As I See It

A cut back in time

First residents trained in phaco show us history in the making.

By Paul S. Koch, MD, Editor Emeritus

Forty-two years ago, Joe Greco and Jim Schutz were among the first residents to learn a new operation, called “phakoemulsification.” They thought it might be helpful to write a paper describing the process and their early results. But one thing led to another and after a first draft, the paper was set aside, unfinished.

Recently Joe gave me a copy of what must be one of the earliest first-person narratives about learning “phako” in the early 1970s and gave me the okay to share it with our readers.

WHERE IT ALL BEGAN

The authors trained (as did I five years later) at the Manhattan Eye, Ear and Throat Hospital where Charlie Kelman had his animal laboratory. Charlie gave residents six 90-minute lectures, followed by several hours of watching videotapes of interesting or complicated cases.

Once the classroom work was completed, each resident performed surgery on three rabbit eyes and six cat eyes until surgical proficiency was established. The residents’ stereopsis was tested when each took a chance passing an electronically wired probe through a pair of wire circles. Touching one set off a very loud bell that “would ring to the chagrin of the surgeon … and the laughter of those observing.”

Next, the resident had to observe more than 20 cases. Then he could perform surgery — if supervised by one of five attendings who had already performed at least five cases. Back then it was see 20, do five, teach one.

Case selection conformed as closely as possible to several criteria, chief among them young patients with a soft lens, a widely dilating pupil and a deep anterior chamber. The 30 patients whose results were analyzed in the Greco-Schutz paper averaged 43 years old.

IN OLDEN DAYS …

The paper is littered with fascinating details. What we now call the phaco handpiece was called a “special irrigating-aspirating instrument.” The goal of the operation was to remove “the lens nucleus and virtually all of the cortex in most cases.” If the posterior capsule was not optically clear at the end of the operation then “a Zeigler knife discission of the posterior capsule was performed.”

In their first 30 cases there were eight ruptures of the posterior capsule and 11 primary discissions, seven of which had intact anterior vitreous faces.

COURTESY GOOGLE IMAGES

Most interesting for me are the questions the authors jotted in the margins, documenting for all time the controversies of the day. “What is the significance of an intact vitreous face?” “How important is the posterior capsule?” “Is phaco with a discission no better than an intracapsular extraction? “Is phaco with an anterior vitreous face broken worse than intracapsular with vitreous face intact?” “How does our eight of 30 cases of vitreous loss compare with our first cases of intracapsular extraction?”

I remember five years later debating the role of extracapsular surgery vs. intracapsular thusly, “Why leave in part of the cataract and let it grow back?” It is fun to reflect back and see how far we’ve come. Thank you, Joe, for sharing the manuscript, and Jim for assisting me on some of my early cases. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, R.I. His email is pskoch@clarisvision.com.