CATARACT SURGERY 2044

... The emulsification was done in the anterior chamber. Healon is shown to have a protective effect on the cornea as judged by corneal thickness measurements and by endothelial cell counts. … [N]o attempt was made to remove Healon from anterior chamber at the end of surgery. It cannot be excluded that Healon may occasionally cause increased intraocular pressure...”– Holmberg AS, Philipson BT. Ophthalmology. 1984 Jan;91(1):53-9.
Three decades ago, ophthalmology stood at the threshold of modern small-incision cataract surgery. Most of the technologies and techniques that make the procedure so reliable and repeatable today were in place at least in embryo, or about to emerge.
In 1984 phaco machines with surgeon-adjustable vacuum and flow were available, as were early viscoelastics. 1984 also saw the first commercial foldable intraocular lenses (IOLs) – the innovation that finally made it possible to take full advantage of the 3.0mm or less incisions provided by phaco technology for more than a decade. 
Within a year the seminal paper outlining the benefits of capsular bag IOL placement by David J Apple MD and colleagues would be published (J Am Intraocul Implant Soc. 1985 Jan;11(1):44-63). The continuous curvilinear capsulorhexis, which all but eliminated previously ubiquitous anterior capsular tears, also would be described independently, by Thomas Neuhann MD, Howard Gimbel MD, John Graether MD and Calvin Fercho MD. Along with IOLs featuring posteriorly-angled compressible haptics, these innovations in technique enabled greater refractive predictability and long-term lens stability.
The confluence of advances in technology and technique proved irresistible. Phaco use jumped from 12 per cent of ophthalmic surgeons responding to the first ASCRS member survey in 1985 to more than half in 1990, according to David Leaming MD. By the end of the century, phaco with foldable IOLs placed in the bag was standard of care throughout the developed world, and is now widely practised in much of the developing world as well.
Today cataract surgery again stands at the threshold of a technology revolution. Femtosecond lasers, 3-D intraoperative imaging and aberrometry, and robotic surgery hold out the tantalising prospect of precision and predictability far beyond what can be achieved manually. New IOLs, both mechanical and electro-optical, hold promise for truly restoring accommodation. And medical advances that may delay or even reverse cataract formation might obviate the need for surgery in many cases.
Ophthalmology is routinely an area of technology innovation, said industry consultant Brad Fundingsland, Santa Ana, California.  In a recent survey of 1,500 ASCRS surgeons, supported by his organisation, nine per cent considered themselves as “first to adopt” new technology, while 51 per cent considered themselves “early adopters”. 
Where these and other unknown developments will take cataract surgery is anyone’s guess. EuroTimes asked several ophthalmology leaders where cataract surgery might be in 30 years, and how it might affect surgeons’ roles and practice opportunities.

Surgical technology
One trend that appears inevitable is increased automation of the cataract procedure. “Laser surgery will spread rapidly, and new devices allowing the patient to remain seated during the procedure will probably be developed. The technician’s role will be more important, as surgery will be semi-automated,” said ESCRS President Roberto Bellucci MD, Verona, Italy. 
He sees the surgeons acting partially as a consultant, explaining options to patients and overseeing procedures carried out largely by machines.
Laser technology will likely advance quickly to the point that lens removal will involve only aspiration, said Douglas Koch MD, Houston, US, former co-editor of the Journal of Cataract and Refractive Surgery.  “The procedure may be highly automated and not require a surgeon’s presence,” he said. He also sees a growing role for corneal procedures to improve visual outcomes.
3-D imaging will also play a growing role, said researcher Pablo Artal PhD, Murcia, Spain. “We get in real time beautiful images of the eye, guiding whatever type of surgery,” he said. He sees automation as good for patients since it could eliminate performance variations due to surgeon fatigue or state of mind. 
Many surgeons believe automated laser procedures will eventually become the norm, said Brad Fundingsland. In the most recent survey of 1,500 ASCRS members his organisation supported  in 2014, 91 per cent believed they will be doing laser cataract surgery in 10 years. However, only 37 per cent believe they will do it on a majority of their patients. 
“The survey data demonstrates that while many are very enthusiastic about the future of laser cataract technology, the most significant barrier to adoption remains the ability to make this a financially viable part of their practice,” notes Mr Fundingsland.

Lens technology
A fully accommodating lens is the holy grail of cataract surgery, and some believe it will be available within 30 years. 
Dr Bellucci believes future surgeons will probably be able to replace the crystalline lens with a fully accommodating artificial lens in a matter of minutes. He believes the availability of such lenses will expand indications for lens surgery to patients with large refractive errors. 
As technology improves, Dr Koch predicts the incorporation of some kind of accommodating lens into standard cataract care. He also sees routine intervention for presbyopia as patients reach their late 30s or early 40s.
What form such lenses might take is a matter of debate. José Güell MD, Barcelona, Spain, sees much potential in biomechanical designs that accommodate by changing shape or moving bioptic lenses. However, late complications such as fibrosis and capsular bag shrinkage must be addressed to make these work for the long-term, noted Oliver Findl, Vienna, Austria.
Dr Artal suggested that getting a biomechanical lens tight may prove too difficult. A lens that moves too easily is difficult to control, whereas a lens that requires too much effort may not accommodate at all. He believes that electro-optical lenses may be the solution for true accommodation.
Dr Artal also believes that current approaches, including multifocal and extended depth of focus, will continue to play a big role. New technology including adaptive optics and adjustable power lenses will allow these lenses to be truly customised, which will greatly improve their performance, he said.

