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    Phaco turns 50

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

     

    David F. Chang, clinical professor at the University of California, San Francisco, and in private practice, Los Altos, CA.

    Dr. Chang describes his first phaco in 1982 as a second-year resident at the University of California, San Francisco, as both equal parts excitement and terror.

    “The concept of nuclear division and disassembly hadn’t yet been introduced, and therefore most beginning surgeons used one-handed phaco to sculpt away as much of the nucleus as possible,” he described. “This left a thinned-out bowl of nucleus adherent to the posterior capsule, a problem that was coupled with our inability to control or reduce the phaco power with a foot pedal.”

    He explained that Dick Kratz, MD, improved the procedure by introducing two important principles.

    “The first was bimanual surgery—using a cyclodialysis spatula to tip and then prop the proximal nuclear pole up into the anterior chamber,” he said. “The second principle was to emulsify as much of the nucleus in the pupil plane, equidistant from the posterior capsule and the endothelium.”

    Dr. Chang said it is remarkable that Dr. Kelman’s basic concept of a vibrating ultrasound needle with co-axial irrigation and aspiration is still the gold standard for cataract surgery 50 years after he performed the first case.

    “Where else in medicine has such a core surgical technology not been supplanted for a period of 50 years?” he asked.

    However, he believes that phaco is not the best way to address the growing backlog of cataract blindness in the developing world because of its high capital and per-case costs, the learning curve, rock-hard mature cataracts, and the lack of vitreoretinal surgeons to manage retained nuclei.

    “In many developing-world settings, small-incision manual extracapsular cataract extraction [ECCE] is safer and more cost effective for these advanced cataracts in eyes with multiple co-morbidities,” he explained.

    Dr. Chang is excited about the potential for manually sectioning a brunescent nucleus with Iantech’s miLOOP as a means of performing a manual ECCE through a much smaller incision without phacoemulsification.

    'Beer can' capsulotomy

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