#4: Phacoemulsification Technology in Cataract Surgery

The first phacoemulsification cataract surgery, performed nearly 50 years ago by Charles Kelman, MD, in New York, was a 4-hour procedure that resulted in endophthalmitis and phthisis in a blind patient. Fortunately, Kelman, who is often remembered as the “father of phaco”, persisted with this new procedure, refining his technique and improving patient outcomes.

As with most new procedures, phacoemulsification took time to catch on among the surgical community. A 1984 survey showed that it was being used in less than 10% of all cataract surgeries, as extracapsular cataract extraction (ECCE) remained the dominant procedure due in part to the rigid nature of that era’s intraocular lenses (IOLs). At the time, experts predicted that there was little potential for growth in phaco procedures. In fact, even the most optimistic visionary expected phaco would be used in only 25% of all cataract surgeries.

How wrong those “visionaries” turned out to be. While new surgical techniques, including capsulorhexis, made the phaco procedure more reliable, it wasn’t until the introduction of the foldable IOL in 1989 that surgeons could take advantage of the smaller incisions made possible by phaco procedures. By 1990, phaco was being used in approximately 50% of all cataract surgeries. Five years later, ECCE had become nearly obsolete.

In the last 25 years, a number of key advances such as refinements in ultrasound systems, microsurgical incisions, and new hardware/software have given surgeons a variety of power options, better control of fluidics, and improved chamber stability. Kelman’s initial 4-hour procedure can now be completed in a matter of seconds.

Dense cataract image acquired with a Heidelberg Engineering swept-source OCT-based Cataract and Refractive Imaging Platform (in development, not available for sale).Prior to and following phaco procedures, optical coherence tomography is typically used to determine central macular thickness (CMT) at various time points, and to assess the link between CMT changes and surgical and biometric parameters.

How phacoemulsification procedures survive and evolve as the market for femtosecond laser continues to grow is a key question for the near future. Many surgeons today combine the use of a femtosecond laser and phaco (femtophaco) during cataract surgery, providing them with a piece of old technology to use with the new.