From Black Sheep to Established: 25 Years of Contemporary Cataract Surgery

This history of cataract surgery is so vast that it is hard to determine where to start and what to include. To tell all of the stories and mention all the people involved in the conception of modern cataract surgery would be impossible. Instead, I will casually retrace the modern cataract surgery movement in Germany, under a biased personal perspective.

From 1973 to 1977, I was in residency at the Heidelberg University Clinic under Professor Wolfgang Jaeger. At that time, Professor Jaeger was the grey eminence of German ophthalmology. As the permanent secretary of the German Ophthalmological Society (DOG; Deutsche Ophthalmologische Gesellschaft), he held enormous political influence. Heidelberg had a good professional reputation, and its forte was diagnostics of rare conditions.

Professor Jaeger also cared for the central collection and documentation of IOL disasters from the first implantations in the late 1950s and 1960s. Germany had a prominent role in this project — just remember the names Fritz Dannheim and Eugen Schreck. At this time, we saw the first attempts of revival with Peter Choyce and Cornelius Binkhorst.

The university transitioned to microsurgery (ie, intracapsular cataract extraction [ICCE] with corneal stepped incision and running Tübingen nylon suture). This was the latest perfection in cataract surgery being performed by the younger assistant professors. When I left residency in 1977, many surgeons were convinced that in addition to the evolution of IOLs — which would never be feasible — there were no major further developments in cataract surgery to be expected — just as Derrick Vale had strongly voiced in 1964.

In February 1977, I started working in Mainz, Germany, under Professor Arno Nover. A few days after I started, in a small meeting for referring ophthalmologists of the region, research on the first patients of our clinic with the Binkhorst iris-clip lenses, who had been implanted 1 week earlier, was presented. In Mainz, apparently, independent thinking and practice was tolerated and encouraged — even if it contradicted the orthodox teaching as I had experienced in Heidelberg.

A conversation with Paul Diether Steinbach, the senior associate professor, later had a — or more accurately, the — decisive impact on my future career: We had chatted about this new surgical technique of a certain Charles Kelman, MD, from New York. The controversy surrounding this technique (ie, phacoemulsification) was immense. Always open for innovation, Professor Steinbach was also practical. Without any of us juniors knowing, he purchased a phacoemulsification machine. Although the machine arrived long after he left the university, the machine was suddenly — and to the surprise of all — delivered in 1979. The faculty occasionally and halfheartedly used the machine, but with no visible result.

I aspirated a few soft lenses with the phaco machine. A few attempts to use the ultrasound ended with abrupt and immediate miosis. A final result, although not affecting the patient's vision, was not easily justified to the chief.

THE WAY OF THE FUTURE
In 1980, I traveled to New York for a meeting on antisepsis. On my trip, I visited Richard Kratz, MD, who was recommended to me as one of the best surgeons performing phacoemulsification. Just a few weeks before, I saw a film by Dr. Arnold, of Atlanta, that demonstrated implantation of a Shearing lens. We were extremely fascinated and immediately knew that it was the way of the future. I visited Dr. Kratz at the Valley Presbyterian Hospital, in Van Nuys, California. The gentle and soft-spoken, but extremely concentrated and focused surgeon, operated with fascinating elegance and precision. His surgical style was lighthanded and technically extremely refined. I had never seen nor imagined this as possible before. And, what was just as unbelievable, although visibly on a tight schedule, Dr. Kratz took me patiently on his rounds, and later took the time to chat with me in his office. I realized that I had glimpsed the future of cataract surgery.

Back in Mainz, I practiced on pathology eyes every single evening. One night, after many failures, the unexpected happened, and the knot burst: I removed a cataract and placed a Shearing lens! The next day, I whispered the success to Ernst Jürgen Schmitt (for some time, we were known to German ophthalmologists as the ophthalmological Stan Laurel and Oliver Hardy, different as we were). In the following months, we introduced phaco and Shearing lenses into clinical treatment. Ulrich Dardenne, Hans Reinhard Koch and Christian Ohrloff, all of Frankfurt, Germany, had started phacoemusification much earlier than us, however, they were not using IOLs. We stuck our nose into a blizzard of opposition and were cast out as black sheep. In 1981, the DOG board attempted to expel Professor Dardenne from the DOG.

Ernst Schmitt and I, however, enthusiastically developed our phaco skills, and the number of cataract cases referred to us increased. In 1979, we performed barely 400 cataract surgeries (we are the major clinic in our state), and in 1980, we had 600 cases. In 1981, we surpassed 1,000 surgeries, a number that was previously unheard of.

