‘Quick Sight’ innovations had long-lasting, wide-ranging effect on cataract surgery
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Thirty years ago, I eliminated injection anesthesia from routine cataract extraction. I combined this with clear corneal incisions and topical anesthesia to create what I termed “Fichman Quick Sight.”
Ocular Surgery News published my techniques, and I am thrilled to revisit those innovations.
When I began my ophthalmology residency, extracapsular cataract extraction was a relatively new procedure. IOLs were not universally accepted, and patients often stayed as an inpatient during the perioperative period. Refractive outcomes after surgery were not stressed, and retrobulbar anesthesia was standard of care.
Retrobulbar injections always made me uneasy. It was essentially a “blind” insertion of a needle close to the globe. There was the rare but catastrophic risk of penetrating the globe or causing a retrobulbar hemorrhage. The heavy use of IV anesthesia to mask discomfort often contributed to postop issues such as lethargy, nausea and vomiting, making the postoperative period stressful for patients. There was also the unknown: Patients did not know if they could see until the patch came off in their doctor’s office the next day.
The use of sutures created significant astigmatism that gradually changed over time, making stable refractions difficult, and most clinic days, a past patient presented with irritation from a suture that had eroded and needed to be removed.
My discomfort with retrobulbar injection led to my search for a different method of anesthesia for cataract extraction.
I began to think about the fact that, when performing argon laser iridotomies, patients did not seem to be uncomfortable. If the iris was exquisitely sensitive, why were they not in pain?
I had performed surgeries on eyes that still moved during the case. That was not problematic.
During a radial keratotomy course with Dr. Charles Casebeer, I learned that he trusted patients to maintain gaze as he incised the cornea from the limbus toward the corneal apex (the American method). That was the epiphany.
If the iris could be disrupted without pain, I could operate on an eye that was not totally immobilized and trust patients to maintain gaze. Could it be possible that I could do cataract surgery without injection anesthesia?
I began reducing the volume of injection from 5 cc to 4 cc until I realized it worked. I performed 75 cases and detailed all the elements of the surgery. I became the first physician to sit a patient up immediately after surgery and ask them to read the clock. The patients were thrilled, knowing immediately that they could see. They could not wait to have the second eye done.
I contacted Ocular Surgery News, and the editors agreed to publish an article, hence changing the paradigm of cataract surgery with a single article. I had created a technique that eliminated needles, sutures and patches. The need for IV sedation and pain medication was dramatically reduced. By using short-acting sedation with propofol, patients were alert and comfortable in the postop area, enjoying a snack and their new vision.
I began thinking about reducing preexisting astigmatism because the effect of sutures was no longer present. I had been performing astigmatic keratotomy (AK) in refractive surgery. It occurred to me that I could utilize the corneal incision as an AK. It could be moved toward the apex in a similar fashion and placed on the steep axis. In steeper corneas, a paired AK could be beneficial. I wrote an article that shared a nomogram I had created for this technique in 1994, hypothesizing that cataract surgery could have a refractive element that would be useful with monofocal implants and as multifocal lenses became available as an added tool during surgery. I have followed that nomogram successfully for almost 30 years.
I perform a great deal of femtosecond laser-assisted cataract surgery (FLACS), and it recently occurred to me that the concepts I developed so long ago are essential for this technique. FLACS could not be performed with retrobulbar anesthesia. FLACS would not work with a scleral tunnel. The three-plane incision was described by me in a book I authored, Clear Corneal Cataract Surgery and Topical Anesthesia, published by SLACK.
I am grateful for the ability to affect cataract surgery in such a significant way. So many patients throughout the world have benefited from these concepts. I am especially proud of my colleagues who “took the plunge” after hearing me speak. It took a lot of courage in the early days.
I am sure that the smiles they witnessed on their patients’ faces were rewarding.
- For more information:
- Richard Fichman, MD, can be reached at Fichman Eye Center/SightMD Connecticut, 178 Hartford Road, Manchester, CT 06040; email: richardfichman@yahoo.com.
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