The History (and Future) of Cataract Surgery in Italy

As estimated by the World Health Organization, 16 million people are blind due to cataract. Worldwide, this figure represents 41% of the blind population. This devastating pathology continues to plague the aging population and will continue to do so for many years to come. That is why, throughout the history of cataract surgery, we have innovated techniques to provide our patients with the best possible outcomes. This article outlines some of the accomplishments that we have embraced in Italy to treat cataract patients.

In Italy, there has been a 10% annual increase in cataract surgery procedures since 1985, and according to the Italian Health Service, it is the top operation performed in public and private health care sectors. Results from a 5-year Italian Institute of Statistics (ISTAT) investigation placed cataract as the fifth leading chronic illness in the population aged ≥65 years. (The first through fourth chronic illnesses were arthrosis/arthritis, vascular hypertension, osteoporosis and varicose veins/varicocele.) In figures split by gender, cataract was the fourth leading chronic illness behind arthrosis/arthritis, vascular hypertension and chronic bronchitis/emphysema for men and women.

Cataracts affect 18% of the Italian population, cause 37% of the routine hospital admissions and account for 49% of the bed-per-day occupation in hospitals. In 2000, cataract was the listed clinical diagnosis for 204,469 patients discharged from the hospital, according to the year's Hospital Discharge Form. The form was based on examination of the top 25 clinical diagnosis aggregates per ordinary admissions for the elderly (ie, acute, rehabilitation and long-term hospital stays).

The FIRST PHACO SYSTEM
Presently, phacoemulsification is the elective technique for cataract removal. Charles D. Kelman invented phaco — extracapsular cataract extraction (ECCE) performed through a mini-incision — in 1967. His idea to perform surgery through a small incision helped reduce patients' hospital stay and provided them with a rapid recovery of visual function. The first instrument patented for this purpose was the Cavitron Kelman system (Cavitron Corporation, acquired by Coopervision [Lake Forest, California] and then Alcon Surgical, [Fort Worth, Texas]) in 1971. Its development, however, was long and laborious; many surgeons were skeptical about the new technique.

The phaco craze reached a small number of Italian surgeons around 1978, and Franco Verzella was the first Italian to perform cataract extraction in this manner. Following his lead, Fabio Dossi and I decided to try performing phacoemulsification. I traveled to the United States to study with Steven P. Shearing, and upon my return, I began using PCIOLs as well.

In the 1970s, most Italian surgeons used intracapsular cataract extraction (ICCE). As Alfano and Pier Enrico Gallenga introduced IOLs in Italy, the technique of extraction shifted to ICCE with an IOL. Using ICCE, the IOL was placed in the anterior chamber. This technique was associated with problems including cystoid macular edema, corneal decompensation, uveitis, iris atrophy, pupil ovalization and glaucoma.

Dr. Shearing introduced the first PCIOL — the J-loop PCIOL. This lens was a major driver of ECCE, however, it did not heighten the use of phaco. About 90% of American surgeons and 98% of surgeons worldwide still did not approve of this technique. The arrival of PCIOLs in Italy caused surgeons to reexamine the ECCE technique. They were starting to realize that ECCE allowed the posterior capsule to be left on site, consenting the introduction of an IOL into the posterior chamber in the same position as the natural crystalline lens. I started using the PCIOL in 1979.

AN UNQUESTIONABLY DIFFICULT TECHNIQUE
Instrumentation (eg, automated I/As) transformed ECCE from a manual to an automated technique. Poor results of the initial phaco operations — unquestionably a difficult technique — were associated with changing routines, the cost of the equipment and the poor diffusion of (1) surgical microscopes and (2) the procedure. Many surgeons opted to perform ECCE with a PCIOL.

Balacco Gabrielli and I helped introduce the YAG laser to Italian ophthalmologists in 1981. This laser was perfected by the Swiss doctor Franz Fankhauser and introduced in the United States by Danièle S. Aron-Rosa in 1980. The YAG laser resolved the problem of opacity in the posterior capsule; until then, surgeons intervened with an invasive surgical technique to correct the opacity.

The first foldable IOLs, introduced by Thomas Mazzocco in 1984, proved advantageous for use with phacoemulsification because they could be inserted through a 3-mm incision. Before this time, the phaco mini-incision had to be enlarged for IOL insertion. This new foldable IOL was flexible and manufactured in silicone. This lens was almost never used in Italy; the design of the lens and the silicone caused problems at the outset and were rapidly replaced with acrylic or acrylic/polypropylene foldable designs.

VISCO INCREASES STABILITY OF PHACO
In 1980, David Miller and Robert Stegmann introduced the use of viscoelastic; I followed suit in 1981 and was the first surgeon in Italy to use it. Visco made the cataract operation safer and facilitated the surgeon's activities. The complications of phaco began to dissipate to such a degree that resistance from surgeons started to crumble. This marked the beginning of its success.

I continued to promote all of the latest developments in cataract surgery, and I specifically focused on phaco. To me, it was obvious that phaco would produce exceptional results. We still used sutures, although only one or two, for simple cases of phaco. If we used a rigid PCIOL, we used four or five sutures. The small incision size caused less astigmatism versus other techniques, and the outpatient procedure resulted in rapid anatomical or functional recovery. Starting in the early 1980s, I began organizing congresses — Videocataratta — featuring live phacoemulsification surgery sessions. These congresses also highlighted (1) other breaking developments in cataract surgery and (2) complicated surgical cases. After 26 years, I still organize this congress each year.

I also wrote a book on cataract surgery, which for many years was a reference point for Italian surgeons and produced some videos and CD-ROMs on phaco and viscoelastics.

In 1992, I founded an ocular surgery teaching institution to spread these new cataract surgery techniques through the Italian surgeons. Courses on phaco, mini-incisions and IOLs were designed specifically for young Italian eye specialists. This same year, I was also the first in Italy to perform cataract surgery with self-sealing incisions and no sutures.

NEW TECHNOLOGIES
Recently, the interest in new techniques to improve traditional phaco has increased across Italy. Attempts to reduce or eliminate ocular trauma have been made by studying (1) the quantity of energy used during phaco, (2) the production of heat that may damage the cornea and (3) a reduced diameter for the incision. Other techniques being studied include the erbium:YAG laser, the neodymium:YAG laser, the phaco sonic system, Neosonix (Alcon Laboratories, Fort Worth, Texas), Whitestar Technology (Advanced Medical Optics, Santa Ana, California), CataRhex (Eye Solutions, Essex, UK) and Aqualase Liquefaction Device (Alcon Laboratories). More recently, there have been studies on Ozil (Alcon Laboratories) and new-technology IOLs. Now, accommodating IOLs as well as multifocal IOLs and those correcting lower order aberrations are being used worldwide.

In the wake of the growing interest for the development of cataract surgery techniques, a number of scientific associations were founded from the 1970s to 1990: The Italian Association for Phacoemulsification (AIF), the Italian Federation for the Diffusion of Eye Surgery in the Day Hospital (FIDOA) and the Italian Association for Cataract and Refractive Surgery (AICCER) are just a few.

We have made leaps and bounds in the progress of cataract surgery, both worldwide and specifically in Italy. I have had the pleasure of introducing many techniques and ideas to Italy, and my journey as an advocate of new cataract surgery techniques continues!

Lucio Buratto, MD, is an ocular specialist at Centro Ambrosiano di Microchirurgia Oculare, in Milan, Italy. Dr. Buratto states that he does not have any financial interest in the products or companies mentioned. He may be reached at office@buratto.com or www.buratto.com.