2004 Albert Lasker Clinical Medical Research Award

Phacoemulsification for outpatient cataract surgery

The 2004 Albert Lasker Award for Clinical Medical Research honors an ophthalmologist who transformed cataract surgery. By devising a relatively noninvasive procedure for removing a flawed lens, Charles Kelman replaced a high-risk operation that required a lengthy hospital stay with a 10-minute outpatient procedure. This procedure is now the most frequently performed surgery in many countries of the western world. It aids about three million people annually in the United States and approximately the same number in Western Europe — figures that are increasing as the population ages. Kelman's innovation of removing a relatively large piece of tissue through a tiny incision paved the way toward similar 'keyhole' surgeries on many other parts of the body.

Cataracts are the single most common preventable cause of blindness in adults. Before Kelman's breakthrough, cataract surgery was a grim prospect. To rectify the cloudy vision that characterizes cataracts, surgeons cut the eye almost half open to remove the blemished lens. Bleeding, retinal detachment, and infection commonly threatened to destroy vision. Recovery required more than a week of hospitalization, with the patient's head immobilized by sand bags. Other complications arising from a lengthy hospital stay and the inability to move — blood clots, bedsores, and muscle atrophy — made the procedure a major ordeal. At home, weeks of recuperation followed. Eventually, the patient would receive ultrathick glasses to compensate for the absence of the lens. In addition to their lack of cosmetic appeal, these spectacles distorted and magnified objects.

In the early 1960s, Kelman (a newly appointed staff ophthalmologist at the Manhattan Eye, Ear, and Throat Hospital in New York City) began to fantasize about a procedure that would cause less trauma, restore vision quickly, and get people back on their feet sooner. He conjured up the idea of removing a cataract through a tiny slit. To extract the lens, he would need to liquefy or fragment it inside the eye and then suck out the debris through the incision — a procedure that would become known as phacoemulsification — "phaco" for "lens" and "emulsi" for "milk out."

For three years, he attacked this problem with a $299,000 grant from the John A. Hartford Foundation and cats as patients. In his first scheme, he snared the lens in a small rubber pouch, crushed it, and slid out the bag. But the bags broke and couldn't be sufficiently miniaturized. Next he tried breaking up the lens using small drills and blenders.

But they sometimes snagged the iris and, even if they didn't, Kelman had to chase the lens around inside the eye, marring other structures in the process. He realized he needed a way to hold the lens in place while he drilled — but even with that innovation, the cats went blind: Splintering the lens hurled material against other parts of the eye.

On the brink of failure — six months before his grant would run out — he visited his dentist. At the time, ultrasonic probes for removing tartar were relatively new. When Kelman felt the vibrations and heard the high-pitched noise of that apparatus, the solution popped into his head. He needed a tool that accelerated so quickly, the lens could not back away, vibrate, or rotate with the tip. An ultrasound machine would pulverize the lens without damaging the surrounding tissue, he realized.

Working with engineers, Kelman adapted the gadget for his purpose. He outfitted the unit with a small hole through which to suction off the broken up cataract. To avoid boiling the eye with heat generated by the vibrations, he devised a cooling system. He finally succeeded in removing a cat's cataract without blinding the animal.

Eventually, Kelman developed a phacoemulsification unit from which today's are derived. He practiced for several years, improving the apparatus so it would perform reliably enough to be used on a person.

In 1967, he carried out the procedure on his first human. This patient's eye was blind and painful from glaucoma, and it needed to be removed. It also had a cataract. Kelman didn't intend to fix the eye, but to find out whether the procedure was feasible. More than four-and-a-half difficult hours later, he had completed the task, but he had mangled other parts of the eye — the cornea and the iris — in the process. For the next couple of years, he refined his strategy. He realized, for example, that he needed a gentle, controlled vacuum that would suck out the broken cataract without also collapsing the cornea. Eventually he made the device work safely. He continued to improve the tool so other ophthalmologists could reliably conduct the surgery — and he began to teach the technique, thus ensuring its large-reaching impact. By 1985, about 15 percent of all cataract removals in the United States were done by phacoemulsification; by 1990, that number had risen to 50 percent, and by 1996 it had reached 97 percent.

Artificial lenses were invented in 1949 by the ophthalmologist Harold Ridley, but their implantation in patients undergoing cataract operations was relatively limited until the 1980s. By then, a number of ophthalmologists, including Kelman, had enhanced their design. The improvements led to flexible folded lenses that fit through the small incision and unfurled once within the eye. These lenses restore good peripheral vision and depth perception with minimal distortion and magnification. Advances in this realm have helped obviate the need for the unwieldy and optically inadequate glasses.

