- Email: [email protected]
Phaco-Emulsification and Aspiration
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FUNDUS FLAVIMACULATUS
riers: Possible genetic implications. Invest. Ophth. 2:107, 1964. 18. Krill, A. E. and Lee, G. B. : The electroretinogram in albinos and carriers of the ocular al bino trait. Arch. Ophth. 69:32, 1963. 19. Krill, A. E. : The electroretinographic and electrcoculographic findings in patients with macular lesions. Tr. Am. Acad. Ophth. Otolaryn 70:1063,1966.
23
20. : Unpublished observations. . 21. Krill, A. E, Morse, P. A., Potts, A. M. and Klien, B. A.: Hereditary vitelliruptive macular degeneration. Am. J. Ophth. 61:1405, 1966. 22. Norton, E. W. D., Gass, J. D., Smith, J. L., Curtin, V. T., David, N. J. and Justice, J., Jr.: Symposium: Macular diseases diagnosis. Fluorescein in the study of macular disease. Tr. Am. Acad. Ophth. Otolaryn. 69:631, 1965.
PHACO-EMULSIFICATION AND ASPIRATION A NEW TECHNIQUE OF CATARACT REMOVAL A PRELIMINARY REPORT CHARLES D. KELMAN,
M.D.
New York This paper describes a method of dissolv ing, emulsifying and aspirating a mature cataract through a two to three mm incision. Until now, only congenital cataracts could be aspirated because of the semifluid con sistency of the lens. For the past four years, I have concerned myself with the possibility of transforming the mature cataract into a solution or an emulsion, thereby making as piration possible. The methods which come to mind for dis solving or emulsifying a cataract are chemi cal (enzymatic) and mechanical. Although the enzymatic approach holds some promise, and although I am continuing investigation along these lines, the possibility of finding an agent which will dissolve the lens with out affecting other structures of the eye seems remote at this time. The mechanical approach lends itself more easily, at present, to experimentation. Various types of microdrills, microburrs and microblenders (simi lar to the Waring blender) have been de veloped and evaluated but are considered to be either too ineffective, too dangerous, or From the Cryo-Research Department, Manhat tan Eye, Ear and Throat Hospital. The canine surgery was performed at New York Medical Col lege. This investigation is supported by a grant from the John A. Hartford Foundation.
unworkable. The most promising approach, and the one I have used successfully in ani mals and on human cadaver eyes, is the phaco-emulsification of a lens, using a low frequency (sonic-ultrasonic) needle com bined with controlled irrigation and suc tion.* In this preliminary paper, the technical specifications of the instruments will not be discussed because they are being constantly changed in an effort to find a combination of optimum size, stroke and frequency. The working tip consists of the following (fig. 1 ) : 1. A central needle with an outside diam eter of approximately one mm and with a very slightly tapered point. 2. A protective outer jacket made of Tef lon. 3. A flow of water between the outer wall of the needle and the protective sheath. 4. Suction in the interior of the needle. The use of an operating microscope is mandatory. The needle is made of titanium and certain other inert superhard alloys to withstand the acceleration and deceleration without fragmenting. The tip is connected to * The phaco-emulsifier was developed in con junction with Cavitron Corporation.
24
AMERICAN JOURNAL OF OPHTHALMOLOGY
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Suction,
Amplitude of Movement Fig. 1 (Kelman). Schematic cross section of sonic-ultrasonic tip.
a hand-held ultrasonic transducer which is controlled by a foot switch. The suction is independently controlled by a second foot switch. The water flowing between the nee dle and the protective sheath is constant at a given rate and its pressure level is con trolled so as not to exceed 25 mm Hg. The outflow of fluid and lens material is through the center of the ultrasonic needle, and a bypass valve allows fluid to leave the eye whether or not the suction is activated. Irrigating solution. Baxter solution or ar tificial aqueous solution is chilled in a special sterile container and flows along sterile plastic tubes to the instrument. Thermocouple and automatic cutoff. A thermocouple is embedded in the protective
sheath of the tip and is connected to an automatic shut-off valve. This is necessary because, if the water flow should cease, the temperature at the tip would rise. Aspiration. A roller type suction pump is being used at present to provide a con stant, measured amount of fluid withdrawal from the eye, as well as instantaneous cutoff. The surgical technique was developed us ing the eyes of more than 200 cadavers, 40 cats and 30 dogs. A well-dilated pupil is es sential to the success of the procedure. A subconjunctival injection of Cyclogyl and 1: 1000 adrenalin one-half hour before and again immediately preceding surgery is recommended. If the pupil should begin to constrict during the procedure, instillation
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of 1: 1000 adrenalin into the anterior cham ber is usually effective. A shelved incision of two to three mm is made at the limbus (fig. 2). Aqueous is allowed to escape from the chamber by holding the lips of the incision apart with a spatula. If aqueous does not flow freely, a small air injection needle can be used to aspirate the aqueous. Air is injected into the anterior chamber so as to reform it completely and expose the anterior surface of the lens to the air. The remainder of the procedure must be performed using an operating microscope at a true magnification of 6 and 8 times. A von Graefe type cystotome knife, which has been purposely dulled except at the tip, is passed into the eye across the lens to en gage the capsule at a point opposite the in-
25
Fig. 4 (Kelman). V-shaped incision made by withdrawing cystotome.
