Cover Focus | Nov/Dec '17

So the Story Goes

Reflections on the trials and tribulations of breaking ground in ophthalmology.

CHARLES D. KELMAN, MD

"I did not have the vaguest idea of how to realize my idea."
(An excerpt from “The Genesis of Phacoemulsification,” published in CRST Europe1)

Four years after my residency, I drafted a grant proposal to study the effects of freezing on the ciliary body, retina, and choroid. I went to bed concerned that the Hartford Foundation would not find the topic of interest, awoke in the middle of the night, and, almost in a trance, added an addendum to my application that would affect the rest of my life and the lives of 100 million patients: “In addition to the freezing studies, this investigator will develop a method for removing a cataract through an incision small enough so that no hospitalization will be required.” Mr. E. Pierre Roy, the head of the John A. Hartford Foundation, could have easily rejected my application and put an end to this matter. Instead, he had confidence in my abilities and gave me a 3-year grant, although I did not have the vaguest idea of how to realize my idea.

Mr. Roy’s confidence was misplaced for 2 years and 8 months, while I tried everything I could imagine. I first attempted to capture the cataract within a folding lens bag, crush it inside the bag with manual disintegrators, and then remove the device containing the fragmented lens material from the eye. The rotating devices I tried simply spun the cataract around inside the anterior chamber. High-speed cutting needles, a miniature blender, drills, tiny meat grinders, engraving tools—nothing worked. All the devices yielded opaque corneas in animal eyes.

I had, meanwhile, allowed my hair to grow down to my shoulders, and my teeth badly needed a cleaning. Sitting in my dentist’s chair, I became interested in the ultrasonic tool he was using to clean my teeth. He explained that its high-frequency vibration removed tartar without disturbing the tooth itself. I raced out of his office with the bib still hanging around my neck and returned 1 hour later with a cataractous lens. Because I was able to engrave lines on the lens without it jumping off my finger, I believed that I could break up a cataract inside the eye without it spinning or vibrating against the corneal endothelium.

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Although I began teaching phacoemulsification in 1970 with the first commercially available machine, the profession vehemently protested the adoption of the technique. Most, if not all, surgeons at that time used only loupes for magnification. As a result, they had to learn to use an operating microscope as well as to perform phacoemulsification. Many politically important ophthalmologists were older and either unwilling or unable to learn these new modalities. The fact that I, the technique’s main proponent, was playing the saxophone and singing in the casinos of Atlantic City, New Jersey, and appearing on the Johnny Carson Show did not help the cause.

When I began performing phacoemulsification, no accurate way for measuring an eye’s endothelial cell count existed. Although patients’ corneas recovered, I am certain that the endothelial cell loss was unacceptable in early cases. If I had not been in the right place at the right time and had an obsessive motivation, I believe we would still be performing intracapsular cataract extraction. I thank my colleagues, supporters, and collaborators. I also thank my opposition for inspiring me to try harder.

Charles D. Kelman, MD, was the inventor of phacoemulsification, Clinical Professor of Ophthalmology at New York Medical College, and Attending Surgeon at the New York Eye and Ear Infirmary and Manhattan Eye, Ear, and Throat Hospital.

1. Kelman CD. The genesis of phacoemulsification. CRST Europe. September 2006.


LEE T. NORDAN, MD

"I fought hard for my point of view, taught my techniques to other members of the profession who were interested, and never knowingly had a lapse in integrity."
(An excerpt from “5 Questions with Lee T. Nordan, MD,” published in CRST1)

When I was a corneal fellow at the Jules Stein Eye Institute in Los Angeles in 1978, I attended a lecture by José Barraquer, MD, during which he showed a film of a surgery named keratomileusis. During the procedure, he removed the front half of the cornea, lathed the frozen corneal disc according to the dictates of a programmable calculator to correct myopia, and then sutured the tissue back in place. I thought that this intricate and innovative surgery was the natural solution to the problem of refractive error, and I knew immediately that I had found my calling. Instinctively, I was attracted to the mechanical precision of the surgery instead of fearing its complexity. No one had ingrained in my mind that eye surgery had to be simple! Yet, within a few months of performing keratomileusis in San Diego, my team had converted keratomileusis into a routine 15-minute procedure.

I followed in the giant footsteps of Dr. Barraquer and Thomas Pettit, MD, my corneal fellowship mentor, who taught me the art and substance of corneal lamellar surgery. Refractive surgery has become an important aspect of ophthalmic surgery because a small group of dedicated ophthalmologists fought for their dream by creative thinking and quality. Progress is difficult. Not all of the surgical techniques have stood the test of time, and frankly, a few of the refractive surgeons in the 1980s might not have had the best judgment.

I fought hard for my point of view, taught my techniques to other members of the profession who were interested, and never knowingly had a lapse in integrity within the profession or industry. I am proud of that record.

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The biggest surprise of my career was the slow adoption of better surgical techniques by the majority of eye surgeons. For example, Kelman phacoemulsification took roughly 20 years (1972-1992) to be adopted by a majority of surgeons. A significant minority of surgeons still does not correct 2.00 to 3.00 D of astigmatism during or after a phaco procedure. The goal of modern anterior segment surgery should be best uncorrected visual acuity for the patient. For at least 15 years, PRK has been used successfully as the most effective means of correcting mild irregular astigmatism and improving the quality of visual function. I am surprised that the majority of refractive surgeons still does not use PRK for this purpose.

Lee T. Nordan, MD, was an early advocate of refractive surgery, a cataract and corneal transplantation surgeon, and an Assistant Clinical Professor of Ophthalmology at the Jules Stein Eye Institute at the University of California, Los Angeles.

