From General to Local to Topical: Anesthesia has Improved Over the Years

In my opinion, the biggest advancements in cataract surgery — to this day — have been (1) topical anesthesia and (2) phacoemulsification. Both innovations have made it possible for cataract surgeons to provide patients with better visual outcomes as well as comfort during and after the procedure.

I started my practice in Belgium exactly 30 years ago in September 1976. At that time, intracapsular was the most popular technique of cataract extraction. The incision was about 8-mm to 9-mm wide, and because IOLs did not exist, patients were forced to return to spectacle dependence after cataract extraction. At that time, we only used general anesthesia in Belgium, and patients were hospitalized for 10 to 14 days after surgery. Because the incision was so large, stitches, which often times induced astigmatism, were needed. The stitches were removed about 2 months postoperatively.

DIFFERENT INDICATION FOR EXTRACTION
Patients generally had good visual outcomes, although the indication for cataract extraction was not the same as it is today. In the mid-1970s, older ophthalmic surgeons waited for the vision of about 1/10 before operation. Now, it is common to operate between 5/10 and 8/10. We had a lot of very black and very white cataracts at that time.

In the early 1980s, cataract surgeons converted to extracapsular cataract extraction (ECCE). Two of the leaders in ECCE in Europe were Cornelius Binkhorst and Jan Worst, both from the Netherlands. The first iris-fixated IOL followed shortly afterward. These advancements enhanced patient outcomes, and generally patients were happy with the results. Other advances that benefitted patients included the use of local anesthesia with extracaps and the reduction in incision size (ie, 8 mm to 9 mm vs 6 mm to 7 mm).

In the late 1980s and early 1990s, Charles D. Kelman unveiled his phacoemulsification technique. I started using phaco in 1990; the early stages did not go smoothly. Without foldable lenses, we were forced to make a 6-mm incision after phaco. I was frustrated at having to perform phaco through a 3-mm incision, which was enlarged to
5 mm or 6 mm for the PMMA IOL implantation. Furthermore, we still had to suture the wound with stitches. By the mid-1990s, the first foldable IOL was manufactured, and the incision size decreased to 3 mm; no stitches were necessary at that time.

The last progress benefiting phacoemulsification was topical anesthesia (eg, proparacaine, tetracaine, cocaine, lidocaine and bupivacaine) — no more general anesthesia and no more local anesthesia! That is still the method of choice for the moment because it eliminated the risk of complications associated with anesthesia delivered via needle injection (eg, posterior positive pressure, iris prolapse, retinal detatchment and choroidal hemorrhage). Furthermore, topical application keeps the cornea well lubricated. Presently, phaco is a 1-day operation. Patients leave the hospital approximately 2 hours after surgery.

In Belgium, we have three types of hospitals: (1) private, (2) university and (3) general hospitals. Patients do not receive reimbursement for cataract surgery if it is performed in a private clinic. The majority of Belgian surgeons perform surgery in general hospitals or universities. The cost for a phaco procedure is approximately ?1,300 to ?1,400 for one eye, including the cost of anesthesia and the IOL. Generally, private doctors charge >?1,400 for one eye, and often the difference is paid by private insurance.

In the past 2 years, development of multifocal and aspheric IOLs has also impacted cataract surgery. In the late 1970s and early 1980s, Albert Galand was a pioneer concerning the envelope technique for ECCE. Personally, we started our research work in phakic IOLs — specially iris fixated lenses now called Artisan lens (Ophtec BV, Groningen, Netherlands) — in the late 1970s. This lens was first used to correct mypoia and afterward also for hyperopia and astigmatism. The Artisan lens was designed by Jan Worst. In 2003, Ophtec BV launched the marketing of a foldable Artisan lens, the Artiflex. This lens is flexible and passes easily through a 3-mm incision. No sutures are necessary, and recovery is fast (eg, myopic patients with -12.00 D can generally return to work the day after implantation).

Over the past 30 years, I have experienced many evolutions in cataract surgery. Each step of the way has been exciting, and each advancement has enhanced the outcomes we can offer our patients. I await future advances, especially to avoid posterior capsule opacification and hope that we can offer patients even stronger visual outcomes.

Camille Budo, MD, practices at Sint-Godfriedstraat, in Sint-Truiden, Belgium. Dr. Budo states that he has no financial interest in the products or companies mentioned. He may be reached at camille.budo@skynet.be.