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Phaco at 50: The Legacy of Charles Kelman

50 Years of Phacoemulsification

The Legacy of Charlie Kelman: Inside, and Outside, Ophthalmology

Fifty years ago, Charles Kelman, MD, published a paper describing a procedure called phacoemulsification, a method of removing the eye's internal lens that ushered in the era of modern cataract surgery. In remembrance, a few who knew him — Paul Koch, Eric Donnenfeld, Larry Patterson, Robert Osher, Richard Lindstrom, Johnny Gayton and Robert P. Lehmann — shared their memories of the man and his contributions to the field of medicine.

Charlie Kelman

Charles "Charlie" Kelman, MD

Here's the thing about Charlie Kelman: his legacy stretches beyond ophthalmology, his impact on the world of medicine is immutable.

When Dr. Kelman and co-inventor Anton Banko filed patent application 655,790 on July 25, 1967 in a Brooklyn patent office, what started as a so-called keyhole procedure to remove a defective lens in a safe, effective way was eventually adopted and modified by other medical specialists — like oncologists for the spine and breast — for their surgical procedures.

Dr. Kelman received the Lasker award for clinical medical research in 2004, a few months before he died at age 74. The Lasker, first awarded in 1946, often precedes a visit to Stockholm: 87 Lasker laureates later became Nobel laureates, nearly half in the last three decades. Fellow Lasker awardees (for another area) include James Watson and Francis Crick, essentially the founders of personalized medicine.

Perhaps the more remarkable association awarded Dr. Kelman is his inclusion in the National Inventor’s Hall of Fame. People like Alexander Graham Bell and Henry Ford are fellow members. It’s a niche membership whose awardees changed people's lives, worldwide.

But for ophthalmologists, who know of his remarkable legacy, like those who have contributed to this 50-year anniversary project of the invention of phacoemulsification, he will always be Charlie.

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July 1, 1967


Phaco-Emulsification and Aspiration: A new technique of cataract removal: A preliminary report
Charles D. Kelman. American Journal of Ophthalmology
Volume 64, Issue 1, July 1967, Pages 23-35

This paper describes a method of dissolving, emulsifying and aspirating a mature cataract through a two to three mm incision ... For the past four years, I have concerned myself with the possibility of transforming the mature cataract into a solution or an emulsion, thereby making aspiration possible.

From the Cryo-Research Department, Manhattan Eye, Ear and Throat Hospital. (The phaco-emulsifier was developed in conjunction with Cavitron Corporation.)

The first surgery took 76 minutes and 20,000 Hz.

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Phaco-Emulsification and Aspiration

Genesis: Dr. Kelman describes his new procedure

Early Memories

Paul Koch, MD

In 1979 I found myself learning phacoemulsification in Room Five at the Manhattan Eye Ear & Throat Hospital. This was the same operating room Charles Kelman screened off from prying eyes when he did his first cases. I was helped by the same scrub nurse and machine technician who worked side-by-side with Dr. Kelman while he was inventing the operation. They stuck with me during my entire residency and gave me insights I’d not find anywhere else.

Cavitron

1970s - Alcon - Cavitron

The machine was a Cavitron 7007, the blue box. A heavy and cumbersome cord led to the hand piece. We had to assemble the hand piece by screwing the fluid pipes onto the barrel, and sliding on a pair of "O"-rings to keep unsterile cooling fluids from leaking into the eye. Then we had to tune it manually. I buzzed the hand piece while Lloyd the tech turned a knob back and forth until a needle on the dial showed its best reading.

Aspiration was limited to two settings: Min and Max. Min was used with the wide-bore emulsification needle while Max was used with the small cortical aspiration post.

The only incision was made at 11 o’clock under a small limbal-based conjunctival flap that we could lift to pucker open the incision to help instrument entry. We never thought of making a side incision for another instrument. Every operation was one-handed. Every incision was closed with a few 8-0 virgin silk sutures.

