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    Phaco turns 50

    Technique, technology transformed cataract surgery; evolution continues for benefit of physicians, patients

    As the ophthalmic community celebrates 50 years of phacoemulsification (phaco) innovation, surgeons and industry alike mark its progress since the inspiration for the procedure came to Charles Kelman, MD, after a visit to the dentist.

    Phaco may have had its early detractors—but there were some who adapted it early on and eventually helped improve the procedure as it is today. Here are some of their stories and predictions for phaco’s future.

    Robert H. Osher, MD, professor of ophthalmology, College of Medicine, University of Cincinnati, and medical director emeritus, Cinncinnati Eye Institute

    Dr. Osher recalled being the first resident at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine in 1978 who performed phacoemulsification, when he was a second-year trainee. His early study and use of phaco made him “extremely passionate” about small-incision cataract surgery.

    “Even as a resident, I decided it was the way I wanted to perform cataract surgery,” he said.

    Still, the early days of phaco were “always an adventure,” he recalled. Cystoid macular edema was not uncommon, and a torn posterior capsule was a frequent event.

    Not unlike Dr. Kelman, Dr. Osher said his own approach to phaco and ways to improve it were usually met with harsh criticism. This included the introduction of astigmatic keratotomy with phaco for the reduction of pre-existing astigmatism, clear hyperopic lensectomy, slow-motion phaco, and the first video symposium to focus on cataract surgery complications. To promote phaco, he introduced the Video Journal of Cataract and Refractive Surgery in the early 1980s.

    Dr. Osher credits fellow surgeons and manufacturers for innovative instrumentation, as well as groundbreaking techniques, including capsulorhexis, bimanual surgery, and nucleus disassembly. His own introduction of slow-motion phaco added a way to safely approach more challenging cases, such as the loose lens, the mature lens, and the small pupil. In 2007, he introduced microcoaxial phaco, which is today’s standard.

    Dr. Osher’s vision for phaco’s future—and the future of vision—is the elimination of cataracts.

    “The scenario is when a patient turns 21, he or she will go see their eye surgeon,” he said. “A clear lensectomy will be combined with an IOL that conquers myopia, hyperopia, astigmatism, and presbyopia.

    “Everyone will walk around with crystal-clear uncorrected vision that makes his or her vision beautiful,” he asserted. “I’m 100% certain of this.”

    Moreover, the lens implanted in the eye also will be able to measure blood sugar levels, IOP, and even deliver medications, Dr. Osher predicted.

    Dr. Osher marvels at how far phaco has come along.

    “[The surgery] is so much better now,” he said. It’s such a great operation. People ask about my exit strategy. It’s called death. I love what I do every day. I can’t imagine doing anything more satisfying.”

    Excitement and terror

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