Microsoft Word - Editorial 26,1,10


 1

Editorial 
 

The on-Going Evolution in Cataract Surgery 
 
Charles Kelman (1930-2004), a Brooklyn New Yorker, 
introduced phacoemulsification in 1967 after being 
inspired by his dentist’s ultrasonic probe. No one at 
that time knew how this discovery would 
revolutionize cataract surgery in the times to come. 
One of the greatest advantages of this technique lies in 
the small size of the surgical wound. The race for the 
decreasing millimeters really took off soon after the 
popularisation of the technique especially with the 
introduction of foldable IOL’s at the end of the 1980’s. 

The surgical technique of phacoemulsification 
itself got evolved enormously as the surgeons gained 
experience since its modern inception. Excessive time 
was spent earlier on construction of scleral pockets 
and extra long tunnels to minimize surgically induced 
astigmatism only to be superceded by a gradual 
forward journey towards the limbus and then the clear 
cornea. The latter approach increased the incidence of 
intra-ocular infection compelling the more wary 
surgeons to retreat. The most favoured approach now 
is at the junction of anterior sclera with the posterior 
limbus which tends to have all the advantages of 
cornea as well as lesser astigmatism and higher degree 
of defence against endophthalmitis. The incision size 
has gone down to 2.2 mm in most of the cases which is 
astigmatically neutral. Micro coaxial phaco tip and the 
smart sleeve have all made it possible making even 
relatively newer bimanual phaco almost obsolete! 
Similarly the painstaking ‘sculpting’, ‘cracking’ and 
‘divide and conquer’ techniques have been largely 
replaced by the modern horizontal and vertical 
chopping thus cutting the surgical time to a fraction of 
what it was earlier. The father of chopping technique 
is undoubtedly Nagahara who first showed his video 
back in 1993. Shortly after, Akahoshi described his 
technique of karate pre-chop but it did not gain wide 
acceptance due to the potential risk of zonular stress. 

The real industrial revolution in the field of 
cataract surgery has been the development of IOL 
technology as well as modernization of the phaco 
equipment and its fluidics (cool phaco, ozil and most 
recently ozil intelligent phaco are just a few examples). 
The main force behind all that being the ever 
increasingly demanding patient to the extent that 

cataract surgery is now evolving into more and more 
of a refractive procedure with the aim of least or no 
dependence on the spectacles! 

Five of the most popular implantable lenses world 
wide are ReStor; ReZoom , Tecnis ZM900, Crystalens 
and Acrysof Toric. ReStor IOL uses a combination of 
an apodized diffractive and refractive lens to focus 
light. ReZoom has multifocal zones that focus light 
simultaneously. Crystalens implant is the first 
accommodating lens to be approved by the FDA. After 
implantation it moves by the tiny ciliary muscles to 
enhance the focusing ability thus best correcting vision 
for distance and intermediate distance. Some patients 
may still need to wear reading glasses but the need is 
greatly reduced. However concerns do remain about 
the long term performance (7 years experience so far), 
behavior in capsular bag phimosis/PCO scenario, and 
the cost. 

The first toric IOL approved by FDA was in 1998 
(Staar-plate haptic) and ever since the technology has 
matured enormously. The on-line lens power 
calculators have made the whole procedure very 
simplified and the results highly predictable; but 
having said that, none of the available IOL’s is perfect 
as there can be some halos and glare at night and dusk 
time with some of them. For example, ReZoom has 
good intermediate and distance vision but not as good 
near vision. Crystalens is very good with distance and 
intermediate vision but not as srong with near vision. 
It is also a bit more cumbersome to implant. The 
original ReStor +4.00 suffers a bit from weaker 
intermediate vision but is strong at distance and near. 
ReStor +3.00 has improved the intermediate power 
while not sacrificing its excellent distance and reading 
powers, and is on the aspheric platform to improve 
night driving as well. 

For those patients who do not mind wearing 
glasses for part of their visual activity, the quality of 
life is splendid after modern cataract surgery! The 
search for the ideal and the flawless goes-on! 
 
 

Prof. Nadeem Riaz