Going ape for cataract surgery

Miami practitioner performs phacoemulsification on a gorilla

Dr. Spektor performs cataract surgery on a gorilla named Josephine Source: Ron Magill, director, Miami Metrozoo

Some cataract patients can be real bears. But recently Frank E. Spektor, M.D., Center for Excellence in Eye Care, Miami, had a patient with genuine ties to the animal kingdom—a 42-year-old lowland gorilla named Josephine with bilateral white cataracts. Initially Dr. Spektor was approached by a veterinary ophthalmologist to assist in the procedure. “She asked me if I would help her with this cataract surgery,” Dr. Spektor said. “It sounded kind of exciting so I said yes.” Then the veterinary ophthalmologist began to have trepidation and asked an equine specialist to take her place as the lead surgeon. “The equine specialist said we needed a human ophthalmologist,” Dr. Spektor said. “That’s when she asked if I would do the case.”
Zookeepers were initially concerned about using anesthesia on the 3-foot-6-inch gorilla. By the time they agreed, her cataracts were quite dense. “She had become somewhat reclusive and always had her back to the wall because she couldn’t see people approaching her,” Dr. Spektor said. “She would smell her food before she tasted it because she really couldn’t see it. Her world was pretty much in grays and shadows.”

Treating Josephine

The month before the surgery Dr. Spektor conducted a pre-op examination of Josephine. “We did an examination under general anesthesia at the zoo where we did some tests on the eye including keratometry, a B-scan to determine the length of the eye, and an ERG to determine the health of the retina,” Dr. Spektor said. “We also dilated the pupils and looked at the cataracts—that was the point I realized this was in fact a human eye.” The only difference was a cosmetic one. Dr. Spektor found that the conjunctiva was black instead of clear. One hitch that Dr. Spektor ran into was that despite having a first-rate ultrasonographer on the scene, the ultrasounds were hard to interpret. “The ultrasonographer came to me and said, ‘The eye is anywhere between 21 and 26 mm,’” Dr. Spektor said. “That’s like saying, ‘I saw a guy who was either 3 feet or 6 feet tall.’”
For the procedure, Dr. Spektor asked Alcon (Fort Worth, Texas) to contribute medical supplies. Because of these inaccurate readings, he had to request many more lenses to have on hand for the bilateral procedure. “Instead of asking for two lenses I asked for 24,” Dr. Spektor said. “The powers ranged from 11 to 29.” On the day of the surgery another ultrasound was performed and Dr. Spektor realized that Josephine had 4 D of astigmatism. “We actually needed completely different lenses, but we worked with what we had,” he said. “She’s probably going to be a little bit nearsighted with acuity of –1 D—just enough to see her food and to see clearly for distance, but not enough to drive at night.” The cataract procedure itself did not require any modification. For the surgery, Dr. Spektor used the INFINITI (Alcon) phacoemulsification machine with an OZil tip. “This was flown in by Alcon from Dallas to the zoo,” Dr. Spektor said. “They even sent a technician to help run the machine.” In addition, Dr. Spektor used some disposable instruments courtesy of Moria (Antony, France). At his side was his scrub tech of 13 years. “The things that weren’t familiar were obviously the animal and the microscope,” Dr. Spektor said. “If I had to give another surgeon advice it would be to make sure that you’ve got the same microscope that you use every day on humans. The microscope I used wasn’t the same quality and it made visibility very difficult.”
To help enhance visibility during the procedure on the second eye, Dr. Spektor used vision blue. “I made the mistake of not using it on the first eye because I didn’t think that I needed it,” he said.
During the procedure, Dr. Spektor found that he had to adjust to the differences in the gorilla’s face. “The structure of her face, the position of her eyes relative to the nose, the absence of the forehead, the huge brow, and the small area that I had to work in were the factors that made it difficult,” Dr. Spektor said. He also found that the cornea was a bit different than in a human patient’s eye. “It was tougher than in a human eye,” he said. “The amount of pressure needed to penetrate it was a little bit more than the normal keratome pressure that I would apply to get into the eye.” Then, of course, there were the dense white cataracts to deal with, which are not something that most U.S. surgeons encounter in their practices.

Post-op follow up

Because Josephine wasn’t able to participate in post-op care, the team did a few things differently as they were finishing the procedure. “I gave her intracameral Vigamox (moxifloxacin, Alcon) straight out of the bottle and put it into the anterior segment,” Dr. Spektor said. “I also gave her a sub-conjunctival injection of betamethasone to reduce inflammation.” Josephine was put on oral anti-inflammatory medication, and a suture was placed in the eye. “During the post-operative period she was never seen rubbing her eyes,” Dr. Spektor said. On the first day following the surgery while Josephine was still somewhat under the influence of anesthesia, Dr. Spektor went behind her cage. “I took photos with my camera and used binoculars to look at her eyes,” he said. “They looked pretty good.” When he got home he loaded the pictures onto his computer and enlarged the eye. “On my screen I could almost see the suture; it was so clear,” he said. “I got a pretty good view of the anterior chamber.” He noted that Josephine appeared to be healing well.
Today Josephine has completely changed her behavior. “She is much more active and more social,” Dr. Spektor said. “She grabbles for her food in the grass, looks at fine bits of grass, and picks raisins out of her keeper’s hands.” He continues to follow her progress with the aid of pictures emailed to him and regards her as one of his many patients.

Editors’ note: Dr. Spektor has no financial interests related to his comments.

Contact information

Spektor: DocSpek@aol.com