• Cataract Surgery: Couching to Phaco

    • Aug 14, 2017

    An exhibit celebrating the 50th anniversary of phacoemulsification and all the achievements in cataract surgery leading to it.


    Couching

    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.

    • George Bartisch

      Georg Bartisch (1535-1606) was a surgeon who limited his practice to ophthalmology and hernia repair. In his book, "Ophthalmodouleia: das ist Augendienst" (1583) Bartisch describes how to fashion a cataract needle and perform couching. He warns patients away from itinerate surgeons at the market place. Instead he suggests surgery should take place inside a “light chamber in which the patient shall have his bed and covers; so that he need not go far. The nearer the bed, the better it is.”

    • The Indian Operation

      In "The Indian Operation of Couching for Cataracts" (1917) Robert Henry Elliot (1866-1936) describes documents several hundred cases of couching that he and other British surgeons observed in colonial India. Elliot calls the procedure “pagan” and states that Westerners “oft-expressed wonder...not that their results are so bad, but that they are ever good.”

     

    ECCE

    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?”

    • Daviel's Operation

      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.”

    ICCE

    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.

    • Capsule forceps

      Capsule forceps like this example was used to grasp the lens capsule and gently pull it from the eye with a side to side motion that broke the zonular insertion.

    • Phacoerysis

      Ignacio Barraquer, MD (1884-1965) introduced suction to cataract surgery in 1917, calling the procedure phacoerysis. Arguing for his technique Barraquer once said, “compare the [use of] forceps to the claw of a cat and the cup to the lips of a beautiful woman. What would you prefer to feel on your cheek?”

    • Cryo-extraction

      Tadeusz Krwawicz, MD (1910-1990) introduced cryo-extraction of the cataractous lens in 1961. Many designs for cryo-extractors quickly followed suit including this instrument.

    Sutures

    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.

    • For Sutures

      Physicians devised a variety of sutures which were believed to promote healing and provide, as Hasket Derby put it, protection from “excessive coughing, vomiting, sneezing, etc. and even from such accidents as falling out of bed.”

    • Against Sutures

      In the late 20th Century, physicians began to question the use of sutures, such as this comment by Leon Alger in 1971: “Sutures in cataract surgery are of such variety as to make one wonder if any given suture is entirely satisfactory…One can imagine the patient’s discomfort for weeks and months while he winks and blinks and nods until these miserable things are finally gone.”

    Anesthesia

    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.”

    • Carl Koller

      Carl Koller (1857-1944) announced topical anesthesia in 1884, revolutionizing cataract sugery. Many physicians immediately recognized its importance. Herman Knapp, for instance, hailed it as the “greatest gift we have received for many years.”

    • Hasket Derby

      Hasket Derby wrote an entire book about general anesthesia and cataract surgery in 1882 in which he noted: “the American patient has been in the habit of demanding artificial insensibility to pain to an extent unusual in other countries, and indeed, unjustifiable…”

     

    IOLs

    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.”

    • The First Implant

      The first intraocular lens implant surgery was performed on November 29, 1949. Ridley used extracapsular cataract extraction because the original IOL was designed to be placed in the posterior chamber.

    • IOL Design

      Ridley’s original design for the intraocular lens was not optimal. Many tried to find the perfect solution by creating posterior chamber, anterior chamber and iris fixation lenses. The IOL finally received FDA approval in 1980.

     

    Phaco

    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.

    • Mastering Phaco

      In the early years many surgeons found phacoemulsification difficult to master. Kelman recognized that surgical outcomes depended heavily on proper use of the machinery so he provided instruction courses starting in the early 1970s.

    • Phaco and IOLs

      There was limited incentive for small incision surgery when the wound had to be opened from 3.0 mm to 7.0 mm in order to accommodate the early intraocular lens implants. It would take over 10 years before foldable IOLS and familiarity with microsurgery made phacoemulsification the procedure of choice.