Surgeons speculate about future of ophthalmic surgery

Will new techniques and technologies make procedures harder or easier to perform?
Jack S. Parker
Gerrit Melles

In the future, will ophthalmic surgeries be easier to perform than they are now? Intuitively, one might expect the answer to be an obvious “yes,” and superficially, some of the recent upgrades in our surgical equipment appear to confirm this impression. But surprisingly, ophthalmology’s historical trend appears to be in the opposite direction: In general, eye surgeries may be becoming more difficult.

Consider, for example, cataract surgery. Initially, the operation consisted entirely of couching the lens into the back of the eye. Intracapsular extraction was the major successor, which was a superior solution but significantly more technically demanding. Next came the extracapsular techniques, which were more demanding still, eventually yielding to the panoply of modern phacoemulsification tactics available today, with their substantial logistical and strategic considerations, concerning, for example, lens type, power, material and position. And although many “simplifying” innovations have indeed been introduced, including the use of trypan blue, iris retractors and upgraded phacoemulsification technologies, for the most part, these steady refinements have been swamped by periodic revolutions, which have increased the complexity of cataract surgery overall (Figure 1).

Figure 1. The increasing surgical complexity of cataract surgery over time, driven by periodic revolutions in technique, tempered by intermittent refinements in tactics and tools.

Image: Parker JS, Melles G

This counterintuitive pattern is likewise evident in modern corneal transplantation techniques. For keratoconus, penetrating keratoplasty has largely been supplanted by the more technically demanding deep anterior lamellar keratoplasty. Even more recently, Bowman’s layer transplantation has emerged as a treatment option for patients with advanced keratoconus, which may be more challenging still. Likewise, for Fuchs’ endothelial dystrophy, PK was displaced by Descemet’s stripping endothelial keratoplasty and then by Descemet’s membrane endothelial keratoplasty.

Counterintuitively, it may be that successive surgical revolutions — rather than simplifying and solving intraoperative issues — have instead tended to multiply and intensify them. New technological possibilities are driving and facilitating our intraoperative challenges, not reducing them. Therefore, anticipating what surgery will be like in the future, we might expect future techniques to be more demanding than those today and that, to achieve bare competency, more surgical specialization may be required. On the other hand, postoperative care may become correspondingly easier and less burdensome. If so, we may expect to see fewer “general” ophthalmologists but more specialists, including “refractive cataract specialists,” and more medical and non-surgical eye doctors, including optometrists.

One may wonder whether this unexpected historical trend is sustainable. Perhaps the answer is “no,” and surely at some point there must be a limit to human physical and mental ability. On the other hand, the best predictor of the future may be the past, and advances in computing technology may enable incredible additional complexity. Certainly, there will be a demand for it — look again at modern cataract surgery and its shift into a cash-based, refractive, specialty lens and sometimes laser-assisted procedure.

One also wonders what to think of the rising reports of “descemetorhexis only” and ROCK inhibitor treatments for Fuchs’ endothelial dystrophy. Are these therapies poised to dramatically overturn this trend toward increasing surgical difficulty, or are they the sort of efforts that the historical record may indicate movement in the wrong direction? Perhaps only time will tell.

Disclosures: Melles reports he is a consultant for DORC International/Dutch Ophthalmic USA and SurgiCube International. Parker reports he is a consultant for DORC International/Dutch Ophthalmic USA and Ziemer Ophthalmic Systems.

Jack S. Parker
Gerrit Melles

In the future, will ophthalmic surgeries be easier to perform than they are now? Intuitively, one might expect the answer to be an obvious “yes,” and superficially, some of the recent upgrades in our surgical equipment appear to confirm this impression. But surprisingly, ophthalmology’s historical trend appears to be in the opposite direction: In general, eye surgeries may be becoming more difficult.

Consider, for example, cataract surgery. Initially, the operation consisted entirely of couching the lens into the back of the eye. Intracapsular extraction was the major successor, which was a superior solution but significantly more technically demanding. Next came the extracapsular techniques, which were more demanding still, eventually yielding to the panoply of modern phacoemulsification tactics available today, with their substantial logistical and strategic considerations, concerning, for example, lens type, power, material and position. And although many “simplifying” innovations have indeed been introduced, including the use of trypan blue, iris retractors and upgraded phacoemulsification technologies, for the most part, these steady refinements have been swamped by periodic revolutions, which have increased the complexity of cataract surgery overall (Figure 1).

Figure 1. The increasing surgical complexity of cataract surgery over time, driven by periodic revolutions in technique, tempered by intermittent refinements in tactics and tools.

Image: Parker JS, Melles G

This counterintuitive pattern is likewise evident in modern corneal transplantation techniques. For keratoconus, penetrating keratoplasty has largely been supplanted by the more technically demanding deep anterior lamellar keratoplasty. Even more recently, Bowman’s layer transplantation has emerged as a treatment option for patients with advanced keratoconus, which may be more challenging still. Likewise, for Fuchs’ endothelial dystrophy, PK was displaced by Descemet’s stripping endothelial keratoplasty and then by Descemet’s membrane endothelial keratoplasty.

Counterintuitively, it may be that successive surgical revolutions — rather than simplifying and solving intraoperative issues — have instead tended to multiply and intensify them. New technological possibilities are driving and facilitating our intraoperative challenges, not reducing them. Therefore, anticipating what surgery will be like in the future, we might expect future techniques to be more demanding than those today and that, to achieve bare competency, more surgical specialization may be required. On the other hand, postoperative care may become correspondingly easier and less burdensome. If so, we may expect to see fewer “general” ophthalmologists but more specialists, including “refractive cataract specialists,” and more medical and non-surgical eye doctors, including optometrists.

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One may wonder whether this unexpected historical trend is sustainable. Perhaps the answer is “no,” and surely at some point there must be a limit to human physical and mental ability. On the other hand, the best predictor of the future may be the past, and advances in computing technology may enable incredible additional complexity. Certainly, there will be a demand for it — look again at modern cataract surgery and its shift into a cash-based, refractive, specialty lens and sometimes laser-assisted procedure.

One also wonders what to think of the rising reports of “descemetorhexis only” and ROCK inhibitor treatments for Fuchs’ endothelial dystrophy. Are these therapies poised to dramatically overturn this trend toward increasing surgical difficulty, or are they the sort of efforts that the historical record may indicate movement in the wrong direction? Perhaps only time will tell.

Disclosures: Melles reports he is a consultant for DORC International/Dutch Ophthalmic USA and SurgiCube International. Parker reports he is a consultant for DORC International/Dutch Ophthalmic USA and Ziemer Ophthalmic Systems.