DR JACK HOLLADAY SAYS YOUNG OPHTHALMOLOGISTS SHOULD AVOID PROPAGANDA AND LISTEN TO THEIR MENTORS

Dr Jack Holladay’s many accomplishments include the invention of the Brightness Acuity Tester and the development of the 'Holladay IOL Consultant' and 'Refractive Surgery Consultant' software programs. He has received virtually every plaudit available in the world of ophthalmology including the Binkhorst Medal, the Ridley Award and the John Pearse Memorial Award. He was recently inducted into the ASCRS Hall of Fame. In 2010 he suffered a Type 1 aortic aneurysm. Luckily he went to the ER in the hospital where the cardiac surgeon was on hand to perform the high-risk surgery that saved his life.

He subsequently retired from performing surgery and seeing patients, but maintains a busy schedule teaching and lecturing on the international conference circuit. He spoke with EuroTimes editor Sean Henahan at the ESCRS Congress in Milan. Doing fine. I’ve retired from patient care but I’m still quite active. Recovery was painstaking but my cognitive and quantitative skills have come back. I notice I probably have to rehearse my talks a little more than before. Honestly, I’m just happy to be here. Where we’ve been, where we’re going. The past 40 years in ophthalmology have seen a remarkable evolution in everything we do. When I started in the mid-1970s we were doing intracapsular cataract extraction and giving people aphakic glasses.

At that time you would wait until they had a white cataract before you would consider surgery. Even with 20/100 vision with a cataract, the result wasn’t much different than 20/20 with a pair of aphakic glasses when you took into account all of the distortion, ring scotoma, etc. Patients couldn't drive, things were magnified. I was fortunate at the time to be in a department where intraocular lenses (IOLs) were used early on. The transition from aphakic glasses to IOLs was dramatic in terms of visual improvement.

However, early problems included the trauma of the IOL and phaco to the cornea because the role of the endothelium was not clear at the time. But we worked through those issues and once we ended up learning how to use viscoelastics and other ways to protect the cornea we began to move from lenses that were on the iris, like the Sputnik, and the Fyodorov lens, to lenses in the anterior chamber (Choyce), then in the sulcus, where there were problems with uveal contact. But by the time we got to the 1980s and we began to put them in the bag, the results were wonderful.

Since then we’ve learned the importance of the capsulorhexis. But this is not the end of the story. Today we’re talking about more improvements, such as correcting higher order aberrations (HOAs) in the cornea, and providing lenses that truly accommodate. I expect that within the next five to seven years we will reach that Holy Grail of having lenses that provide wonderful vision at all distances and correct most HOAs. Fine tuning. Predicting the Effective Lens Position (ELP) of the IOL is one of the remaining problems.

Are we ever going to get to the point where we know where the lens will be exactly in the eye before surgery? There is always going to be some variability in that, because the anatomy of the eye is very complicated. Our ability to refract a patient is plus/minus a quarter. So once you get down to a quarter of a dioptre, additional improvements won’t make much of a difference to the patient. However, improving those other HOAs, coma, trefoil and spherical aberration, will make a difference. We will be able to improve quality of vision in patients who already see a pretty good 20/20, getting closer to 20/10. We will be able to make adjustments intraoperatively. The Calhoun light adjustable lens already allows adjustments using UV.

There are other ways to do this coming along. Companies are making femtosecond lasers that will adjust the index of refraction within the lens that will also be able to correct aberrations. Problems with multifocals. The multifocal IOLs have given us an interim solution for providing distance and near vision, but with a compromise in contrast and night-time dysphotopsias. This has been a good step along the way. But I think as we go forward we will see the use of multifocals drop off, as truly accommodative lenses become available. Then we won't have the problems with night-time dysphotopsias that doctors and patients fear with multifocal lenses. Future of LASIK.

In ophthalmology we often see a pattern of an initial wave of excitement in the short term when positive results are announced, when a lot of people jump on the wagon, until the long-term results come in, and people begin to jump off. However, with laser refractive surgery we can now look back 20 years and see the benefits in terms of producing good spectacle-free vision, without seeing any large-scale problems, provided we avoid the patient with forme fruste keratoconus. The benefits of the laser continue to be refined in terms of optical performance. I think we will continue to see improvement in terms of providing optimal vision.

Wavefront still has some delivery issues, but we are almost there. I expect to see significant improvement within the next few years to achieve 20/10 to 20/12 visual acuity in almost everyone with improvement in contrast sensitivity, so top gun pilots are not the only ones with “super visionâ€. Evidence and clinical experience. Ophthalmology is becoming more evidence based, which is clearly a good thing. We’ve always wanted to have science as the reason for why we did things. The shift to what we call evidence based makes that more concrete, in terms of proving that the treatment modalities we use really are best for the patient.

However, I would also say oftentimes clinical opinion is quicker, and predicts what evidence-based approaches will show. For example, back in the 1980s the US FDA had an advisory council that looked at 17,000 articles published on cataract surgery, and concluded that there was no study to show that it was beneficial. Sometimes the criteria for a clinical trial become so stringent and the theoretical basis for doing a double blind, randomised, age-matched, sex-matched clinical trial that accounts for every possible variable becomes so onerous that it doesn't get done. The studies become so costly and so long that the information becomes outdated by the time it is available. There has to be some balance.

There is an important role for approaches such as the EUREQUO registries. Avoiding the hype and propaganda. There is a certain amount of propaganda one encounters on the conference trail. I advise young ophthalmologists to retain a healthy scepticism. It is essential at conferences to get to know people you feel have been honest and forthright, who give their financial disclosures, who you respect and have a proven track record of honesty. Listen to them, they provide long-term opinions. It is also important to keep up with the peer-reviewed journals. These tend to lag behind maybe a year, but that is a good thing. If you are within a year of the latest technology, you will do well.