Fig. S (Kelman). Edge of anterior capsule grasped with special forceps. Fig. 2 (Kelman). Shelved two to three mm incision at limbus.
Fig. 3 (Kelman). Cystotome engages capsule. Air fills anterior chamber.
cision (fig. 3). The cystotome is then pressed onto the lens and withdrawn toward the in cision, pulling with it a large V-shaped por tion of capsule (fig. 4 ) . The cystotome is then withdrawn from the eye. A special wire closure capsule forceps (fig. 5) is passed into the eye and the free edge of the capsule is grasped and withdrawn (fig. 6 ) . Without exerting undue traction on the capsule (so as not to rupture the zonules adjacent to the incision), the surgeon holds the capsule while the assistant cuts it flush with the eye ( % 7). A specially designed retractable loop is inserted into the lens posterior to the nu cleus in the closed position (fig. 8) and then opened (fig. 9 ) . The nucleus and part of the
26
AMERICAN JOURNAL OF OPHTHALMOLOGY
JULY, 1967
Fig. 6 (Kelman). V-capsule withdrawn.
waits until the temperature of the irrigating fluid within the eye is 10°C or lower. At this point, the suction apparatus is activated with the foot switch. A certain amount of cortical material will now be aspirated (fig. 11). When no further cortical material is being removed from the eye, short bursts of energy are given to the needle with the foot switch to emulsify the remainder of the nu cleus and cortical material while, at the same time, aspirating it from the eye (figs. 12 and 13).
Fig. 7 (Kelman). Capsule cut flush with cornea.
cortex is then gently maneuvered out of the capsule. Care must be taken not to rub the lens material against the endothelium of the cornea. The retractable loop is now closed and removed from the eye and the phacoemulsifier is introduced into the anterior chamber so that it touches the lens (fig. 10). Chilled irrigating fluid is now allowed to flow slowly into the eye and the surgeon
Fig. 8 (Kelman). Retractable loop (closed) placed behind nucleus.
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PHACO-EMULSIFICATION AND ASPIRATION
After several minutes, the lens material anterior to the capsule will be completely re moved (fig. 14). There may be remnants of cortex in the folds of the capsule (fig. 15). The phaco-emulsifier is removed from the eye and a blunt, rounded aspirator is passed into the anterior chamber and into the recess between the anterior and posterior capsule (fig. 16). The suction is used to withdraw the material from the recess and allow it to emerge anterior to the capsule (fig. 17). It will not be possible to place this aspirator into the folds immediately subjacent to the incision but, because the capsular incision is the widest at this point, the likelihood of lens material being trapped here is small and, even if there should be lens material, it will be dealt with further on in the pro cedure. The blunt aspirator is removed from the anterior chamber and the phaco-emulsifier is again placed in the eye and with aspiration only, the remainder of the material is re moved (fig. 18). If the tip becomes blocked, or if the remaining particles are too solid to pass into the needle, short bursts of energy
Fig. 9 (Kelman). Retractable loop (open) maneu vers lens out of capsule.
27
Fig. 10 (Kelman). Phaco-emulsifier placed.
are given to emulsify the remaining parti cles, making aspiration possible. In the animal eye, the posterior lens cap sule is attached to the vitreous. Removing the remainder of the capsule in these eyes always causes hyaloid rupture with loss of vitreous. In animal eyes, therefore, it is ad visable to terminate the procedure at this point and place a corneoscleral suture (fig. 19) ; the lids are sutured shut to prevent clawing at the eye. In human eyes, the capsule may be com pletely removed in the following manner: A 1: 5000 solution of alpha chymotrypsin is placed between the remnants of the an terior capsule and the iris (fig. 20). Imme diately after withdrawing the needle, air is used to refill the chamber to recreate the tension on the zonules which allows maxi mum effect of the enzyme (fig. 21). After three minutes, the anterior chamber is washed and the anterior capsule is grasped at a point subjacent to the incision with the special capsule forceps (fig. 22). This part of the capsule is drawn toward the center of the pupil, releasing the zonules closest to the incision (fig. 23). The jaws of the capsule forceps are now opened and the forceps is passed to the opposite edge of the capsule (fig. 24). The anterior capsule is grasped at this point and withdrawn back toward the incision, bringing with it the entire poste rior capsule and remains of the anterior cap-
28
AMERICAN JOURNAL OF OPHTHALMOLOGY
JULY, 1967
Figs. 11, 12, 13 and 14 (Kelman). Use of controlled suction, irrigation and bursts of energy.
Fig. 15 (Kelman). Remnants of cortex in capsule fornices.
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PHACO-EMULSIFICATION AND ASPIRATION
sule (fig. 25). No attempt should be made to grasp the posterior capsule directly. At this point, air is again injected into the ante rior chamber and under high-power magni fication (10 times) the face of the vitreous is studied to ascertain that no capsule re mains. Gentle irrigation may be used to re move small particles of lens material, but once the posterior capsule is removed, the phaco-emulsifier must not be employed. At this point, the lens has been removed with its capsule through a two to three mm incision, which, being shelved, will be healed within a couple of days. Figures 26 through 31 show the removal of a cataract from a dog.
