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On May 20, 2015, Mahathir bin Mohamad, the former Prime Minister of Malaysia, visited Japan.
While his primary objective was to lecture at a Tokyo university and attend international conferences, he also had a more important, private agenda: to undergo cataract surgery at Mitsui Memorial Hospital, in Tokyo’s Chiyoda Ward.
For that operation, Mahathir relied on the world’s leading authority on cataracts, Dr. Takayuki Akahoshi.
No One to Take on Surgery For an Ultra-VIP
Cataracts are a condition in which the lens of the eye, which performs a role similar to the lens of a camera, deteriorates and becomes cloudy with age, making it difficult to see. Because 90% of those in their 70s suffer from cataracts, they are sometimes considered an inevitable part of aging. In Japan, cataract surgery is usually available on an outpatient basis, leading to the impression that cataracts are a simple matter. In fact, globally they are the leading cause of loss of vision, and even today rob as many as 18 million people a year of their sight. That said, why did a former prime minister feel it necessary to go a hospital outside his own country for surgery? Where there no doctors in Malaysia capable of performing the procedure?
In fact, there weren’t.
At age 90, Mahathir suffered from diabetes, heart disease and a number of other conditions, making even straightforward cataract surgery highly risky. At home and abroad, every doctor he consulted turned him down, and the only one who agreed to perform the operation was Dr. Akahoshi.
What made this difficult surgery possible was a procedure developed by Dr. Akahoshi in 1992 called the Phaco Prechop method. As the name indicates, this technique involves pre-chopping the phaco, or internal lens of the eye, prior to ultrasonic emulsification and aspiration. The surgery can be performed on an outpatient basis with a minimal physical toll: it requires an incision of just 1.8 mm, can be completed in three or four minutes, and results in zero bleeding. Not only is it safe and effective, but no other cataract surgery results in less strain on the body. This method enables Dr. Akahoshi to complete surgery in less than a minute and a half for each eye, a boon for patients who have difficulty remaining in a prone position for extended periods of time.
Ordinarily, the procedure used in Japan involves applying ultrasound to the lens of the eye in its whole state, requiring a lengthy 10 to 30 minutes; this generates heat, which along with pressure on the eye during surgery creates a significant strain on the cornea and the optic nerves. The incision can be as large as 3-6 mm, and because it requires stitches, can easily lead to distortion of the eyeball and post-operative astigmatism. Dr. Akahori has succeeded in solving all of these problems with his procedure.
Twin Operating Rooms, The Ultimate in Ingenuity
“For the patient, cataract surgery is a once-in-a-lifetime operation. We always do our best to eliminate anxiety, and to ensure that the patient is relaxed and able to undergo the finest procedure possible,” says Dr. Akahoshi.
Part of that effort is represented by Dr. Akahoshi’s twin operating rooms. These were designed to enable him to move back and forth between them, safely and efficiently performing an astounding 60 cataract operations a day, and upwards of 9,670 procedures a year (in 2014). The two units are connected, with a pre-op preparation room between them; each of the units has the same equipment and instruments arranged the same way, and identically composed surgical teams stand by in each room.
“Good afternoon, Mr. A. Are you nervous? Don’t worry, this won’t take long.”
After a few gentle words to the patient laid out on the operating table, Dr. Akahoshi begins surgery. Since only topical anesthesia is used, the patient remains awake and is able to talk.
First, using a specially designed ultra-thin diamond scalpel, the doctor opens a 1.8 mm incision in the cornea. There is no bleeding. Next, he uses a special tool called a prechopper to quadrisect the lens, which is a cloudy white due to the cataract, before using an ultrasound oscillating tool that looks like a microscopic vacuum cleaner to break up the lens prior to emulsification and aspiration.
Inserting a 6 mm Lens Into a 1.8 mm Incision
“There’ll be some pressure, so you may feel a little weight, but it’s nothing to worry about, okay?”
Dr. Akahoshi continues to operate, constantly talking to the patient to share his anxiety and reassure him. His fingertips are unerring in their movements as he peers into his microscope. The microscope, ultrasound output, and suction pressure are all controlled by foot. The doctor is in his stocking feet to ensure he feels even the slightest reaction from the pedals as he works them. He doesn’t wear sandals. He also listens carefully to the patient’s breathing, and if he sense the patient is particularly nervous, he’ll immediately tell his nurse to squeeze the patient’s hand reassuringly.
The cloudiness that had covered the eye is quickly removed. The climax comes after the entire lens is clear. The doctor uses a special instrument to compress a 6 mm intraocular lens to a size small enough to slide all at once through the 1.8 mm incision. The move takes place literally in the blink of an eye. “When I first presented the procedure at an international conference in 2004, everyone was stunned,” laughs Dr. Akahoshi. “They were so surprised, they thought it must some kind of computer graphics.”
After a few fine adjustments to the placement of the lens, the operation is complete. The incision will heal on its own without any need for stitches. In the span of just three or four minutes, the patients once-cloudy vision has been restored to clean, clear sight.
Thanks to this incredible speed, Dr. Akahoshi’s procedure has earned the nickname “The F-1 of operations.” The faster and more accurately the surgery can be performed, the less strain there is on the eye. In this case, the pursuit of speed is also a pursuit of quality. To ensure the best possible operation without burdening the patient, Dr. Akahoshi has developed all of the tools needed to perform the work, from the diamond scalpel that makes microscopic incisions possible, to the prechopper used to divide the lens, the injector that enables him to insert a lens more than three times the diameter of the incision, and even the drapes that cover the patients face during surgery, leaving only the eye visible. This is because nowhere in the world was he able to find instruments that met his expectations.
