many courses together, learned from each other and were very generous in our mutual exchange of ideas.

In February 1986, a group of surgeons including Charlie Kelman, Eric Arnott, Hans Reinhard Koch, Rene Trau, Phillipe Crozafon, Daniéle Aron-Rosa, Ulrich Dardenne and I met in Paris. We formed the European Society of Phaco and Laser Surgery, the model for the amalgamation of disciplines leading to the European Intraocular Implant Council (EIIC), which became the European Society of Cataract and Refractive Surgeons (ESCRS). In the spring, I attended the American Implant Society meeting and was approached by STAAR Surgical. I tested the company's foldable silicone IOLs; they were the first human implants I did with a small incision. These plate-haptic lenses could not go into the capsular bag (they would buckle with capsular contraction), and the material quality was poor.

I accompanied Charles Kelman in 1986 on a European phaco tour with courses and live surgeries in London, Antwerp, Munich, Bologna and Athens. In Bologna, I met Franco Verzella, who pioneered refractive lens exchange in high myopes using phaco. I had never had so much fun while learning so much! Charlie was a great raconteur and very forthcoming with good advice. I still have a T-shirt and video to prove that I was part of this venture!

CAPSULORHEXIS TECHNIQUE
In June, Charlie and I were on the surgical faculty for a meeting in Bordeaux, France. We were eclipsed by Jürgen Greite, of Munich, Germany. To an audience of 500, he demonstrated the Neuhann capsulorhexis technique (Figure 7). When he finished his case, there was a standing ovation. Many of us realized that phaco would never be the same again, as all previously used nuclear removal techniques were obsolete. Despite this, we continued to encourage the three steps to phaco devised by Bill Maloney. He was, more than most, responsible for giving a sensible and repeatable structure to teaching phaco. Unfortunately, three steps did not work well if capsulorhexis was used (Figure 8).

Other silicone foldable lenses were produced by Advanced Medical Optics and Adatomed (Ratingen, Germany), and poly-HEMA lenses were produced by IoGel (Australia). In 1988, at the EIIC meeting in Copenhagen, I reported results from 20 lens implantations with the AMO SI18: For the first time, the visual benefit of a small-incision IOL for patients was demonstrated.

By 1989, many surgeons were developing techniques to remove nuclei after capsulorhexis. My preferred technique was similar to the chip and flip that Howard Fine performed. Howard Gimbel and John Shepherd also had interesting techniques, Gimbel with his divide-and-conquer technique, and Shepherd with his four-quadrant nucleofractis technique. I performed the latter until I learned phaco chop, but for many surgeons around the world, this is still their preferred way to remove the nucleus.

I then participated in the multicenter study of a foldable hydrophobic acrylic (ie, Acrysof; Alcon Laboratories). On December 14, 1990, I implanted the world's first (Figure 9). At the time, we did not like the material because we were used to handling silicone or hydrogel, and our instruments were not designed for a tacky material like Acrysof. Lucio Buratto designed an easy-to-use implanting forceps that is still in use today. At this time, we did not know what an important advance this lens would be.

At 1 year follow-up, there was much less posterior capsular opacification (PCO) than we had been used to. David Spalton, at St Thomas' Hospital, in London, developed a digital camera. With colleagues at Kings College, he adapted image analysis software to quantify PCO for the first time. He and Milind Pande demonstrated the difference in the PCO between different lens materials. The full significance of the design did not become apparent until some years later.

ACRYSOF PRECURSOR
In 1992, Graham Barrett asked me to participate in a study with his latest version of the poly-HEMA Iogel lens. This open-loop IOL was the precursor of the one-piece Acrysof as well as most of the current hydrogel lenses. It had floppy haptics with what Graham called minimal haptic rigidity, but it did not decenter.

Another seminal year for cataract surgery was 1993. Kunihiro Nagahara showed his phaco chop technique at the American Society of Cataract and Refractive Surgery (ASCRS) meeting. This technique caused a sea of change in nuclear removal. Although I tried it, I preferred Paul Koch's modification, stop-and-chop (Figure 10), and subsequently, karate or quick chop. The cornea emerged as the preferred site of the incision, and topical anesthesia was demonstrated in this year. It took me a longer time than I care to admit before I was convinced that topical was a better way to operate. Two new phaco machines were also introduced (ie, Prestige [Allergan, Irvine, California] and Legacy [Alcon Laboratories]). The Prestige was the first machine that controlled surge by using less compressible tubing, thus enabling safer use of higher vacuums and flow rates. This ushered in the era of fluidics rather than power-driven phaco. The Legacy soon followed suit in this regard, and on both machines and the AMO Diplomax, power modulation started to become available. No longer was full-on continuous phaco needed to remove the nucleus.