29
Fig. 18 (Kelman). Phaco-emulsifier aspirates remaining material.
Fig. 19 (Kelman). Suture placed (animal). Fig. 16 (Kelman). Aspirator fixes remnants.
RESULTS I. CATS
*&£? Fig. 17 (Kelman). Lens remnants brought to center of pupil.
At this stage of development of phacoemulsification, a statistical evaluation is not possible, primarily because each procedure was different from the other. Changes were being incorporated in the instrument, tech nique and method of procedure in a con stant effort to improve the results. The ani mals in the early series had many more complications than those of the middle series and the animals most recently operated on had few or no complications. At two days postoperative, these eyes appeared quieter and less irritated than a patient's eye with a healing 180-degree incision at three to four weeks. Mature cats were used. Although
30
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 20 (Kelman). Alpha chymotrypsin placed (human). their lenses were not cataractous, they were extremely hard, tenacious and fairly similar in consistency to human cataracts. Under no circumstance, could these lenses be re moved by simple aspiration. The last four cat eyes in which this procedure was per formed had no complications. In those ani mals on which bilateral procedures were done, vision is apparently excellent. Histo logie slides of animal eyes with no compli cations during surgery showed normal ret ina, ciliary body and cornea. A mild iritis was present in some of these eyes owing to the inability to remove the capsule because of its attachment to the vitreous, as mentioned previously. The surgical complications seen in the earlier cases were: 1. Complete corneal opacification. This was the most serious immediate problem and was a difficult one to solve because of
JULY, 1967
the many factors which can provoke opacification. Some of the factors which caused cor neal clouding in the early cases were: a. Excessive heat buildup in the eye. Once this problem was recognized, it was easily solved by using a sufficient quantity of chilled irrigating solution to remove the heat. b. Excessive manipulation of the lens against the corneal endothelium. In the early attempts to maneuver the hard cat lens into the anterior chamber, the lens was inadver tantly rubbed against the endothelium after the capsule had been opened. It appears that, when the lens material is rubbed on the endothelium, it is either toxic to the endothe lium or the mechanical trauma causes loss of sufficient endothelium to produce a per manent corneal opacity. This problem, once recognized, was solved in cats by not at-
Fig. 22 (Kelman). Anterior capsule margin grasped.
Fig. 21 (Kelman). Air injected to refill anterior chamber.
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PHACO-EMULSIFICATION AND ASPIRATION
tempting to bring the lens into the anterior chamber until a portion of the lens had been emulsified and aspirated. It should be mentioned, however, that the cat or dog lens has almost four times the volume of the human lens and that this problem will prob ably be less important in human surgery. c. External massage. In the early cases, remnants of lens in the folds of the capsule were brought to the central portion of the cornea by external massage of the peripheral margins of the cornea with a muscle hook. Again,, the corneal endothelium was being subjected to trauma by the pressure of the muscle; hook against the lens material. d. Excessive amplitude of vibration. It is important in this technique that the ultra-
Fig. 23 (Kelman). Traction toward center of pupil.
Fig. 25 (Kelman). Capsule extraction.
31
Fig. 24 (Kelman). Opposite edge grasped. sonic energy be localized to the tip of the instrument and not transmitted to other por tions of the eye. In the early series of opera tions, performed almost two years ago, a much larger amplitude was used. It would appear that this in itself was enough to cause corneal clouding. 2. Iris atrophy. In the animal eye, an iridectomy is difficult because of the pres ence of a large blood vessel at the root of the iris. Attempts to cauterize this blood vessel are rather ineffectual and hemorrhage often occurs during and following surgery if an iridectomy is attempted. For this rea son, unless pupillary dilation is maximal, a portion of the iris adjacent to the incision
32
AMERICAN JOURNAL OF OPHTHALMOLOGY
is subjected to the action of the instrument tip. With proper dilation of the iris or a sector iridectomy (in humans), the compli cation of iris inflammation and degenera tion at the point of incision is eliminated. 3. Vitreous loss. Perhaps the most serious surgical complication, to be avoided at all costs, is perforation of the posterior capsule with the phaco-emulsifier. Once this happens there is little recourse but to complete the incision to 180 degrees and extract the lens with an efficient cryoextractor. To continue with the phaco-emulsifier on a lens mixed with vitreous will lead to uncontrollable iridocyclitis. For this reason, in the later series, the lens mass was brought forward into the anterior chamber to minimize the possibility of touching the posterior capsule with the phaco-emulsifier. In animals, as mentioned before, vitreous loss is inevitable if, after the lens is extracted, an attempt is made to remove the posterior capsule. 4. Secondary cataracts. In the last four cases, there were no secondary cataracts be cause the efficiency of the instrument was improved, as was the technique. In earlier cases, there were several secondary cataracts with pigment proliferation across the mem brane, due to retained lens material and es pecially to retained anterior capsule. 5. Fibrinous exudate in the anterior cham ber. When operating on cats, dogs and rab bits, no matter what the procedure, one ex pects a fibrinous exudate in the anterior chamber following surgery. This can be eliminated by the use of heparin in the ir rigating solution. Figure 32 shows a cat eye following phaco-emulsification and aspiration. The cornea is clear, the iris is normal, and ophthalmoscopic examination shows a normal fundus. Both eyes were operated on in the same manner and the cat runs, climbs, jumps and walks normally. II.
