History confirms that it is never easy to introduce a new concept in ophthalmic surgery. That was especially true for a young ophthalmologist who had just completed his training and was unknown to everyone except his family. This is my story.
JUST AFTER MY TRAINING
I had just finished my third fellowship under the mentorship of Donald Gass, MD. I felt well trained when, after 5 years at the Bascom Palmer Eye Institute and Wills Eye Hospital, I eagerly returned home in 1980 to enter private practice with my dad (my hero), Morris Osher, MD. He was a terrific ophthalmologist and a great boss who encouraged me to travel around the country visiting some of the leaders in cataract surgery.
Between 1980 and 1982, I observed Richard Kratz, MD; Robert Sinskey, MD; James Little, MD; David Brown, MD; Manus Kraff, MD; James Gills, MD; Barry Thrasher, MD; and Norman Jaffe, MD, to name a few. Most agreed that Kelman phacoemulsification, PCIOLs, the latest ultrasound devices, and novel IOL formulas would provide patients with wonderful vision following surgery. The focus in cataract surgery, however, was on induced rather than preexisting astigmatism, and surgeons were obsessed with the Terry keratometer and the Kratz scleral tunnel incision as well as the suture materials and closure techniques that attempted to minimize the amount of astigmatism created by routine surgery.
I was intrigued by the new and highly controversial idea of refractive surgery. I visited the ORs of Spencer Thornton, MD; Albert Neumann, MD; Robert Fenzl, MD; and Lee Nordan, MD, who were all exploring ways of correcting preexisting astigmatism. Then, while watching George Tate, MD, operating on an eye with surgically induced astigmatism, I suddenly had a shocking idea. Ophthalmologists had not considered reducing preexisting astigmatism at the time of cataract surgery, perhaps because their success routinely was not known until several months postoperatively and was always measured with spectacle correction. The reality was simple: cataract surgeons were fixated on the spherical component of the pseudophakic refractive error but had totally ignored the astigmatic component. The time was never better for the birth of a new species: the refractive cataract surgeon.
STUDYING AN IDEA
With enthusiasm and trepidation, I initiated a study in 1983 to investigate the correction of preexisting astigmatism through a combination of transverse corneal relaxing incisions at the time of cataract surgery. I believed that ophthalmologists could no longer accept the traditional standard of measuring their success by patients' BSCVA several months following surgery. The new definition had to center upon the UCVA achieved soon after surgery.
My original technique consisted of phacoemulsification through a 6-mm scleral tunnel incision, the implantation of a PMMA IOL, and the placement of a single straight relaxing incision in the corneal periphery, perpendicular to the steepest meridian. After a small number of cases, I added a second parallel incision around a conservative 7.0- to 10.5-mm optical zone. My nomogram was simple (Table 1).
After 3 months of follow-up, I collected the results of my first 50 cases and sent the spreadsheet to Clifford Terry, MD, the guru of astigmatism. Even before his favorable interpretation, I knew that the concept worked and that the litmus test was convincing two of my closest friends, Richard Lindstrom, MD, and Douglas Koch, MD. They were skeptical but supportive.
THE CALM BEFORE THE STORM
At the Welsh Cataract Congress held in Houston in September 1984, I presented my first large series to an audience composed of virtually every big gun in cataract surgery. Based on the results of the study, I stated the following conclusions:
- eighty-eight percent of the eyes undergoing astigmatic keratotomy at the time of cataract surgery experienced a reduction in preexisting astigmatism;
- the size of the optical zone, a consistent incisional depth, and the patient's age were major factors in the outcome;
- the IOL power calculation was not affected by the astigmatic keratotomy, because the average pre- and postoperative K readings were equivalent;
- no complications arose except for minor corneal abrasions;
- all eyes in the study, except one with amblyopia, achieved a BCVA of 20/40 or better, comparable results to the control population; and
- the UCVA attained was 20/40 or better in 76 of the patients, individuals who otherwise would never have enjoyed spectacle independence at distance.
SPEAKING THE TRUTH
During my fellowship in neuro-ophthalomology, J. Lawton Smith, MD, had prepared me for my experience in Houston with one of his favorite sayings: "The truth is never defined by the majority opinion." Every young ophthalmologist should recite this maxim and never fear challenging the status quo.
For more than 25 years, I have performed astigmatic keratotomy on the eyes of any patient with preexisting astigmatism greater than 1.50D and for a lesser amount with a multifocal lens implant. I still use intraoperative keratoscopy (a modification [DK 6-706; Duckworth & Kent Ltd, Hertfordshire, UK] of the original astigmatic ruler of Frederick Hyde, MD) to identify the axis and to quantitate the cylinder.
It pleases me to see the growing popularity of limbal relaxing incisions, and the introduction of the single-piece toric IOL (Acrysof Toric IOL; Alcon Laboratories, Inc., Fort Worth, TX) will add to ophthalmologists' surgical options. I am indebted to so many surgeons who have advanced the refractive principles I have described. It has been satisfying to witness the slow but steady acceptance of the concept of coupling cataract and astigmatic surgery, a combined procedure that indeed has stood the test of time.
Robert H. Osher, MD, is Professor of Ophthalmology at the University of Cincinnati and Medical Director Emeritus of the Cincinnati Eye Institute. Last year, Cataract & Refractive Surgery Today presented Dr. Osher with the Nordan Award for his contributions to refractive cataract surgery. He also serves as the editor of the Video Journal of Cataract and Refractive Surgery. Dr. Osher is a consultant to Advanced Medical Optics, Inc., Alcon Laboratories, Inc., and Bausch & Lomb but acknowledged no financial interest in the products mentioned herein. Dr. Osher may be reached at (513) 984-5133; email@example.com.