Aspen Report 3 – Removing the Blinders: Dr. Kelman’s Wonderful Contribution, Brian Klepper

One
of the most fascinating and moving experiences at the Aspen Health
Forum – Given the quality of the content there, this is saying
something. The audience was rapt – was a talk by Neen Hunt, Executive
Director of the Lasker Foundation.
Each year this organization bestows a hugely prestigious prize to
individuals who have made significant contributions to scientific
medicine, clinical medicine and public service.

Dr. Hunt’s talk
focused on combating the geeky stereotypes that often are associated
with people with dedicated passions, and on conveying their broad
humanity. Her vehicle was a character portrait of Dr. Charles D.
Kelman, an ophthalmologist practicing in Manhattan during the latter
half of the 1900s, who in an incredibly bold stroke, blew past
convention, inciting the wrath of those tied to the established order,
and revolutionized the way that cataract surgeries are performed.

Much
of Dr. Hunt’s speech was borrowed, with permission, “almost verbatim”
from an account of Dr. Kelman written and presented by Dr. Joseph
Goldstein, Chairman of the Lasker Awards Jury, at the 2005 Albert
Lasker Medical Research Awards Program in New York City.

After
the Aspen Health Forum, I asked Dr. Hunt whether I might obtain a copy
of her talk. She graciously agreed, with the stipulation that I
acknowledge that most of these words are really Dr. Goldstein’s. I am
delighted to do so.

This presentation had a special, personal
meaning for me. When I was 15 in 1967, my father, a strapping, utterly
engaged man, had the old-fashioned, draconian cataract removal
procedure that Dr. Kelman’s innovation replaced. I vividly remember
gasping, seeing him so diminished immediately post-surgery, eyes
patched, head sandbagged, wrists restrained. For the remainder of his
life he wore the Coke-bottle glasses Dr. Goldstein describes (and
later, hard contact lenses that, while still miserable, were an
improvement). I couldn’t know it at the time, but this experience
provided a frame of reference that allowed me to appreciate all medical
achievements, Dr. Kelman’s included, that relieve impairment and suffering, and that
dramatically improve the quality of lives.

Now
read this wonderful excerpt from Dr. Goldstein’s account of Dr.
Kelman’s contribution, relayed nearly perfectly intact through Dr.
Hunt’s warm, passionate delivery.

