Architect of our future: Charles D. Kelman, MD

The effects of the small-incision revolution that Dr. Kelman started are still being felt today.

ByWilliam F. Maloney, MD

“There is no action in a man’s life which is not the beginning of so long a chain of consequences. The influence of an individual extends from generation to generation.” — Mcleod

$OSN Lens-Based Refractive Surgery [logo]$ Few people forever alter the course of history. For all ophthalmologists, Charles D. Kelman, MD, did just that. His contribution of phacoemulsification in 1967 is today the cornerstone of cataract and lens refractive surgery. Refractive lens exchange and its precursor, refractive cataract surgery would not be possible without phaco. Without Charlie Kelman we would not have phaco.

He was a gifted visionary who early on saw the refractive potential of cataract surgery. He understood that reliable and refined refractive outcomes would have to start with a small incision. This is the vision that led him to develop phaco. But there is a big difference between developing phaco and finally delivering it. Delivery lay on the other side of a titanic struggle that Charlie faced with both courageous determination and statesmanlike dignity.

I suspect the younger half of our profession has little appreciation of that struggle. With phaco now fully accepted worldwide, it is easy to forget how Charlie was initially vilified for his most important contribution. In an interview with Ocular Surgery News in 2002, he recalled, “When I started phaco, I constantly had to fight for it. I was labeled a charlatan.” Without the courage of his conviction, he would surely have wavered in the face of the strong opposition and criticism that confronted him.

Ambushed

I once experienced firsthand how vitriolic such criticism could be.

Shortly after completing my fellowship with Richard P. Kratz, MD, I was invited to give a brief presentation at a meeting in Rome. My title was, “The Three Essential Steps to Phaco,” the technique as Dr. Kratz had taught it to me. Phacoemulsification was mainly an American phenomenon as yet, but still it was used by less than 10% of U.S. surgeons. In 1985 it was rarer still in Europe.

During the discussion that followed my paper, a member of the panel, unknown to me at the time but clearly British, stood up and launched an emotional appeal to ”ignore this dangerous technique.” He characterized phaco as a reckless adventure that would never be accepted by responsible members of our profession.

Then came the ad hominem attack. “We must beware of surgeons such as our young American friend here. He represents a new generation that apparently shares neither our values nor our Hippocratic Oath,” the panel member said.

I recalled then Charlie telling me of similar incidents years earlier in the United States. I felt sure that he had been able to hold his own and respond appropriately under fire. But I was so stunned that even if I had been given the chance, I would have been unable to respond. I was young, and nothing had prepared me for this. My attacker knew an easy mark when he saw one, and he took dead aim.

In 1967 Charlie was young too and I wondered how he had ever managed to surmount this kind of attack.

I felt so ineffective that it seemed only revenge would help. Once at home, I called Charlie to ask his advice.

“History will prove you right, Bill. That is all the satisfaction you need,” he said with complete confidence in his vision. He was right of course, and in the convoluted way of these things, satisfaction did come with a phone call four years later in 1989.

“Dr. Maloney, I would like to invite you to present your ‘Three Steps to Phaco’ course to our residents and consultant staff,” said the voice on the other end of the line. “I would indeed be honored if you are able to accept.”

It was my sharp-tongued adversary from the meeting in Rome! This man, who ultimately became an admired friend, was now the chairman of one of the most prestigious institutions in our profession. What sweet irony! The most hallowed halls in ophthalmology were about to be breached by phaco.

After I presented that course, Charlie jokingly told me that he considered the struggle for phaco to be “officially over.” After more than 20 years of hard work and determination, he was becoming increasingly revered, and believe me, he had earned it. To prevail through such adversity demonstrated Charles Kelman’ rare strength. From then on, it was his courageous character that impressed me even more than his genius.

A glimpse of the possible

When we work toward a goal, it is often true that the most enduring value lies not necessarily in achievement of that goal, but in allowing others to see what is possible. Charlie achieved his goal and eventually saw phacoemulsification become synonymous with cataract surgery. Between 1985 and 1995, phaco use increased from 10% to 90% in the United States. In that single stunning decade Charlie’s small incision revolution rendered a very good extracapsular procedure suddenly no longer good enough.

His influence was felt in far more than this new technique, however. Charlie’s goal indeed began to change our view of the possible. As the paradigm shifted and small incision phaco was seen as a permanent part of our future, synergistic technologies seemed to line up waiting to be discovered – none more important, of course, than the foldable IOL.

To illustrate how this crucial innovation was spawned right from Kelman’s vision, let me take you to 1980. I was in the middle of my fellowship with Dr. Kratz and his associate at the time, Thomas Mazzocco, MD. Their standard procedure then was phaco with a 6-mm PMMA IOL, which required enlarging the 3-mm phaco incision. On this particular morning I was scrubbing with Tom, and one case was scheduled for phaco without an IOL. Tom and I both commented on the difference between this eye and the others with an enlarged incision. Not only was the 3-mm incision astigmatically neutral, but the eye was so quiet that it seemed almost untouched. I remember how impressed we were that just 3 mm of enlargement made such a significant difference in the entire procedure, not just the incision size.

Tom commented how great it would be if all of the cases could look like that one. “If only these implants could be folded,” he said in passing as we turned to the next case. To me it was such a fantastical notion that it didn’t register as a real possibility. Fortunately for us all, Tom’s vision reached further. Five years later — never having mentioned it again – he announced to the world his development of the first foldable silicone IOL — a direct descendent of Charles Kelman’s small incision phaco.

The Kelman legacy

Today’s refractive cataract surgery and refractive lens exchange are remarkable achievements. They embody important contributions by many. Review the components however — topical anesthesia, clear corneal temporal incision, phaco, injected foldable IOL and limbal astigmatic keratotomy — and it is immediately clear that none would be meaningful without small incision phacoemulsification.

Achievements of the scope and magnitude of refractive cataract surgery and refractive lens exchange ought not to be taken for granted. It didn’t have to happen this way. The fact that it did is to our great benefit and due in large part to Charles Kelman. Had he wavered, we would not be here. These procedures are a part of his legacy. That legacy is now in our hands and the hands of future generations of ophthalmologists. There is perhaps no more fitting tribute than for us to continue advancing his vision – hopefully further than even he might have thought possible.