In 1996, Lucio Buratto invited me to speak at his Videocataratta meeting, in Milan, Italy. He demonstrated bimanual I/A, and I instantly realized its advantages and began using it upon my return to the United Kingdom. I continue to use this technique today. In the same year, Okihiro Nishi determined why Acrysof had a low PCO rate. Although later work by Reijo Linnola indicated that the material played some part, it was the sharp edge of the optic that was important factor. This feature is now found on almost all IOLs.

Carrying out a capsulorhexis in a white or black cataract had always presented a challenge to even the most experienced surgeon. In 1999, Gerrit Melles proposed a very simple solution: Stain the capsule with trypan blue dye (Figure 11). I use Bob Osher's method of creating a layer of balanced salt solution under viscoelastic to trap the dye against the capsule.

WHITESTAR SOFTWARE
Although the Allergan Sovereign was introduced in 1999, its major impact occurred in 2001 when the Whitestar software, which allowed micropulsing of phaco power with 4- to 8-millisecond bursts and variable spacing to produce different duty cycles and linear power, became available. What this meant for phaco was less repulsion and less heat production.

Amar Agarwal had a few years before he demonstrated a bimanual bare needle phaco technique, and Randy Olson was doing cadaver work on wound temperatures using Whitestar, which as it seemed positive, prompted me to use a bare phaco needle with micropulsing on the Allergan Sovereign. We had to design the instruments (ie, irrigating choppers and microcoaxial capsulorhexis forceps) for this procedure. Duckworth and Kent (Baldock, Hertfordshire, UK) helped us to perfect the design. With a bare phaco needle, even the most dense cataracts could now be removed without a wound problem (Figure 12). This started another seminal change in phaco techniques relating first to incision size and then phaco power delivery. It also renewed my acquaintance with Howard Fine, Amar Agarwal and Keiki Mehta as well as a whole new group of enthusiasts including Jorge Alio, Ekkehard Fabian, Alessandro Franchini, Mark Packer and Ken Rosenthal, all of whom contributed to the advancements of bimanual microincision cataract surgery.

In 2003, two more important products came into my life. The first was the Alcon Infiniti phaco machine that combined the power delivery features of the Sovereign with better fluidics. The company also had Aqualase for nonphaco nuclear removal and Neosonix. I was a bit skeptical about these last two, but there are great enthusiasts for Aqualase, and I think its use bimanually would be an advance for capsular cleaning. Second, I switched from the one-piece Acrysof IOL to the Natural version, injecting it through a 2.8-mm incision.

The prospect of a multifocal lens seemed tempting. Bill Graham, then a senior member of Alcon research and development, asked me in what proportion of patients would I use such a lens. I responded that if it worked well, I would implant them in patients who wanted to get rid of their spectacles. So far, >250 of my private patients have felt that need, and >90% achieve true spectacle independence (Figure 13).

MICROCOAXIAL PHACO DEVELOPED
In 2005, Taka Akahoshi, the pioneer of phaco prechop, devised microcoaxial phaco. With a smaller thinner sleeve over the phaco needle and raising the height of the irrigation bottle, he was able to use a 2.2-mm incision. He modified his one-hand Royale lens injector (Royale Unihand Injector; ASICO, Westmont, Illinois) to allow a full-sized Acrysof IOL to be injected through this same incision. Although many of the advantages of bimanual microincision cataract surgery are lost, the majority of surgeons may choose this technique to decrease their wound size.

This year, a new modality has been added to my Infiniti (Alcon Laboratories) phaco machine. Torsional phaco (ie, Ozil; Alcon) has no longitudinal but only lateral movement of the phaco tip at ultrasonic frequencies. I am working with this, as are many others, to determine the best way to deliver this new power modulation (Figure 14). It seems to work without any need for cavitation.

In my 27 years as a phacoholic, many people have influenced the way that I perform my surgery — far too many to mention them all here. The exciting thing for me is that this is still work in progress!

Richard B. Packard, MD, FRCS, FRCOphth, is in practice at The Prince Charles Eye Unit, King Edward VII Hospital, in Windsor, Berkshire, UK. Dr. Packard states that he is a consultant for Alcon Laboratories, on the Infiniti Vision System and for Advanced Medical Optics, on the Sovereign system, but he states that he holds no financial interest in any of the other products or companies mentioned. Dr. Packard may be reached at eyequack@vossnet.co.uk or +44 1753 860441.