High-tech innovation and advanced surgical techniques have transformed the field of ophthalmology, with new treatment options making surgery faster and more accurate. We speak to Professor Rudy Nuijts, a leader in the field of cataract surgery, about the radical changes he has seen and what the future may hold.
How has cataract care changed since you began working as an ophthalmic surgeon?
I was trained in extracapsular surgery which involved making incisions of at least 6mm to remove the patient’s lens. In the early 1990s, ophthalmologists in the Netherlands started to embrace phacoemulsification – a new alternative where the lens is broken into tiny fragments using ultrasound energy before being removed. That changed everything.
How did these advances help patients?
The recovery process was much faster and there was less post-operative astigmatism. Since then, technology has improved further: the machinery we use results in a more stable anterior chamber, with less risk of posterior capsule rupture and there is much more choice and versatility in the range of lenses available for implantation.
Are there other technological advances that have improved outcomes for patients?
The introduction of multifocal intraocular lenses (IOLs) has meant patients can be spectacle-independent after cataract surgery. Instead of just fixing the cloudy vision caused by their cataract, patients can now have a refractive lens implanted which improves their vision. These include toric IOLs which allow us to correct astigmatism and make patients spectacle independent for distance.
Another big leap forward has been multifocal lenses. Most surgeons in Europe have, over the last year or two, moved from bifocal to trifocal lenses. This has big advantages for patients. For example, with multifocal trifocal lenses they can read at intermediate distances – for iPads or reading a computer screen, this is a distinct advantage. Bifocal lenses were good for seeing things close to you – around 35cm – and at distance, but they were not as good for intermediate vision.
What other benefits have there been for patients?
One of the big steps forward has been the use of intracameral antibiotic injections at the end of surgery. This involves injecting antibiotics into the eye to prevent infection and has been shown to reduce risks for patients.
We are also seeing significant changes in the imaging technology available to ophthalmologists. We are now able to take preoperative biometrics of the eye and couple this with what we are seeing in real-time during surgery. This is very valuable information, for instances, in the peroperative alignment process of toric IOLs.
Taken together, all of these advances allow faster visual recovery, more predictable outcomes, and high levels of spectacle independence after cataract surgery.
What do you think ophthalmology has been such a hotbed of innovation?
One reason may be that ophthalmologists generally embrace innovation. Another is that our field is one with high-volume procedures – cataract surgery is one of the most common in the world – so it attracts investment and new ideas.
With so many treatment options, how do you guide patients?
The decision is always a shared decision between the patient and the ophthalmologist. Your task as a doctor is to discuss the options that are out there – to address the advantages and disadvantages, explain any risks. We have to be realistic about what the technology can provide to patients, and patients have to have realistic expectations.
You have an interest in advanced surgical techniques. What future role do you see for robots in eye surgery?
I think we’ll see a more defined role for robotics in cataract surgery and there are a number of pilots taking place in this area. Some robotic technologies are already in use in surgery of anterior segment of the eye. Femtosecond laser cataract surgery is already a refined way of using robotic eye surgery where the laser takes the job of making the incisions, capsulotomy and (pre)fragmentation of the lens.
You have used live surgery demonstrations to train surgeons. What are the benefits of this?
I like to organise these demonstrations because it shows students and younger surgeons what happens in real time. It’s not like playing a few minutes of an educational video; you can show what it means to implement a new technology or procedure into your daily routine. The secret of a successful live surgery is the combination of excellent surgeons and demonstration of innovations like new phaco or imaging technology, or medical devices including IOLs and glaucoma stents. There is always some discussion about whether live demonstrations put the teaching surgeon under a lot of pressure during a delicate operation but for me it has always been a worthwhile experience.
What future do you see for stem cell technologies?
Stem cells can be used to create new tissues like the cornea and one day it may even be feasible to develop new lenses using the patient’s own cells to create the ultimate accommodative lens.
A European multicentre study is looking at how corneal limbal epithelial stem cells can be taken from a patient, transferred to a lab, grown into a new layer of corneal epithelial cells and put back into the eye. Other research initiatives are exploring how this could be done using induced pluripotent stem cells. For example, cells could be taken from a patient’s skin, turned into stem cells and then into corneal cells. It’s very exciting times in eye research at the moment!