Medical treatment of cataract
While current trends suggest an ever-larger need for cataract surgery, medical advances could reduce the need, Dr Koch said. “We will have better ways to modulate cataract progression and to maintain flexibility of the crystalline lens that may delay the onset of presbyopia and visually significant cataract. That may come through medication or some form of genetic therapy.”
Such medical non-surgical approaches might increase the age of presbyopia onset and the need for lens removal, which may be good given that patients are living longer, Dr Güell said. 
“I definitely expect some drugs will be available to be used topically or systemically to reduce the speed of crystalline lens sclerosis. Presbyopia symptoms that are significant today for those older than 40-55 will probably come much later, at 75, 80 or 85.”
But advances in lens technology may offset that, Dr Koch said. “It will be an interesting tug of war between advances in technology for delaying presbyopia and cataract, and the spectacular technology we will have on hand for insertion of lenses and the improved quality of vision they may provide.”
Others believe that medicine won’t make much difference. “I do not think drugs preventing or reverting cataract formation will play an important role: people prefer rapid surgery to the prolonged care required to avoid it,” Dr Bellucci said. 
Dr Findl agreed. “Prophylactically you would have to take medicines for years or decades. The side effects could be worse than the procedure.”

The surgeon’s role
Technological advances will likely reduce the need for surgeons to perform all aspects of surgery – but not the need for surgeons. 
“It’s possible in the foreseeable future that you may see robotic surgery in straightforward cases without risk factors. But you will still need a surgeon to survey what is happening. If things don’t go as planned you need a surgeon to rectify things,” Dr Findl said.
Dr Koch agrees. “Some procedures may be highly automated, and ancillary personnel may do these. Surgery will still require an ophthalmologist, and there will still be all the complications we see today – loose zonules, white cataracts.” 
While automation may reduce the number of surgeons required, this might be offset by people living longer and requiring more high-skill late services, such as removing dislocated lenses. Still, the growing scarcity of ophthalmic surgeons could result in some procedures being taken over by non-surgeons, Dr Findl said. Local culture and law will likely have a big effect on who does what. But the surgeon will always have a place. 

Impact on training
Automation of cataract surgery will likely create training challenges. Without a large volume of uncomplicated cataract patients, surgeons will lose the opportunity to develop and maintain basic microsurgical skills needed to perform more complex procedures, Dr Güell noted. Already, since the advent of phaco, many young surgeons cannot do an extracapsular or intracapsular extraction, or even manage sutures.
Advanced simulators may take up some of the slack. Current simulators help develop spatial skills and manual dexterity, and help students get used to using a microscope, said Sonia Manning MD, a resident in training in Dublin, Ireland. “Simulators are very helpful at the beginning, but they are less helpful later on,” she commented.
The biggest drawback is a lack of tactile feedback, she said. However, newer simulators add this feature and may be more effective.
Though she has not yet used a laser system, Dr Manning believes that if they are adopted, they could limit hands-on training, leaving surgeons unprepared should an emergency arise.
Dr Koch suggested that it may become necessary to separate trainees into two groups, those who do routine procedures and those groomed for more complex manual procedures. “We will have to figure out a way to train at least a small cadre of students to do more complex procedures,” he said.

Practice opportunities
Automation also may influence practice opportunities. Dr Manning is convinced that the cost of new technology will make it nearly impossible for ophthalmologists to enter solo practice. She sees most of her colleagues going to public, hospital or private group practice.
“The number of machines needed to assess patients properly today and the cost is mind-boggling.” 
As presbyopia treatments become more accurate and repeatable, Dr Findl expects that more public and private insurance plans will cover them. However, he still sees a lot of demand for private practice and premium refractive procedures. “People still want personal care and to be taken care of in a personal fashion.”
Dr Bellucci sees public hospitals continuing to offer basic cataract services, with private practices offering a higher standard of care for those who want to be spectacle-independent while having little or no cataract. Private surgeons will be compelled to join forces to afford equipment and learn from each other, but opportunity will be plentiful. 
“Owing to the reduction in the number of ophthalmologists that is foreseen in Europe, I still see a bright future for those young people who want to undertake this career,” he said.
However, technology may not advance as quickly as most anticipate. Dr Artal notes that many technologies, such as liquid injectable lens materials, have been in development for more than two decades. “We are too optimistic. We are playing with new things, new toys, but the reality takes much longer in general.”
But no one really knows, Dr Manning said. “You should never say never. Things that seem impossible now might be the norm in 30 years’ time.”

Sonia Manning: sonia.sofia1@gmail.com
Roberto Belllucci: robbell@tin.it
Brad Fundingsland: brad@tfgeducation.com
Oliver Findl: oliver@findl.at
José Güell: guell@imo.es
Douglas Koch: dkoch@bcm.edu
Pablo Artal: pablo@um.es

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