Cataract Surgery: Couching to Phaco
An exhibit celebrating the 50th anniversary of phacoemulsification and all the achievements in cataract surgery leading to it.
Couching is an ancient procedure for reclination of the cataractous lens. The earliest known description is found in the "Sushruta Samhita," published in 600 BCE in India. Knowledge of the surgery was likely spread via the Silk Road. Established in 130 BCE by the Han Dynasty in China, the Silk Road connected countries from Turkey to Japan for over a thousand years. Couching remained the most popular method of cataract surgery until the 19th Century.
Jacques Daviel (1696-1762) performed the first planned extracapsular cataract extraction on a living human eye in 1750. Three years later, Samuel Sharp reported on intracapsular cataract extraction. The debate about whether to perform extractions led to heated exchanges between ophthalmologists, leading Michel de Wenzel in 1791 to lament, “Why do [surgeons] not agree among themselves, which mode is most simple and easy; and which the most likely to procure success?”
Extracapsular cataract extraction, as described by Jacques Daviel, required several instruments including keratome, knife, spatula, scissors, needle and spoon. According to Julius Hirschberg’s "History of Ophthalmology," “The incision was made near the lower limbus, because of the patient’s tendency to roll the eyes upward.”
Intracapsular cataract extraction (ICCE) was introduced in 1753 by Samuel Sharp. It was generally dismissed until the 20th Century because it was considered incredibly difficult when compared to the relatively simple procedure of Daviel. Lt. Col. Henry Smith (1859-1948) of India is credited for making ICCE popular again at the turn of the last century.
The first known use of sutures in cataract surgery was by Henry Willard Williams (1821-1895) in 1865. Their use was more universally accepted, however, after the introduction of topical anesthesia in 1884. In 1891 Ferdinand Suarez de Mendoza described the first preplaced sutures.
Ophthalmologists were aware of general anesthesia but rarely used it because of side effects such as nausea and retching, as well as their desire to keep patients responsive during surgery. In 1882 Hasket Derby wrote “anesthesia is…only necessary in the case of very nervous patients or for those who lose their self-control when the speculum is applied.”
After WWII, Dr. Harold Ridley (1906-2001) was operating on a cataract patient when a resident remarked how it was a pity not to be able to replace the removed lens. This comment was the impetus for Ridley’s innovation. He later remarked that cataract extraction was “but halfway to a cure.”
Charles Kelman, MD (1930-2004) famously had an “aha” moment when a dentist used a Cavitron high-frequency ultrasonic probe to clean his teeth. The dental probe had to be significantly modified, but the phacoemulsification procedure was ready for the first human patient in 1967. Two of his colleagues talk about his influence on cataract surgery in this video.