Advances in eye surgery
Advances in ophthalmology have brought better outcomes and convenience for our patients. This has occurred not just because of new technology but also due to inventive surgeons thinking outside the box and challenging dogma. In this article, we discuss two advances in ophthalmic surgery: immediately sequential bilateral cataract surgery and DMEK.
Cataract surgery has changed dramatically in the last three decades, thanks to two novel ideas: keyhole phacoemulsification and intraocular lens. Cataract surgery is now the most successful surgery in all of medicine. The far majority of patients have day case surgery with complications rates much lower than the days of large wound extracapsular cataract extraction. However, our thinking has not caught up with the increased safety. Previously, due to difficulty and complications of surgery and the time it took for eyes to settle, we only offered unilateral cataract surgery. The advantages of immediately sequential bilateral cataract surgery (ISBCS) are numerous yet few surgeons offer this modality of treatment, despite the same safety profile compared with operating on the two eyes on separate dates. There is convenience for patients and their carers in that there is only one pre-op and post op visits, one surgical date, and one visit to the optometrist for new glasses without having the bother of imbalance between two eyes whilst waiting for second eye cataract surgery. Having devised a strict protocol on patient selection, treating the two eyes as completely separate operations (new trolley of instruments and regowning and regloving), and the option not to proceed should the first eye operation not have gone well as it should, Professor Christopher Liu is now able to offer ISBCS to suitable patients.
Another revolution has occurred in cornea transplantation. Full thickness corneal grafting is hardly done nowadays. The trend is only to replace the defective layer. Thus we use endothelial keratoplasty instead of penetrating keratoplasty in patients with endothelial disease such as Fuchs’ dystrophy. The results are rapid visual rehabilitation with little astigmatism, lower risk of corneal graft rejection and retention of strength of the globe thanks to keyhole surgery. The most common form of endothelial keratoplasty is Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK). In DSAEK, we transplant a donor lenticule of a thin layer of stroma as carrier for the endothelium. Although the outcomes of DSAEK are reasonably good, Dr Melles invented an improved but fiendishly difficult technique called Descemet's Membrane Endothelial Keratoplasty (DMEK) in 2006. The donor graft in DMEK does not have any stroma (Figure 1) which yields optical perfection (Figure 2) and almost zero risk of immunological graft rejection. Having learnt the technique from master surgeons in continental Europe three years ago, Professor Liu is considered a pioneer of DMEK in England. He has made three further inventions for DMEK surgery and has excellent audited results.
To conclude, in addition to our efforts to progress medical advancement, we must also critically look at the evidence and provide novel (but proven) services to our patients which enhance their experiences and outcomes.
Professor Christopher Liu BScHons, MBBS, DO, FRCOphth, FHKAM (Ophth), CertLRS
