History of cataract surgery

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Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper" (in left hand) Cataract surgery.jpg
Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper" (in left hand)

Cataract surgery has a long history in Europe, Asia, and Africa. It is one of the most common and successful surgical procedures in worldwide use, thanks to improvements in techniques for cataract removal and developments in intraocular lens (IOL) replacement technology, in implantation techniques, and in IOL design, construction, and selection. [1] Surgical techniques that have contributed to this success include microsurgery, viscoelastics, and phacoemulsification. [2]

Contents

Cataract surgery is the removal of the natural lens of the eye that has developed a cataract, an opaque or cloudy area. [3] Over time, metabolic changes of the crystalline lens fibres lead to the development of a cataract, causing impairment or loss of vision. Some infants are born with congenital cataracts, and environmental factors may lead to cataract formation. Early symptoms may include strong glare from lights and small light sources at night and reduced visual acuity at low light levels. [4] [5]

Couching was the original form of cataract surgery, and was used from antiquity. It is still occasionally found in traditional medicine in parts of Africa and Asia. In 1753, Samuel Sharp performed the first-recorded surgical removal of the entire lens and lens capsule, equivalent to what became known as intracapsular cataract extraction. The lens was removed from the eye through a limbal incision. [1] At the beginning of the 20th century, the standard surgical procedure was intracapsular cataract extraction (ICCE). [6] In 1949, Harold Ridley introduced the concept of implantation of the intraocular lens (IOL), which made visual rehabilitation after cataract surgery a more efficient, effective, and comfortable process. [1]

In 1967, Charles Kelman introduced phacoemulsification, which uses ultrasonic energy to emulsify the nucleus of the crystalline lens and remove cataracts by aspiration without a large incision. This method of surgery reduced the need for an extended hospital stay and made out-patient surgery the standard. [7] In 1985, Thomas Mazzocco developed and implanted the first foldable IOL. Graham Barrett and associates pioneered the use of silicone, acrylic, and hydrogel foldable lenses, making it possible to reduce the incision width. [6] In 1987, Blumenthal and Moisseiev described the use of a reduced incision size for ECCE. [8] In 1989, M. McFarland introduced a self-sealing incision architecture, [8] and in 2009, Praputsorn Kosakarn described a method for manual fragmentation of the lens, which consists in splitting the lens into three pieces for extraction, allowing a smaller, sutureless incision, and requires implantation of a foldable IOL. This technique uses less expensive instruments and is suitable for use in developing countries. [8]

Couching

"Couching for cataract"; Wellcome Collection illustration of Indian doctors performing couching. Couching for cataract. Wellcome L0021165.jpg
"Couching for cataract"; Wellcome Collection illustration of Indian doctors performing couching.

Couching is the earliest-documented form of cataract surgery, and one of the oldest surgical procedures ever performed. In this technique, the lens is dislodged and pushed aside into the vitreous cavity, but not removed from the eye, thus removing the opacity from the visual axis, but also the ability to focus. [9] After being used regularly for centuries, couching has been mostly abandoned in favor of more effective techniques, due to its generally poor outcomes, and is currently only routinely practiced in remote areas of developing countries. [10] [11]

Cataract surgery was first mentioned in the Babylonian code of Hammurabi 1750 BCE. [12] The earliest known depiction of cataract surgery is on a statue from the Fifth Dynasty of Egypt (2467–2457 BCE). [12] According to Francisco J Ascaso et al, a "relief painting from tomb number TT 217 in a worker settlement in Deir el-Medina" shows "the man buried in the tomb, Ipuy ... one of the builders of royal tombs in the renowned Valley of the Kings, circa 1279–1213 BC" as he underwent cataract surgery. Although direct evidence for cataract surgery in ancient Egypt is lacking, the indirect evidence, including surgical instruments that could have been used for the procedure, show that it was possible. It is assumed that the couching technique was used. [12] [13]

Couching was practiced in ancient India and subsequently introduced to other countries by Indian physician Sushruta (c. 6th century BCE), [14] who described it in his medical text, Sushruta Samhita ("Compendium of Sushruta"); the work's Uttaratantra section [lower-alpha 1] describes an operation in which a curved needle was used to push the opaque "phlegmatic matter" [lower-alpha 2] in the eye out of the way of vision. The phlegm was then said to be blown out of the nose. The eye would later be soaked with warm, clarified butter before being bandaged. [15] The removal of cataracts by surgery was introduced into China from India, and flourished in the Sui (581–618 CE) and Tang (618–907 CE) dynasties. [16]

