Evolution of Cataract Surgery1

The eye is one of surgery's oldest interests.

There are numerous references to cataracts and their treatment in the literature of many ancient civilizations. Perhaps the first is in the code of Hammurabi (1750 BC). This includes a schedule of payment for the surgeon, should sight be restored, along with the penalty removal of the surgeon's finger should the paor loose his or her vision (Fig. 1.2).

The authentic records of cataract surgery come from ancient Hindu medicine long before the Christian era. In this amazingly advanced community the occurrence of cataract was recognized as an opacity in the “eye apple” long before the acceptance of this view in Europe and its treatment by couching was widely practiced in India.

Susruta is said to be the first surgeon in the world to remove cataract by couching (some 800 BC), and taught the foundations of surgery based on anatomical dissections.

He pierced the sclera with a sharp lancet, then inserted a blunt instrument which depressed the lens in the vitreous cavity (In Susruta Samhita).

He practiced aseptic surgery by having the operating room fumigated with sweet vapors and the surgeon keeping his hair and beard short, his nails and hands clean and wearing a sweet smelling dress and apparently using some kind of inhalation anesthetic (Fig. 1.3).

It seems obvious that this extremely detailed account, probably written before the Hippocratic era, was the outcome of previous knowledge and experience accumulated over a long period in the rich civilizations of early Hindustan.

“It is interesting that while in Hindu medicine cataract was defined by Susruta as opacity due to derangement of the intraocular fluid, subsequent history is full of fantasies and prejudices concerning its nature” (Fig. 1.4).

“All in all Susruta must be considered the greatest surgeon of the premedical period”. AO Whipple

Although there is no record of cataract operation in ancient Egyptian or Greek medicine-Roman writers Celsus (25 BC–50 AD) and Galen (AD 131–201) 5indicated that cataract surgery was practiced in the Alexandrian school probably because Susruta's teaching reached Alexandria during or after the Indian expedition of Alexander the great. Most probably the Hindus filtered westward to Alexandria (Fig. 1.5).

This tradition of couching was maintained in Arabian Ophthalmology also, which was essentially an interpretation of Alexandrian and Romanian teaching.

Later on the Susruta Samhita was translated into Arabic before the end of the eighth century AD and was named “Kitab-I-Susrud” by Abillasiabil (Fig. 1.7).

Arab surgeons performed couching by the safer Hindu technique with two instruments instead of one as Celsus had done except Rhazes in 925 AD - and Ammar in 1015 AD who operated by tearing the cataract to pieces with a needle and sucking out the soft lens matter through a hollow glass tube or needle. Probably Rhazes and Ammar were motivated by the knowledge of the relief of cataract among the ancients derived from the fable that wild goats with this disease practised selfsurgery by charging into a thorny bush and puncturing the eye (Fig. 1.8).

In 1575-Ambroise Pare of France introduced ocular speculum which we are still using today (Fig. 1.9).

In 1585-Jacques Guillemeau of France was the first to recognize that the disintegration and dissolution of a soft cataract could occur and he deliberately practiced the operation of discission (Fig. 1.10).

In 1622, Richard Banister of London also used to do discission. They all introduced the needle posteriorly through the sclera (Fig. 1.11).

In medieval Europe couching prevailed until the middle of the 17th century-but there was strong controversy of opinion regarding the morphology of the cataract as a corrupt inspissated humor as documented by Celsus (25 BC – 50 AD) and Galen (AD 131– 210). The same opinion of corrupt inspissated humor was also adopted in Arabian writings and largely because of the immense authority of Galen, it was maintained throughout Europe for centuries (Fig. 1.12).

