Preface to the Second Edition

Coming from a background where ophthalmology ordained the dining table conversation for over seven decades and three generations it is not surprising that the need for revised second editions was thought necessary and mandatory. Especially since our understanding of cataract surgery has been in a perpetually accelerating flux.

Sometimes revelations have been quite by accident however most often progress is steady and slow, depending on many factors like available resources and necessity The more we read and more we try to assimilate information the more we realize how far we are from the understanding of the topic.

Of late it is difficult to understand progress in the coming years of the new millennium without the assistance and utilization of lasers, computers and advanced technology. More often than nought the space traveler it seems enjoys more information and technological advancements than does the mundane operation theater of medical personnel. However even this equation seems to be changing and much like a science fiction movie our operation theaters reel away progress only thought of to exist in future centuries.

Retaining the same concept of cataract surgery this edition throws much light on the why and wherefores with an insight into the modalities of treatment. Along comes research from the offices of Dr David Apple, a person who has brought glamor into ocular pathology and the understanding of different treatment types, along with Dr SK Pandey have explained the reasons why they have come to a conclusion where there seems to be no difference between intracameral anesthesia, topical anesthesia, and now venturing into new grounds—No anesthesia itself.

However good a surgery comes to nought when plagued with bacterial or microbial invasion, many ophthalmic surgeons have gone through sleepless nights in the pursuit of infection control and its management. This leads us to believe that it was essential to have detailed chapter written on the subject. Much to our chagrin there was hardly any material on the topic of Sterilization. It seems to be we all know about it, understand its importance in the surgical field, yet have never really written about it. The maximum one finds in known literature is something written as a chapter of a microbiology book. Still nothing much from a clinician’s point of view, still nothing much in terms of explaining to us what works best, and still nothing more telling us how to work it. Quoting a cop friend of mine, “An assassin has to be lucky just once, I have to be lucky every day, every instant.” In the same light we as surgeons have to be on our guard every time, every instant, the bacteria need be lucky only once. Add to this is sometimes the diplomatic approach of instrument engineers who wave aside grave consequences to patient’s wellbeing in the interest of their product image. Sometimes we overlook the obvious, just like we look for the source of light standing right under the sun, similarly the internal tubing of an ultrasound machine that gauges the pressure inside the eye, is actually the prime source of infection in phacoemulsification.

With the Mediterranean influence of L Burrato we have a new chapter on the adversities of a small pupil and still manage to perform phacoemulsification with the greatest of finesse, “Pushing an elephant through a keyhole”. Giving importance to Incisions is S Pallin, small steps of the surgery which go a long way in its success. Posterior Polar Cataract has new light from A Vasavada whose immense knowledge on phacoemulsification makes him a leader in this field.

Coupled with this progress is the inroads made by Indian ophthalmology along with Indian engineering and scientific skill that have been displayed for all to see at the pinnacle body internationally as far as cataract and refractive surgery are concerned, the American Society for Cataract and Refractive Surgery (ASCRS) were witness to live surgery telecast from India to America at the 1999 ASCRS meeting. This instruction course made history with it being the first time such an event had occurred and displayed live—No Anesthesia Laser Phakonit (under 1 mm) Cataract Surgery. Thus all that we had written about came to pass when delegates were able to see the surgery in its full form. Such feats would be repeated more often at different meetings since seeing is believing!

As the volume of knowledge has expanded, so too the need for multiple contributors. To strengths of diversity and multiple forms of expertise, this trend has created a burden on the editorial. Thus consistency of writing form is difficult to maintain, however this also adds to the texts’ value as a learning and teaching tool. The whole volume of the book has therefore extended and with more color plates and more reading material, we hope dear reader you enjoy reading this as much as we have in writing it!

Editors

Preface to the First Edition

Forewords rarely touch the reader’s heart unless the writer sends them out from the same location. That gives us a fighting chance, because we have spent our entire life in the pursuit of ophthalmic sciences and still count this as one of our good friends that always reserves its gratitude and encourages our chances of discovering further and further in its wake.