The first references to cataract and its treatment in Europe are found in 29 CE in De Medicina , a medical treatise by Latin encyclopedist Aulus Cornelius Celsus, which describes a couching operation. [17] In 2nd century CE, Galen of Pergamon, a prominent Greek physician, surgeon, and philosopher, reportedly performed an operation to remove a cataract-affected lens using a needle-shaped instrument. [18] [19] Although many 20th-century historians have claimed that Galen believed the lens to be in the exact centre of the eye, there is evidence that he understood the crystalline lens is located in the anterior aspect of the eye. [20]

The removal of cataracts by couching was a common surgical procedure in Djenné [21] and many other parts of Africa. [22] Couching continued to be used throughout the Middle Ages, and is still used to this day in some parts of Africa and in Yemen. [23] [11] However, it has been proven to be an ineffective and dangerous method of cataract therapy, which often leads to blindness or only partially restored vision. [23] The technique has mostly been replaced by extracapsular cataract surgery, including phacoemulsification. [24]

The lens can also be removed by suction through a hollow instrument: bronze oral-suction instruments that seem to have been used for this method of cataract extraction during the 2nd century CE have been unearthed. [25] Such a procedure was described by the 10th-century Persian physician Muhammad ibn Zakariya al-Razi, who attributed it to Antyllus, a 2nd-century Greek physician. According to al-Razi, the procedure "required a large incision in the eye, a hollow needle, and an assistant with an extraordinary lung capacity". [26] This suction procedure was also described by Iraqi ophthalmologist Ammar Al-Mawsili in his 10th-century medical text, Choice of Eye Diseases . [26] He presented case histories of its usage, while claiming to have successfully performed it on a number of patients. [26] : p318  Extracting the lens has the benefit of removing the possibility of the lens migrating back into the field of vision. [27] According to oculist Al-Shādhili, a later variant of the cataract needle in 14th-century Egypt used a screw to grip the lens. It is not clear how often, if ever, this method was used; other writers, including Abu al-Qasim al-Zahrawi and Al-Shadhili, appear to have been unfamiliar with this procedure, or claimed it was ineffective. [26] : p319 

Eighteenth and nineteenth centuries

Beer-type cataract knife and needle, cased, Paris, 1820-1866 Beer-type cataract knife and needle, cased, Paris, 1820-1866 Wellcome L0058108.jpg
Beer-type cataract knife and needle, cased, Paris, 1820-1866
A cataract surgery. Dictionnaire Universel de Medecine (1746-1748) Cataract surgery dictionnaire universel.jpg
A cataract surgery. Dictionnaire Universel de Médecine (1746–1748)

On Sep. 18, 1750, Jacques Daviel performed the first documented planned primary cataract extraction on a cleric in Cologne. [28] In 1753, Samuel Sharp performed the first-recorded surgical removal of the entire lens and lens capsule: the lens was removed from the eye through a limbal incision. [1] In America, cataract couching may have been performed in 1611, [29] while cataract extraction was most likely performed by 1776. [30] Cataract extraction by aspiration of lens material through a tube using suction was performed by Philadelphia-based surgeon Philip Syng Physick in 1815. [31]

King Serfoji II, Bhonsle of Thanjavur, India, reportedly performed cataract surgeries in the early 1800s, according to manuscripts stored in the Saraswathi Mahal Library. [32]

In 1884, Karl Koller became the first surgeon to apply a cocaine solution to the cornea as a local anaesthetic; the news of his discovery spread rapidly, but was not without controversy. [33] [34]

Early-to-mid 20th century

At the beginning of the 20th century, the standard surgical procedure was intracapsular cataract extraction (ICCE). The work of Henry Smith, who first developed a safe, fast way to remove the lens within its capsule by external manipulation, was considered particularly influential; the capsule forceps, the discovery of enzymatic zonulysis by Joaquin Barraquer in 1957, and the introduction of cryoextraction of the lens by Tadeusz Krwawicz and Charles Kelman in 1961 continued the development of ICCE. [6] Intracapsular cryoextraction was the favoured form of cataract extraction from the late 1960s to the early 1980s: it consisted in using a liquid-nitrogen-cooled probe tip to freeze the encapsulated lens to the probe. This required a large incision and the cornea to be folded back and the anterior chamber to be drained. [9] [35] [36]

In 1949, Harold Ridley introduced the concept of implantation of the intraocular lens (IOL) which made visual rehabilitation after cataract surgery a more efficient, effective, and comfortable process. [1]

Artificial IOLs, which are used to replace the eye's natural lens removed during cataract surgery, increased in popularity since the 1960s, and were first approved by the US Food and Drug Administration in 1981. The development of IOLs was considered a notable innovation, as patients previously had to wear very thick glasses, or a special type of contact lens, in order to cope with the removal of their natural lens. IOLs can be used to correct other vision problems, such as toric lenses for correcting astigmatism. [37] IOLs can be classified as monofocal, toric, and multifocal lenses. [38]

Ocular anaesthesia has improved since Alfred Einhorn synthesised procaine in 1905, which was used in retrobulbar anaesthesia.

