historical perspectives in cataract surgery
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A Historical Overview of Cataract SurgeryIn Humans and Animals
Enry Garcia da Silva
DVM, MS, DACVO
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From Ancient Times to the Present
Outline
Anatomy Definition History
Ancient Tecniques Milestones/Developments Current Techniques
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ANATOMYANATOMY
LENS
ZONULES
ZONULES
LIMBUS
SCLERA
CORNEACORNEA
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Definition
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“Cataract”
• First/oldest record
• Cairo Museum (Egypt) has the oldest description of a cataract (4500 year-old statue)
• Excavated in 1870
• Sheikh el-Balad
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- “Principal procedure in
Ophthalmology today”
- “One of the oldest and most
gratifying operations for both
surgeon and patient”
- “Responsible for Ophthalmology
becoming one of the first surgical
specialties”
“Evolution of cataract surgery over the centuries: one of the great sagas of medical history”
CATARACT SURGERY
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When did it all start?• First surgical procedure was mentioned in the Rig-Vedas (~2000 BC)
• the earliest account of ancient Indian civilization
• Prosthetic leg was attached to a queen’s leg so that she could walk and even participate in war
• Cataract surgery dates to ancient times
• Likely born in India
• Conflicting dates of its first description/invention
• Era of no documentation, “Upanishads”
• Mentioned in the “Mahabharata/BhagavadGita”
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Sushruta/Suśruta
• Indian Sage/Rishi/Physician, 800 BCE
• “Father of Surgery”; father of brain surgery, cataract surgery, plastic surgery
• Sushruta Samhita/“Sushruta's Compendium” – oldest texts in the topics
• Work of several historical layers, described all basic principles of surgery
• 184 chapters, 1120 illnesses, 700 medicinal plants
• Practice of mock operations on inanimate objects such as watermelons, cadavers, clay plots and reeds
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Sushruta’sdefinition of an ideal surgeon
“A person who possesses courage and presence of mind, a hand free from perspiration, tremor less grip of sharp and good instruments and who carries his operations to the
success and advantage of his patient who has entrusted his life to the
surgeon. The surgeon should respect this absolute surrender and treat his patient as his own son.”
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Treatment Concepts
• Cataractous lens was initially pushed/displaced out of the visual field within the eye
• Removal of the lens out of the
eye, with or without its capsule
• Different methods in different eras and multiple breakthroughs
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Introducing an era
• Couching(with or without
sectioning/needling)
• Extraction
(extracapsular/
intracapsular)
• Phacoemulsification
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CouchingCataractous lens was initially pushed/displaced
out of the visual field within the eye
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• From antiquity to the mid-17th
century (~3000+ years)
• Instruments and techniques (such as entry location) changed with time
• Teachings eventually reached many regions due to regional expansions/explorations
• i.e. Expedition of Alexander the Great
Couching
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Archeological sites
• Valley of the Kings
• 16th-11th century BC
• Wall paintings depicting
various techniques
• Couching instruments found
in tombs
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Collage of an era
• Different paintings/drawings/ sculptures depict different practices employed throughout the ages
• Instruments, location (by the window for sun light), restraint, clothes, accessories, standing vs sitting position
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Drawing Analysis
• The surgery is outside, the patient sits close to the ground. Dr sits a little higher
• Assistance in a sitting position
• Dr uses the left hand for the right eye (ambidexterity), thumb opens the eyelid
• Spectacles worn by the doctor
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Instruments for couching
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• Thorns from the gum arabic tree
Egyptian acacia or thorny acacia
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“Jabamukhi Salaka”
Curve needle used for couching
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VIDEO COUCHING
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Complications galore
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Introducing an era
• Couching
(with or without
sectioning)
• Extraction
(extracapsular/
intracapsular)
• Phacoemulsification
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Extraction - ECCE
• The era of Jacques Daviel
• 4 Steps: corneal section, anterior
capsulotomy, expression of the
cataract, cortical removal (+/- iridotomy)
• Reported 206 sx, 182 successful
• Started from April 8th 1745
- Lasted from Mid-17th
until early 20th century (~300 years) Perhaps the most important date in ophthalmic history
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Instrument Manufacture
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von Graefe – Linear extraction
• Upper limbus linear incision
• Von Graefe Knife = >100 years
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VIDEO von Graefe Knife
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ICCE
• Similar origin timepoint as ECCE
• Samuel Sharp in 1753
• More vitreous loss
• Post-op infection
• High incidence of complications
• From late 19th century until 1970s
• <100 years
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• 1884 – von Graefe introduced asepsis and antisepsis
- Knapp described retrobulbar anesthesia
- Koller discovered topical anesthesia
• 1891 – De Mendosa described suturing techniques
• 1917 – Suction cup developed by Barraquer
Major Milestones
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Barraquer Suction Cups
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VIDEO Barraquer Suction Cups
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ICCE (cont)
• Capsule forceps
• 1957 – Barraquer’s son described chemical ablation/zonulolysis
• 1959 – Krawics introduces cryoextraction
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VIDEO Cryoprobe
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Cryoguns and probes
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2 heroes from the 20th century
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Harold Ridley• Treated Royal Air Force pilots who suffered from eye injuries
• Germany launched the air attack known as the Battle of Britain (1940)
• Noticed the lack of inflammatory response in ocular penetrating injuries with material made of PMMA (Polymethyl methacrylate)
• Found PMMA to be inert, with no signs of rejection
• PMMA was used in the
canopies of two planes in the
Royal Air Force, the Spitfire
and the Hurricane
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Colleagues were highly distrustful• Including neighbor Duke-Elder
• It took until the 1970s for IOLs to be considered standard of care
• If not started in 1949, IOLs might have been discovered for yet another forty years
• Immediately after a war many were accustomed to accepting risk of injury
Duke-Elder
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VIDEO Ridley’s First Lens
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“Shoemaker’s son always goes barefoot?”
• Ridley performed the first surgery at St Thomas
Hospital (where 1st Minister Boris Johnson was
recently admitted with COVID-19)
• Monumental plaque is
has the wrong date!
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British Parliament locatedacross the hospital
• Painting made 2 years prior to diagnosis of cataract
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Collage of the era
Various types of INITIAL intraocular lens implants ever
since
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Collage of the era• Multifocal implants
• Various materials
• Implant in various positions (iris-claw, transscleral, sulcus)
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• Intraocular implants have chips to measure intraocular pressure 24/7
• Implants for presbiopia
Collage of the era
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Telescopic IOL for Macular Degeneration
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ASCRS 2021
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ECCE comeback
• 20 years prior to the next era (phaco)
• Improved success rates, vision, comorbidities
• Improvements in magnification devices, medications
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Magnification Sources
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Introducing an era
• Couching(with or without
sectioning/needling)
• Extraction
(extracapsular/
intracapsular)
• Phacoemulsification
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Phacoemulsification
• In 25 years the technique achieves near technical perfection; becomes universally taught in the USA, then the world of medicine and veterinary medicine.
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First Phaco
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Eureka Moment
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t
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Collage of an eraFirst phaco took 76
minutes
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In-patient to Out-Patient Surgery
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Incision size, shape, architecture
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Phaco Handpiece Innovations
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VIDEO New Handpiece Technology
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Ophthalmic Viscoelastic Devices
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Video Phacoemulsification
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A letter from the 1st generation
• “Consider yourselves lucky and honored for the scientific advancements in realms of surgical innovations, anesthesia & analgesia, instrumentation and anti-inflammatory drugs; no matter the case today, there is always room to do better tomorrow”
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Thank you! [email protected]
www.facebook.com/vetophthosurgeries
@drenrygarciadacvo (Instagram)
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