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The more things change, the more they stay the same

Khor, Wei Boon; Afshari, Natalie A.

Current Opinion in Ophthalmology: January 2013 - Volume 24 - Issue 1 - p 1–2
doi: 10.1097/ICU.0b013e32835b078b

aDuke Eye Center, Duke University Medical Center, Durham, NC, USA

bSingapore National Eye Centre, Singapore

cShiley Eye Center, University of California San Diego, La Jolla, CA, USA

Correspondence to Natalie A. Afshari, MD FACS, Chief of Cornea and Refractive Surgery, Professor of Ophthalmology, Shiley Eye Center, University of California San Diego, 9415 Campus Point Drive, La Jolla, CA 92093, USA. E-mail:

Ophthalmologists who started their surgical career with extracapsular cataract extraction (ECCE) may remember the inevitable transition to phacoemulsification cataract surgery. For some individuals, there was the niggling fear that the introduction of the phaco machine would somehow make us less of a ‘surgeon’ and ultimately render surgical skill obsolete. In reality, ophthalmologists acquired a whole new set of surgical skills with phacoemulsification surgery that was no less expert than what we had developed with ECCE.

The introduction of femtosecond laser cataract surgery has generated similar philosophical musings amongst cataract surgeons. Would we gradually lose our ability to perform a manual capsulorhexis or to crack the nucleus as we outsource these steps to the laser machine? The answer is that there is little danger of surgeons losing their skills with conventional phacoemulsification. In practical terms, the cost of the technology makes it unlikely to be as widespread or as essential as the phaco machine and will probably remain a premium option for the cataract patient. Furthermore, there will always be eyes where femtosecond cataract surgery would be unsuitable or would encounter difficulties. In their review ‘Femtosecond Cataract Surgery: Transitioning to Laser Cataract’, Dr Gerard Sutton and colleagues (pp. 3–8) find femtosecond cataract surgery to be well tolerated, effective, and a viable alternative to conventional phacoemulsification, but suggest avoiding laser cataract surgery in eyes with corneal opacity or with advanced glaucoma. These are situations that are also highly pertinent in conventional phacoemulsification surgery, and Drs Jonathan Greene and Shazad Mian (pp. 9–14) review the issues with ‘Cataract surgery in patients with corneal disease’, whilst Dr Helen Danesh-Meyer (pp. 15–20) discusses the ‘Incidence and management of cataract after glaucoma surgery’. Drs Dhivya Ashok Kumar and Amar Agarwal (pp. 21–29) also present an excellent review on glued intraocular lenses, which serves as a further reminder that there will always be patients with complex cataracts that will require our surgical expertise.

Of course, phacoemulsification was a paradigm shift in how ophthalmologists managed cataracts, and made possible the innovations that surgeons now utilize to optimize the visual function of their patients during cataract surgery. Without the refractive predictability and rapid visual recovery of phaco surgery, ‘Approaches to Corneal Astigmatism in Cataract Surgery’ as reviewed by Dr Jonathan Rubenstein and Dr Michael Raciti (pp. 30–34) would have been much more limited. Similarly, it is fair to say that the advantages of phacoemulsification made presbyopia-correcting intraocular lens much more viable and widespread, so much so that we can now even consider ‘The Role of Presbyopia-Correcting Intraocular Lenses after LASIK’. And the evolution of cataract surgery continues at a rapid pace – Dr William Fishkind (pp. 41–46) analyses the latest technology in use with phaco machines, Dr Pho Nguyen and Dr Vikas Chopra (pp. 47–52) discuss ’Applications of Optical Coherence Tomography in Cataract Surgery’ (including the use of optical coherence tomography-guided femtosecond laser cataract surgery), while Drs Yu-Chi Liu, Tina Wong, and Jodhbir Mehta (pp. 53–59) consider the possibility of using the intraocular lens as a drug delivery reservoir. In the midst of these changes, Drs Jayesh Vazirani and Sayan Basu (pp. 60–65) provide surgeons with a timely update on the use of antibiotics in cataract surgery, whereas Drs Bradley Shoss and Linda Tsai (pp. 66–73) discuss ’Postoperative care in cataract surgery’. Finally, Dr Robert Copeland and Dr Neal Desai remind (pp. 74–78) us that despite all our technological advances, there still remain significant gender and socioeconomic disparities in the access to cataract surgery, both within the United States and in the wider world.

It is still too early to predict whether femtosecond cataract surgery will be a great and lasting advance on cataract surgery, as phacoemulsification proved to be over ECCE. What we can say with certainty is that ophthalmologists will find their surgical skill sets expanding, not shrinking, as we learn and adapt to femtosecond laser cataract surgery.

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Conflicts of interest

There are no conflicts of interest.

Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.