From the middle of the 17th century, dissenting opinions started particularly in France when Francois Quarre taught that the cataract is an opacity of the lens and not a corrupt humor. Werner Rolfinck—the anatomist who dissected executed criminals at Jena—demonstrated in 1656 that cataract is the opacity of the lens. Their revolutionary opinions were not published. In 1685, French surgeon Antoine Maitre-Jan on couching two patients noted the rounded lens and not an inspissated membrane appear in the anterior chamber which he confirmed after dissection on dead patients whose eyes he had previously couched. He also did not publish his findings at that time. While this controversy raged throughout Europe Stephan Blaukaart, the Dutch surgeon, removed cataract through a corneal incision in 1668 and ruled out the existence of inspissated humor.7

In 1745, Jacques Daviel of France (made a planned extraction of cataract from its natural position behind the iris) while operating failed to couch the lens and then based on his extensive dissection on cadavers during the plague epidemic-he incised the lower-half of the cornea and removed the lens. That started a revolution in ophthalmic surgery. After that debate over the merits of couching and extraction raged into the next century. Daviel's technique was by no means easy and for some considerable time couching remained the standard method of treatment (Fig. 1.13).

In 1759 three dramatic advances were made by Pierre-Francois Benezet Pamard of Avignon belonging to the Pamard family having seven generations of eye surgeons (Fig. 1.14). These were:

In 1766 Tadini, an itinerate eye doctor of the French Court was the first person who mentioned the possibility of lens implantation. Tadini came from an old and distinguished Milanese medical family. His imagination has come true today (Fig. 1.15).8

Thus, creative imagination is more important than knowledge.

In 1786, Wenzel was the first eye surgeon who made an incision in the upper part of cornea by keratomea method frequently used today (Fig. 1.16).

Another milestone in the development of cataract surgery was in 1797, when George Conradi of Gottingen was the first surgeon who performed discission by the anterior approach through the cornea. In the 16th and 17th centuries the same operation was performed through the posterior route from the sclera.

In 1801 Carl Himly Gottingen of Germany introduced mydriasis before cataract surgery (Fig. 1.17).

In 1811, John Cunningham Saunders of Moorfields Eye Hospital, London established discission as an operation for cataract in children. He introduced the needle by anterior approach through the cornea. Three years later in 1814 Benzamin Travers of the same Hospital established curette evacuation for soft cataract in children (Fig. 1.18).

In 1862-Preliminary iridectomy was introduced by Albert Mooren of Dusseldorf of Germany (Fig. 1.20).

In 1867 Henry Williams of New England for first time introduced the suture as a safety method for wound closure (Fig. 1.23).10

During the second-half of the 19th century surgeons became interested in the complete removal of the lens with its capsule. All the previous techniques involved pressure on the globe leading to loss of vitreous. Cataract was then removed by ‘Traction’, not by pressure or thrust on the globe.

In 1970, Terson was the first surgeon who grapsed the capsule with a tooth forcep and removed the cataract with its capsule. In 1978 Landesberg used an iris forcep for ICCE. In both the above cases while grasping the capsule it ruptured and ICCE was not achieved (Figs 1.24 and 1.25).

The introduction of general anesthesia was widely accepted since 1846 and patients wanted it for all operations by 1884. However general anesthesia was not welcomed by ophthalmologists. Though Thomas Morenay Maiz of Peru suggested the medicinal use of Cocaine - in 1884 Dr. Koller of Vienna and Dr. Sigmund Freud were the first to use cocaine as local anesthesia (Figs 1.26 and 1.27).

In 1884, H. Knapp introduced the technique of retrobulbar anesthesia where the anesthetic is injected into the muscle cone directly behind the eye (Fig. 1.28).

In 1894, Eugene Kalt of Paris devised a smooth forcep especially for intracapsular extraction of lens and he successfully delivered the lens with its capsule (Fig. 1.29).11

In 1902, Stoewer was the first person who used a suction cup for intracapsular cataract extraction. Later on Hulen did it in 1910 (Figs 1.30 and 1.31).

In 1910, Colonel Henry Smith of India popularized the technique of intracapsular cataract extraction by pressure on the globe by curette or strabismus hook. He did operations on an incredible number of patients at Madras in India. His technique is very suitable for hypermature Morgagnian cataracts and is popularly known as “Smith's technique” today.