To write a book today in the world of entertainment with video, movies and the whirlwind of computers seems gratuitous. Still the beauty and magic of reading will never fade and the history of writing that dates back more than 5000 years can never be surpassed. To the memory of the writers of yore and to encourage the many more writers to come, we have taken the task of bringing you the latest synopsis of the trends in cataract surgery through the nineties.

The scientists and researchers of today are full time clinicians who have placed their energy in the development of new ideas. In fact if you go back in time, most discoveries and inventions have been made by the person attempting to correct human malady, and while doing so perchance steps onto some discovery or invention.

It was in this same manner the father of Intraocular lenses while treating pilots from the Royal Airforce during the Second World War came to the conclusion that IOLs were a possibility. He noticed that pieces of windshield material lay immersed in ocular tissue producing no reaction and were transparent and could thus be implanted into the eye (in the place) of spectacles. Dr Harold Ridley thus brought about one of the greatest advancements in this century as far as ophthalmic sciences are concerned. To him and his batch of pioneers, ophthalmology down the ages will always have a place of honor. Salutations to such torchbearers and more to come.

When we look down at the achievements that the human mind has achieved in the realm of ophthalmology and its progress, we are baffled by its enormity especially when we know that there is still so much more to be discovered and so much more to be invented. The scientific progress that has occurred in the last 100 years has bypassed all that could have occurred in the last 5000 years from the Neanderthal cousin of ours, and that which will occur in the next decade itself will be a renaissance in ophthalmology. We still know only a drop in the ocean of the ophthalmic sciences and we realize that what we can dream, we can certainly achieve in the forthcoming years. This book aims at giving you dear Reader not only food for thought but also in contributing to this Renaissance, thereby, achieving the dreams our forefathers had in this beautiful world of Vision.

Through the reading of this book you will find subjects divided into six basic structures to ease you in the understanding of what cataract and its management mean today. The contributing authors are themselves authorities on the topics of their choice. All stages of learning have been taken care of through these six stages from the learner

through the advanced surgeon, bringing you to bear down on mayhap a forgotten episode, for we all know “Trifles make perfection, though perfection is no trifle.”

The computer has brought into our world a dream of precision and this has come to become a part of every machinery developed in the modern world. In fact when we look into what “robotics” have done to this factor, we realize we are very close to making the blind man see. Many have been the times that patients have asked their eye surgeon, “Cannot you change my eye itself?” Yes, now we can reply them with the idea of repositioning a video camera and sending the signals into the brain directly. Unthought of till only yesterday, and today will soon be a reality.

A surgeon in the midst of surgery in his or her home town can now think of operating in orbit around the world with a little help from satellites and robotics. Now most distant of patients can get the precise expertise from the dexterous experience of the surgeon. Very soon no one will be bereft of resourceful opinion and/or surgery in this world and that beyond the stars.

Marching towards the next millennium we have accessed cataract surgery with an intraocular lens insertion under the 2-mm mark with the latest “laser cataract surgery,” becoming a reality. Coupled with changes in ultrasound technology it will create many newer trends in the years “beyond 2000”. Phakonit has brought the incision of cataract surgery to 0.9 mm. Computers and lasers have crossed many marks, and “intrastromal lasers” will soon see the light of the day. Spectacles will not be worn for the want of refractive errors with the latest modalities of the LASIK laser and its contemporaries.

This reading hopes to take you down the lane from humble beginnings of a retrobulbar to peribulbar anesthesia and now to the present exodus of topical anesthesia to the advanced “No anesthesia” ophthalmic surgery, taking its first few steps of infancy in India. After all, have we all not seen sudden injuries to the eye reflecting no pain to the patient? It hopes to give you food for thought and may be rethink the corneal reflex, rethink the anatomy and physiology of the eye itself and delve into the basic sciences of our specialty, “the eye”.

It is said that the pen is mightier than the sword (here the surgical knife) and in this case both go hand in hand, and thus, whatever the knife has done the pen has put it down for you to read.

Contributing authors have already left footprints on the sands of time. Let us further your objective in strengthening the armor of ophthalmology.

Editors