Cataracts are the major
cause of reversible blindness throughout the world, affecting about 20
million people. About half of us here today will suffer from impaired
vision because of cataracts. There are no drugs, no eye drops, and no
diet that will make a cataract disappear; the only treatment is
surgical removal. Historically, cataract surgery is one of the oldest
operations, second only to circumcision. Prior to 1970,
cataracts were the leading cause of blindness in the United States.
Today, cataracts no longer have this distinction – thanks to the
pioneering and daring achievement of Charles D. Kelman. As recently as
20 years ago, cataract surgery was a major ordeal, requiring a hospital
stay of 10 days and a post-hospital convalescence of several months. In
a typical operation, the patient underwent general anesthesia, after
which a large semicircular incision of 180-degrees was made in the
cornea to allow the entire lens to be grasped with a forceps and pulled
from the eye in one piece. The incision was closed with 8 or 9 sutures,
and the patient was kept at absolute bed rest for 3 to 5 days with both
eyes covered with patches. To prevent the patient from moving his or
her head, sandbags were placed along both sides of the head, and both
wrists were bound with restraints to the bed. This enforced
immobilization often led to mental disorientation, prostatic
obstruction, bedsores, and blood clots to the lung. As many as 20% of
patients developed eye infections, bleeding, macular edema, and retinal
detachment. After discharge from the hospital, the eyes and lids
remained red, swollen, and irritated for as long as 6 weeks. The
operated eye had to be patched for several months, and the patient had
to wait for six months to be fitted with ultra thick, unattractive
glasses that rarely restored vision to normal. In 1967, while
Charles Kelman was a practicing ophthalmologist at the Manhattan Eye,
Ear, and Throat Hospital in New York City, he invented a totally new
and incredible procedure for removing cataracts, which he called
phacoemulsification (phako being Greek for lens; emulsi being Greek for
milk out). In its currently practiced form, phacoemulsification
involves making a small incision in the cornea (only 3-degrees rather
than the traditional 180-degrees), after which a tiny ultrasonic probe
is inserted through the incision. The vibrations of the probe break and
liquefy the cataractous lens without damaging the surrounding tissues.
The emulsified fragments of the lens are then suctioned through the
sonic tip, and a foldable intraocular lens is inserted through the
small incision. Once inside the eye, the flexible lens unfolds like a
parachute, and vision is restored to 20/20 or 20/40. There is no longer
a need for the thick spectacle glasses of the pre-Kelman era. The
entire procedure, which can be done in 5-10 minutes, is performed on an
outpatient basis under topical anesthesia. Because the eyelids are not
anesthetized, no eye patch is required, and recovery is almost
immediate. Many patients go in for their cataract extraction in the
morning and return to work in the afternoon. The genius of
Charles Kelman was to recognize the need for a rapid and painless way
to remove cataracts; and his discovery transformed the operating habits
of ophthalmologists. The idea for phacoemulsification came to Kelman in
1964 while sitting in his dentist’s chair and having his teeth cleaned.
As Kelman writes in his memoir, “As I sat in his chair, he reached
over, took a long silver instrument out of its cradle and turned it on.
A fine mist came off the tip but the tip didn’t seem to be moving. He
applied the tip to my teeth, and I felt an exquisite vibration and
heard a high-pitched sound.” Kelman asked, “What is that thing?” The
dentist replied, “An ultrasonic probe.” “I knew this was the moment,”
Kelman wrote. This moment must surely be the only moment in
history in which a jolt from a dental drill produced a bolt from the
blue. Kelman’s epiphanous moment was followed by several years of
intensive research on the eyes of cats and human cadavers before
phacoemulsification was first applied to a patient in 1967. By 1969,
Kelman had used his procedure to remove cataracts in 12 patients.
Between 1967 and 1973, 3500 cataract removals were done by
phacoemulsification, 500 of them by Kelman. It is instructive
to note that the vast majority of ophthalmologists viewed
phacoemulsification as a radical procedure that totally challenged
their conventional wisdom. They were shocked by Kelman’s audacity to
discharge his patients on the same day of surgery and permit them to
return to full activity on the first or second postoperative day. For
many years, Kelman, the practicing eye surgeon without proper academic
credentials, was treated with overt hostility by the established
academic surgical community. Largely owing to Kelman’s
ingenuity, dedication, perseverance and inspiration,
phacoemulsification has become not only the most common, but also the
most successful, surgical procedure in history. Last year 3 million
Kelman-type cataract operations were performed in the U.S. and 6
million worldwide. Kelman’s vision extended beyond the eye.
Phacoemulsification was the first minimally invasive surgical
technique, and it stimulated the development of other “keyhole”
surgeries, such as fiber optic removal of the gall bladder, lumpectomy
of the breast, and repair of vertebral discs. Kelman’s
legendary contributions to the field of ophthalmology have been widely
recognized. In 1992 he was awarded the National Medal of Technology by
President George H. Bush. In 1994, his peers named him “Ophthalmologist
of the Century,” He was inducted into the National Inventors Hall of
Fame whose elite members include the likes of Alexander Graham Bell,
Orville Wright, Henry Ford, and Enrico Fermi.” Goldstein’s
portrait of Charlie Kelman reveals that Kelman wasn’t a geek or a
weirdo- all too often the stereotype of brilliant scientists. According
to Goldstein, “He was the ultimate extrovert and the quintessential bon
viveur. He flew his own helicopter, jetting from hospital roof to
hospital roof all over Manhattan and Long Island. He also traveled the
world, saving the eyesight of hundreds of famous people – from Hedy
Lamar to Golda Meir. He was beloved by people who had the privilege of
knowing him—grateful patients, artists, medical practitioners, media
personalities and his family. Kelman was an accomplished saxophonist
who played with jazz stars like Lionel Hampton and Dizzy Gillespie. He
once rented Carnegie Hall to give his own concert. He produced several
Broadway plays, entertained in clubs as a stand-up comedian, and was a
frequent guest on the Tonight Show, Merv Griffin show, Barbara Walters
Show, David Letterman Show, and the mother of all shows – the Oprah
Winfrey show. Although today we take outpatient cataract
surgery for granted, it took 25 years for Kelman’s phacoemulsification
to become the definitive technique for removing cataracts. 1996 was the
first year in which 97% of all cataract operations in the U.S. were
done by phacoemulsification. Dr. Goldstein, one of the most revered
scientists in medical research, asks this simple question: “Why does it
take so long —often more than a quarter of a century—for the general
population to recognize, appreciate and embrace works of science that
have such enormous benefits for humanity?” Goldstein replies, “It would
be fair to say, that most of us, unlike Charles Kelman, apparently lack
the vision.”

Brian Klepper is a health care analyst based in Atlantic Beach, FL. He attended the Aspen Health Forum as a Fellow.
      
   

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Tina
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per person. Currently, the eye drop has to be ejenctid into the eye, so it has to be administered by an ophthalmologist. However, Girard is hoping to make it into a drop or ointment that can be administered by any health professional, including nurses and social assistants. While surgery is still the most effective way to restore eyesight, it’s possible the day may come when submitting to surgery is a last resort. And this treatment holds great promise for medical missionaries who have been frustrated by cataract-induced blindness. The best eye drops I’ve found use an amino acid called glutathione.… Read more »

Barry Carol
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Barry Carol

What an incredible man and fascinating story. The initial rejection of his invention by his peers is yet another example of the Semmelweis Reflex. We all need to work harder at keeping an open mind to new ideas and fresh thinking.