Motor akinesia was initially introduced by Van Lint of Brussels in 1914. He paralysed the orbicularis muscle, a technique modified by R. E. Wright of Madras in 1921, who injected the trunk of the facial nerve as it emerged from the stylomastoid foramen, and simplied by 0’ Brien of Iowa in 1920 who injected the temporofacial division of the nerve as it crossed over the condyle of the mandible (Fig. 1.32).

In 1917, ICCE was done by traction through was very popular and useful for intumescent and Erysophake controlled by electric pump and popularized hypermature Morgagnian cataracts (Fig. 1.36) by Ignacio Barraquer of Barcelona (Fig. 1.33).

In 1922, Anton Elschnig of Prague introduced the famous Elschnig intracapsular forcep for intracapsular surgery by traction which we are still using (Fig. 1.34).

In 1930, though Knapp had introduced the technique of retrobulbar injection in 1884, Procaine was used for the first time in that year.

In 1932, Lacarrere of Madrid innovated diathermocoagulation with a double pronged needle for ICCE by traction.

In 1933, H Arruga introduced his famous Arruga's forcep for removing the cataract with its capsule by traction (Fig. 1.35).

In 1948, AE Bell introduced a stiff rubber bulb for suction in removing the cataract. It was very simple and was very popular and useful for intumescent hypermature Morgagnian cataracts (Fig. 1.36).

In the same year (1948) the operating microscope was first used by Dr Ken Swann of Portland, Oregaon, USA.

The modern lens implantation was introduced in ophthalmology by Harold Ridley of London. In 1949, at the end of a cataract operation, Ridley was asked by a medical student why he did not replace the sick lens with a new one. That question gave Ridley the impetus to explore the possibility of lens implantation. The first intraocular lens was implanted in the capsular bag following extracapsular cataract extraction at St. Thomas Hospital in London on November 29,1949. The second was on August 23, 1950. Both these two patients developed high refractive power and postoperatively had 20.0 and 15.0 dioptre myopia. Ridley recalculated the power of the IOL and again implanted. Even after that patients developed high refractive error and ultimately he abandoned the implantation of lens in posterior chamber (Fig. 1.37).

Failure of posterior chamber lens implantation lead to the development of anterior chamber lens implantation and in 1951 anterior chamber lens implantation was performed by Strampelli of Italy and Daneheim of Germany.13

In 1958, J. Barraquer of Spain established ICCE by an enzyme, alpha chymotrypsin, causing zonulolysis and thereby helping in easy removal of the lens (Fig. 1.39).

In 1960, ICCE done by cryosurgical probe through traction was introduced by T Krwawicz of Lubin of Poland and AmoHs of South Africa (Figs 1.40 and 1.41).

In the same year Atkinson advocated retrobulbar injection with hyaluronidase.

For a perfect lens implantation, it is important that the optimum power of the pseudophakos should be calculated, for which the axial length of the eye is mandatory. In 1966, Weinstein et al developed ultrasound which was better than formerly employed X-rays.

In 1967, Harmann Gernet of Germany was the first to work with echometry. Later on several investigators, first Gernet et al (1970), CD Binkhorst (1972), Colenbrander (1973) and RD Binkhorst (1981) developed useful formulas for calculation of IOL power and presented the results in tables, nomograms and computer programs (Fig. 1.42).

Endothelium of the cornea has a great role in regaining vision after cataract surgery. In 1968, Maurice described a so-called specular microscope for the observation of the endothelium. The instrument was later modified by Laing et al (1975), and Bourne and Kaufman (1976) so that one can examine the eyes of a sitting patient.

