September 20, 2019
2 min read

Creativity and innovation require thinking outside the box

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Ehud Assia, MD
Ehud Assia

PARIS — In 1889, Charles Holland Duell, commissioner of patents, stated that the U.S. patent office would soon shrink in size and eventually close because “everything that can be invented has been invented.” He could not be more wrong, judging from the steady increase of patents over time. With this anecdote, Ehud Assia, MD, introduced his Binkhorst Medal lecture during the opening ceremony of the European Society of Cataract and Refractive Surgeons meeting.

“Thinking outside the box” was the leitmotif and core message of his lecture and has been the drive of his personal achievements. Many of the devices and techniques he invented were the result of “looking at things from different angles, so that one can see things never seen before,” he said.

First in the list was the “side view” or “keyhole” technique, developed with David Apple, MD, which allowed visualization of the anterior chamber in a way that reveled how wrong anatomical drawing were.

Two of his own ideas, simple and clever, addressed some of the most difficult challenges of cataract surgery: the capsular anchor for the management of lens subluxation and the pupil expander for surgery in eyes with small pupils.

Thanks to his mentor, Michael Blumenthal, MD, Assia embraced the concept of continuous irrigation and anterior chamber maintainer-assisted phaco surgery to prevent pressure drop and anterior chamber collapse, unavoidable otherwise “when the phaco tip is drawn out of the eye,” he said.

He took this method a step further with the use of his own anterior chamber maintainer, sleeveless tip and visco fluids.

“Fluid [balanced salt solution] and viscoelastic are used at different stages of surgery. Why not combine them in a visco-fluid substance, which runs slower than fluid, provides a comfortable environment with less turbulence, protecting the corneal endothelium,” he said.

He proposed that further protection of the endothelium from free radicals-induced damage could be provided by the addition of small amounts of ascorbic acid to this new substance. A study proved that endothelial cell loss is significantly diminished as compared with the use of balanced salt solution alone.

“There is so much more and better you can do if you think outside the box,” he said. A last example he showed to prove this point was a mobile OR, created by a voluntary organization for surgery in developing countries in which surgeons operate in a protected environment, with only the head of the patient inside and the rest of the body “outside the box.” – by Michela Cimberle


Assia E. Thinking outside the box: New perspective on current surgical technologies. Binkhorst Medal Lecture 2019. Presented at: European Society of Cataract and Refractive Surgeons meeting; Sept. 13-18, 2019; Paris.

Disclosure: Assia reports he is a consultant for Hanita Lenses, Biotechnology General, Vision Care, IOPtima, APX Ophthalmology, Visidome and CorNeat Vision.