Chapters Transcript Cataract Surgery Past to Future: It is projected we will have 50 million blind from cataracts by 2050 Course: Current Concepts of Ophthalmology 2025 Uh, we're gonna take you on a little bit of a journey today. We're gonna talk about where we are in terms of, uh, global blindness, but specifically talk about cataract surgery. I'm gonna talk about some technologies that aren't the answer but are going to be part of the answer and and I say part of the answer because we don't yet have the answer to how we can get on top of the burden of cataract blindness throughout the world. Uh, I have no financial disclosures. Uh, the International Association Agency to Prevent Blindness IAPB is a membership organization. That membership organization has academic institutions, NGOs, um, World Health Organization, etc. and they put together something called the Vision Atlas, which I do want all of you to go to. You can go to the next slide. So the Vision Atlas, um, gives you this really nice visual representation of what's happening in the world and why we have different types of blindness. You can go to the next slide please. Uh, how are we doing with blindness? Uh, this is 1990 on the left all the way to 2020 on the right, and as you look, age standardized uh prevalence of vision loss, we're doing better, and so for age groups 65 to 85, there are less blind, and, and in particular you see the changes occurring in the yellow bar, and that is from cataract surgery. Uh, how is that possible? Well, uh, that's really possible because of some really extraordinary institutions and surgeons around the world who have found ways to provide the highest quality cataract surgery at extraordinarily efficient, uh, both in terms of cost and then surgical expertise means. Uh, let's go ahead and go forward then, uh, to our, we'll just go straight to the video and if you wouldn't mind playing that. So, for those of you that haven't seen a small incision cataract surgery, uh, it's a type of manual cataract surgery where you're going to deliver the entire lens hole. The lens itself, uh, in these, you know, of course, is about the size and shape of an M&M, so you need a large wound. Those who trained in traditional sutured extracapsular cataract surgery, when you make that large opening, it requires you to then suture that closed, and it really is that suturing that took as much time as anything. So throughout the world, when we all pivoted toward Feo sometime around the 80s. The rest of the world or many parts of the world, low and middle income countries, continued to do this manual form of cataract removal, and what they evolved over time doing thousands upon thousands, is they evolved the surgery that does not require sutures anymore. So what you'll see here is this beautiful scleral tunnel. This is partial thickness, it's a funnel funneling out large there within the cornea. And now we need to go in and we're going to make a tunnel. Again, it's sort of a blind pocket there. Um, this is my mentor, Doctor Bia Pont. I, I, during my international fellowship, I spent 6 weeks with him, frankly learning how to do the surgery. So now we're in the anterior chamber to the right, and as we cut to the left, we're going to open that up entirely, and now don't blink cause you might miss a capsulotomy. This is not going to be the CCC you're used to, this right here. Is called an envelope capsulotomy. So entering into the anterior capsule, taking that to the right and to the left. Now we've got this large envelope where we can deliver this large lens up. Now for all cataract surgeons, you know, well, what do I need to do? One, I need to get that lens up a little bit, and I need to put in some viscoelastic because I don't want that posterior capsule to be hugging up against this lens. This is creatively named a fish hook. This is a modified 25 gauge needle. That's curved to a point and because so many of these lenses are dense, you can just remove them. Um, this is again Doctor Pont's surgery. He's about 90 seconds into the surgery at this point. You can also see how he is my north star for being elegant and quiet in the eye. So interestingly, and I've edited some of this out, um, the removal of cortex takes just as long as that entire first step of removing the rest of the lens, and the reason for that is these patients, often coming from, you know, miles away saving up a month's worth of income travel into an eye hospital, they can't just pop in for a yag and so you will see again this incredible amount of of of cleaning. I'm gonna just advance forward. Some of you might be asking, well, what about this envelope thing? First of all, you, you already broke all these rules of cataract surgery by cutting into the anterior capsule. Well, we have this envelope and this is a single piece PMMA. This is all plexiglass sliding in. This is manufactured for less than $1 in Nepal. Now we're gonna remove the anterior capsule. And that's removed by cutting one side of the envelope, cutting the other, and now we have this roof still in place, so you could grab it with the eutrota. In this case, the more efficient way to do it is to aspirate it with your simmco cannula, and now you no longer have an anterior capsule sitting on top of the lens. You remove the rest of the viscoelastic in the eye, the rest of the cortex, and you're off and running. Now, these type of surgeries take as little as, you know, 4 to 5 minutes uh in the right hands. For those of you that are learning, they take longer than that and you will meet a lot of complications. Thank you, this is working. I appreciate it, team. Now as we look here at this slide, we're back to age standardized prevalence, so I want you just to think for a moment. We're age standardized. I said percentage of people who are blind between 65 and 85, uh, that's gone down from cataract. Now we're gonna look at crude overall prevalence, what you see in the entire population. So this is different And now all of a sudden, hm that doesn't feel quite so good. So why is that? Um, and the answer is really illustrated here in our next slide, uh, and this is showing the overall numbers affected by vision loss or blindness from 1990. To 2020 and despite these amazing efforts by extraordinary surgeons and hospitals, there's more blindness throughout the world, and that's simply because of the math of aging simply the, the, um, baby boomer equivalent throughout the world, uh, is, is overwhelming our ability to uh to keep up. So what does this mean then looking forward, um. Three types of vision loss here, blindness moderate to severe or mild, that's basically 2200 or worse is blindness, 2060 to 2200 moderate to severe, uh, and then there's mild near vision loss that is just people that don't have reading glasses throughout the world that need them. That's one we certainly by 2050 had better be on top of, but again, why are we projecting. That we will have more blind. Why are we projecting that we're going from 20 million blind now to 50 million blind then? The answer is the math of demographics of an aging population. But we've got time Couple of different maps, these could represent a lot of different things. I'll tell you, uh, give you a little mental exercise. One of these maps represents where the blindness is in the world, and