Peribulbar anaesthesia was introduced in 1980 by Mandal and David. Since the turn of the millennium, sub-Tenon's anaesthesia hascome into common use, and by ising a blunt cannula to deliver local anaesthetic, the risk of accidentally puncturing the globe is reduced. The more recent tendency is to administer topical local anesthesia without use of a needle. [9]

Also in the 1960s, the development of A-scan ultrasound biometry contributed to provide more accurate predictions of implant refractive strength. [39]

In 1967, Charles Kelman introduced phacoemulsification, which uses ultrasonic energy to emulsify the nucleus of the crystalline lens and remove cataracts by aspiration without a large incision. This method of surgery reduced the need for an extended hospital stay and made out-patient surgery the standard. Patients who undergo cataract surgery rarely complain of pain or discomfort during the procedure, although those who have topical anaesthesia, rather than peribulbar block anaesthesia, may experience some discomfort. [7]

Late 20th century

Ophthalmic viscosurgical devices (OVDs), which were introduced in 1972, facilitate the procedure and improve overall safety. An OVD is a viscoelastic solution, a gel-like substance used to maintain the shape of the eye at reduced pressure, as well as protect the inside structure and tissues of the eye without interfering with the operation. [1]

In 1980, D.M. Colvard made the cataract incision in the sclera, which limited induced astigmatism. [8] In the early 1980s, Danièle Aron-Rosa and colleagues introduced the neodymium-doped yttrium aluminum garnet laser (Nd:YAG laser) for posterior capsulotomy. [6] In 1985, Thomas Mazzocco developed and implanted the first foldable IOL. Graham Barrett and associates pioneered the use of silicone, acrylic, and hydrogel lenses. [6]

According to Cionni et al (2006), Kimiya Shimizu began removing cataracts using topical anaesthesia in the late 1980s, [6] though Davis (2016) attributes the introduction of topical anaesthetics to R.A. Fischman in 1993. [1] In 1987, Blumenthal and Moissiev described the use of a reduced incision size for ECCE. They used a 6.5 to 7 mm (0.26 to 0.28 in) straight scleral tunnel incision 2 mm (0.079 in) behind the limbus with two side ports. [8]

In 1989, M. McFarland introduced a self-sealing incision architecture; in 1990, S.L.Pallin described a chevron-shaped incision that minimized the risk of induced astigmatism; in 1991, J.A. Singer described the frown incision, in which the ends curve away from the limbus, similarly reducing astigmatism. [8] Toric IOLs were introduced in 1992 and are used worldwide to correct corneal astigmatism during cataract surgery; [37] [1] they have been approved by the FDA since 1998. [40] Also in the late 1990s, optical biometry based on partial coherence infrared interferometry was introduced: this technique improves visual resolution, offers much greater precision, and is much quicker and more comfortable than ultrasound. [39]

21st century

According to surveys of members of the American Society of Cataract and Refractive Surgery, approximately 2.85 million cataract procedures were performed in the United States throughout 2004, while 2.79 million operations were executed in 2005. [41] In 2009, Praputsorn Kosakarn described a method for manual fragmentation of the lens, called "double-nylon loop", which consists in splitting the lens into three pieces for extraction, allowing a smaller, sutureless incision of 4.0 to 5.0 mm (0.16 to 0.20 in), and requires implantation of a foldable IOL. This technique uses less expensive instruments and is suitable for use in developing countries. [8]

As of 2013, medical staffs had access to instruments that use infrared swept-source optical coherence tomography (SS-OCT), a non-invasive, high-speed method that can penetrate dense cataracts and collects thousands of scans per second, with the ultimate goal of generating high-resolution data in 2D or 3D. [39] As of 2021, approximately four million cataract procedures take place annually in the U.S. and nearly 28 million worldwide, a large proportion of which are performed in India; that is about 75,000 procedures per day globally. [42]

Notes

  1. ↑ chapter 17, verses 55–69
  2. ↑ kapha in Sanskrit

Related Research Articles

<span class="mw-page-title-main">Cataract</span> Clouding of the lens inside the eye, causing poor vision

A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision of the eye. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colours, blurry or double vision, halos around light, trouble with bright lights, and difficulty seeing at night. This may result in trouble driving, reading, or recognizing faces. Poor vision caused by cataracts may also result in an increased risk of falling and depression. Cataracts cause 51% of all cases of blindness and 33% of visual impairment worldwide.