The Dutch ophthalmologist CD Binkhorst visited Ridley at the very early stage of implant history when there was dissatisfaction among the ophthalmologists regarding the failure of Ridley's posterior chamber lens implantation. Binkhorst realized that Ridley's lens dislocated due to its weight, lack of fixation, extension of lens into the chamber angle which often lead to corneal edema. Binkhorst introduced its four loop lens on 1st August 1958. Original Binkhorst lens had a large dislocation rate. The problem of fixation still remained. Mild iritis due to prolonged use of miotic and increasing corneal endothelial decompensation lead to abandonment of 4 loop lens and in 1975 Binkhorst introduced the two loop lens (Fig. 1.43).

The Russian ophthalmologist Fyodorov modified the Binkhorst lens and introduced this in the Soviet Union in 1963 as Fyodorov I-Binkhorst lens. In 1965, Fyodorov and Zakarov introduced a lens with three posterior loops (Sputnik lens)-Fyodorov II. This lens was extremely light weight and over the years did not cause any damage to the sphincter of the pupil (Fig. 1.44).

For safe intraocular surgery reduction of IOP (intraocular pressure) is very helpful. In 1967, D Vorosmarthy 15invented oculocompression for lowering intraocular pressure. New mechanical techniques have been developed to assure very soft eye having a deep anterior chamber with a concave anterior vitreous surface. This was done by Honan's balloon in 1978. In 1979, Gills introduced “Super Pinkie” which is very cheap and quite safe for reducing lOP by the compression method. Outer retinal ischemia or retinal artery occlusion may occur on rare occasions. “Nerf ball” invented by Robert C Drews in 1981 is safe because it is much softer and impossible to induce high pressure on the orbit to occlude the central retinal vessel (Figs 1.45 and 1.46).

In 1967, Kelman introduced ECCE by phacoemulsification, a technique which emulsifies the lens content using ultrasonic vibrations and aspirating the emulsified cataract. Kelman himself said. “Although I invented

Phaco, many ideas can develop, with everyone participating in the evolution.” The first operation was done in April 1967 and it took 76 minutes and that eye ultimately turned into a painful blind eye. In 1970, Kelman's Cavitron Unit came into existence (Figs 1.47 A and B).

The ingenuinity and perseverance of Charles Kelman led to the development of phacoemulsification which in combination with advanced bioengineering science and improved surgical technology, transformed the procedure from a fringe concept into a most useful and viable procedure for cataract surgery today. Dr Kelman's method is to prolapse the nucleus into the anterior chamber for emulsification. He created a large anterior 16capsulotomy by a cystitome in a “Christmas tree” or triangular fashion and impaled the nucleus and brought it into the anterior chamber by the same cystitome under air. At that time, he used a one handed technique to emulsify the nucleus in the anterior chamber.

In 1970, early propagators of phacoemulsification found marked corneal edema following surgery as most of the ophthalmologists were not fully aware of the, corneal endothelial physiology and they did not appreciate the fact that corneal clarity depends on healthy corneal endothelium which once insulted or injured will not regenerate. Moreover, viscoelastic materials and present vitrectomy techniques did not exist at that time. They also frequently experienced difficulty in maneuvering the lens nucleus into the anterior chamber. Pioneers such as Richard Kratz, and Robert Sinskey relocated the emulsification action away from the endothelium for protection of the cornea.

Since 1980, with the advent of viscoelastic materials, capsulorhexis and with advanced technology of operative surgery, more and more surgeons are inclined to phacoemulsification as the cornea is protected by viscoelastic materials and the circular capsulorhexis traps the nucleus within the capsular bag where emulsification is done. The difficulty of elevating the entire lens nucleus out of the capsular bag led the surgeons to develop methods for dividing the nucleus and moving the pieces from the capsular bag for safe emulsification. Ophthalmologists devised a nuclear subqivision method in linear, circumferential, or combined forms. Additionally, hydrodissection evolved as a means of moving and rotating the nucleus within the capsular bag, and thereby facilitating the subdivision process.

Howard Gimbel described linear division as nucleofractis.

John Shepherd developed four quadrant divide and conquer technique.

Howard Fine developed chip and flip nucleus removal technique.

