Femtolaser Cataract Surgery Federica Gualdi, Luca Gualdi
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History of Cataract SurgeryChapter 1

F Gualdi,
M Gualdi
The history of surgery (from the Greek words, cheiros: hand, and ergon: work) is lost in the mists of time. We can say that the disease, and hence the cure, were born with man himself. The first signs showing the existence of rudimentary surgery are ascribed to the prehistoric era.
In the era of the Egyptians surgery was mostly on bones. They were experts in the art of embalming, more for religious purposes rather than for scientific reasons.
The Assyrians-Babylonians cured wounds and fractures with early forms of surgery; for the surgeons the rules were so strict that the Hammurabi Code called for the amputation of arms and phalanxes of those who failed in their treatments.
In ancient Greece, tasks such as trepanation of the skull and other rudimentary surgical techniques were performed. This was the time that the science of anatomy was developing.
Thanks to Hippocrates (480–390 BC), the father of western medicine, surgery was formed as a science. It acquired its intrinsic procedures, and joined diet and exercise in the art of care.
In imperial Rome, Celso, remembered as an encyclopedist, adviser and a great admirer of surgery, was the first physician of ancient Rome who could operate cataracts and bladder stones. He is the author of “De medicina”, where he divided this science into three branches: dietary, pharmaceutical and surgical. Thanks to a careful study and thorough revision of Greek and Latin texts, the layout of Celso's work represented an original methodological approach bringing together the empirical with the rational.
 
Cataract Surgery: From “Couching” To “Femto-Phaco”
As a pathological entity, cataract has been known for thousands of years. Nevertheless, until the middle of the 17th century it was a belief that cataract was a clot of “bad spirit in front of the pupil, able to block the enactment of the visual spirit out of the eye, interfering with his sight”.
From the found illustrations, historians have deduced the possibility of some surgical techniques by the Mayans and Aztecs. The interpretation is still dubious; it is possible in fact that the purpose was not surgery but simple and savage acts of sacrifice.
The authorship of the first surgical techniques of discission and depression of cataract is attributed to Indian surgeons. In the Book of Susruta (2500 BC), it is reported that before the operation, the eye was heated with the breath and wet with breast milk, then the surgeon pricked the anterior chamber with a lance, opened it, and split the cataract with a sharp instrument (discission) and/or the cataract was depressed with a fine instrument (couching).2
According to the ancient Egyptians, cataract was known and defined as “rising water in the eyes”. Cataract surgery with a depression method was probably practiced by ancient Egyptians which may be proven by: the finding of stilettos similar to those used up until a few years ago by Moroccan itinerant surgeons, the high probability that this kind of surgery was practiced at the time of the kings of Babylon, the certainty that the cataract depression was already used by Antilo of Alexandria in century 2 AD, and the ancient Egyptian texts on medicine (Figs 1A and B).
In ancient Greece, cataract and glaucoma were considered as a single “affliction with symptoms such as alteration of the normal black pupil foramen, caused by diseases of the internal humors of the eye for excessive humidity, dryness or thickening”.
The first ophthalmic surgical techniques occurred in Italy during the Roman Empire, when the cataract or soffusio was considered by Celso and Galen, “caused by the thickening of the humor present in the locus vacuus”, meaning the empty space between the cornea and the lens. They classified cataracts into curable and incurable. According to these authors, curable cataracts were small, motionless, light-colored aquamarine or bright steel; incurable cataracts were large, with distorted pupils, bright yellow or sky blue colored. The Romans had not located the exact source of the disease process, but they had already unconsciously introduced the concept of hypermature cataract, subluxated, complicated, etc.
The Roman surgical technique was preserved unchanged for almost 1,700 years until it became clear that opacity resided in the lens itself. Thereafter, a more rational therapeutic approach to remove the cataract was considered, and no longer the simple displacement.
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Figs 1A and B: Ancient instruments probably used for cataract surgery
In 1748, the Mercure de France published the new surgical technique of cataract removal performed by Jacques Daviel. He is considered as the pioneer of modern cataract surgery. Even if other doctors, such as the Italian Durante Sacco in 1684 or the Dutch Blankaart in 1688, already attempted cataract extraction; Daviel was the first surgeon who exported the technique beyond French borders, and performed a high number of surgeries. As always, when a new surgical technique shows up, many opponents line up against the progress, especially if the technique subverts a method, which has lasted for over 2,000 years, as in the case of cataract. It took almost 1 century for the cataract removal to replace the “couching” technique (Fig. 2).
Throughout the 19th century, cataract extraction was performed following Daviel's teachings of the extracapsular technique. He would make a limbal and lower cut with the patient sitting in front of the surgeon. Not until the 20th century do we see the patient operated in the supine position, the surgeon behind the patient's head and the appearance of the intracapsular method. In 1927, A Bietti in his Treatise on Oftalmojatria refers to the lens-capsule extraction. He says that it is an ideal technique for cleaning the pupillary field, but it is difficult to perform and requires a particular instrument such as the Barraquer wire speculum (pneumatic suction extractor) (Fig. 3).