<span class="mw-page-title-main">Farsightedness</span> Eye condition in which light is focused behind instead of on the retina

Far-sightedness, also known as long-sightedness, hypermetropia, and hyperopia, is a condition of the eye where distant objects are seen clearly but near objects appear blurred. This blur is due to incoming light being focused behind, instead of on, the retina due to insufficient accommodation by the lens. Minor hypermetropia in young patients is usually corrected by their accommodation, without any defects in vision. But, due to this accommodative effort for distant vision, people may complain of eye strain during prolonged reading. If the hypermetropia is high, there will be defective vision for both distance and near. People may also experience accommodative dysfunction, binocular dysfunction, amblyopia, and strabismus. Newborns are almost invariably hypermetropic, but it gradually decreases as the newborn gets older.

<span class="mw-page-title-main">Eye surgery</span> Surgery performed on the eye or its adnexa

Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.

<span class="mw-page-title-main">Radial keratotomy</span> Refractive surgical procedure to correct myopia (nearsightedness

Radial keratotomy (RK) is a refractive surgical procedure to correct myopia (nearsightedness). It was developed in 1974 by Svyatoslav Fyodorov, a Russian ophthalmologist. It has been largely supplanted by newer, more accurate operations, such as photorefractive keratectomy, LASIK, Epi-LASIK and the phakic intraocular lens.

<span class="mw-page-title-main">Refractive surgery</span> Surgery to treat common vision disorders

Refractive surgery is optional eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea (keratomileusis), lens implantation or lens replacement. The most common methods today use excimer lasers to reshape the curvature of the cornea. Refractive eye surgeries are used to treat common vision disorders such as myopia, hyperopia, presbyopia and astigmatism.

<span class="mw-page-title-main">Phacoemulsification</span> Method of cataract surgery

Phacoemulsification is a cataract surgery method in which the internal lens of the eye which has developed a cataract is emulsified with the tip of an ultrasonic handpiece and aspirated from the eye. Aspirated fluids are replaced with irrigation of balanced salt solution to maintain the volume of the anterior chamber during the procedure. This procedure minimises the incision size and reduces the recovery time and risk of surgery induced astigmatism.

<span class="mw-page-title-main">Intraocular lens</span> Lens implanted in the eye to treat cataracts or myopia

An Intraocular lens (IOL) is a lens implanted in the eye usually as part of a treatment for cataracts or for correcting other vision problems such as short sightedness and long sightedness, a form of refractive surgery. If the natural lens is left in the eye, the IOL is known as phakic, otherwise it is a pseudophakic lens. Both kinds of IOLs are designed to provide the same light-focusing function as the natural crystalline lens. This can be an alternative to LASIK, but LASIK is not an alternative to an IOL for treatment of cataracts.

<span class="mw-page-title-main">Phakic intraocular lens</span> Lens implanted in eye in addition to the natural lens

A phakic intraocular lens (PIOL) is a special kind of intraocular lens that is implanted surgically into the eye to correct myopia (nearsightedness). It is called "phakic" because the eye's natural lens is left untouched. Intraocular lenses that are implanted into eyes after the eye's natural lens has been removed during cataract surgery are known as pseudophakic.

<span class="mw-page-title-main">Charles Kelman</span> American ophthalmologist and entertainer

Charles David Kelman was an American ophthalmologist, surgeon, inventor, jazz musician, entertainer, and Broadway producer. Known as the father of phacoemulsification, he developed many of the medical devices, instruments, implant lenses and techniques used in cataract surgery. In the early 1960s, he began the use of cryosurgery to remove cataracts and repair retinal detachments. Cryosurgery for cataracts remained in heavy use until 1978, when phacoemulsification, a procedure Kelman also developed in 1967, became the modern standard treatment. Kelman was given the National Medal of Technology by President George H. W. Bush and recognized as the Ophthalmologist of the Century by the International Congress of Cataract and Refractive Surgery in Montreal, Canada. He was also inducted into the National Inventors Hall of Fame in Akron, Ohio, and received the 2004 Lasker Award.

<span class="mw-page-title-main">Cataract surgery</span> Removal of opacified lens from the eye

Cataract surgery, also called lens replacement surgery, is the removal of the natural lens of the eye that has developed a cataract, an opaque or cloudy area. The eye's natural lens is usually replaced with an artificial intraocular lens (IOL) implant.