JULY, 1967
not operated on until a year's experience was obtained with cats and therefore the complications were much fewer and less serious than in the early group of cats. Sev eral dog cataracts were also operated on suc cessfully by this technique. III.
H U M A N CATARACTOUS LENSES
Approximately 300 cataractous lenses re moved by conventional techniques in sur gery were subjected to phaco-emulsification in vitro. Although some of the lenses were almost bone hard, they all were emulsified and aspirated on a piece of gauze with the phaco-emulsifier. Figure 33 shows an ex ceptionally hard cataract which has been channeled and burrowed into with the phacoemulsifier, without fixing the lens but merely placing it on a piece of moist paper and ap plying the phaco-emulsifier to it. The lens is held against the phaco-emulsifier by means of suction. IV.
CADAVER EYES
Because the cadaver eyes, which I could obtain, had edematous corneas and because the iris could not be dilated, the procedure was imitated by completely removing the cornea and cutting the iris away to its root
DOGS
The mature dog lens is similar to the cat lens, that is, hard and sticky. Dog eyes were
Fig. 33 (Kelman). Hard senile cataract burrowed with phaco-emulsifier
Figs. 26-31 (Kelman). Phaco-emulsification and aspiration, a new technique of cataract removal. Fig. 26. Cystotome enters anterior chamber through two-mm shelved incision. Air fills anterior chamber. Pupil well dilated. Fig. 27. Cystotome engages capsule of lens at a point opposite the incision. Fig. 28. V-shaped opening made in capsule. Cystotome withdraws capsule from the chamber and the capsule is cut (not shown). Fig. 29. Phaco-emulsifler
introduced
into lens mass. Irrigation, sonic-ultrasonic energy and aspiration are employed.
Fig. 30. Sharp edges of lens material demonstrate solid nature of cataract. Teflon sleeve protects cornea. Lens half rem< n four minutes. Fig. 31. Lens completely removed except for posterior capsule in six minutes. One suture placed.
Figs. 32 and 34-38 (Kelman). Phaco-emunification end aspiration, a new technique of cataract removal. Fig. 32. Aphakic cat eye four days postoperative. Fig. 31. Cvstotome engages capsule and makes V-opening. Fig. 35. Phaco-emulsification and aspiration. Fig. 36. All cortex and nucleus removed. Fig. 37. Alpha chymotrypsin introduced. V-opening apparent. Fig. 38. Removal of capsule.
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PHACO-EMULSIFICATION AND ASPIRATION
to simulate a dilated pupil. The procedure is identical to that described for the animal. The cystotome, passed across the anterior capsule, cuts a V-shaped portion of the capsule away (fig. 34). The phaco-emulsifier removes all of the lens material (figs. 35 and 36). The lips of the anterior capsule are easily noted. Alpha chymotrypsin is in stilled (fig. 37) and the remainder of the anterior capsule, along with the posterior capsule, is easily withdrawn (fig. 38). SUMMARY
AND
CONCLUSION
A technique for emulsifying and aspirat ing a hard, senile-type cataract through a two to three mm incision is described. This procedure would shorten recuperation, mini mize hospitalization and give almost imme diate rehabilitation. At this date, preparations are being made to remove cataracts from
35
certain volunteer patients who have little or no function of the retina. If there are no complications, the technique will be em ployed on more useful eyes with cataracts. A subsequent report will give the details of the instrument and the results of phacoemulsification in humans, as well as an opin ion on the validity of this technique. ADDENDUM
Since the preparation of this manuscript, this technique of cataract removal was per formed on two patients with blind eyes, dem onstrating the eventual feasibility of phacoemulsification. 215 East 64th Street (10021). ACKNOWLEDGMENT
I wish to thank Mr. Otto Richter, Miss Cheryl Chase and Mr. Anton Banko for their willing as sistance and encouragement on this project.
OCULAR LESIONS IN RELAPSING POLYCHONDRITIS AND O T H E R R H E U M A T O I D SYNDROMES T H E EDWARD JACKSON MEMORIAL LECTURE BANKS ANDERSON, SR.,
M.D.
Durham, North Carolina
Edward Jackson, born in 1856, was grad uated from Union College in 1874 with a B.S. degree in civil engineering. Four years later he was awarded the M.D. degree by the University of Pennsylvania. His first paper appeared in 1882, his last of more than 600 publications in 1926. He died 16 years later, at the age of 87 years. His prolific pen attests to his wide ranging and continuous concern with the problems of ophthalmology. His paper on "The theory and technique of skiascopy" introduced to American ophthalmologists this valuable ad junct to refraction. His papers recom mending the use of the cross cylinder in de termining the degree and axis of astigmaFrom the Department of Ophthalmology, Duke University Medical Center.
tism were largely responsible for the accep tance of this method in this country. These solid and time-tested contributions are over shadowed by his influence on the postgradduate training of ophthalmologists. He or ganized the first course in postgraduate edu cation. He was one of the founders and for many years chairman of the American Board of Ophthalmology. He was largely responsible for bringing into one organiza tion a group of ophthalmic publications that became the AMERICAN JOURNAL OF O P H THALMOLOGY, which he served as editor-inchief for many years. In the area of refrac tion, in postgraduate teaching, and in bed time reading the impact of this man per sists long beyond his time. So it is that one cannot be insensitive of the privilege of
FUNDUS FLAVIMACULATUS
riers: Possible genetic implications. Invest. Ophth. 2:107, 1964. 18. Krill, A. E. and Lee, G. B. : The electroretinogram in albinos and carriers of the ocular al bino trait. Arch. Ophth. 69:32, 1963. 19. Krill, A. E. : The electroretinographic and electrcoculographic findings in patients with macular lesions. Tr. Am. Acad. Ophth. Otolaryn 70:1063,1966.