Paul Koch developed a hybrid method which is known as “stop and chop”, where the surgeon uses ultrasound to divide the lens nucleus into two pieces and then chop the heminuclei bimanually.

After establishing the maintenance of corneal endothelium by retentive viscoelastic and circular capsulorhexis, more attention was given in this latter part of the century to low amount of ultrasonic energy to the cornea, so that clear cornea will be achieved on the first postoperative day with any variety of nuclear densities. The results were achieved partly by the modulation of emulsification energy in the form of bursts or pulses, high vacuum aspiration and chopping the nucleus.

Kunihoro Nagahara described nuclear chopping by using high vacuum ultrasound to impale the lens nucleus by emulsification tip which is firmly attached to the nucleus. The surgeon simultaneously places a sharpened chopper near the equator of the lens and draws it towards the phacotip in order to chop the lens into 17portions before emulsifying and aspirating. This technique reduces the total amount of ultrasonic energy to which the anterior segment structures are exposed.

In 1978, Dr Keiki Mehta, Mumbai, India introduced HEMA and silicon lens with excellent results. Later on silicon lenses were used by Blumenthal in 1983, Fyodorov and Epstein also in 1984 (Fig. 1.49).

In the same year 1978, GF Worst of Netherlands designed iris claw lens or Lobster claw lens based on the recognition that it is possible to prepare a sheet of PMMA in such a way that it forms an elastic claw into which the iris can be incarcerated without loosing its physical properties of coherence and tensile strength except for the points of the tissue directly squeezed between the branches of the claw. Iris claw lens can be implanted after both intra or extracapsular cataract surgery and as a primary or secondary procedure (Fig. 1.50).

Cataract surgery reached its peak with the development of viscoelastic materials. In 1983, the development of Healon, a hyaluronic acid polymer was used as a viscoelastic material in implant surgery by Dr Endre Balazs of Columbia University.18

In 1984, foldable lens was introduced by Mazzocco of USA and Epstein of South Africa (Fig. 1.53).

In 1986, David B Davis II and Mark R Mandel of Medical Surgical Eye Centre, Hayward California startled the ophthalmic world with their publication of peribulbar anesthesia (Fig. 1.54).

Continuous curvilinear capsulorhexis: Round capsulorhexis is suitable for ECCE. It is amazing that three doctors staying in three different countries in the world were thinking on the same lines at the same time.

In 1985, Gimbel gave the nomenclature of continuous capsulotomy (Fig. 1.55).19

In 1986, Neuhann gave the nomenclature of capsulorhexis (Fig. 1.56).

In 1987, Kimiya Shimizu gave the nomenclature of circular capsulectomy. One word from each inventor comes to ‘continuous circular capsulorhexis’.

In 1991, cataract refractive surgery was introduced in the USA.

In October 1993, Richard A Fichman performed cataract surgery first under topical anesthesia.

In 1997, Cumming Kammon of Europe introduced accommodation IOL prototype.

At the end of 20th century Dr Amar Agarwal in Chennai, India introduced one after another new inventions in the field of ophthalmology (Fig. 1.60).

How the idea came in the mind of the inventor : Basically he is a vitreo-retinal surgeon and used to do all his lensectomies with the phaco hand piece as he did not have a fragmatome. He removed the infusion sleeve and passed the phaco needle into the lens through the pars plana. Infusion was done through the infusion canula which is conducted in all vitrectomies. Later on, he thought about using this system for cataracts for the anterior segment surgeon also. On 15th August 1998, on India's Independence day, he thought a needle could be bent like a chopper which could be used for irrigation and chopping of the nucleus.