ReLExSmall incision lenticule extraction (SMILE), second generation of ReLEx Femtosecond lenticule extraction (FLEx), is a form of laser based refractive eye surgery developed by Carl Zeiss Meditec used to correct myopia, and cure astigmatism. Although similar to LASIK laser surgery, the intrastromal procedure uses a single femtosecond laser referenced to the corneal surface to cleave a thin lenticule from the corneal stroma for manual extraction.

Howard V. Gimbel FRCSC, AOE, FACS, CABES, is a Canadian ophthalmologist, university professor, senior editor, and amateur musician. He is better known for his invention, along with Thomas Neuhann, of the continuous curvilinear capsulorhexis (CCC), a technique employed in modern cataract surgery.

<span class="mw-page-title-main">Eric Arnott</span> British ophthalmologist

Eric John Arnott, MA, FRCS, FRCOphth was a British ophthalmologist and surgeon who specialized in cataracts, a condition which in many parts of the world still remains the principal cause of blindness. He is known for inventing new surgical techniques for treatment of various ophthalmological disorders, and received professional awards for his contributions.

<span class="mw-page-title-main">Capsulotomy</span> Incision into the capsule of the crystalline lens of the eye

Capsulotomy is a type of eye surgery in which an incision is made into the capsule of the crystalline lens of the eye. In modern cataract operations, the lens capsule is usually not removed. The most common forms of cataract surgery remove nearly all of the crystalline lens but do not remove the crystalline lens capsule. The crystalline lens capsule is retained and used to contain and position the intraocular lens implant (IOL).

<span class="mw-page-title-main">Glued intraocular lens</span> Surgical treatment for eyes lacking functional lens capsules

In ophthalmology, glued intraocular lens or glued IOL is a surgical technique for implantation, with the use of biological glue, of a posterior chamber IOL in eyes with deficient or absent posterior capsules. A quick-acting surgical fibrin sealant derived from human blood plasma, with both hemostatic and adhesive properties, is used.

Intraocular lens scaffold or IOL scaffold technique is a surgical procedure in ophthalmology. In cases where the posterior lens capsule is ruptured and the cataract has not yet been removed one can insert the intraocular lens (IOL) inside the eye under the cataract. This way the IOL acts as a scaffold and prevents the cataract pieces from falling inside the back of the eye. The cataract can then be removed safely by emulsifying it with ultrasound and aspiration. This technique is called IOL scaffold and was started by Amar Agarwal from Chennai, India, at Dr. Agarwal's Eye Hospital.

Micro-invasive glaucoma surgery (MIGS) is the latest advance in surgical treatment for glaucoma, which aims to reduce intraocular pressure by either increasing outflow of aqueous humor or reducing its production. MIGS comprises a group of surgical procedures which share common features. MIGS procedures involve a minimally invasive approach, often with small cuts or micro-incisions through the cornea that causes the least amount of trauma to surrounding scleral and conjunctival tissues. The techniques minimize tissue scarring, allowing for the possibility of traditional glaucoma procedures such as trabeculectomy or glaucoma valve implantation to be performed in the future if needed.

<span class="mw-page-title-main">Phacolytic glaucoma</span> Medical condition

Phacolytic glaucoma (PG) is a form of glaucoma which is caused due to a leaking mature or immature cataract. Inflammatory glaucoma which occurs in phacolysis is a condition which is a result of the leakage of protein within the lens into the capsule of a mature or hyper mature cataract and involves a simple procedure to be cured that is referred to as cataract extraction.

Manual small incision cataract surgery (MSICS) is an evolution of extracapsular cataract extraction (ECCE); the lens is removed from the eye through a self-sealing scleral tunnel wound. A well-constructed scleral tunnel is held closed by internal pressure, is watertight, and does not require suturing. The wound is relatively smaller than that in ECCE but is still markedly larger than a phacoemulsification wound. Comparative trials of MSICS against phaco in dense cataracts have found no difference in outcomes but MSICS had shorter operating times and significantly lower costs. MSICS has become the method of choice in the developing world because it provides high-quality outcomes with less surgically induced astigmatism than ECCE, no suture-related problems, quick rehabilitation, and fewer post-operative visits. MSICS is easy and fast to learn for the surgeon, cost effective, simple, and applicable to almost all types of cataract.

Clear lens extraction (CLE), also known as refractive lensectomy or refractive lens exchange (RLE) is a surgical procedure in which clear lens of the human eye is removed. Unlike cataract surgery, where cloudy lens is removed to treat cataract, clear lens extraction is done to surgically correct refractive errors such as high myopia. It can also be done in hyperopic or presbyopic patients who wish to have a multifocal IOL implanted to avoid wearing glasses. It is also used as a treatment for diseases such as angle closure glaucoma.

References

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