We used Christmas Tree capsulotomies and prolapsed the nucleus into the anterior chamber by dislodging it so far that the equator crossed the midline of the pupil. We pushed the nucleus against the endothelium first when we advanced the tip and again when we retreated it — all without viscoelastics. Looking back today, I wish I had taken more photographs of what was then audacious; now a Legacy.

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Daisy

1986 - B+L's first Phaco machine dubbed Daisy: Digital Aspiration Irrigation System

A Close and Pleasant Encounter

Eric Donnenfeld, MD

I had finished my first year of medical school and was home on Long Island for the summer. I was visiting my [doctor]. He asked me what area of medicine interested me. I said I wasn’t certain but I had always thought … that ophthalmology might be interesting. It turned out that his cousin was an ophthalmologist on Long Island and he arranged for me to spend a day with him in the operating room. The cousin turned out to be an extremely friendly man and he welcomed me into the world of ophthalmology. As a first-year medical student I watched in awe and was inspired while he spoke to patients, told stories and performed the first phacoemulsification I’d ever seen. I knew after that day all I wanted to do was become an ophthalmologist. [His name] was Charlie Kelman.

His ideas about cataract surgery and intraocular lens implantation were not embraced by mainstream ophthalmology.

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Cavitron

1972 - Alcon - A slimmed down Cavitron

Shaping the Risk Takers

Larry Patterson, MD

Although I've been in ophthalmology nearly 30 years, I was one of the few who did his first private practice cataract surgery case utilizing phacoemulsification.

Millennium

1996 - B+L's Millennium was one of the first modular platforms created

It wasn't without controversy. Knowing that around 90% of eye surgeons were not using phaco emphasized the fact that most felt the procedure was too technically challenging, too much of a risk to the eye, or a combination of both.

One evening in 1989, a small group of eye surgeons in my area met for an informal meeting and dinner. One was a skilled extracapsular surgeon in his mid to late 30s. He remarked that with the growing popularity of phaco, we would, in the not too distant future, experience a rash of blindness from corneal decompensation the likes of which our profession had never encountered. As a 29-year-old solo practitioner and the only surgeon in my region performing phaco, the thought of that happening to my patients was sobering at best. Of course that didn't happen, and the rest, as they say, is history.

Robert Osher, MD

Besides being a creative and surgical genius, Charlie Kelman also possessed great empathy, encouraging people like me whose ideas were rejected by mainstream ophthalmologists. In 1983, I presented at a Cataract Congress in Houston my procedure for combined phacoemulsification with astigmatic keratotomy for the reduction of pre-existing astigmatism. The star-studded faculty considered this a mutilating surgery. But Dr. Kelman and Dr. Spencer Thornton, a leading authority on astigmatism, wanted to know the results and encouraged me to continue down this early path of refractive cataract surgery.

That same year, I presented a case at Academy on implanting a posterior chamber lens into the capsular bag when the posterior capsule was torn. The universal management consisted of a backup anterior chamber lens. Even though Dr. Kelman was king of anterior chamber lenses, he put his arm around me and told me to continue investigating these new ideas.

The following year, I developed the first surgeon-controlled machine. Cooper Vision rejected this concept. An Italian company, Optikon, was willing to gamble and introduced the Phacotron Gold. It had surgeon-controlled ultrasound, aspiration rate, a vacuum, and adjustable, continuous irrigation. Charlie sent me a letter that I have always treasured. Slow-Motion Phaco eliminated most of Charlie's published contraindications including the small pupil, the mature cataract, and the loose lens.

When a few years later I presented the first case of clear lensectomy in high hyperopia, my peers severely criticized me for operating upon the transparent lens. But Charlie advised me to ignore the criticism; peer rejection, he said, was the price of innovation. Charlie took the pain that he had suffered from overwhelming rejection and converted it into positive energy. I still miss him every day.