23
20. : Unpublished observations. . 21. Krill, A. E, Morse, P. A., Potts, A. M. and Klien, B. A.: Hereditary vitelliruptive macular degeneration. Am. J. Ophth. 61:1405, 1966. 22. Norton, E. W. D., Gass, J. D., Smith, J. L., Curtin, V. T., David, N. J. and Justice, J., Jr.: Symposium: Macular diseases diagnosis. Fluorescein in the study of macular disease. Tr. Am. Acad. Ophth. Otolaryn. 69:631, 1965.
PHACO-EMULSIFICATION AND ASPIRATION A NEW TECHNIQUE OF CATARACT REMOVAL A PRELIMINARY REPORT CHARLES D. KELMAN,
M.D.
New York This paper describes a method of dissolv ing, emulsifying and aspirating a mature cataract through a two to three mm incision. Until now, only congenital cataracts could be aspirated because of the semifluid con sistency of the lens. For the past four years, I have concerned myself with the possibility of transforming the mature cataract into a solution or an emulsion, thereby making as piration possible. The methods which come to mind for dis solving or emulsifying a cataract are chemi cal (enzymatic) and mechanical. Although the enzymatic approach holds some promise, and although I am continuing investigation along these lines, the possibility of finding an agent which will dissolve the lens with out affecting other structures of the eye seems remote at this time. The mechanical approach lends itself more easily, at present, to experimentation. Various types of microdrills, microburrs and microblenders (simi lar to the Waring blender) have been de veloped and evaluated but are considered to be either too ineffective, too dangerous, or From the Cryo-Research Department, Manhat tan Eye, Ear and Throat Hospital. The canine surgery was performed at New York Medical Col lege. This investigation is supported by a grant from the John A. Hartford Foundation.
unworkable. The most promising approach, and the one I have used successfully in ani mals and on human cadaver eyes, is the phaco-emulsification of a lens, using a low frequency (sonic-ultrasonic) needle com bined with controlled irrigation and suc tion.* In this preliminary paper, the technical specifications of the instruments will not be discussed because they are being constantly changed in an effort to find a combination of optimum size, stroke and frequency. The working tip consists of the following (fig. 1 ) : 1. A central needle with an outside diam eter of approximately one mm and with a very slightly tapered point. 2. A protective outer jacket made of Tef lon. 3. A flow of water between the outer wall of the needle and the protective sheath. 4. Suction in the interior of the needle. The use of an operating microscope is mandatory. The needle is made of titanium and certain other inert superhard alloys to withstand the acceleration and deceleration without fragmenting. The tip is connected to * The phaco-emulsifier was developed in con junction with Cavitron Corporation.
24
AMERICAN JOURNAL OF OPHTHALMOLOGY
JULY, 1967
Suction,
Amplitude of Movement Fig. 1 (Kelman). Schematic cross section of sonic-ultrasonic tip.
a hand-held ultrasonic transducer which is controlled by a foot switch. The suction is independently controlled by a second foot switch. The water flowing between the nee dle and the protective sheath is constant at a given rate and its pressure level is con trolled so as not to exceed 25 mm Hg. The outflow of fluid and lens material is through the center of the ultrasonic needle, and a bypass valve allows fluid to leave the eye whether or not the suction is activated. Irrigating solution. Baxter solution or ar tificial aqueous solution is chilled in a special sterile container and flows along sterile plastic tubes to the instrument. Thermocouple and automatic cutoff. A thermocouple is embedded in the protective
sheath of the tip and is connected to an automatic shut-off valve. This is necessary because, if the water flow should cease, the temperature at the tip would rise. Aspiration. A roller type suction pump is being used at present to provide a con stant, measured amount of fluid withdrawal from the eye, as well as instantaneous cutoff. The surgical technique was developed us ing the eyes of more than 200 cadavers, 40 cats and 30 dogs. A well-dilated pupil is es sential to the success of the procedure. A subconjunctival injection of Cyclogyl and 1: 1000 adrenalin one-half hour before and again immediately preceding surgery is recommended. If the pupil should begin to constrict during the procedure, instillation
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of 1: 1000 adrenalin into the anterior cham ber is usually effective. A shelved incision of two to three mm is made at the limbus (fig. 2). Aqueous is allowed to escape from the chamber by holding the lips of the incision apart with a spatula. If aqueous does not flow freely, a small air injection needle can be used to aspirate the aqueous. Air is injected into the anterior chamber so as to reform it completely and expose the anterior surface of the lens to the air. The remainder of the procedure must be performed using an operating microscope at a true magnification of 6 and 8 times. A von Graefe type cystotome knife, which has been purposely dulled except at the tip, is passed into the eye across the lens to en gage the capsule at a point opposite the in-
25
Fig. 4 (Kelman). V-shaped incision made by withdrawing cystotome.