In phakonit, the infusion sleeve was taken out. The titanium tip was passed inside the eye and as there was no infusion sleeve present the size of the incision was 1.2 mm. In the left hand an irrigating chopper was held which had fluid passing inside the eye through the side port incision. The assistant injects balanced salt solution (BSS) continuously at the site of the incision to cool the phakotip. On August 22nd 1998, Dr Amar Agarwal performed Phakonit live surgery through 0.9 mm incision at Pune, India, at the Indian Intraocular Implant and Refractive Society Conference where 350 ophthalmologists watched his technique. In 1999, Phakonit and no anesthesia cataract surgery were telecasted live via satellite from India to Seattle, USA in ASCRS 99 Conference. The live surgery went very well and on invitation Dr Amar Agarwal went to Seattle, USA, and gave lectures in the ASCRS. Subsequently live surgeries were conducted on Phakonit and no anesthesia cataract surgery in ASCRS, AAO and ESCRS Conferences.21

Clear corneal incision made with the keratome (1.2 mm). The left hand has a straight rod to stabilize the eye.

Rhexis started with a needle.

Phakonit irrigating chopper and phako probe without the sleeve inside the eye.

The Phakonit needle in the right hand and an irrigating chopper in the left hand, the crack created by karate chopping. The assistant continuously irrigates the phako probe area from outside to prevent corneal burns.

Phakonit completed. The nucleus has been removed and there are no corneal burns.

In 1999, Hiroshi Tseunoka of Japan studied the use of ultrasonic phacoemulsification and aspiration for lens extraction through a microincision. Tseunoka used a large incision as he felt that when the incision size is larger than phacotip, the tips get cooled by the leakage of infusion solution through the incision. The extraspace according to him also prevents deformation at the incision site due to the tip movement (Fig. 1.62).

Randall defined Microphaco as completing cataract surgery through two stab incisions of no more that 1 mm. Microphaco can have as its energy source ultrasound, laser or sonic'energy. The emphasis is given on laser or sonic energy to remove a cataract by 23microphaco. The main reason of shifting to microphaco is the problem of irrigation in traditional phacoemulsification where irrigation and phaco aspiration needles are wrapped together to avoid wound burn and to maintain the chamber. The irrigation surrounding aspiration requires at least 2.5 mm to 3 mm.

Jorge L Alio from Spain coined the term MICS or Microincision cataract surgery - being done through a 1.5 mm incision or less. This included laser cataract surgery (Fig. 1.64).

In traditional phacoemulsification irrigation maintains the chamber but otherwise is not a positive force. Increased turbulence during irrigation results in spinning and bouncing the lens fragments which produces 24endothelial damage. Furthermore, irrigation pushes nuclear fragments away when we want to have the particles come to the phacotip. Nuclear fragments buffeted and pushed away by the irrigation and phacotip is to be moved for aspiration. When irrigation is separated from aspiration it can be a positive force by which free nuclear fragments automatically flow to the phacotip because this is the only exit if the wounds are tight. All these irrigation advantages significantly decrease the amount of fluid necessary and thereby damage to endothelium is minimized which improves the efficiency and safety of the surgery.

In 1999, He introduced ‘Air Pump’. One of the main problems in phacoemulsification is the fluidics. The amount of fluid entering the eye is less compared to the amount of fluid exiting the eye. Dr Sun ita Agarwal (sister of Dr Amar Agarwal) understood this problem and started pushing the air into the infusion bottle to get more pressurized fluid out of the bottle. When it worked she took an Aquarium air pump and connected it to the infusion bottle via an IV set. This gave a constant supply air into to the infusion bottle and the amount of fluids coming out of the irrigation chopper was quite enough (Fig. 1.65).

In 2000, Dye enhanced cataract surgery was introduced by Dr Suresh K Pandey, Liliana Warner and David J Apple (Fig. 1.66). Its purposes are:

In 2001, Dr Anthony Maloof of Australia introduced “Sealed lens capsule irrigation”. Despite recent advances in lens design, instrumentation and surgical technique -PCO remains the most common complication associated with cataract surgery particularly in the pediatric age group (Fig. 1.68).

Friends, please listen. You are not alone in the process of evolution. Almighty GOD is with you in trying to evolve the human race in the direction of elimination of shortcomings and enhancing benefits since the inception of human creatures (Fig. 1.69).