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Fig. 2: Couching technique
3
Thanks to the Barraquer family, first Ignacio, creator of the wire speculum and then his son Joaquin, experimenter of alpha-chymotrypsin, an enzyme that dissolves the zonular fibers, the intracapsular extraction technique acquired more proselytes.
The cryoextraction made the technique safer, and certainly marked a point in favor of intracapsular extraction supporters (Fig. 4).
In the 20th century, surgical schools were fairly divided between supporters of extracapsular cataract extraction (ECCE) (Fig. 5) and admirers of the intracapsular cataract extraction (ICCE); until the end of the 1980s when Kelman, creator of the modern phacoemulsification, significantly shifted the balance in favor of the extracapsular technique (Figs 6 and 7). He achieved a new milestone that revolutionized cataract surgery upto the present day. He took inspiration from dentistry during a session of dental hygiene; he thought that the same ultrasounds used for tartar removal could be effective in cataract fragmentation.
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Fig. 3: Cataract extraction with Barraquer technique
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Fig. 4: Cryoextraction
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Fig. 5: Extracapsular cataract extraction (ECCE)
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Fig. 6: Charles D Kelman, father of phacoemulsification
Two other important and basic technological advances in cataract surgery occurred in the 20th century; the implantation of the first intraocular lens (IOL) (Fig. 8) in November 29, 1949; thanks to Sir Harold Ridley and the advent of the operating microscope in the 1970s.4
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Fig. 7: Kelman's phacoemulsifier
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Fig. 8: Dr Harold Ridley's first intraocular lens (IOL)
During World War II, Sir Harold Ridley understood that the materials with which British pilots were injured were inert and therefore, implantable without risk of rejection (Fig. 9).
From here onward there have been continuous updates in materials, equipment and variations of surgical techniques such as the transition from the sclerocorneal cut with “Graefe” (sharp blade) to the ruby scalpel and then diamond scalpel, etc. that allowed smaller and smaller incisions to be performed with articulated geometry. The cataract removal was becoming safer, less invasive and showed better results in terms of visual recovery. It became one of the most practiced surgeries in the world with only a minor number of complications.
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Fig. 9: Knighthood of Harold Ridley by Queen Elizabeth II (February 9, 2000)
Today, phacoemulsification remains the chosen intervention for cataract surgery. To abolish or reduce the ultrasound emissions during surgery, many alternative devices were created such as the catarex of optex ophthalmics [San Juan Capistrano, California (CA)], presented by P Kratz in 1998. He used a high speed rotation inducer with a hand piece of 1.25 mm. This created, with 30,000–70,000 rotations per minute, a vortex that could suck up an emulsified nucleus and cortex without leaving a groove. Experimentation was supported by “Bausch & Lomb”.
Ultraviolet lasers were tested, such as the 193 mm (argon fluoride), the 248 mm (krypton fluoride), the 308 mm (xenon chloride) and 351 mm (xenon fluoride), and an infrared laser, such as neodymium-doped yttrium lithium fluoride (Nd: YLF) (1,053 nm) that with laser pulses in the order of picoseconds, was able to fragment the core and cortex from the outside with the aid of a slit lamp.
Dodick/ARC laser yttrium aluminum garnet (YAG) phacolysis with monomanual or bimanual probes was marketed after Food and Drug Administration (FDA) approval in 1991. This machine was able to fragment and aspirate the lenticular material with the same hand piece, without generating heat, but with very long surgical times.
The paradigm system photon phacolysis YAG device of Eichenbaum, equipped with fiber optics, fragmented 5the lens inside a metal-walled chamber (chamber of photovaporization).
The erbium (Er: YAG) laser (2,940 mm) was able to perform continuous curvilinear capsulorhexis, the cataract fragmentation, the filtration surgery for glaucoma and vitrectomy. The technique failed because of the frequent complications with the laser just as the erbium laser, experimented in Italy by Frosini and Franchini, and the holmium laser that was also abandoned due to treatment complexities. The AquaLase was introduced by Alcon (Fort Worth, Texas); a water system with limited use in the fragmentation of soft cataracts.
Handpieces and probes were also subjected to many changes in order to achieve ultrasound reduction. Thus, it was born the torsional phacoemulsification (2005) and machines that allow the adjustment of vacuum and maintenance of the anterior chamber stability.
At the same time, anesthesia changed from general anesthesia in the 1960s to local retro/peribulbar, until the current topical anesthesia.
