UNENDING INNOVATION

I’ve been involved with the ESCRS from when it was still the European Intraocular Lens Implant Council (EIIC) and I went to the first meeting under its present name, and have been to every meeting ever since. It is therefore an enormous honour, one of the crowning achievements of one's career, to be asked to give such a prestigious lecture and to receive the medal. So much so, that my children and their sundry spouses will be in attendance to watch the old man strut his stuff. So it's a big deal. Later on this year, the UKISCRS will be giving me a lifetime achievement award. So it's going to be a big year for big lectures for me.

The title of my lecture is ‘The Evolution of the Capsulotomy: From Crude Forceps to Precision Laser’. The reason I thought of this title was because I'm involved with a small start-up company called Capsulaser, which has a very interesting laser for doing a capsulotomy in a completely different way from the femtosecond laser. It is a thermal laser and it is a tiny device which fits underneath the microscope, and enables you to have a perfectly precise capsulotomy which is actually stronger than you can achieve either manually or with the femtosecond laser, and at a fraction of the cost of the latter technique.

We want to combine it with devices like the Callisto system (Zeiss) or Verion (Alcon), which will enable a perfectly centred capsulorhexis as well as a perfectly sized one. Capsulaser is going into clinical trials with their new capsulotomy laser this year. They've done 1,000 pig eyes and 100 cadaver eyes and the laser will do a perfect capsulotomy in two seconds. It will be something that virtually every cataract surgeon will want to have on their microscope to
do the capsulotomy.

There are also other new devices under development, such as the Zepto device, which is being developed again by a small start-up company, Mynosys, in the US. It is a device that you can push through the wound and it sits on top of the capsule, and in a few nanoseconds it creates a capsulotomy. They haven't done any clinical trials with it yet, they have done pig eyes, but again it's new technology.

An awful lot of people are not convinced, as I am not convinced, that femtosecond laser cataract surgery is going to be going anywhere. So far, every study that has been done comparing femtosecond laser with cataract surgery done in the conventional manner has shown no real difference between the two techniques in terms of clinical outcomes.

I also thought this would be a good opportunity to review the whole business of capsulotomy use, from Daviel in the 18th Century onwards, and look at the different roles capsulotomy has had over the years, how it has been done, how the shape has changed. Initially, for example, it was just a means of getting the nucleus out of the eye - it still serves that purpose, but over the years it has also been adopted in various ways and in various shapes to secure the stable placement of the intraocular lens (IOL) in the capsular bag. There are also other ways that capsulotomy has been used, such as Tassignon’s bag-in-the-lens IOL and Samuel Masket’s new grooved-optic lens which fits into a perfect capsulotomy.

I think the topic of my Binkhorst lecture is particularly appropriate, since it was Binkhorst who brought everyone back to extracapsular surgery. I'll be talking about his two-loop iridocapsular lens and how he thought this would give them greatest stability. What Binkhorst wanted to develop when he moved away from the Ridley lens to the four-loop lens, which was held in the pupil, was to accomplish perfect centration. But since he found that the four-loop lens could be dislocated, he thought that a two-loop lens which had loops in the capsule, but with the optic still in front of the iris, would be a better option. Finally he developed his endocapsular lens, which was called the “moustache” lens, because the haptics looked a bit like Salvador Dali’s moustache.

As I will mention in my lecture, I in fact met Cornelius Binkhorst as a senior registrar at Charing Cross. Eric Arnott, who was my mentor there and taught me phacoemulsification in the late 70s, had organised a huge meeting with multiple international surgeons like Binkhorst and Worst and everybody that had a lens named after them. I assisted Binkhorst in a cataract procedure and watched him put in a “moustache” lens.

Richard Packard: mail@eyequack.vossnet.co.uk