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    Phaco turns 50

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

     

    Jack M. Dodick, MD, in private practice in New York City

    Dr. Dodick was a third-year resident at Manhattan Eye and Ear in June 1967 when Dr. Kelman did his first phaco. The procedure lasted just under four hours.

    “It’s interesting that phaco was not readily adapted until 10 years after its introduction,” Dr. Dodick said.

    With time, handpieces—3 lbs. at the time of Dr. Kelman’s first surgery—became smaller and made more efficient. Phaco needles also became smaller, Dr. Dodick said.

    “In the early days, a ‘beer can’ capsulotomy was performed, and at times this led to an extension of a radial tear with an unintended opening of the posterior capsule,” he said. “With the advent of capsulorhexis, this complication decreased.”

    The introduction of nuclear disassembly techniques, such as chopping and prechop, made the procedure more efficient, faster, and helped to reduce the amount of energy needed.

    Among various innovations, Dr. Dodick believes the introduction of viscoelastic material was a major step in further improving safety and efficacy.

    “They would assist us by helping preserve corneal endothelium in dense lenses and requiring extended ultrasound time and in short axial length eyes with shallow anterior chambers,” he said. “The use of iris hooks and later other pupillary expanders aided in addressing small pupils and a floppy iris.”

     

    Richard L. Lindstrom, MD, adjunct professor emeritus at the University of Minnesota Department of Ophthalmology, and founder and attending surgeon, Minnesota Eye Consultants, Minneapolis

    Dr. Lindstrom performed his first phaco in 1977, 10 years after Dr. Kelman performed his first procedure and at a time when fewer than 1% of cataract surgeries were phacoemulsification.

    “The equipment was quite primitive compared to today,” Dr. Lindstrom said, describing the careful set-up required and the common occurrence of corneal edema due to corneal endothelium damage that was not yet well understood.

    The evolution of techniques and technical advances—including better fluidics, the use of viscoelastic material, and a continuous capsulotomy—all made a difference in phaco’s safety and efficiency, Dr. Lindstrom said.

    “We used to have a lot of post-occlusion surge issues that doctors learned how to manage one way or another, and we used a high bottle height,” he said.

    The introduction of pulse and torsional phaco, the divide-and-conquer technique, stop-and-chop technique, and nuclear disassembly at or below the iris plane all were major steps for phaco, he noted, while also looking to the future.

    “We’re still trying to decide if femtosecond laser-assisted cataract surgery is a mainstream advance,” he said. “It hasn’t crossed the chasm yet to middle adopters.”

    However, some handheld methods for anterior capsulotomy intrigue him, as does the idea of lesser use or even no use of ultrasound.

    “A lot of surgeons are finding that for many lenses, you can do the procedure with no ultrasound, especially if you disassemble into many pieces,” he said.

    “For younger surgeons, ultrasound will go away,” he said. “We’ll probably move away from phacoemulsification to phacoaspiration.”

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