Today cataract surgery involves a 1.5–3.0 millimeter incision. Instead of submitting to eight or ten sutures, patients usually need none. They go in for cataract surgery in the morning and can be back at work in time for lunch. Visual acuity returns almost immediately and people return to their normal activities within hours or days.

In 1992, President George H.W. Bush awarded Kelman the National Medal of Technology, and this year he was inducted into the National Inventors Hall of Fame. His peers named him Ophthalmologist of the Century in 1994.

Kelman's success marked a radical moment not only in cataract surgery, but in multiple medical specialties, turning myriad inpatient procedures into outpatient ones and bestowing on millions of people gifts of health and quality of life. Practitioners in other areas picked up on his idea of removing unwanted tissue through a tiny hole to improve, for example, gall bladder and joint surgery. Neurosurgeons have also adopted the emulsification machine to dissect tumors from the brain and spinal cord. Surgeries that used to require multiple-week hospitalizations can now be performed in minutes, thus reducing the risk of life-threatening clots and difficult-to-treat hospital-acquired infections as well as other complications.

Kelman died on June 1, 2004. At the request of his widow, Ann Kelman, the Lasker honorarium will be awarded to the International Retinal Research Foundation in his memory.

by Evelyn Strauss

Key publications by Charles Kelman

Kelman, C.D. (1967). Phacoemulsification and aspiration: A new technique of cataract removal. Am. J. Ophthalmol. 64, 23–25.

Kelman, C.D. (1969). Phacoemulsification and aspiration: A progress report. Am. J. Ophthalmol. 67: 464–477.

Kelman, C.D. (1994). The history and development of phacoemulsification. Int. Ophthalmol. Clin. 34, 1–12.

Kelman, C.D. (2000) Phacoemulsification. In The University of Miami Bascom Palmer Eye Institute Atlas of Ophthalmology, R.K. Parrish, II, ed., Current Medicine, Inc., Philadelphia, pp. 247–256.

Kelman, C.D. (2001) Kelman electromagnetic technique. In Cataract Surgery and Intraocular-lenses: A 21st Century Perspective, Second Edition, J.G. Ford and C.L. Karp, eds., 2001, American Academy of Ophthalmology, pp. 182–190.

Award presentation by Joseph Goldstein

More than half of us here today will eventually develop impaired vision caused by cataracts. There are no drugs, no eyedrops, and no "Eyekins" 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 are no longer a significant cause of blindness — thanks to Charles Kelman, this year's recipient of the Lasker Clinical Medical Research Award.

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 eight or nine sutures, and the patient was kept at absolute bed rest for three to five days with both eyes occluded 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, bed sores, and blood clots to the lung. As many as 20 percent 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 six weeks. The operated eye had to be patched for several months, and the aphakic 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 here in New York City, he invented a totally new 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 five to ten 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. This is reminiscent of the genius of Ray Kroc, the founder of McDonalds. Kroc discovered that people like to be served in 60 seconds — a discovery that changed the eating habits of the world. Charles Kelman's discovery changed 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. 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. Today, we take outpatient cataract surgery for granted, but it took 25 years for Kelman's phacoemulsification to become the definitive technique for removing cataracts. 1996 was the first year in which 97 percent of all cataract operations in the US were done by phacoemulsification.

Largely owing to Kelman's ingenuity, dedication, 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 United States 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 fiberoptic removal of the gall bladder, lumpectomy of the breast, and repair of vertebral discs. Kelman clearly had the knack for seeing beyond the cataract.

Kelman's legendary contributions 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," and earlier this year he was inducted into the National Inventors Hall of Fame, whose elite members include the likes of Alexander Graham Bell, Orville Wright, Henry Ford, Enrico Fermi, and Leo Szilard.

Charlie Kelman 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 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.

It's a real tragedy that Charlie Kelman is not here today to bask and revel in the glory of his medical accomplishments. He died 4 months ago on June 1 at the age of 74. It's extremely rare for the Lasker Jury to present a posthumous award. We made an exception in this case because Kelman's work was so extraordinary and because he was at the top of our list at the time of his death. One might ask, Why were we so slow in recognizing Charlie Kelman? The answer is obvious: We didn't have his vision.

Charles D. Kelman

Acceptance remarks by Ann Kelman, 2004 Lasker Awards Ceremony

Nature Medicine Essay

It is with mixed feelings that I humbly stand here before you to accept this prestigious honor on behalf of my husband. Our family is extremely proud of Charlie's dedication, persistence, and relentless belief that phacoemulsification would greatly improve the quality of life of cataract patients. We are honored that the scientific community, specifically the Lasker committee, has recognized his contribution. And sad, that although Charlie knew he was nominated, he never knew of today's honor.