In 1982, I took over my father's practice and surgery department, which he had founded at the Red Cross Hospital, in Munich, Germany. My father had a good reputation, but the staff was wary of me: My introduction of phaco in Munich and Bavaria was observed with resistance. Surgeons thought that the procedure was costly and outright criminal to risk patients' eyes. Phaco was also condemned because of the notion that it was a moneymaker: This reproach was particularly ridiculous since we did not get an extra penny. I also performed routine Shearing lens implantation despite that, in Munich, it was only occasionally accepted to implant an IOL in carefully selected cases. The combination of phaco and IOL implantation as my routine cataract surgery approach made the beginning of my practice extremely difficult toward the professional community, but successful with the patients.

Ophthalmology insidiously but continuously changed, and IOLs gained acceptance. Patients were overwhelmed by the results they obtained with IOL implantation, and more started requesting referral to surgeons who implanted lenses. In order to not lose patients, more nonsurgeon practitioners referred their patients for IOL implantation, and surgeon-practitioners and clinicians observed those of us who were already implanting IOLs.

Among the establishment, Karl Jacobi and Richard Kratz greatly furthered the cause of modern cataract surgery. Dr. Jacobi implanted IOLs and performed extracapsular cataract extraction (ECCE), and Dr. Kratz, the invited speaker at a meeting that would eventually become the German Intraocular Lens Implant Society (DGII; Deutsche Gesellschaft für Intraokularlinsen Implantation), announced that he had performed >10,000 phacoemulsifications. A murmur of astonishment and awe went through the audience. Although the acceptance of IOLs had increased, surgeons were still against phaco, as they believed it was superfluous and needlessly costly, risky and ethically irresponsible.

In 1987, Professor Jochen Küchle, retired chief of the University Klinik, in Münster, Germany, was appointed chairman of the professional association of German ophthalmologists. He faced a dissatisfaction of the small but growing minority of surgeons in private practice, and they formed a competing association. I was asked to take charge of the association's dormant unit for private practice surgeons. I managed to integrate all the surgeons, created a regionalized structure and an annual meeting. This was the beginning of what is today the German Ophthalmic Surgeons (DOC; Deutsche Ophthalmo-Chirurgen) a meeting with >2,000 physician attendees.

Five years later, Dr. Jacobi suggested that I chair the DGII meeting. While this meant a further unexpected move toward establishment between the general ophthalmology community and the progressive academicians, it also stiffened the opposition by the traditional academic fraction. It culminated when later I tried to promote a close cooperation between the DGII and the EIIC, later known as the European Society of Cataract and Refractive Surgeons (ESCRS). At the 1993 membership assembly, I proposed that we support the European association with its journal, and a long-lasting European dimension was now added to the American connection. Surgeons such as Emanuel Rosen, Peter Barry, Ulf Stenevi, Paddy Condon and Michael Blumenthal were the names of that period.

Not that one could point to a certain day or year, but it was certainly around this time that the surgeons who were so adamantly resisting the new technologies hastily tried to catch up with the progress of our generation. The techniques and implants evolved at a breathtaking pace now that European surgeons had partnered with their American teachers.

STANDARDS OF SURGERY
Between 1992 and 1993, I gave a speech at the inauguration of a private eye center in Heidelberg, Germany. My talk — "How to get the ship into the bottle" — featured phaco and foldable lenses as standards of cataract surgery. It should be noted that ECCE with PMMA IOLs had just been accepted, and only in suitable cases. My former professor, Wolfgang Jaeger, was at the meeting and kindly and sovereignly acknowledged what he had fought so strongly earlier. A highlight in the development of my career was my election for president of the ESCRS (in 1998 and 1999). To the general German understanding, a private practitioner as the president of an international society marked a revolution. As I honored Sir Harold Ridley with the ESCRS medal of honor, many of my German colleagues saluted this as proof of our ophthalmological standing in the international community.

The rest of the story is quickly told: Today, >70% of cataracts are operated on private practice, as opposed to <10% when I started. Phaco is now the standard of care, and foldable lenses are paid for by public insurance. The lines of defense are inverted. Clinical institutions are fighting for the same remuneration as private practitioners to survive. The old controversy (ie, private vs public) is revived, but this time with reversed premises.

Thomas Neuhann is senior partner of a group practice, head of the ophthalmological department of the Red Cross Hospital, head of the private Alz Eye Laser Center and professor of ophthalmology at the Technical University, all located in Munich. Professor Neuhann states that he has no financial interest in the products or companies mentioned. He may be reached at prof@neuhann.de.