MAJOR ADVANCES

Günther Grabner MD with Roberto Bellucci, president of the ESCRS after the 2014 Ridley Medal lecture

While the past 40 years have produced major advances in cataract surgery leading to enhanced safety and excellent visual outcomes for most patients, there is still some unfinished business, according to Günther Grabner MD, who delivered the Ridley Medal Lecture at the XXXII ESCRS Congress in London.

As one of the renowned innovators in the field of cataract surgery, Dr Grabner’s wide-ranging lecture encompassed the entire span of modern ophthalmology, paying tribute to early pioneers at the 2nd University Eye Clinic in Vienna, where he trained, such as Eduard Jaeger, Karl Koller and Ernst Fuchs, personal mentors such as Prof Hans Slezak, Dennis Shepard MD, Santa Maria, and his teachers at the FI Proctor Foundation, UCSF, such as Dick O'Connor, Gil Smolin MD, Mitch Friedlaender MD and the visionary accomplishment of Harold Ridley, the inventor of the intraocular lens (IOL).

Looking back to the early days of his residency training, Dr Grabner said that cataract surgery as practised then was radically different to today’s procedures.

“I was taught the fundamentals of intracapsular cataract extraction (ICCE) and it was basically the same technique for many years. We used retrobulbar anaesthesia and neural block of lids, 10 minutes of oculopression, and no gloves or microscopes as surgery was carried out using loupes. We performed a 180-degree incision with a big scissors, followed by cryoextraction and no IOL implantation, with one to seven silk sutures to seal the wound and the patient was typically hospitalised for five to seven days,” he said.

Key questions

Dr Grabner said his lecture would seek to answer four key questions in relation to cataract surgery over the last 40 years. Addressing the question of safety in cataract surgery, Dr Grabner said that issues such as aphakia, endothelial cell loss, aqueous loss, vitreous loss and postoperative infection all
posed potential problems for surgeons operating in the 1970s and 1980s.

“Aphakia, for instance, was terrible,” said Dr Grabner. “We rendered 100 per cent of our patients aphakic, sometimes only in one eye, and kept them some time before the second eye was done. They usually had very low optical quality and a lot of patients suffered from falls as a result of their aphakia that was corrected with thick spectacles.”

Typical rates of endothelial cell loss were about 20 per cent after ICCE surgery and vitreous loss rates were up to 10 per cent, said Dr Grabner. The most feared complication, however, was postoperative endophthalmitis. In this respect, Dr Grabner said he was proud to have played a part in the landmark ESCRS endophthalmitis study, which helped to establish important guidelines for the prevention of this sight-threatening condition. Overall, Dr Grabner said there was no doubt that safety has significantly improved over the past 40 years.

Full visual function

In terms of restoring full visual function, Dr Grabner said that a lot of progress has been made in terms of biometry, reduction of PCO formation, astigmatism control and presbyopia, but that unresolved issues remained to be tackled.

While around 90-95 per cent of patients have sufficiently precise biometry to be happy, some outliers still exist. He said the concept of adjustable IOLs is intriguing, but that the practical difficulties of asking people to return to the clinic for “lock-in” procedures and to wear dark glasses between treatments might pose an obvious obstacle to widespread adoption.

For astigmatism control, Dr Grabner said that today’s toric lenses and advanced eye trackers deliver excellent results. “I think astigmatism above 0.5 D should be treated and yet not all of these potential patients are treated. There is quite low patient request because they are used to spectacles, we need additional chair time, it costs more and it needs surgery time and special equipment to be performed properly,” he said.

Unfinished business

While some progress has also been made on PCO formation, Dr Grabner said that this was still “unfinished business” and that new IOL materials and designs should help to reduce the risk in the future.

In terms of presbyopia solutions, Dr Grabner said that many approaches have been tried over the years, including accommodating and special IOLs simulating intracorneal inlays, but that the mission is not yet completed in terms of finding a universally accepted solution to the problem.

Turning to the introduction of the femtosecond laser into cataract surgery, Dr Grabner said it represents a significant surgical advance for the patient in terms of safety, with over 99.6 per cent of capsulotomies successfully completed in over 1,600 cases in his own surgery, and more interesting options such as intrastromal arcuate keratotomy (ISAK) to be fine-tuned for widespread use.

In terms of rapid visual rehabilitation, he made a plea for more widespread use of immediate sequential bilateral surgery.

Dr Grabner finished his lecture with an emotional tribute to his colleagues and family and said that it was important never to lose sight of the everyday wonder of a profession that could do so much good for so many people. “We need to remember the words of Sir Harold Ridley that ‘even when a miracle becomes routine, it still remains a miracle’,” he said.

Günther Grabner: g.grabner@salk.at