Samuel Sharp first performed a successful intracapsular cataract extraction (ICCE) in 1753, by removing a cataractous lens, capsule intact, through a limbal incision using pressure from his thumb. Intracapsular cataract extraction had arrived.
One of the chief problems to be solved in the development of ICCE was how to lyse or break the zonular fibers. Lieutenant Colonel Henry Smith, an Englishman stationed in India, used external manipulation with a muscle hook to break the inferior attachments mechanically and expel (express) the cataractous lens from the eye through a limbal incision. The lens would “tumble”: the inferior pole of the lens would exit the eye before the superior pole. (Compare this intracapsular maneuver with the modern “phaco-flip” technique, described later in this chapter.) His technique, called the Smith-Indian operation, was used in 50,000 cases over a 25-year period at the end of the 19th and beginning of the 20th century.
Another method of lens removal was direct extraction. Toothless forceps, developed by ophthalmologists such as Verhoeff and Kalt, were used to grasp the lens capsule (Fig 8-4). The cataract was then gently pulled from the eye with a side-to-side motion that broke the zonular insertion. Suction cup–like devices called erysiphakes were devised by Stoewer and by Ignacio Barraquer (1884–1965) to remove the lens with traction or tumbling (Fig 8-5).