New technologies in cataract surgery- Editorial from Richard Packard

In July of this year it will be 46 years since I started my first post as a junior doctor in ophthalmology. What extraordinary changes there have been in our specialty in that time and not least in cataract surgery.

My first experience in 1970 was, as stated elsewhere in this edition, to see a Graefe knife used to open the eye. My own first cataract removal in 1972 was an intracapsular extraction with no implant. At the end of 1978 I saw phacoemulsification and lens implantation as I joined Eric Arnott at Charing Cross Hospital in London. This changed my life in ophthalmology.

Also for the first time I became very aware that the capsule needed to be opened to remove the nucleus from the eye. When I did my first phaco in January 1979 I used the “Christmas tree” technique. That was the easy part; getting the nucleus to prolapse into the anterior chamber for emulsification was the most challenging. Very soon after this Eric and I started to use the “can opener” capsulotomy which gave better access to the nucleus and allowed posterior chamber or at least iris plane phaco.

STANDING OVATION

In 1986 at a meeting in Bordeaux, having performed my live surgery as had Charlie Kelman, we were sitting together in the audience when Jürgen Greite from Munich performed the Neuhann style capsulorhexis most beautifully. Not only were Charlie and I stunned, the whole audience was silenced until he finished. Then there was a standing ovation. This was going to change the way that phaco was performed but it did not happen overnight.

By the time EuroTimes was born 20 years ago, most surgeons were performing phacoemulsification. They may have been using a variety of techniques to break up the nucleus, but all used capsulorhexis, creating the capsular opening either with a needle or specially designed forceps like those of Peter Utrata.

This really where capsule matters stood until the late noughties when a new technology emerged for parts of the cataract procedure, the femtosecond laser. As has been stated elsewhere, Zoltan Nagy was the pioneer here who showed how perfectly round, consistently sized capsulotomies could be produced. The femtosecond laser could also make incisions and break up the nucleus all under optical coherence tomography or similar control. Although there was considerable initial excitement associated with femtosecond laser-assisted cataract surgery (FLACS) this has somewhat waned.

Cost has been a major issue and also there has as yet been no refractive outcome advantage demonstrated. There was significant agreement among FLACS users, however, that the most important function of the laser was to create the capsulotomy. So was it going to be possible to do this by other means?

As reported in the cover story, there are two new technologies which aim to do this. One, CAPSULaser, has the advantage of small size - it bolts on to the operating microscope. The other is a handheld thermal device, Zepto, which is applied to the capsule to create the capsulotomy. There are now intraocular lenses out there, Oculentis FEMTIS and Morcher ND, to take advantage of these developments. Time will tell whether outcomes will improve.