The revolutionary idea for the prechopper, one of these tools, came to Dr. Akahoshi as he was watching a movie on TV, and took note of a scene where dynamite was used to blow up solid rock. “At the time, I thought it might be possible to cleanly divide the lens from the inside by inserting a sharp pair of ultrasound oscillating forceps into the nucleus of the lens (like dynamite),” recalls Dr. Akahoshi.
Cataract Surgery Developed by Dr. Akahoshi
The Phaco Prechop Method process
(1) Clouded lens is divided using the prechopper
(2) The quadrisected lens
(3) Emulsification and aspiration of the lens using ultrasound
(4) Intraocular lens inserted with an injector
As a Youth, Taking Apart and Reassembling Wristwatches for Fun
Growing up in a family that couldn’t afford to buy him plastic models, Dr. Akahoshi played by building his own model trains, and taking apart and then reassembling wristwatches. The creativity that later enabled him to devise his revolutionary surgical methods was likely nurtured during this development process.
One instrument he has been proud of in recent years is his electronic toric marker. This tool is used to precisely measure and mark the direction of astigmatism when inserting a toric lens, an intraocular lens used to correct astigmatism. In 2014, 37% of patients who underwent surgery by Dr. Akahoshi were able to use toric lenses thanks to this instrument.
Traditionally, marking is a troublesome process that requires advanced skill, and as a result, few if any ophthalmologists were willing to use the toric lens. While machines were available to simplify the procedure, they cost tens of millions of yen apiece. By going to a camera store in Akihabara, picking up a level that sells for about 4,000 yen, and using its parts, Dr. Akahoshi succeeded in developing a marking instrument that was faster and easier than machines priced at tens of millions of yen, and at a cost of just a few tens of thousands of yen.
Dr. Akahoshi’s top priority is always to provide every patient with the best possible surgery. This is why he has not applied for patents for his marker and most of the other instruments he’s developed. As a boy, his eyesight was poor, and out of his frequent trips to the eye doctor grew a dream of becoming a doctor who could cure patients everywhere suffering from diseases affecting the eyes, like the doctors that treated him, and like Dr. Albert Schweitzer, whom they all admired. Dr. Akahoshi says that, “My hope is to spread these surgical techniques worldwide, so that even one more person at risk of losing their vision can be saved. If applying for patents makes my instruments more expensive, won’t that also make it more difficult for doctors and hospitals in developing countries to use them?”
A Minor Player in Japan
Thanks to these efforts, the Phaco Prechop method has come to be used in 66 countries around the world. Patients such as Mahathir who come from overseas are also, according to the Internationalization Office at Mitsui Memorial Hospital, “Increasing at a pace well beyond the hospital’s expectations.”
Naturally, they are also overrun with patients from within Japan, and the wait for surgery is now as long as six months to two-and-a-half years. “We get patient referrals from over 1,500 practitioners. We are working to be creative and handle as many consults as we can, so that we can operate as early as possible on as many patients as possible. That effort goes on 365 days a year.”
Oddly enough, the Phaco Prechop method has only a minor presence among ophthalmologists in Japan. Dr. Akahoshi explains that, “When I first developed the technique, I worked hard at trying to disseminate the procedure by presenting my research finding at academic conferences and holding open surgeries. Not only was it not accepted—I was heavily criticized, the critics’ reasoning being that ‘If the operation is too short, people will think cataract surgery is simple. That will lower its points for insurance reimbursement, and cost us ophthalmologists income.’ They weren’t reacting to the quality of the surgical method itself, but to a completely different issue. I’m disappointed in the academic community in Japan.”
While undeservedly getting the cold shoulder at home, globally, Dr. Akahoshi’s reputation only continues to grow. He has been honored with a great number of awards, from the American Society of Cataract and Refractive Surgery, an international authority, and other institutions in the U.S., Europe and Asia. He is also the first doctor from Japan to operate publicly at the international conference held by the American Academy of Ophthalmology, considered the world’s leading authority in the field.
Today, Dr. Akahoshi flies around the world to promote the dissemination of his surgical technique, giving lectures and holding open surgeries. If invited, he’ll even take the initiative to travel three days each way to the interior of the Amazon region or to regions of political instability. In fact, he has had many experiences where he found his life at risk.
Flying Around the World, Undaunted by Terrorism
“In Sri Lanka, a terrorist bomb exploded right in front of a building I was just leaving. The blast blew me off my feet. The car I was supposed to get in was surrounded by pools of blood. That was a close one!” recalls Dr. Akahoshi.
Unintimidated, however, he never thought to cease his activity. There were so many seriously ill patients beyond the skills of ordinary doctors, and so many doctors hoping to get his personal guidance. Dr. Akahoshi says that, “Once the operation is done, the patients have such smiles on their faces, and the local doctors proudly report back on how their skills have advanced to where they can perform such a difficult operation. Nothing makes me happier.”
Born in Kanagawa Prefecture in 1957. After graduating from Jichi Medical University, served on the ophthalmology staff at the University of Tokyo Hospital and at the Japanese Red Cross Musashino Hospital, before assuming his current position in 1992. Renowned as the inventor of the Phaco Prechop Method, a new cataract surgical technique. Also serves as a visiting professor of ophthalmology at four universities overseas.
text / Hiromi Kihara