History of Cataract Surgery - An Overview

Introduction

Cataract surgery is one of the most common and oldest medical procedures. It has evolved from basic techniques to advanced methods with better technology for replacing the lens in the eye. It is considered one of the most successful treatments in medicine. The eye's lens is a clear, flexible part that helps focus light onto the retina to see clearly. It has different layers, including a capsule, a layer of cells, and the central part of the lens. As people age, the lens can become cloudy, which leads to poor vision. Surgery is usually the best option when a cataract affects vision enough to meet the current standard (20 by 40 vision or worse). In the past, cataract surgery was only done when the cataract was severe, almost leading to blindness. The first successful cataract surgery occurred in Paris in 1747 and was performed by a French surgeon named Jacques Daviel.

What Is the History of Cataract Surgery?

Cataract surgery is one of the oldest and most common procedures done worldwide. It has evolved significantly, with major surgical techniques and lens replacement technology advancements. A cataract happens when the eye's clear lens becomes cloudy, causing blurry vision, color changes, and halos around lights. Aging is the most common cause, but other factors like smoking and too much sunlight can also contribute. Cataracts are a leading cause of blindness, affecting millions of people globally.

Old Surgical Methods:

• Couching: This was one of the earliest methods, dating back to around 500 BC (before Christ). It involved using a sharp needle to push the cloudy lens out of the way, but this method often led to serious complications like glaucoma and blindness. Surprisingly, it is still used in some parts of the world today due to tradition and lack of access to modern methods.

• Extracapsular Cataract Extraction (ECCE): This method, practiced as early as 600 BC, involved removing the cloudy lens while leaving the lens capsule behind. Over time, a French surgeon named Jacques Daviel improved this method in 1747 by making a larger incision to extract the lens. While this was an advance, it still came with complications like infections and issues with the lens remaining in the eye.

• Intracapsular Cataract Extraction (ICCE): Introduced in 1753 by Samuel Sharp, this technique removed the cloudy lens and capsule in one piece. However, due to the large incision required, it often caused complications like retinal detachments.

• Intraocular Lenses: Before modern lenses, people who had cataract surgery needed thick glasses to see clearly. The development of intraocular lenses (IOLs) changed this. In 1949, Dr. Harold Ridley performed the first surgery using a plastic IOL. Despite initial skepticism and complications, this breakthrough paved the way for today’s advanced lens technology. Later innovations, like foldable IOLs, made surgery easier and recovery faster.

Modern Cataract Surgery: Today’s cataract surgery is much safer and more effective. Modern techniques include:

1. Phacoemulsification: This method uses ultrasound to break up the cataract and remove it through a tiny incision. This approach has reduced recovery times and complications.

2. Femtosecond Laser-Assisted Surgery (FLACS): Approved in 2010, this technology uses lasers for more precise cuts and lens fragmentation, improving outcomes and allowing for advanced lenses like those correcting astigmatism.

Advancements: The field continues to advance with new technologies, such as improved intraoperative systems and IOLs, aiming to make surgery even safer and more precise. Despite these advancements, access to modern cataract surgery remains limited in some areas, but ongoing improvements are working towards making it more widely available.

Cataract surgery has come a long way from its ancient beginnings. Today’s techniques are highly effective and safe, but with a growing aging population, the demand for cataract surgery will continue to rise. Future advancements aim to make the procedure even better and more accessible.

How Was Cataract Surgery Done in the 1960s?

In 1967, Charles Kelman introduced a revolutionary method called phacoemulsification for cataract surgery. This technique uses high-frequency sound waves to break up the cloudy lens in the eye into tiny pieces, which are then sucked out. This method is now the most common way to treat cataracts. Phacoemulsification is a modern method for cataract surgery where the cloudy lens in the eye is broken up and removed using ultrasound waves.

Phacoemulsification Procedure:

• A person might get numbing drops for the eye, an injection, or, in rare cases, general anesthesia.

• It typically lasts ten to twenty minutes. A person lies on an operating table while their eye is held open with a tool. The surgeon makes small cuts, breaks up the lens, removes it, and places the new lens in the eye.

• The surgeon makes a small incision in the eye and creates an opening in the lens’s covering.

