You’re Going To Vacuum Out My Eye

I’m going to take a short break from posting the Cataract Surgery Essentials Audio Series as I’m having some mild technical difficulty installing the Podpress plug-in. If you don’t know what that is, I just learned about it myself (which probably explains why I’m having difficulty with it).

I had dinner last night with one of LA’s top cataract surgeons, Dr. Barry Seibel. He is one of the few surgeons on the Westside of LA who actually did write an influential textbook on cataract surgery, Phacodynamics (I have a dog-eared copy in my office). For those of you who don’t know it already, almost every cataract and refractive surgeon on the Westside says he or she has taught (insert ridiculously large number here) other surgeons or was one of the first to do this or that surgery…yadda, yadda, yadda (oh boy am I gonna get flamed by some slick Westside surgeons for that comment). The difference is that Dr. Seibel actually did write a real textbook that has been read (or should have been read) by most ophthalmology residents since the book was originally published. This was not some sort of ghostwritten vanity press book produced as a marketing shill. It’s the real thing and a continual source of reference for me and other surgeons.

If you live on the Westside and have cataracts I’d recommend scheduling a consultation with him (BTW, I have no financial interest or arrangement with Dr. Seibel and suppose I should be asking you to come and see me, but I know that if you live on the Westside you’re not going to schlep out to the San Gabriel Valley anyway – so just save the gas, stay off the freeway, and go see Dr. Seibel).

In any case, Dr. Seibel and I had a wonderful conversation which had nothing to do with phacodynamics but made me realize that most people have no idea about the complexity involved with physically removing a cataract. In order to give you an idea of the dynamic process involved in emulsifying and removing a cataract try the following mental experiment (don’t really do this as it’s just a metaphor):

Imagine you have a plastic trash bag (the cheap thin ones from a discount store, not the Heavy Duty Hefty bag) – this is going to be our imaginary capsular bag. In the eye this bag is only a few millionths of a meter thick. Now fill it up with oatmeal – this is our model cataract. Let it sit overnight so that the oatmeal gets real hard and sticky. Now, in order to remove the cataract we are going to use an instrument that both pours fluid into the bag and vacuums the oatmeal out of the bag. For imaginary purposes we’ll use a vacuum cleaner with the hose attachment and ducttape a garden hose to it so that both nozzles face the same direction.

OK, turn on the vacuum cleaner and water hose. Stick it in the bag full of crusty oatmeal – uh, this is actually a bit messier than cataract surgery. Can you see the water hose breaking up the oatmeal and he vacuum sucking it out?  Good. Not too difficult, right?

Oh, but wait, there’s oatmeal stuck to the sides of the plastic bag. You’ve got to get that out too. In real cataract surgery if you leave part of the cataract stuck to the capsular bag your patient won’t see any better after surgery than they did before – in fact, they might be worse off with inflammation, poorer vision, and a painful eye.

Anyone who has ever used the vacuum cleaner attachments knows that if you get them anywhere near loose fabric, the vacuum will suck the fabric into the nozzle. If you get your nozzle too close to the side of the plastic bag, the bag will get sucked into the nozzle and tear. Now you’ve got a big hole through which all of the oatmeal has just spilled out onto your floor. In cataract surgery we call this a “capsular rent” and try to avoid it at all costs because such a tear will allow the remaining cataract to spill into the back of the eye resulting in floaters, inflammation, and increased risk of infection or retinal detachment.

Right about now you might be thinking, “That sounds like a bad idea, why would anyone try to do something like use a water hose and vacuum to take a cataract out?” Well, it does sound risky and early pioneers of phacoemulsification such as the late Dr. Charles Kelman (a true renaissance man) were severly chastized by their fellow surgeons for taking “unnecessary risks.” However, the method of cataract surgery used at the time was called “delivering” the cataract (as in delivering a baby). It required a large incision, took weeks to months for the eye to heal, and had it’s own set of surgical risks. Fortunately, the techniques and technology of phacoemulsification have significantly evolved over the last 40 years.

A major reason we can now remove cataracts safely using a microscopic water hose and vacuum is that the fluidics of phacoemulsification have been studied and taught by doctors such as Barry Seibel. Tools and techniques have been developed that allow cataract surgeons to get very close to the capsular bag (close enough to remove individual microscopic strands of cataract) without tearing the bag.

In short, modern cataract surgery is nothing short of miraculous. Even after performing over 2,000 cataract surgeries, I often find myself in awe at what can be done thanks to the imagination, efforts, and risks of the many pioneer surgeons (and their patients) that preceded me. We all owe them a debt of gratitude.