Twenty-five years of breathtaking innovations

I’m not sure whose idea it was to try and cram the 25 biggest innovations in 25 years into one issue, but we did! Seemed like a crazy idea to me. Also, a lot of work. It’s problematic of course. A top-25 innovation for one person isn’t for another. Plus, when did this or that development come in to play? Was it 20 years — 30 years ago?

But as someone who has been in practice for more than 33 years, I still remember quite well certain aspects from the last 25 years and thought I would take a stroll down memory lane.

BACK IN THE DAY

First of all, we had no OCTs back then. Today we utilize these tools many, many times every day in our office for retina. Yes, they also have a role in glaucoma, but they absolutely revolutionized our diagnosis and treatment of retinal diseases. I think we all agree that few of us can recognize early edema in diabetic retinopathy just with the slit lamp.

Of course, 25 years ago all we had available to treat diabetic retinopathy and wet AMD was laser. Laser did help diabetic retinopathy, especially the proliferative type, and still today has some value. But laser for wet AMD was awful. It only could be used for the minority having extrafoveal disease. Sure, you could stop subfoveal neovascular membranes with laser, but that also led to permanent loss of vision. Back then, almost all of our patients with wet AMD lost vision, and often lost it quickly. Today we can often actually improve vision.

My first cataract cases in private practice in 1988 were phacoemulsification, and even though we had to extend the wound to 6 mm to accommodate the PMMA implants, followed by suturing, it was still much better, I thought, than extracapsular surgery. But I was part of the only 10% of surgeons using phaco, and still remember criticism from other surgeons predicting it would someday lead to mass corneal decompensation. Thankfully, that never happened, and I know of no one arguing for going back.

Twenty-five years ago we used A-scans for biometry coupled with older formulas, hoping to get within a diopter or so of plano. Treating astigmatism wasn’t really discussed much. Who would have thought the surgery would become so accurate that we would be taking out clear lenses for refractive purposes?

And speaking of cataract surgery, for me maybe the most amazing advance that I now often take for granted is dropless cataract surgery. For nearly 4 years, we’ve had the best results ever by using subtenon’s Kenalog (triamcinolone acetonide injectable suspension, USP), intracameral antibiotics and Omidria (Omeros), which together negate any need for postop drops and have improved outcomes.

My head spins the more I think about all this. When I started, glaucoma patients had a choice of timolol, pilocarpine and oral acetazolamide. Argon laser trabeculoplasty was pretty new, and lots of our glaucoma patients ended up with guarded or full-thickness filtering surgeries. Newer medications and MIGS procedures have really changed that dynamic. Corneal transplants were pretty much full thickness. No DMEK back then. And RK was all the rage.

SO WORTH IT

Some docs wax nostalgic for the old days when reimbursements were higher, government intrusion was less and electronic medical records were on few people’s radar. But thinking about all the changes that this issue illustrates, I’d overwhelmingly rather practice in 2021 — COVID notwithstanding. OM

Larry E. Patterson, MD, is an instrument-rated private pilot. He is also the chief medical editor of Ophthalmology Management. On the side, he is the founding partner of Eye Centers of Tennessee. His e-mail is larryp@ecotn.com.