Half a century of developments in ophthalmology: One doctor’s reflections

Dr Frank J. Goes

I started my ophthalmology training in 1965 at Ghent University, Ghent, Belgium, in the department of Prof. Jules François, who was a man of many talents (author or co-author of 1,870 peer-reviewed articles; doctor honoris causa at 21 universities) and a very didactic teacher!

Later, I founded the Ghent University clinic department of ultrasound, where I stayed some 15 years as a consultant. In 1968 I started my private practice in Antwerp, Belgium, as a solo practitioner.

I have had the privilege to be a spectator, often a participant and sometimes a leader in the most important developments in ophthalmology over the 50-plus years since I started my ophthalmology career. It is my honour to share the most important learnings and developments with the reader.

Most of these happened during the first 30 years of my career in ophthalmology. Indeed, except for the introduction of intravitreal anti-vascular endothelial growth factor injections, there have been no spectacular advancements in ophthalmology since then.

I observed, during those first 30 years, the birth of the IOL,the introduction of phaco-emulsification techniques and the use of lasers in the treatment of eye diseases and in refractive eye surgery. Vitreoretinal surgery has boomed and modern eye examination methods (OCT, retinal scans, topographic modelling) have improved and now help in making better diagnoses.

Cataract surgery

During my first years in ophthalmology, we worked with a head loupe(with a 6x magnification) and had to open the eye for cataract surgery with a von Graefeknife over 145°, remove the cataract with forceps and close the corneal wound with eight 6-0 silk sutures. The patient stayed in hospital for 5 days and recuperation of normal vision, after removal of the stitches and prescription of the very high hyperopic lens, took 7 weeks.

Artificial IOL “miracle”

Thedevelopment of the artificial IOL—first implanted by the late Sir Harold Ridley at St Thomas’ Hospital in London in February 1950—changed the course of cataract surgery. However, it took several years before Ridley’s invention became widely accepted; I performed my first lens implant in the late 1970s. Before then, it made no sense to perform unilateral cataract surgery.

Indeed, the obligatory use of the very disturbing postoperative aphakic correction was only supported when used bilaterally. These high hyperopic(+12 D)glasses caused a 25% magnification of the image, which was not supported when prescribed unilaterally. These ugly glasses were also responsible for the very annoying roving ring scotoma called the “jack in the box phenomenon,” which made driving a car a very risky business.

Only when contact lenses for the correction of aphakia were introduced, towards the end of the 1970s, did it make sense to operate unilaterally, as the contact lenses created a magnification of only 6–8% and this difference could be supported by the other phakic eye.

Phacoemulsification

Once phacoemulsification became available, after the late Charlie Kelman’s discovery in 1967, the corneal opening needed only to be 5 mm and then, after the introduction of foldable implants, 3 mm. Stitches were no longer needed because a scleral tunnel approach was already in use before foldable lenses became available.

In 1987 I mastered the technique during a course given by Dr Jim Little, an associate of Kelman, in Geneva, Switzerland. At that time there were only four surgeons in Belgium using this method. I recall that in the United States some time later, a wet lab on pig and rabbit eyes was organised in the ballroom of the Hilton Hotel. One hour later, a wedding party was held in the same room!

Presbyopia-correcting lenses

IOLs improved progressively over time. Tinted and UV-coated lenses became available and, from around 1990, presbyopia-correcting lenses(bifocal, trifocal and so-called accommodative lenses) were introduced.

The evolution continued and I became involved in many studies on foldable IOLs (Tecnis) and presbyopia-correcting lenses, and lectured on them at European and American meetings. The most difficult part was selecting the right patient for the right lens.

Phakic IOL implantations

The use of phakic IOL implantations in myopia and hyperopia became important in refractive surgery.Lenses included the Artisan lens, an iris-fixated lens first launched for cataract surgery and later also used for myopia and hyperopia correction in phakic eyes; the Verisyse IOL; and the Veriflex, which is the foldable IOL; all designed by Jan Worstfrom the early 1980s onwards.

The Artisanwas initially referred to as the “worst” lens and so this was a difficult one to promote! I used to perform the surgery bilaterally in one session under topical anaesthesia so that the patient immediately obtained an excellent result. These surgeries gave me the most satisfaction.

Continuous curvilinear capsulorhexis

This technique, now used in every modern cataract surgery procedure, was unknown when I performed my first cataract surgeries. It was popularised simultaneously by Dr Howard Gimbel in Calgary, Alberta, Canada, and Prof. Thomas Neuhann in Munich, Germany, in 1983–1985, both of whom went on to publish their work in 1991.

I visited the two ophthalmologists, acquired the technique and have excellent memories of working with them during many American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery (ASCRS) courses.

Buried corneal knots

The use of aburied corneal knot when stitching up corneal wounds was also unheard of when I started cataract surgery. This technique, whereby the corneal silk stitches knot is reversed and buried in the stroma, was introduced in France by Dr Jacques Charleux in the 1970s.

Before this, the surgeon had to cut the stitches very short so that they did not cause too much irritation, which is difficult to imagine. Of course, nowadays, in most cataract surgeries the incision is so small that stitches are unnecessary.

Freestanding centres

Cataract surgery in a freestanding centrewas undertaken for the first time in Arizona, US, in the 1970s, being unknown in Europe at that time.Of course I wanted to apply these new approaches in my practice: in 1984 I realised the first cataract surgery on an outpatient basis in the Benelux region (Belgium-Netherlands-Luxemburg) in my clinic in Antwerp.