one of these maps represents where the ophthalmologists are in the world. And you'll see there's an inverse relationship and Doctor Basras I want to give all credit to, um, he, uh, out of the UK and he really kind of coined this idea of the inverse relationship of blindness and where the physicians are, and this is where we really have an opportunity. Sitting in this room. Right now in Tanzania, where I've been working for over a decade, there's 1 ophthalmologist per million people. And that you can take in washer and for a lot of sub-Saharan Africa and many, many places in the world. Until you have enough competent surgeons, it doesn't matter how efficient someone is, you just need enough people to do the surgery, so that does not, that means if we all pitched up and went and did cataract surgery for one month out of each year in Tanzania, just one country. We probably, if you do the math, you probably don't really change things for about 10 years. However, if we as an academic entity and the academic entities within the United States and Europe and Africa and India, if we really put our efforts into raising academic ophthalmology in these places, we actually have a shot. Because if you all 3 of you in this room help them facilitate a residency that in 10 years is training surgeons in the country, you've really started to scale some of the impact that we need and that's really what was behind the global ophthalmology summit. Uh, this is a uh partnership with the American Academy of Ophthalmology that we started a few years ago, uh, and also backing this is now a growing group of academic institutions is very new, um. Certainly have a conversation with Doctor Colby about this. Um, these are institutions backing, uh, this, this summit and this idea of how we can in academic medicine make a difference. It's still here Uh, imagine I'm not a sales person. Uh, I do, I do have to, um, divulge. I am a consultant for Zeis and Alcon, and this is a Zeis product. Uh, but imagine if I could take this and this was all I needed for cataract surgery to go in somewhere and do cataract surgery and I could have 50 of these in my carry-on bag. Now, that's my hope for this, and I'll just tell you now, it's not there and it's not the solution. And something like this will have to be developed for us to do what we need to in the future. Um, this is FDA approved. It's actually being used here in the United States. It's called the my core device. This is how it looks. This cord actually plugs into uh the wall. So, um, you plug something into the wall and you've got this little motor. This motor spins, that's all that it does. This connects to the motor. This is the FAO hand piece. This is also the IA hand piece rather than a foot pedal, you have this little lever here on top that actuates the motor and creates the aspiration or agitation to remove a lens. When I'm ready to do IA, I switch over to this tip, pop it on, and we're off and running, and we're doing our IA portion of our surgery. This rotates This also is annoyingly loud. So This is in our lab doing some work. I actually had a patient that I was doing surgery on ask for more sedating medication because that noise was so irritating and bothersome to them. What does it look like actually inside of an eye? You can do lots of different techniques. It particularly lends itself to something like this. This is an Akahoshi pre-chopper, by the way, for early residences is a really lovely way to learn surgery. It's really one handed. You can see I've got quadrants and you'll see it kind of looks and behaves largely like the eco hand piece would. So we're just gonna pull this up into the AC and just start, uh, aspirating and kind of emulsifying this with this hand piece now. You can also do a horizontal chop technique, you can do a vertical chop technique. You can groove in a soft lens, but it really doesn't lend itself well to that. But again, it largely looks similar, um, in, in, in sort of our early experience across the country, um, you might hear some people say this cuts OR time. Well, I think so if you're only doing 2020 soft cataracts because as we've looked with a few different surgeons, it just doesn't do as well on anything plus a 2 + lens yet. Now that doesn't, it's not to say it won't, um, I can only imagine what Charlie Kelman's first VAO machine looks like versus what, uh, we're currently doing. So I just want to leave that as a construct again this, this, there's certainly some edema that develops, um, so we're talking about again. Scaling surgery to millions. With a finite number of trained surgeons throughout the world, are we ever going to get to a point where we can do something like robotic cataract surgery, um, or some sort of, uh, autonomous cataract surgery? Uh, um, to say no, I think would be be perhaps not having an open enough enough uh enough mind yet. Let me just show you one technology that could be something really interesting that the um uh again that can play a role. This is called the bionics microscope. Um, there's a company out of Israel, um, they, they started in flight, not flight simulation but actually air, um, uh, fighter pilots, and so you'll see there's actually a heads up display here and what does this look like? So the microscope sits over the patient, you put on this heads up display. This is, uh, our resident here assisting. Uh, and the interesting thing is she actually sees my view. Everything I see through the scope is something she sees. Now here's the thing that's gonna hopefully, well, not even hopefully potentially blow your mind. This has an infrared mode. So here we're doing your typical cataract surgery and all of a sudden you're gonna see the red reflex goes purple. And that's because there's infrared light going into the eye. And that infrared light actually gives you this really amazing, uh, again, purple reflex. So thinking about something like a, a DSE, um, you know, this, this amount of, of kind of clear detailed resolution here that you can see, it's, it's certainly is more another crazy thing right here and I'll just pause here. All the lights are off. There is no overhead light shining on the patient right now. This is a dark room, and there's infrared light shining into the patient's eye and you're getting this infrared reflex back. Why do I bring this up and I talk about global uh blindness? We don't have the answers. Our current models are insufficient to change how we're going to cure 50 million blind cataracts by 2050. One thing that young people do really really well is come up with innovations and ideas and when you look at Nobel Prizes, uh, or you look at innovations that have come in tech, they've all come from people whose brains are teenagers up through about age 30. They might get their awards a little later in life. You all will be the group that comes up with the innovations and ideas and hopefully perhaps seeing some of what you've seen today piques your interest because we need to learn from you because our current models while great, decreasing the prevalence in age, they're not decreasing the overall prevalence of blindness like we need to. Thank you and thank you AV team. Published January 24, 2025 Created by Related Presenters Jeff Pettey, MBA, MD
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