ESCRS 2024 Heritage Lecture Awardee Dr. Richard Packard takes us down memory lane, celebrating how eye surgeon cum saxophonist Charles “Charlie” Kelman introduced phacoemulsification to the world, a breakthrough that continues to benefit millions today.
The Heritage Lecture Award, one of the most anticipated events at ESCRS 2024, honors individuals who have made significant and lasting contributions to the field of ophthalmology.
This year, this prestigious award went to Dr. Richard Packard (United Kingdom) who has played a significant role in shaping the society and its heritage projects, contributing to its growth over the years, as noted by ESCRS President Filomena Ribeiro.
In his opening remarks, Dr. Packard humbly expressed gratitude for the honor, especially as it coincided with the 75th anniversary of the intraocular lens (IOL). The theme of his lecture focused on phacoemulsification—a revolutionary technique introduced by Dr. Charles Kelman in the 1960s.
Dr. Packard chose this topic to highlight the legacy of Charles Kelman, who passed away 20 years ago, as he felt many younger ophthalmologists might not be fully familiar with his contributions to this seminal technology.
From musician dreams to phacoemulsification pioneer
Dr. Packard described Charlie Kelman as a man of many talents from a young age, with dreams of becoming a musician. However, after a dramatic encounter with his father, Kelman was encouraged to pursue medicine.
But despite his luminous medical career, his passion for music never waned, and he even adopted the stage name Kerry Adams. One of his songs, “Telephone Numbers,” led to a recording contract, but his music career eventually stalled, leading him to refocus on medicine.
One day, he envisioned a revolutionary idea: could a cataract be removed through a tiny incision, enabling patients to leave the hospital within a day or two rather than enduring a lengthy ten-day stay? To make this vision a reality, he dedicated years to experimenting with various methods, from encapsulating lenses in rubber bags to drilling and grinding them. It wasn’t until a breakthrough moment in his dentist’s office that the concept of ultra-acceleration through ultrasonics occurred to him.
This led to the creation of the first phacoemulsifier, a machine so heavy that it had to be suspended above the patient’s eye during surgery. Despite the challenges, Charlie persisted, patenting his invention and conducting the first human phacoemulsification in 1967. Early procedures were difficult, with surgeries taking up to four hours and complications arising frequently.
Dr. Packard shared dramatic moments from those early surgeries. One assistant, Cheryl Jarvin, described the tension in the operating room when complications arose. Despite these difficulties, Charlie’s determination paid off. By 1970, he was ready to teach the technique, holding rigorous week-long courses in New York. These sessions introduced surgeons to both phacoemulsification and operating under microscopes, a new skill for many at the time.
From skepticism to standard of care
The spread of phacoemulsification across the globe was gradual, with early adopters like Dr. Eric Arnott (Dr. Packard’s mentor) bringing the technique to Europe in the early 1970s. However, resistance was strong and complications from the procedure raised concerns among practitioners.
Dr. Packard reflected on this period of skepticism, recalling how patients with bad outcomes were highlighted at conferences and an open mic session allowed people to share their negative experiences.
Despite this, Charlie persisted, capturing the media’s attention with his dual identity as both a saxophone player and a doctor. Although his practice grew, phacoemulsification did not gain widespread popularity. Dr. Packard explained, “The reason was that the iris clip or anterior chamber lenses in use at the time required large incisions, so people questioned the need for phaco.”
By the late 1970s, there were estimated to be over 700 phaco machines in the USA but most were not being used by patient demand due to surgeon’s concerns about complications.
Dr. Packard recalled that when he finished his Moorfield residency in 1978, phaco and intraocular lenses (IOLs) were not widely used. However, things began to change, thanks to the development of foldable lenses.
Dr. Packard recalled how he and his colleagues experimented with folding lenses to fit them into phaco incisions. “Some of the original phaco adopters were producing new designs to overcome issues with incision size needed with iris supported lenses, such as the J loop lens and the Sinskey/Kratz lens,” he said.
In 1984, Thomas Mazzocco successfully produced the first folded silicone lens that could be injected through a cartridge, revolutionizing foldable lenses. “This, and other foldable and small incision lenses that appeared in the 1980s turned many surgeons from ICCE (intracapsular cataract extraction) and ECCE (extracapsular cataract extraction) to phaco,” he said.
“During the 1980s, several key advancements in cataract surgery emerged, including scan biometry and YAG lasers, eliminating guesswork and the need for frequent adjustments,” Dr. Packard explained. He also noted that in 1989, the four quadrant nucleofractis technique by John Shepherd (commonly called ‘divide and conquer’ today) brought many surgeons to phaco.
“Phaco and Charlie were at long last, being recognized. He received from President HW Bush the National Medal of Technology in June 1992,” he recounted. “He was overwhelmed, as he felt that his dream of minimally invasive cataract surgery had now come to fruition.”
Throughout the 1990s, a variety of foldable lenses made from different materials became available. As these foldable IOLs gained popularity, phacoemulsification became the standard of care for cataract surgery in the developed world by the mid-1990s.
At the same time, phacoemulsification techniques also continued to evolve, with new methods emerging such as Dr. Nagahara’s ‘Phaco chop’ in 1993, Dr. Akahoshi’s ‘Phaco prechop’ in 1994, and the ‘vertical chopping’ in 1998.”
In the 2000s, lasers began assisting with various parts of the cataract surgery process. Advances in phaco fluidics and power delivery have continued to enhance the safety and efficiency of the procedure.
“Much has happened to phaco over the 60 years since Charles Kelman sought faster recovery from cataract surgery. In 2003, the AAO, which had once criticized Charlie, finally honored him as an AAO Laureate,’ Dr. Packard remarked.
“Phaco has brought us to a point of sutureless micro-incisions, viscoelastics, capsulorhexis, phaco machines with power modulation and advanced fluidics, as well as techniques like phaco chop, stop and chop, and prechop.
“We now have increasingly accurate biometry, square-edge foldable lenses capable of correcting astigmatism and presbyopia, and laser assistance for parts of the surgery. Thank you, Charlie, for all you have given us and our patients,” Dr. Packard said, concluding his speech.
Editor’s Note: Reporting for this story took place at the 42nd Congress of the European Society of Cataract and Refractive Surgery (ESCRS 2024), held from 6-10 September in Barcelona, Spain.
