Expert reflects on evolution of cataract surgery over 200 months
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This issue’s installment marks the 200th column of Back to Basics by Uday Devgan, MD, for Ocular Surgery News. These columns have continually been instructive on all aspects of cataract surgery for new and experienced surgeons alike, and a valuable aid to surgical practice. I would like to thank and congratulate Uday for his contribution to the publication and his contribution toward perfecting the art of cataract surgery.
— Richard L. Lindstrom, MD
OSN Chief Medical Editor
In the fall of 2005, I worked with the editors of Healio/Ocular Surgery News to start this Back to Basics column to review the fundamentals of cataract and refractive surgery.
Now, almost 17 years later, we are at monthly column No. 200, and so much has changed in ocular surgery, particularly with refractive cataract surgery. It seems like the only constant in ocular surgery is change, as our techniques and technologies continue to evolve every year.
Phaco machines
Phaco machines have come a long way with regards to fluidics as well as ultrasonic energy delivery. Previous technology was an incision of 3 mm wide or greater with gravity-fed infusion and limited phaco power modulations. Modern machines now offer forced infusion, active pressure monitoring and advanced power modulations, resulting in a far more stable anterior chamber. A decade ago, we had a foray into bimanual phaco with the infusion split from the phaco needle, which was used without a silicone sleeve. While this allowed the use of two incisions, each less than 2 mm wide, it did not achieve widespread adoption in the U.S. We are now back to coaxial phaco albeit with a smaller incision in the mid-2-mm range. Our phaco machines now provide an unprecedented level of safety and precision for cataract surgery.
IOL designs
There were multifocal IOLs 200 months ago, but their designs were more rudimentary than what we have today. Newer trifocal and bifocal diffractive IOL designs provide a wide range of good vision without spectacles. In the past, toric IOLs were primarily of the silicone plate haptic design and did not have the stability that we have with today’s hydrophobic acrylic IOLs. We also have toric IOLs in a wide range of powers and across a variety of different IOL designs. We have reached the conclusion that smaller is not always better, and we would rather have a great IOL that requires a 2.5-mm incision instead of a lesser model that would go through a 1.5-mm incision. The extended depth of focus lenses are continuing to evolve, and new designs for accommodating IOLs are in the pipeline (Figure 1). In the future, accommodating IOLs will be able to restore truly youthful vision to our patients.
Source: Uday Devgan, MD
Refractive accuracy
We have dramatically increased refractive accuracy with IOLs, and that has brought refractive cataract surgery to the forefront. Better biometry, both in axial length measurements and corneal power determination, gave a large step up in refractive precision, and that is being further advanced with better formulae. We are now at the point at which the idea of a single static formula will soon be replaced with the dynamic and evolving methods of lens calculation using crowd sourcing and artificial intelligence. With future self-calibrating ocular biometers, patients can be measured on the same machine before and after cataract surgery to collect data for continuous improvement in refractive outcomes.
Surgical techniques
Over the past 200 months, our surgical techniques have evolved significantly. While the basics of intraocular surgery remain, we have built upon this foundation to achieve better outcomes for our patients. All surgeons should look at their current techniques and acknowledge that the way they do surgery today is better than it was 10 years ago. Femtosecond lasers, intraoperative aberrometry, digital surgical guidance systems and heads-up three-dimensional displays are now available for our operating rooms. With multiple different methods of IOL fixation to the sclera, the use of anterior chamber IOLs is diminishing. In subspecialties, entirely new classes of surgeries have been developed, such as minimally invasive glaucoma surgery and lamellar corneal transplantation. Even manual lens extraction, typically saved for the densest cataracts, has evolved from the standard extracapsular extraction in which multiple sutures were required to close incisions made with scissors to the manual small-incision cataract surgery technique with a shelfed incision that seals much better with fewer, if any, sutures.
Surgical learning
I still enjoy receiving the print copy of Healio/Ocular Surgery News twice a month on my desk, but I also find myself reading Healio emails almost daily and browsing the online versions of my favorite publications quite frequently. The biggest advancement in surgical learning has to be the widespread use of videos, which we can now enjoy in high definition right from our mobile phones and tablets. In that regard, 4 years ago I started a free teaching website called CataractCoach.com, where a new, edited, narrated video is posted every day (Figure 2). As of the writing of this column, there are already 1,500 videos available covering all topics in cataract surgery. And if I can keep that up for 200 months, that will be about 6,000 videos. I can only imagine how amazing the future of cataract surgery will be.
- For more information:
- Uday Devgan, MD, is in private practice at Devgan Eye Surgery and partner at Specialty Surgical Center in Beverly Hills. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.CataractCoach.com.
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