Letter to Bob Osher

A letter from Dr. Kelman to Dr. Osher (1980s)

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A Great Teacher and Mentor

Richard Lindstrom, MD

Phaco Plus

2004 - AMO design's first digital footpedal

Charlie Kelman was also an innovator in surgical skills-transfer education. He developed the first phaco courses in New York and taught them himself. He then created a West Coast course with the help of phaco pioneers Dick Kratz and Bob Sinsley. He would screen course participants for dexterity, including holding a simulated phaco handpiece steadily inside a ring for 60 seconds. If the edge was touched, a buzzer would sound. If a surgeon could not pass this test, he would refund his money and not allow that surgeon to take his course. Just like today, trainees wanted to see the experts perform surgery in their own operating rooms in “routine” nonedited cases. … Because the ability to transmit live surgery cases did not exist in the 1970’s and 80’s, Charlie invented “Surgicus”: He hired a videographer to travel to 10 surgeons’ operating rooms each year and video a full day of surgery. All cases were recorded from start to finish, including complex and complicated cases, and then sealed and mailed back to New York. He then selected cases from the so-called “best “ surgeons in the world and showed their challenges and complications. He also presented awards, including a “Golden Hands” award for the surgeon he thought demonstrated the greatest skill applying his beloved phacoemulsification technique. He also ruthlessly skewered those who demonstrated poor judgment and poor technique.

I participated in this program several years as a surgeon. It was in many ways quite intimidating. I won the “Golden Hands” award one year while managing a case of intraoperative choroidal hemorrhage. Some amazing cases were shown, including a famous surgeon chasing a dropped nucleus into the vitreous with a phaco probe; another removing the entire iris followed by an anterior chamber full of blood along with many capsular tears; and vitreous loss managed with varying levels of skill. It was an extraordinary learning experience — another Kelman original.

Johnny Gayton, MD

I was on the ASCRS's Innovator's program with Dr. Kelman in 1996, the same year Dr. James Gills was honored. He liked my work with astigmatism reduction in cataract surgery and the piggyback technique. I asked him if he was willing to write a forward for my book on eye care for the general public; he graciously agreed. My admiration and gratefulness for him soared. In 1997 I became even more grateful to him when Dr. Richard MacKool used phacoemulsification to remove my cataracts. Dr. Kelman enhanced the lives of many millions of people around the world. I am one of those fortunate people.

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Book jacket

Dr. Kelman considered Dr. Gayton's book, The Crystal Clear Guide to Sight For Life, "Highly readable & educational..."

Another Side of Charlie Kelman

Robert P. Lehmann, MD

Kelman

Dr. Kelman, also an avid saxophone player, once played Carnegie Hall for the Louis Braille Foundation for blind musicians

I was at dinner with Charlie one night when he talked about an ophthalmologist from outside the country who was quoted in the press about how quick and easy cataract surgery had become because of phacoemulsification. Now, I had seen Charlie as a performer, (he played the saxophone) speaker, fellow course instructor and on occasions socially, but the only time I saw him really get his face red and blood pressure up was when it came to doctors making stupid statements about how simple cataract surgery had become. At the same time that this physician was in the press a number of US guys were starting to advertise but not in the way that we do now.

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On Dr. Kelman's Legacy

Eric Donnenfeld, MD

Charlie Kelman was instrumental in developing and growing our organization as a safe haven for pioneering ophthalmologists to share radical ideas, develop new concepts and question authority in a protected, supportive environment.

There are very few surgical procedures in all of medicine that have survived for 50 years as the treatment of choice. However, longevity is not the most impressive aspect of phacoemulsification; this was the first small-incision surgery ever performed and the harbinger to every other small-incision surgery performed today. The common ancestor of laparoscopic gall bladder, spine, hip and knee surgery is Charlie Kelman. His contribution to medicine was disruptive in every respect and I believe he will someday be honored with the Nobel Prize for medicine.

Robert P. Lehmann, MD

Innovation begets innovation, and Charlie Kelman opened the door of innovation to all of us.

Over the years, Phaco machines have gotten taller and slimmer. These are relatively new to the market.

Stellaris Elite

2017 - B+L - Stellaris Elite

Centurion

2013 - Alcon - Centurion

Sovereign

AMO - Sovereign

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