Charlie always believed that the journey was as important as the destination. He knew of the many letters written by colleagues worldwide to support his nomination. This gave him some satisfaction, and for us there is comfort in this knowledge. Many times, Charlie told me how happy he was to see phacoemulsification become the accepted, safe cataract operation, and he always added that he never expected that it would impact ophthalmology and general medicine as it has. In November 2003, the American Academy of Ophthalmology celebrated 35 years of phacoemulsification. It was the last honor Charlie received personally. Please allow me to read excerpts from his presentation.

The story of phacoemulsification reads like a high wire act. Every step was fraught with possible failure, loss of equilibrium, and catastrophe. Even the concept itself might have never happened, had I not been touched by the infirmity and suffering of elderly cataract patients. Four years after my residency applying for a grant to study the effects of freezing on various ocular structures, I finished the application and went to bed. But I was troubled that the Hartford Foundation would not find this exciting enough to warrant a grant. In the middle of the night I awoke and almost in a trance, I added the words, which would affect the rest of my life, and the lives of more than a hundred million others. I wrote as an addendum, "In addition to the freezing studies, this investigator will develop a method for removing a cataract through an incision small enough so that no hospitalization would be required." It could have ended there... Instead, even though I could not say how I would do it, since I had no idea, Mr. Roy somehow had confidence that I would succeed and gave me a grant for three years.

Mr. Roy's confidence was misplaced for 2 years and 8 months, while I tried Lens bags, and every rotary, every oscillating, every pulverizing tool I could get my technician to miniaturize. It would have ended there, but because of my obsession with this problem, I had neglected my personal appearance, and I needed a haircut and a teeth cleaning. It was at the dentist that I discovered the ultrasonic vibrator to clean tartar off teeth. This device had no suction, only a vibrating needle, and needed to be modified. Cavitron refused to spend the time or money to do so, not knowing whether this would ever be a commercial product. It could have ended there, but I persisted with the company, and they finally agreed to make a prototype.

After several months of successful animal work, I was ready for my first patient, a man with a painful blind eye from burned out glaucoma, who agreed to let me experiment. The next day, his eye had to be removed. It could easily have ended there. I spent two years looking for and developing a way to prevent corneal collapse. One year later, I finally had the nerve to try again. The difficult operation was a success. The next patient fared even better. The senior surgeon at my hospital found out what I was doing, and tried to convince the board to rescind my operating privileges. Fortunately, by this time, my results were quite good. One bad case, and it could have ended there. I began teaching the technique in 1970 with the first commercial model, but the profession rose up against all those who adopted the technique. Surgeons had to learn not only phaco, but the use of a surgical microscope. The fact that its main proponent, me, was playing the saxophone and singing in the casinos of Atlantic City, and appearing on the Johnny Carson show did not help the cause. And if it were today, with the FDA, and with malpractice, the operation would have absolutely been abandoned. Had I not been in the right place at the right time, with the right obsessive motivation, I believe we might still be doing intracapsular 180-degree surgery.

Looking back on all that I did, I have to wonder what kept me going. What made me take the risks I took? I'm sure there were many reasons, a desire to be recognized, a fear of failure, but most of all, when I would close my eyes and dream, it was the dream of someday addressing you on an occasion such as this.

Another point I would like to make is that no animal was ever treated cruelly. I probably sacrificed more than a few laboratory animal,s but contrast these animals against the 100 million patients who have benefited from this work.
Charlie wanted be described as lucky. He said, "It means that they're looking at your life as a package rather than one little facet. If you're lucky, your life has been a happy passage."

On behalf of my husband Dr. Charles Kelman, I thank you for this most prestigious honor and for respecting our wishes and presenting the honorarium to the International Retinal Research Foundation.

Key publications by Charles Kelman

Kelman, C.D. (1967). Phacoemulsification and aspiration: A new technique of cataract removal. Am. J. Ophthalmol. 64, 23–25.

Kelman, C.D. (1969). Phacoemulsification and aspiration: A progress report. m. J. Ophthalmol.  67, 464–477.

Kelman, C.D. (1994). The history and development of phacoemulsification. Int. Ophthalmol. Clin. 34, 1–12.

Kelman, C.D. (2000). Phacoemulsification. In The University of Miami Bascom Palmer Eye Institute Atlas of Ophthalmology, R.K. Parrish, II, ed., Current Medicine, Inc., Philadelphia, pp. 247–256.

Kelman, C.D. (2001). Kelman electromagnetic technique. In Cataract Surgery and Intraocular-lenses: A 21st Century Perspective, Second Edition, J.G. Ford and C.L. Karp, eds., 2001, American Academy of Ophthalmology, pp. 182–190.