Fig. S (Kelman). Edge of anterior capsule grasped with special forceps. Fig. 2 (Kelman). Shelved two to three mm incision at limbus.
Fig. 3 (Kelman). Cystotome engages capsule. Air fills anterior chamber.
cision (fig. 3). The cystotome is then pressed onto the lens and withdrawn toward the in cision, pulling with it a large V-shaped por tion of capsule (fig. 4 ) . The cystotome is then withdrawn from the eye. A special wire closure capsule forceps (fig. 5) is passed into the eye and the free edge of the capsule is grasped and withdrawn (fig. 6 ) . Without exerting undue traction on the capsule (so as not to rupture the zonules adjacent to the incision), the surgeon holds the capsule while the assistant cuts it flush with the eye ( % 7). A specially designed retractable loop is inserted into the lens posterior to the nu cleus in the closed position (fig. 8) and then opened (fig. 9 ) . The nucleus and part of the
26
AMERICAN JOURNAL OF OPHTHALMOLOGY
JULY, 1967
Fig. 6 (Kelman). V-capsule withdrawn.
waits until the temperature of the irrigating fluid within the eye is 10°C or lower. At this point, the suction apparatus is activated with the foot switch. A certain amount of cortical material will now be aspirated (fig. 11). When no further cortical material is being removed from the eye, short bursts of energy are given to the needle with the foot switch to emulsify the remainder of the nu cleus and cortical material while, at the same time, aspirating it from the eye (figs. 12 and 13).
Fig. 7 (Kelman). Capsule cut flush with cornea.
cortex is then gently maneuvered out of the capsule. Care must be taken not to rub the lens material against the endothelium of the cornea. The retractable loop is now closed and removed from the eye and the phacoemulsifier is introduced into the anterior chamber so that it touches the lens (fig. 10). Chilled irrigating fluid is now allowed to flow slowly into the eye and the surgeon
Fig. 8 (Kelman). Retractable loop (closed) placed behind nucleus.
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After several minutes, the lens material anterior to the capsule will be completely re moved (fig. 14). There may be remnants of cortex in the folds of the capsule (fig. 15). The phaco-emulsifier is removed from the eye and a blunt, rounded aspirator is passed into the anterior chamber and into the recess between the anterior and posterior capsule (fig. 16). The suction is used to withdraw the material from the recess and allow it to emerge anterior to the capsule (fig. 17). It will not be possible to place this aspirator into the folds immediately subjacent to the incision but, because the capsular incision is the widest at this point, the likelihood of lens material being trapped here is small and, even if there should be lens material, it will be dealt with further on in the pro cedure. The blunt aspirator is removed from the anterior chamber and the phaco-emulsifier is again placed in the eye and with aspiration only, the remainder of the material is re moved (fig. 18). If the tip becomes blocked, or if the remaining particles are too solid to pass into the needle, short bursts of energy
Fig. 9 (Kelman). Retractable loop (open) maneu vers lens out of capsule.
27
Fig. 10 (Kelman). Phaco-emulsifier placed.
are given to emulsify the remaining parti cles, making aspiration possible. In the animal eye, the posterior lens cap sule is attached to the vitreous. Removing the remainder of the capsule in these eyes always causes hyaloid rupture with loss of vitreous. In animal eyes, therefore, it is ad visable to terminate the procedure at this point and place a corneoscleral suture (fig. 19) ; the lids are sutured shut to prevent clawing at the eye. In human eyes, the capsule may be com pletely removed in the following manner: A 1: 5000 solution of alpha chymotrypsin is placed between the remnants of the an terior capsule and the iris (fig. 20). Imme diately after withdrawing the needle, air is used to refill the chamber to recreate the tension on the zonules which allows maxi mum effect of the enzyme (fig. 21). After three minutes, the anterior chamber is washed and the anterior capsule is grasped at a point subjacent to the incision with the special capsule forceps (fig. 22). This part of the capsule is drawn toward the center of the pupil, releasing the zonules closest to the incision (fig. 23). The jaws of the capsule forceps are now opened and the forceps is passed to the opposite edge of the capsule (fig. 24). The anterior capsule is grasped at this point and withdrawn back toward the incision, bringing with it the entire poste rior capsule and remains of the anterior cap-
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JULY, 1967
Figs. 11, 12, 13 and 14 (Kelman). Use of controlled suction, irrigation and bursts of energy.
Fig. 15 (Kelman). Remnants of cortex in capsule fornices.
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sule (fig. 25). No attempt should be made to grasp the posterior capsule directly. At this point, air is again injected into the ante rior chamber and under high-power magni fication (10 times) the face of the vitreous is studied to ascertain that no capsule re mains. Gentle irrigation may be used to re move small particles of lens material, but once the posterior capsule is removed, the phaco-emulsifier must not be employed. At this point, the lens has been removed with its capsule through a two to three mm incision, which, being shelved, will be healed within a couple of days. Figures 26 through 31 show the removal of a cataract from a dog.