IOL power calculation

Nowadays, a maximum error of 0.25 in the outcome of IOL power calculation seems achievable, but this was not always so. Ridley’s first two cases resulted in an important postoperative refractive error because the refractive power of the material used was unknown and the importance of eye-length measurement had still to be discovered.

IOL power calculation formulas were progressively developed and improved. As American ophthalmologist Prof. Jack Holladay once said, surgeons have the best outcomes with their own formulas.

Measurement techniques have improved spectacularly from the starting point of a contact method that used A-scan biometry, applying a contact probe on the eye with the risk of causing an eye deformity, implementing anatomical instead of optical biometry and creating inaccuracies.

At Ghent University in the late 1970s, together with Dr Roger Allewaert, we developed one of the first optical biometry calculation programs. Optical biometry using the Zeiss IOL master appeared in the late 1990s and I later became involved in teaching many courses on this subject.

International meetings

When I started working in ophthalmology there were no important congresses in Europe, although there were a few very famous professors working in France, Germany, Italy and Belgium. Meetings were more social gatherings than scientific sessions; wet lab and video courses were non-existent and those interested in learning about the latest developments in ophthalmology and meeting pioneers in the field had to visit the US and attend the AAO or the ACS (later ASCRS) meeting.

It was in the US that I learned about outpatient cataract surgery, radial keratotomy, lens implants and phaco surgery, as well as peribulbar(Drs David Davis and Mark Mandel, 1985) and, later, topical anaesthesia (Dr Richard A. Fichman, 1991). The European congresses(for example, European Society of Ophthalmology and European Society of Cataract and Refractive Surgeons) gradually became more important and began to compete successfully with the American congresses.

Botox

Botulinum toxin for the treatment of strabismus was introduced by the late Alan Scott in 1973. When I started using botulinum toxin type A for the treatment of blepharospasm in 1980, the condition was still considered a psychiatric disease. At that time I had no idea that this treatment would become so widespread for so many other medical conditions as well as for cosmetic reasons.

After I had met Scott at one of the AAO meetings, I was able to order the product overseas. It was delivered in a protected lead container because one such a shipment could have killed a huge proportion of the citizens of Antwerp! The dry product was dissolved, diluted one million times and made ready for injection by our pharmacist.

The product received US Food and Drug Administration (FDA) approval for strabismus and blepharospasm in 1989, and in 2002 it received FDA approval for the cosmetic applications as ‘Botox’ (Allergan).

Radial keratotomy

In 1970, Svyatoslav Nikolayevich Fyodorov (1927–2000), a surgicalpioneer, wasthe first to discover that the curvature of the cornea, and consequently its refractive power, changed after it had been perforated by a traumatic impact.This was the start of radial keratotomy whereby 8–16 or sometimes 32 radial incisions were used to flatten the cornea, reducing myopia. This treatment was brought to the US by Leo Bores in the late 1970s.

I attended some courses during weekends in the US, then flew back to Europe and started practising the technique, but first I tested the extremely sharp diamond knife on rabbit eyes. I incised their corneas then placed the rabbits in my mother’s garden and checked on them the next morning.

I found that they were happilyjumping around and eating as if nothing had happened. This was proof for me that I had mastered the technique and could start operating on human patients.

Lasers

In 1985, I became acquainted with the first application of the excimer laser for refractive surgery. Eight European surgeons attended a session in Wangen, Germany, whereit was demonstrated how the excimer laser (MEL 50) could improve the making of radial incisions.

Dr Stephen Trokel, who is regarded as being the first ophthalmologist to recognise the significance of the excimer laser for use in corneal refractive surgery,was present.He had flown in that morning and was extremely tired, falling asleep during the evening dinner.

We later realised that the incision approach was not the right one and that removing part of the cornea was a much better way. In 1992,after a European meeting in Brussels, I organised the first live refractive laser surgery with an excimer laser.

This had never been done before anywhere in the world, but I did not realise that until later. Nearly all European and many American surgeons who were later to become famous in the discipline of laser refractive surgery were in attendance. Together with Prof. Dieter Dausch and some pioneers of excimer laser refractive surgery (members of the Carl Zeiss Academy), and later on Prof. Dan Reinstein, we lectured worldwide on the use of the excimer laser in ophthalmic refractive surgery.

At first we used the rather brutal technique of PRK, whereby the corneal epithelium was removed before the application of the laser. Healing took 3 days and was very painful. The use of a bandage contact lens relieved the pain and the switch to LASIK made it possible to treat both eyes in the same session and practically without pain. Later on, the femtosecond laser was introduced in my eye centre.

I was fortunate to have been involved in the first discussions, at the Zeiss Academy group in Barcelona, Spain, in 2008, where the idea of femtosecond lenticule extraction with a flap (FLEx) and, later on, SMILE was developed. “Mr SMILE,” Prof. Walter Sekundo, was at the forefront of this development.

Nobody at that time could have foreseen that refractive laser eye surgery would become the second most-performed surgery on the human body, after cataract surgery.

Nd YAG laser

Other lasers (argon and krypton lasers) featured in ophthalmic treatmentfrom 1970 onwards. Specifically, the introduction of the Nd-YAG laser after 1980 created a revolution in the treatment of posterior capsule opacification.Until then, this complication had had to be treated by a surgical incision of the opacified capsule.

Final wish

My ultimate hope is that my colleagues experience still more improvements in the beautiful discipline of ophthalmology and that all patients have the possibility of accessing timely and speedy access to the eyecare they need.

Frank Joseph Goes, MD

E: frank@goes.be

Dr Goes is the founder of the Goes Eye Center in Antwerp, Belgium (www.drgoes.be), and is still active as a consultant at the centre. He has no relevant financial disclosures.