The first steps toward the separation of tissues with ultrashort laser pulses have occurred in the late 1980s when DJ Schanzlin applied a picosecond laser (Nd: YLF) in cataract surgery. The laser emitted 1,000 pulses per second of the duration of one thousandth of a billionth of a second (10−12 second) at a wavelength of 1,053 nm, with a power from 1 microjoules to 400 microjoules. The picosecond laser, called intelligent surgical laser (ISL), was capable of performing capsulotomy and lens liquefaction (Fig. 10). The picosecond laser, although proved ineffective for the treatment of cataracts, offered a huge degree of safety for the treatment of vitreous opacity because the emitted pulse was not dangerous to the retina (Figs 11 and 12). Some doctors report a widespread use of lasers for the treatment of vitreous floaters in the 1980s, dropped significantly with the divestment of the latest equipment remained outstanding. In the mid 1990s in fact, the manufacturer of laser ISL was bought by IntraLase, which produces laser for refractive surgery and the latest model of such lasers has been lost and not produced anymore.
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Fig. 10: Effect of the picosecond laser on lens tissue by slit lamp
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Fig. 11: Intelligent surgical laser (ISL), neodymium-doped yttrium lithium fluoride (Nd: YLF)
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Fig. 12: Effect of the picosecond laser on lens tissue by scanning electron microscope
It was clearer and clearer that the real revolution was to find a computer-controlled laser pulses delivery system with some characteristics; extremely short pulses, very low energy and high repetition rate.
The femto-laser for cataract allows, in addition to the substantial reduction of ultrasound, the evolution of the phase of capsulorhexis and arcuate incisions. Therefore, we are giving a nod of recognition to both surgical histories.
The anterior capsulotomy was born with the advent of the extracapsular technique, and was subjected to numerous changes until the introduction of continuous curvilinear capsulorhexis (CCC) in 1985 by H Gimbel 6(USA) and simultaneously by T Neumann (Germany). Prior to this, the procedure consisted of “linear downward or upward capsulotomy” (Pearce, 1976), “envelope capsulotomy” (Sourdille and Galand, 1980), “Christmas tree capsulotomy”, “beer can capsulotomy”, etc. These were performed with cystotomes or a bent insulin needle. The goal was to make a large capsulotomy for the extraction of the nucleus, but far enough from the zonula not to tear it. The first radial or lateral incisions were performed forming a tight circle for the accommodation of the first rigid IOLs. Surgeons first tried to perform capsulorhexis with radiofrequency, and then with YAG laser, but both techniques were abandoned. Even today, the manual CCC is essential for the proper positioning of the modern IOL, and the accuracy obtained with the femtosecond laser guarantees greater stability.
With concern to the arcuate incisions, Shotz in Norway in 1885 was the first to carry out a corneal incision for astigmatism correction. Other surgeons experimented with them as well such as Bates (1894), Faber (1895), Lucciola (1896) and Leandert (1898). The technique only later became important in 1939, when T Sato noted that in advanced cases of keratoconus, in which spontaneous rupture of Descemet's membrane occurred, a flattening of the cornea would appear resulting in reduction of myopia and induced astigmatism due to the keratoconus ectasia. T Sato experimented with a myopia reduction technique with incisions on the corneal posterior surface, but it was soon abandoned because of the high incidence of postoperative endothelial edema and replaced with anterior incisions of 50% of the corneal thickness.
In 1974, S Fijodorov (Russia) introduced the radial keratotomy for the correction of myopia and curved or transverse keratotomy for astigmatism with incisions of 90% of the corneal thickness. Thanks to the impressive case reports and good results achieved by Fijodorov; the technique was widely adopted in the United States (US) (by Bores) and in Europe since 1979, and dominated the stage in the 1980s. With the birth of corneal topography and increasingly sophisticated pachymeters, the incisions for astigmatism became progressively more precise. An unparalleled contribution was made by U Merlin. He found that in cases of curved opposed incisions, the bottom one should be less deep and extensive because of the weight of the upper eyelid that would induce a hyper-effect after time. The anatomical, surgical, instrumental and scarring variables made the technique inaccurate and surgeons made use of nomograms such as those of Thornton, Lindstrom, Merlin and Kershner. In the 1990s, the sectorial ablation with an excimer laser [photorefractive keratectomy versus laser-assisted in-situ keratomileusis (PRK-LASIK)] was introduced. Instead of performing a treatment with an excimer laser a few months after cataract surgery, now it is possible to surgically remove the cataract and correct the astigmatism at the same time with a computerized and precise femtosecond laser-assisted treatment (Table 1).
Table 1   Nomograms for astigmatism treatment during phaco with manual opposed corneal relaxing incision (CRI)
Theoretical astigmatism (dt)
Optical zone (mm)
Arc incisions (degree)
0,75
7
25
1,00
7
30
1,25
7
35
1,50
7
40
1,75
7
6
50
30
2,00
6
35
2,25
6
40
2,50
6
45
2,75
6
5,5
50
35
3,00
5,5
40
3,25
5,5
45
3,50
5,5
50
3,75
5,5
55
4,00
5,5
60
The current trend in the history of ophthalmic surgery and in cataract surgery, in particular, is to reduce the time and power of ultrasounds rather than replace them and to increase the accuracy of the results. The femto-laser seems to have achieved this goal.
Bibliography
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