29
Fig. 18 (Kelman). Phaco-emulsifier aspirates remaining material.
Fig. 19 (Kelman). Suture placed (animal). Fig. 16 (Kelman). Aspirator fixes remnants.
RESULTS I. CATS
*&£? Fig. 17 (Kelman). Lens remnants brought to center of pupil.
At this stage of development of phacoemulsification, a statistical evaluation is not possible, primarily because each procedure was different from the other. Changes were being incorporated in the instrument, tech nique and method of procedure in a con stant effort to improve the results. The ani mals in the early series had many more complications than those of the middle series and the animals most recently operated on had few or no complications. At two days postoperative, these eyes appeared quieter and less irritated than a patient's eye with a healing 180-degree incision at three to four weeks. Mature cats were used. Although
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Fig. 20 (Kelman). Alpha chymotrypsin placed (human). their lenses were not cataractous, they were extremely hard, tenacious and fairly similar in consistency to human cataracts. Under no circumstance, could these lenses be re moved by simple aspiration. The last four cat eyes in which this procedure was per formed had no complications. In those ani mals on which bilateral procedures were done, vision is apparently excellent. Histo logie slides of animal eyes with no compli cations during surgery showed normal ret ina, ciliary body and cornea. A mild iritis was present in some of these eyes owing to the inability to remove the capsule because of its attachment to the vitreous, as mentioned previously. The surgical complications seen in the earlier cases were: 1. Complete corneal opacification. This was the most serious immediate problem and was a difficult one to solve because of
JULY, 1967
the many factors which can provoke opacification. Some of the factors which caused cor neal clouding in the early cases were: a. Excessive heat buildup in the eye. Once this problem was recognized, it was easily solved by using a sufficient quantity of chilled irrigating solution to remove the heat. b. Excessive manipulation of the lens against the corneal endothelium. In the early attempts to maneuver the hard cat lens into the anterior chamber, the lens was inadver tantly rubbed against the endothelium after the capsule had been opened. It appears that, when the lens material is rubbed on the endothelium, it is either toxic to the endothe lium or the mechanical trauma causes loss of sufficient endothelium to produce a per manent corneal opacity. This problem, once recognized, was solved in cats by not at-
Fig. 22 (Kelman). Anterior capsule margin grasped.
Fig. 21 (Kelman). Air injected to refill anterior chamber.
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tempting to bring the lens into the anterior chamber until a portion of the lens had been emulsified and aspirated. It should be mentioned, however, that the cat or dog lens has almost four times the volume of the human lens and that this problem will prob ably be less important in human surgery. c. External massage. In the early cases, remnants of lens in the folds of the capsule were brought to the central portion of the cornea by external massage of the peripheral margins of the cornea with a muscle hook. Again,, the corneal endothelium was being subjected to trauma by the pressure of the muscle; hook against the lens material. d. Excessive amplitude of vibration. It is important in this technique that the ultra-
Fig. 23 (Kelman). Traction toward center of pupil.
Fig. 25 (Kelman). Capsule extraction.
31
Fig. 24 (Kelman). Opposite edge grasped. sonic energy be localized to the tip of the instrument and not transmitted to other por tions of the eye. In the early series of opera tions, performed almost two years ago, a much larger amplitude was used. It would appear that this in itself was enough to cause corneal clouding. 2. Iris atrophy. In the animal eye, an iridectomy is difficult because of the pres ence of a large blood vessel at the root of the iris. Attempts to cauterize this blood vessel are rather ineffectual and hemorrhage often occurs during and following surgery if an iridectomy is attempted. For this rea son, unless pupillary dilation is maximal, a portion of the iris adjacent to the incision
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is subjected to the action of the instrument tip. With proper dilation of the iris or a sector iridectomy (in humans), the compli cation of iris inflammation and degenera tion at the point of incision is eliminated. 3. Vitreous loss. Perhaps the most serious surgical complication, to be avoided at all costs, is perforation of the posterior capsule with the phaco-emulsifier. Once this happens there is little recourse but to complete the incision to 180 degrees and extract the lens with an efficient cryoextractor. To continue with the phaco-emulsifier on a lens mixed with vitreous will lead to uncontrollable iridocyclitis. For this reason, in the later series, the lens mass was brought forward into the anterior chamber to minimize the possibility of touching the posterior capsule with the phaco-emulsifier. In animals, as mentioned before, vitreous loss is inevitable if, after the lens is extracted, an attempt is made to remove the posterior capsule. 4. Secondary cataracts. In the last four cases, there were no secondary cataracts be cause the efficiency of the instrument was improved, as was the technique. In earlier cases, there were several secondary cataracts with pigment proliferation across the mem brane, due to retained lens material and es pecially to retained anterior capsule. 5. Fibrinous exudate in the anterior cham ber. When operating on cats, dogs and rab bits, no matter what the procedure, one ex pects a fibrinous exudate in the anterior chamber following surgery. This can be eliminated by the use of heparin in the ir rigating solution. Figure 32 shows a cat eye following phaco-emulsification and aspiration. The cornea is clear, the iris is normal, and ophthalmoscopic examination shows a normal fundus. Both eyes were operated on in the same manner and the cat runs, climbs, jumps and walks normally. II.