1. Nordan LT. 5 questions with Lee T. Nordan, MD. CRST. July 2011.


LUCIO BURATTO, MD

"An important speaker said he would ‘sit on the bank of the river waiting for all the blind eyes Buratto had treated with phaco."

I started doing phacoemulsification in 1978. I was a young doctor in private practice in Italy, where 95% of doctors were employed by hospitals or university clinics. I was continuously attacked because most eye doctors were against this procedure; they said that the scenario was apocalyptic and that the procedure brought irreparable damage to the cornea and high percentages of blindness in the short, medium, and long term.

To help readers understand the atmosphere, I will quote an episode at a congress where I was a speaker: An important professor said that he would “sit on the bank of the river waiting for all the blind eyes Buratto had treated with phaco.” The professor who had introduced me to ophthalmology insulted me about the “bad road” I had taken.

Additionally, the editor of a review asked me to write a booklet about phacoemulsification and posterior chamber IOLs; however, when it finally came time to publish it, he rejected it, saying “As a manager of the company, I need to work with everyone, and no one wants to have a book published on phacoemulsification.”

On October 25, 1989, I did the first keratomileusis operation with intrastromal ablation using an excimer laser (Summit Technology) for the treatment of high myopia on a seeing patient. This was the first case worldwide of so-called excimer laser intra stromal keratomileusis (now known as LASIK) performed on a seeing patient. I began treating cases using the laser on the back of a thick flap of more than 300 μm. A few weeks later, I had the idea of modifying the technique developed by Luis Antonio Ruiz, MD, namely performing the refractive cut in situ with the laser instead of the microkeratome. And that is how the lamellar techniques with the laser were born!

Countless improvements have been made to the technique over the years, and today the procedures are completely different than they were back then. However, it gives me great joy and satisfaction to know that I played an instrumental role in the evolution of refractive surgery. But I encountered many problems with my colleagues in Italy. At that time, refractive surgery was considered a malpractice for the whole category, not only in Italy, and I faced many threats and negative comments.

However, after having had so many problems previously with phaco, my shoulders were much stronger, and I continued using the excimer laser intrastromally on the back of a thick lamellar disc and in situ, but always without the hinge. I remember that there was an important congress in Rome at that time, and I received the task of managing a session on the correction of myopia and giving a presentation on the use of the excimer laser in keratomileusis. Strangely, the session was canceled …

Lucio Buratto, MD, is a pioneer in phacoemulsification and became the world’s first surgeon to use the excimer laser for intrastromal keratomileusis in 1989. He is currently in practice at Centro Ambrosiano di Microchirurgia Oculare, in Milan, Italy, and can be reached at iol.lasik@buratto.com.


MARGUERITE McDONALD, MD

"I wrote up the case but was castigated mercilessly in the ophthalmic publications."

After thousands of plastic eyes, then cadaver pig and cow eyes, then living rabbit eyes, then living monkey eyes, we (Dr. Steve Trokel, Dr. Charles Munnerlyn, and myself) moved on to the blind eye study in humans. I was part of the research team developing the excimer laser and was also the surgeon for the research team. Our first living patient was a unique situation: She had PRK in an eye scheduled for exenteration 11 days later. We watched her heal and obtained the postoperative specimen for histology.

One of our first patients in the blind-eye trial (eyes intended for long-term follow-up) had been declared blind in the eye by three prestigious institutions after a retinal detachment and a transphenoidal adenomectomy had left her with no light perception. Two surgeons had warned the patient preoperatively that she would probably be blind after PRK.

After we performed the procedure on this purportedly blind eye, the patient called me a few weeks afterward. “I can see!” she declared. I said that this was not possible. She said that she had been hit in that eye with a piece of birthday cake by her 4-year-old son and that, as she wiped the cream away, she could suddenly see. I told her to come into the clinic.

By chance—truly by chance, and randomly—we had done a PRK for the amount of myopia (approximately -4.50 D) that corresponded to the patient’s true refractive error. All of the other blind eyes had been assigned to a refractive correction that did not correspond to their refractive error. We were trying to cover a range of refractive errors.

When the patient came in with 20/20 uncorrected vision, I was both thrilled and terrified. I was actually nauseated as I examined her. She had a classic case of what Freud had described as hysterical blindness, ie, the two surgeons had told her she would likely go blind, so she did. I knew instantly what it would look like: that we had “hoodwinked” the FDA to get a clinical first of historical significance.

I wrote up the case but was castigated mercilessly in the ophthalmic publications. One of the most prominent names in ophthalmology wrote an editorial in a peer-reviewed journal, casting me as a liar and an opportunist of the worst sort. It was also a diatribe against refractive surgery. He was 60 years old and a god in ophthalmology; I was a 30-year-old woman in a southern state university with no reputation at all.

This editorial was read by everyone, and it scarred my soul. It haunted me for many years. Doctors would frequently mention it and would tease me for decades. It significantly affected my career, even though this patient’s findings were verified by other observers, as were the findings of the other first blind, partial-sighted, and sighted patients.

Not long after publishing this editorial, this doctor’s son died of cancer, and then he died as well. Much as he had negatively affected my career, I felt great sorrow for him and the anguish he must have felt about his son’s death and his own declining health in his last years. Regarding my excimer research, he had done what he thought was right at the time in writing his editorial. We all make mistakes during the course of our careers; it is inevitable. We must try to understand the other person’s point of view and roll with the punches when we get hit.

Marguerite McDonald, MD, performed the world’s first excimer laser treatment in 1987. She is a Clinical Professor of Ophthalmology at NYU Langone Medical Center, New York; Clinical Professor of Ophthalmology at Tulane University Health Sciences Center, New Orleans; and a cornea, cataract, and refractive surgeon at Ophthalmic Consultants of Long Island. Dr. McDonald can be reached at margueritemcdmd@aol.com.

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