Cataract Surgery From 1918 to the Present and Future-Just Imagine!

PURPOSE

To review the history of cataract surgery over the past 100 years, and to offer predictions about new developments that may occur during the next 50 years.

DESIGN

Interpretive essay.

METHODS

Review of historical literature and author experiences pertaining to cataract surgery, with commentary and perspective.

RESULTS

By this time, cataract surgery has advanced to the point that Kelman's introduction of phacoemulsification and use of intraocular lenses (IOLs), both very controversial when initially introduced, have become state of the art. Outpatient surgery, minimally limited mobility, sutureless incisions, and topical anesthesia also have become key components of standard treatment. The author envisions availability of medications for nuclear sclerosis and presbyopia, expansion of lens surgery for refractive purposes with postsurgical adjustment and unprecedented precision, increased mechanization of lens removal with emphasis on uncomplicated surgery rather than refractive precision, and accommodating IOLs all becoming standard.

CONCLUSIONS

Acknowledging and appreciating the past contributions of pioneers in cataract surgery is vital to understanding the development of today's clinical care. Clues as to the future do help give us a possible scenario worthy of such conjecture.

The Oculist's Eye: Connections between Cataract Couching, Anatomy, and Visual Theory in the Renaissance

We now know that cataract couching involves depressing an occluded crystalline lens to the bottom of the vitreous chamber, but from the time of Galen until the seventeenth-century cataracts were thought to be separate concretions arising between the crystalline lens and the pupil. From Antiquity through the Renaissance, the combination of visual theory in which the crystalline humor is the author of vision, and surgical experience—that couching cataracts restored some degree of sight—resulted in anatomists depicting a large space between the crystalline lens and the pupil. In the Renaissance, oculists—surgical specialists with little higher education or connections to learned surgery or medicine—overwhelmingly performed eye surgeries. This article examines how the experience and knowledge of oculists, of barber-surgeons, and of learned surgeons influenced one another on questions of anatomy, visual theory, and surgical experience. By analyzing the writings of the oculist George Bartisch (c. 1535–1607), the barber-surgeon Ambroise Paré (1510–1590), and the learned surgeon Hieronymus Fabricius ab Aquapendente (1533–1619), we see that the oculists’ understanding of the eye—an eye constructed out of the probing, tactile experience of eye surgery—slowly lost currency among the learned toward the beginning of the seventeenth century.

The Evolution of Cataract Surgery

Cataract surgery is one of the most common procedures performed worldwide. It is also one of the oldest. Alongside advancements in cataract surgical techniques have been improvements in intraocular lens replacement technology. Cataract surgery may be considered among the most successful treatments in all of medicine. This article discusses the fascinating evolution of cataract surgery, from the earliest approach of couching to modern day phacoemulsification and lens replacement.

Sir Harold Ridley: innovator of cataract surgery

Cataract surgery has evolved greatly over the years, from the ancient practice of 'couching' where the lens is dislodged, to the modern surgical techniques of today. Sir Harold Ridley's invention of the intraocular lens (IOL) has altered the approach towards cataract surgery, benefitting individuals worldwide. This has been his most notable contribution, it is therefore interesting to explore the build up to this event and gain an understanding of the issues faced by Sir Ridley. This paper explores the significant events and key developments that influenced one of the most valuable innovations in the context of cataract surgery--the intraocular lens.

Sushruta in 600 B.C. introduced extraocular expulsion of lens material

It is generally accepted that Jacques Daviel introduced in the 18th century the extracapsular technique of extraction of the lens while the couching method of cataract operation had already been practiced since ancient times. Present study analyses the first known cataract surgery description in three translations into English from the original Sanskrit Sushruta textbook and all the available literature on the subject. We found evidences that some sort of extraocular expulsion of lens material through a limbal puncture (paracentesis) was described by the Indian surgeon. Nevertheless, this incision cannot be considered as a classic extracapsular procedure because it was not large enough to allow the extraction of the entire lens.

Cataract surgery in ancient Egypt

Ophthalmology was one of the most important specialties in Egyptian medicine, and more specialists are known in this field than in any other. This specialization seems, however, to have been of a purely noninvasive nature. Even though it has been claimed that cataract surgery was performed in pharaonic Egypt, careful analysis of the sources does not support the claim. No example of cataract surgery or of any other invasive ophthalmologic procedure can be found in the original sources.