• An ultrasound device breaks the cloudy lens into tiny pieces using high-frequency sound waves. These pieces are turned into a jelly-like substance.

• The jelly-like substance is then flushed out and suctioned away.

• A replacement lens, called an intraocular lens (IOL), is placed in the eye to restore clear vision.

• A person will be taken to a recovery room and monitored until the anesthesia wears off. Have someone drive home as their vision may be blurry.

• Rest and avoid swimming or hot tubs for at least a week. Be cautious of dust and dirt, and wear protective eyewear if needed. Follow the surgeon’s instructions on using any prescribed eye drops to prevent infection.

Phacoemulsification vs Other Cataract Surgeries:

• Femtosecond Laser-Assisted Cataract Surgery (FLACS): Uses a laser to cut the eye and remove the lens. This method is newer and more precise but may require more specialized skills.

• Extracapsular Cataract Extraction (ECCE): An older method where a larger cut is made to remove the lens. It is less common now because phacoemulsification is more effective and less invasive.

Benefits of Phacoemulsification:

• Requires only a small incision, leading to faster recovery and fewer complications.

• Quicker than ECCE and similar in speed to FLACS.

• The lens capsule remains, providing a stable base for the new lens.

• More surgeons perform this method compared to FLACS, which has a steeper learning curve.

• Phacoemulsification is a safe and effective way to restore vision by removing cataracts with minimal disruption.

How Cataract Surgery Is Done Over Time?

Ancient Times:

• Circa 1279–1213 BCE: Cataract surgery was performed in ancient Egypt, possibly using the couching technique.

• 6th Century BCE: Indian physician Sushruta described coaching in his medical texts. This technique involved pushing the cloudy lens aside rather than removing it.

• 2nd Century CE: In Europe, early descriptions of cataract surgery appear, including techniques using needles.

• 10th Century CE: Islamic physician Ammar Al-Mawsili described a suction method to remove the lens.

Middle Ages:

15th to 16th Century: Couching was common in Africa and parts of Europe but was known for poor outcomes and complications.

18th to 19th Century:

• 1750: Jacques Daviel performed one of the first planned cataract extractions.

• 1753: Samuel Sharp performed a recorded complete removal of the lens and its capsule.

• 1815: Philip Syng Physick in America performed cataract extraction by suction.

• 1820–1866: Tools like the Beer-type cataract knife were used for surgery.

Early 20th Century:

• 1949: Harold Ridley introduced the idea of implanting artificial lenses (IOLs) to improve vision after cataract surgery.

• 1961: Charles Kelman developed phacoemulsification, using ultrasound to break up and remove cataracts through a small incision.

• 1967: Phacoemulsification became the standard for cataract surgery due to its efficiency and reduced recovery time.

Late 20th Century:

• 1972: Ophthalmic viscosurgical devices (OVDs) were introduced to protect the eye during surgery.

• 1980: New methods like the neodymium-doped yttrium aluminum garnet (Nd) lasers were introduced to treat secondary cataract complications.

• 1987: Surgeons began using smaller incisions for cataract removal.

• 1992: Toric IOLs were introduced to correct astigmatism during cataract surgery.

21st Century:

• 2004–2005: Around 2.8 million cataract surgeries were performed annually in the U.S.

• 2009: The "double-nylon loop" technique allowed for smaller, sutureless incisions and was suited for use in developing countries.

• 2013: Infrared swept-source optical coherence tomography (SS-OCT) improved imaging of cataracts.

• 2021: Approximately 4 million cataract surgeries were performed annually in the U.S., with about 75,000 procedures done globally each day.

Conclusion

Cataract surgery, one of the oldest medical procedures, has evolved from ancient methods like couching to advanced techniques with modern technology. Initially performed with methods that often led to complications, it has significantly improved with innovations such as phacoemulsification, introduced by Charles Kelman in 1967. This technique uses ultrasound to break up and remove cataracts through a small incision, enhancing recovery and reducing complications. Modern cataract surgery continues to advance with technologies like femtosecond lasers and improved intraocular lenses, making the procedure safer and more effective. Despite its progress, access to advanced cataract surgery remains limited in some areas.