JULY, 1967
not operated on until a year's experience was obtained with cats and therefore the complications were much fewer and less serious than in the early group of cats. Sev eral dog cataracts were also operated on suc cessfully by this technique. III.
H U M A N CATARACTOUS LENSES
Approximately 300 cataractous lenses re moved by conventional techniques in sur gery were subjected to phaco-emulsification in vitro. Although some of the lenses were almost bone hard, they all were emulsified and aspirated on a piece of gauze with the phaco-emulsifier. Figure 33 shows an ex ceptionally hard cataract which has been channeled and burrowed into with the phacoemulsifier, without fixing the lens but merely placing it on a piece of moist paper and ap plying the phaco-emulsifier to it. The lens is held against the phaco-emulsifier by means of suction. IV.
CADAVER EYES
Because the cadaver eyes, which I could obtain, had edematous corneas and because the iris could not be dilated, the procedure was imitated by completely removing the cornea and cutting the iris away to its root
DOGS
The mature dog lens is similar to the cat lens, that is, hard and sticky. Dog eyes were
Fig. 33 (Kelman). Hard senile cataract burrowed with phaco-emulsifier
Figs. 26-31 (Kelman). Phaco-emulsification and aspiration, a new technique of cataract removal. Fig. 26. Cystotome enters anterior chamber through two-mm shelved incision. Air fills anterior chamber. Pupil well dilated. Fig. 27. Cystotome engages capsule of lens at a point opposite the incision. Fig. 28. V-shaped opening made in capsule. Cystotome withdraws capsule from the chamber and the capsule is cut (not shown). Fig. 29. Phaco-emulsifler
introduced
into lens mass. Irrigation, sonic-ultrasonic energy and aspiration are employed.
Fig. 30. Sharp edges of lens material demonstrate solid nature of cataract. Teflon sleeve protects cornea. Lens half rem< n four minutes. Fig. 31. Lens completely removed except for posterior capsule in six minutes. One suture placed.
Figs. 32 and 34-38 (Kelman). Phaco-emunification end aspiration, a new technique of cataract removal. Fig. 32. Aphakic cat eye four days postoperative. Fig. 31. Cvstotome engages capsule and makes V-opening. Fig. 35. Phaco-emulsification and aspiration. Fig. 36. All cortex and nucleus removed. Fig. 37. Alpha chymotrypsin introduced. V-opening apparent. Fig. 38. Removal of capsule.
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to simulate a dilated pupil. The procedure is identical to that described for the animal. The cystotome, passed across the anterior capsule, cuts a V-shaped portion of the capsule away (fig. 34). The phaco-emulsifier removes all of the lens material (figs. 35 and 36). The lips of the anterior capsule are easily noted. Alpha chymotrypsin is in stilled (fig. 37) and the remainder of the anterior capsule, along with the posterior capsule, is easily withdrawn (fig. 38). SUMMARY
AND
CONCLUSION
A technique for emulsifying and aspirat ing a hard, senile-type cataract through a two to three mm incision is described. This procedure would shorten recuperation, mini mize hospitalization and give almost imme diate rehabilitation. At this date, preparations are being made to remove cataracts from
35
certain volunteer patients who have little or no function of the retina. If there are no complications, the technique will be em ployed on more useful eyes with cataracts. A subsequent report will give the details of the instrument and the results of phacoemulsification in humans, as well as an opin ion on the validity of this technique. ADDENDUM
Since the preparation of this manuscript, this technique of cataract removal was per formed on two patients with blind eyes, dem onstrating the eventual feasibility of phacoemulsification. 215 East 64th Street (10021). ACKNOWLEDGMENT
I wish to thank Mr. Otto Richter, Miss Cheryl Chase and Mr. Anton Banko for their willing as sistance and encouragement on this project.
OCULAR LESIONS IN RELAPSING POLYCHONDRITIS AND O T H E R R H E U M A T O I D SYNDROMES T H E EDWARD JACKSON MEMORIAL LECTURE BANKS ANDERSON, SR.,
M.D.
Durham, North Carolina
Edward Jackson, born in 1856, was grad uated from Union College in 1874 with a B.S. degree in civil engineering. Four years later he was awarded the M.D. degree by the University of Pennsylvania. His first paper appeared in 1882, his last of more than 600 publications in 1926. He died 16 years later, at the age of 87 years. His prolific pen attests to his wide ranging and continuous concern with the problems of ophthalmology. His paper on "The theory and technique of skiascopy" introduced to American ophthalmologists this valuable ad junct to refraction. His papers recom mending the use of the cross cylinder in de termining the degree and axis of astigmaFrom the Department of Ophthalmology, Duke University Medical Center.
tism were largely responsible for the accep tance of this method in this country. These solid and time-tested contributions are over shadowed by his influence on the postgradduate training of ophthalmologists. He or ganized the first course in postgraduate edu cation. He was one of the founders and for many years chairman of the American Board of Ophthalmology. He was largely responsible for bringing into one organiza tion a group of ophthalmic publications that became the AMERICAN JOURNAL OF O P H THALMOLOGY, which he served as editor-inchief for many years. In the area of refrac tion, in postgraduate teaching, and in bed time reading the impact of this man per sists long beyond his time. So it is that one cannot be insensitive of the privilege of