Blindness of Johann Sebastian Bach

Johann Sebastian Bach (1685-1750) was one of the greatest composers of all time. Apart from performing as a brilliant organist, he composed over 1.100 works in almost every musical genre. He was known as a hardworking, deeply Christian person, who had to support his family of 20 children and many students staying at his home. At the age of 64 years, his vision started to decline. Old biographies claim that it was the result of overstressing his vision in poor illumination. By persuasion of his friends, he had his both eyes operated by a travelling British eye surgeon. A cataract couching was performed. After surgery, Bach was totally blind and unable to play an organ, compose or direct choirs and orchestras. He was confined to bed and suffering from immense pain of the eyes and the body. He died <4 months after surgery. In this paper, as the plausible diagnosis, intractable glaucoma because of pupillary block or secondary to phacoanaphylactic endophthalmitis is suggested.

[The development of cataract surgery after 1745]

Nowadays, cataract surgery is the most commonly performed surgical procedure in the Netherlands. This is due to the increasing incidence of cataracts, the changing indication for surgery in our society where good vision is becoming increasingly important, and the quality of the operation. How was this modern procedure developed? Cataracts were treated by couching until the middle of the 18th century. Since then, many discoveries by a number of doctors changed the procedure gradually from couching to lens extraction and through extracapsular to intracapsular extraction with the simultaneous implantation of an intraocular lens. This article outlines the development and also discusses some of the many inventions in the field of instrumentation and materials that have brought this intervention to its current high level; these include the cryo-probe, implantation of artificial lenses, the use of hyaluronic acid, phaco-emulsification, smaller incisions without sutures and the development of foldable intraocular lenses.

Modern cataract surgery: unfinished business and unanswered questions

We summarize information, based on clinicopathologic studies over the past decade, on various cataract intraocular lens (IOL) procedures and modern "specialized" IOLs, that will help surgeons continuously improve long-term results for cataract patients. Although most operations do initially provide excellent refractive correction and visual rehabilitation, late complications occur. These sometimes are missed because they are outside of the routine period of follow-up care. We have tried to determine if the various techniques and IOLs truly deliver the long-term results that we desire. Most safety and efficacy information is derived from the manufacturer and is passed through the U.S. Food and Drug Administration (FDA). This is often based on limited, relatively short-term observations made by the manufacturer. After a lens receives FDA approval, there are few means to assess the outcome of each procedure and lens years later. We rarely hear of a 10- or 20-year follow-up study. We have found that one of the best means to assess long-term results is pathologic analyses. We discuss recently studied aspects of pathologic reactions, such as posterior capsule opacification, intracapsular fibrosis, glistenings, intralenticular opacification, and other issues with the various IOL platforms; we then present a clinicopathological overview of tissues and IOLs from our database. These include hydrophobic and hydrophilic acrylic designs, plate lenses, and a dual optic lens.

[Cataract--short history of treatment methods tried and abandoned]

The author presents a brief history of treatment methods used for cataract, emphasizing key moments and highlightening Romanian contribution to this kind of surgery.

[Couching then and now]

Cataracts are the most important cause of acquired blindness worldwide. The oldest known surgical treatment for cataracts dates back to around 1,000 years before Christ. The Indian surgeon Sushruta described the technique of 'couching', in which the opaque lens is pushed from the line of vision using a needle. At the time of Alexander the Great this technique spread across Europe and then to the rest of the world. Couching was the only available treatment for cataracts for a long time, until the discovery of lens extraction by Jacques Daviel in 1748. Since then lens extraction has replaced couching in the western world, because of poor results and high complication rates. This procedure is, however, still practiced in areas of Africa and Asia.

19th century cataract surgery and surgeons in Mexico

Cataract surgery has at least a 3000-year history, but it was not until the 19th century when it was refined to become a routine and successful procedure. Until early this century, the extracapsular technique, introduced by Daviel in 1748, was generally performed in Europe and America, and Mexico was no exception. The brightest and most distinguished Mexican physicians practiced that surgery. Several of their names designate the streets of "Colonia de los Doctores" in Mexico City. For the last quarter of the 19th century, ophthalmology was a defined and independent medical discipline in Mexico. The first Ophthalmologic Society in Latin America was established here in 1893, and in 1898 the oldest current journal of this specialty began its publication in Spanish. Since the 19th century--and perhaps before--cataract surgery in Mexico has been practiced at the same level as in the U.S. and Europe.

The multifaceted career of Louis Borsch

John Louis Borsch Jr, MD (1873-1929), was an ophthalmologist from Philadelphia who spent most of his career in France. During his lifetime he was probably best known as the inventor of the first fused bifocal lens, which was marketed very successfully as the Kryptok lens. He may be better known today for performing cataract surgery on Mary Cassatt (1844-1926), the American Impressionist artist, and on James Joyce (1882-1941), the Irish author. Little known, but remarkable, is his thesis for his second medical degree, Le Traitement Chirurgical de l'Astigmie (The Surgical Treatment of Astigmatism).

