Robert H. Osher, MD
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CHAPTER HIGHLIGHTS |
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When I was invited to write a brief closing chapter on the future of cataract surgery, I knew there would be inevitable advances that did not require a crystal ball to predict. The machines will get better, the incisions will get smaller, and the lenses will outperform even our wildest expectations! Having demonstrated my clairvoyance, this chapter could now be concluded, although I could also safely predict that another invitation to re-write this chapter in the future would never be forthcoming.
So let's begin our glimpse into the future by exploring patient qualifications necessary for cataract surgery. Virtually every person will become a candidate as refractive lens replacement becomes a birthright. Ironically, it is likely that cataract surgery will become an infrequent operation when the transparent crystalline lens is routinely removed for the correction of refractive errors. Spherical, cylindrical, and presbyopic “tune-ups” will become highly accurate, quick, and enormously successful procedures that will ultimately eliminate glasses and contact lenses. Similar to the economics of goods and services, satisfaction will rise but expensive pricing will decline. The biggest winner of all will be Medicare since the government will no longer foot the bill for millions of cataract surgeries each year. Hospitals will be the big losers as ophthalmologists continue to distance themselves from institutional medicine and the rest of the medical community.
In the near future, cataract removal and subsequently clear lens removal will be achieved through smaller and smaller incisions. Phaco-ersatz was a concept developed by Jean Marie Parel, Henry Gelender, MD, and Edward Norton, MD in the early 1980s whereby the lens content was removed through a tiny opening in the capsule and injectable material was used to reform the lens.[1] Okihiro Nishi, MD has continued this intriguing work in Japan while many surgeons have already embraced sleeveless bimanual micro phacoemulsification or microcoaxial phacoemulsification through incisions 2mm or less.[2] Amar Agarwal, MD and his colleagues from India were the first to crack the 1mm barrier with phaconit.[3] While phacoemulsification has withstood the test of time, 40 years is almost forever on the technology timeline. Innovations such as torsional ultrasound may improve efficiency but eventually alternative technologies for lens removal will emerge, introducing failsafe thermal and capsular protection. Virtual media textbooks will no longer contain chapters on the management of intraoperative complications. When the patient asks, what is the worst thing that can happen during surgery, the surgeon will be able to smile and respond, “For me to die … other than that, nothing!”
With respect to the future of intraocular lenses (IOLs), newer materials with preloaded injection devices will allow insertion through tiny incisions. Every lens will have the capability to correct all types of pre-existing refractive errors and higher-order aberrations. Technology will become available for confirming that the ideal intraocular lens has been implanted at the conclusion of surgery, also conquering the challenge of IOL accuracy in an epidemic of patients who have undergone previous refractive surgery. Should an inadvertent residual refractive error occur, adjustment of the lens will be possible, a concept introduced by Calhoun Vision with their proprietary method of changing the shape of the IOL by postoperative irradiation. It may be possible to incorporate electronic features into the lens that offer telescopic imaging at distance and macroscopic magnification at near. Moreover, the lens of the future will contain pharmacologic agents that empower the IOL with anti-inflammatory, antibiotic, hypotensive, and posterior capsule opacification-inhibiting characteristics. Frenchman, Gilbert Serpin, MD has already introduced an IOL that leaches out Diclofenac over a 15-day interval.[4] and Guy Kleinmann and colleagues have published preliminary results with a hydrophilic lens that delivers antibiotics.[5] Intracameral drug delivery will stimulate a variety of devices that will be used for glaucoma and other disorders. Since 1993, I have predicted that a CTR was a viable candidate to serve as a reservoir and drug-delivery system, which will cause present-day issues of penetration and compliance to vanish.
The IOL will become a vehicle capable of providing other solutions for ocular disease. There will be improved optical systems that will address the severe disability of age-related macular degeneration without compromising peripheral vision, and it is likely that pressure-sensing devices may be incorporated into the IOL design for continuous monitoring of the glaucoma patient. The lens may even serve to monitor blood sugar in diabetics and other chemistries like the creatinine and BUN in the patient with renal failure. I will volunteer to be the first with a “signature” IOL that will confirm my identity and allow me to pass quickly through the airport security lines!
I will offer one final word about the regulatory process in the future. Innovation in ophthalmology has been restrained by the US Food and Drug Administration, which has established nearly insurmountable hurdles that often keep new products and devices from gaining approval in a timely and affordable fashion. More than 11 years were required for the approval of the capsular tension ring since Robert Cionni, MD and I implanted the first rings in the United States in 1993. Kenneth Rosenthal, MD was the first American to implant the twin inter-digitating prosthetic iris devices in 1996 and I quickly followed with the full-size iris and the sector device manufactured by Morcher. Even though the prosthetic irides are the only effective method of reducing intolerable glare in patients with severe iris loss, these devices are still not approved in the USA. This is to our national shame.
At some point there will be an outcry from either the public or, more likely, the politicians in Washington that will expedite the review process and make it affordable for start-up companies to gain product approvals. Moreover, there will also be a backlash from the years and years of drastic cuts in the reimbursement from Medicare and from private carriers that have driven many of our more innovative physicians into other specialties where their ideas are financially rewarded. The industry will continue to consolidate since these severe reductions limit the dollars available for research and development. However, by sidestepping Medicare and the traditional payment systems, it is likely that the highly competent, refractive lens surgeon will be fairly compensated for his or her wonderful contribution to society. One final prediction is certain: the future for the compassionate and adaptable anterior-segment surgeon committed to excellence will continue to be exciting and enormously satisfying.
References
[1]. Parel J., Gelender H., Trefers W., et al: Phaco-Ersatz: Cataract surgery designed to preserve accommodation. Graefes Arch Clin Exp Ophthalmol 1986; 224:165-173.
[2]. Nishi O., Nishi K., Mano C., Ichihara M., Honda T.: Lens refilling with injectable silicone in rabbit eyes. J Cataract Refract Surg 1998; 24:975-982.
[3]. Agarwal A.: Microphakonit. In: Agarwal's A., ed. Phaco nightmares: conquering cataract catastrophes, Thorofare, NJ: Slack Inc, USA; 2007:395-405.
[4]. Serpin G.: Loaded IOL: a new anti-inflammatory delivery system. Vid J Cataract Refract Surg 2004; XX:
[5]. Kleinmann G., Apple D.J., Chew J., Hunter B., Stevens S., Larson S., et al: Hydrophilic acrylic intraocular lens as a drug-delivery system for fourth-generation fluoroquinolones. J Cataract Refract Surg 2006; 32:1717-1721.