Johan Lorenz Odhelius and cataract extraction in Sweden

In 1775, Johan Lorenz Odhelius presented a lecture to the Royal Academy of Science at Stockholm describing his preferred operation for cataract. Odhelius generally endorsed the technique described by Daviel (1753) 22 years earlier, but included additional observations and modifications based on his own experience. This address was published in Swedish (Odhelius 1775) in the same year and is one of the earliest ophthalmological monographs by a Swedish author. Odhelius' publication is now translated into English and put into its historical perspective.

[History of cataract surgery]

By analysis of ancient surgical instruments it's possible define the history of medical specialties, and acquaint the evolutions of specific surgical techniques and operations through the centuries. The aim of the article is to reconstruct the history of the conception of cataracts, of theories and pathological interpretations in different eras, through the descriptions of surgical instruments and methodologies found in medical texts and the analysis of the artefacts kept in the Museum of History of Medicine of Rome.

History and development of the apodized diffractive intraocular lens

The ReSTOR intraocular lens presents a unique apodized diffractive design within a refractive foldable acrylic optic, which makes an unprecedented level of mulifocal optical performance available. We describe the history and principles of diffractive optics used in the development of this refractive-diffractive IOL.

[The eyes of Johann Sebastian Bach]

Limited vision seems to have been Johann Sebastian Bach's (1685-1750) only physical problem. Myopia seems the most likely cause and he probably developed cataracts later in life. In addition to the cataracts, his worsening vision may have been due in part to some other eye problem. In 1750 Bach's vision became so poor that he had his eyes operated on by the travelling English eye surgeon John Taylor. Most likely the first operation was Taylor's standard couching procedure. About one week after the first operation, Bach was operated on again because of the reappearance of the cataract. Many painful and/or vision-reducing complications could have been induced by these intraocular operations: uveitis or endophthalmitis, secondary glaucoma, haemorrhage, retinal detachment, and even sympathetic ophthalmia. After the second operation Bach was blind. He died less than four months later.

Couching for cataract and Sino-Indian medical exchange from the sixth to the twelfth century AD

This paper investigates the processes of interpretation and integration of the Indian ophthalmic technique known as 'couching for cataract' into Chinese medicine from the sixth to the twelfth century ad. The Indian medical knowledge of this procedure was eventually accepted because it could be reconstructed following Chinese medical concepts.

[Prolapse of the uterus and cataract: a comparison of veterinary and human medicine in Greco-Roman antiquity]

A number of surgical interventions in ancient veterinary medicine were modelled on the same procedures in human medicine. This is discussed in some detail for the prolapse of the uterus and the couching of the cataract in horses. In the introductory section, the importance of Switzerland and neighbouring areas for the transmission of ancient veterinary medicine is highlighted.

[Jacques Daviel--the inventor of the extracapsular cataract extraction surgery]

On April 8, 1747, Jacques Daviel called to operate on M. Garion, a master wigmaker, whose cataracts appeared very favorable for surgery. Nevertheless, the expert Daviel was unable to depress lens. At that moment, he decided on a deliberate extraction. After widely opening the right cornea, he passed a small spatula through the pupil and extracted from the posterior chamber the lens. Thus was initiated the first significant advance in cataract surgery since the invention of couching in ancient India.

[Sir Harold Ridley--the creator of modern cataract surgery]

In February 2000, the worldwide ophthalmology community celebrated the 50th anniversary of one of the twentieth century's most important innovations in eye care--the implantation of the first intraocular lens after cataract extraction by Sir Harold Ridley. It was the initiation of a golden age for the development of ophthalmology, especially cataract surgery. In our paper we would like to remember this outstanding English ophthalmologist and his great invention.

[Linnés pupil J G Wahlbom, physician and eye surgeon]

Johan Gustaf Wahlbom (1724-1808). One of Linnés first pupils, physician and eye-surgeon. Studied at Uppsala University 1744-51. Defended a dissertation pro exercitio, Sponsalia Plantarum under Linné 1746, swed.translation Blomstrens Biläger 1750. Dissertation pro gradu Ampherina catarrhalis under Rosen 1750. Studied anatomy, surgery and obstetrics in Berlin !752-53. - Provincial physician in the county of Kalmar 1754-94. Introduced inoculatons against smallpox and started one of the first hospitals for venereal diseases in the country. - A scientific dispute with OlofAcrel on cataract surgery aroused great interest. After a public demonstration ofWahlboms and Acrels operative skils,.the controversies were finally settled in a friendly manner. - By employing a rigorous hygienic regime Wahlbom and Anders Sparrman were able to stop a serious infectious disease in Karlskrona 1789. - In appreciation of Wahlboms scientific contributions in Botany and Medicine, Linné named a moth and Thunberg a new plant after Wahlbom. He was appointed First Physician to the King in 1794.

Sir Nicholas Harold Ridley. He changed the world, so that we might better see it

Cataract surgery with intraocular lens (IOL) implantation has become the most common and most successful of all operations in medicine. Sir Harold Ridley's first cataract extraction with implantation of an IOL marked the beginning of a major change in the practice of ophthalmology. Millions of patients worldwide have benefited from Sir Ridley's invention, and are likely to continue to derive benefit from this device. However, the development of the IOL was not without its share of ups and downs. Sir Harold Ridley, the inventor of IOL, died at the age of 94, on 25 May 2001, and ophthalmology lost one of its greatest and most influential practitioners. We are happy that he lived to enjoy the fruits of his labour--to see the amazing improvements and the expansive growth that evolved in the cataract-IOL technique, from early and unsatisfactory operations in previous decades, to the superb results attainable today. The invention of the IOL has not been just the addition of one new form of treatment, but rather, Sir Harold's tiny disc-shaped sliver of plastic has changed the world so that our patients may better see it. This article presents a brief biographical sketch of Sir Harold and lists his major inventions and contributions to ophthalmology.

[The evolution of cataract surgery, extra- and intraocular correction of aphakia]

The evolution of cataract surgery during the recent 2 centuries, and especially in the last 50 years, witnessed essential changes--from reclination of the lens and a traditional extracapsular cataract extraction to cataract microsurgery including phacoemulsification. A lack of the lens in the eye, i.e. aphakia, is considered to be a serious complication. The optic extraocular correction of aphakia is implemented mainly by the use of spectacles and contact lenses, which are not deprived of essential shortcomings. H. Ridley was the first to implant, in 1949, a polymethylmethacrylate (PMMA) intraocular lens (IOL). After that, anterior-chamber and iris-clips lenses as well as extrapupillary lenses with fixation to Sulcus cyliaris, which had by some complications, were offered. Only in 1973, we offered, for the first time in the world practice, an intracapsular implantation and intercapsular fixation of IOLs of various models. The designed intraocular correction of aphakia was checked by time and it is used now in cataract microsurgery, including small-incisions as well as ultrasound and laser phacoemulsification. The use of the lens bag as a natural bed for the fixation and isolation of IOL from intraocular structures is a priority direction in the Russian research ophthalmology.

[Ophthalmology in the ancient river cultures. Was cataract surgery performed during the time of King Hammurabi?]

The article presents the state of ophthalmological knowledge in the Ancient River Cultures. Medical and ophthalmological information included in King Hammurabi Code is discussed. The author presents a critical analysis of the views related to the hypothesis of possible performance of cataract operation in Babylon during the Hammurabi period. Terminological and medical matters related to this issue are discussed. The original opinion about surgical treatment of symblepharon or pannus trachomatosus is presented.

[The life work of Sir Nicholas Harold Lloyd Ridley]

On may 25th 2001 Sir Harold Ridley died at age 94. With him Ophthalmology lost one of the greatest and most influential Ophthalmologist of the post-war time. He is the founder of modern cataract surgery implanting the first intraocular lens after extracapsular cataract extraction 50 years ago. He pioneered in what became one of the most important success stories in Ophthalmology. His vision and concepts managed to succeed against strong opposition worldwide. Modern cataract surgery and modern refractive IOL surgery would not been possible without his contribution. Sir Harold Ridley reached a high age and was therefore able to see his visions become reality and finally receive all honours and awards he deserved over the past 15 years, including the knighthood by Queen Elisabeth II in the year 2000. The following article gives a summary of his biography and contributions to Ophthalmology.

[History of the development of intraocular lenses]

Even though cataract surgery has been practiced for over 2000 years, modern cataract surgery started just some 50 years ago. with the first IOL implantation by Sir Harold Ridley. The development of intraocular lenses was accompanied by great successes and disasters. With the fast development of cataract surgical techniques over the past 15 years (ECCE, Phacoemulsification, Capsulorhexis) a successful marriage between IOL-developments and surgery was established. Indication profiles for cataract surgery and IOL implantation extended to more and more patient groups. At this time classical cataract surgery is further developing into refractive intraocular lens surgery to correct higher ametropia in clear lens or phakic eyes. This development was only possible because of the improvements of surgical techniques and implants in classical cataract surgery.