PERSPECTIVES
The Evolution of Cataract Surgery: Controversies
Through the Ages
Aifric Isabel Martin, MRCOphth, MB BCh BAO,*Þ
Gerard Sutton, MD, FRANZCO,þ and Christopher Hodge, BAppSc*
Abstract: Cataracts have been in public consciousness since ancient
times. Throughout the ages, the comfort of established practices, at times,
has obstructed the implementation of improved policies. The opposition
to lensectomy, hygiene practices, intraocular lenses, and phacoemulsification (phaco) are explored. As femtosecond laser cataract surgery attempts
to secure a foothold in cataract treatment, we consider whether it is destined to be a forgotten footnote or if, like other contributions to the history books, the difficulties of establishing a new technique are abstracting
the benefits represented.
Key Words: cataract surgery, history of surgery, femtosecond
cataract surgery, phacoemulsification, couching
(Asia Pac J Ophthalmol 2013;2: 213Y216)
C
ataract treatments have been in existence since antiquity.
Yet, they remain the leading cause of blindness worldwide.1
Surgical evolution has been cautious, with the earliest recorded
method, couching, retaining favor from its first mention in Hindu
manuscripts circa 600 BC until the mid-18th century.
From the earliest documentation, treatment methods and
expected results have been a source of controversy. The code of
Hammurabi (1750 BC) described a payment structure for services, which included removal of the surgeon’s fingers if ocular loss or death occurred as a consequence of the procedure.2
Although reticence to change is an oversimplification of complex social and economic interactions, the continued practice of
couching despite poor results serves as testament to the innovator’s struggle.3
In this article, we review the archives and explore the skepticism with which many of the cornerstones of current ophthalmic practice were initially met. We consider femtosecond laser
cataract surgery (LCS) and question what impact it may have.
Does it deserve to be relegated to the realm of historical text or
are opponents allowing shortsighted obstacles to obstruct the true
potential represented?
COMPETITION FOR COUCHING:
EXTRACAPSULAR SURGERY AND
INTRACAPSULAR SURGERY
A French surgeon, Jaques Daviel, first introduced extracapsular cataract surgery as an alternative to couching in 1748.4
Daviel’s procedure heralded the birth of the cataract operation
we know today.
However, victory did not arrive easily for the new technique. Debate raged over the century that followed with passionate adversaries arguing virtues of both methods. Two such
contemporaries were Samuel Sharp and Percival Potts. Both were
accomplished surgeons and pioneers within the profession.5 Despite similarities in other respects, their opinions regarding the
new cataract technique could not have been more polarized. Based
on evidence derived from his experience with Daviel’s method,
Sharp was a proponent and recognized scope for further improvement. Potts failed to entertain the concept from its inception,
believing its advocates greatly exaggerated the benefits reported.
However, his derision was not as retrograde as it may appear in
hindsight. His failure to recognize promise in the new method
was based on a patient-centered concern. He was striving to promote the least invasive and technically demanding operation
capable of producing acceptable results. This concept is one of
the fundamental precepts of surgical management today.5
Over time, cataract removal superseded lens dislocation with
modified versions of Daviel’s original procedure gaining widespread acceptance. The adjustment made by Samuel Sharp6 actually represented the first described intracapsular method of
cataract extraction. Henry Smith,7 an Irish ophthalmic surgeon,
created a brief resurgence in the popularity of the intracapsular
technique in the early 20th century. Smith was a prolific surgeon
and published a large volume of results impressively arguing
his case for the intracapular technique. In the year up to May 1905,
he performed 2616 intracapsular cataract extractions (ICCEs), reporting lower incidences of inflammation and infection coupled
with better visual acuities than were being achieved with extracapsular cataract extraction.7 Barraquer’s8 discovery of the zonule
lysing enzyme, >-chymotrypsin, complimented Krwawicz’s9 introduction of cryoextraction in further advancing the case for
intracapsular extraction.
Both methods retained supporters throughout the first half
of the 20th century. However, with the development of the intraocular lens (IOL) and growing popularity of phacoemulsification, extracapsular cataract extraction began to supersede ICCE
as the operation of choice. The resounding death knell for ICCE
came when vitreous was declared an enemy, and the protective
role of the capsule was recognized.10,11
ANTISEPSIS
From the *Vision Eye Institute, Chatswood, New South Wales, Australia;
†University College Dublin, Dublin, Ireland; and ‡Save Sight Institute,
University of Sydney, Sydney, New South Wales, Australia.
Received for publication April 30, 2013; accepted May 29, 2013.
The authors have no funding or conflicts of interest to declare.
Reprints: Aifric Isabel Martin, MRCOphth, MB BCh BAO, Vision Eye
Institute, Level 3 270 Victoria Ave, Chatswood, New South Wales 2067,
Australia. E-mail: [email protected].
Copyright * 2013 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.1097/APO.0b013e31829df4bf
Asia-Pacific Journal of Ophthalmology
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Oliver Wendell Holmes and Ignaz Philipp Semmelweis were
initially ridiculed when, independently, they each arrived at a similar conclusion. Despite significant objective evidence, respective
colleagues on opposite sides of the Atlantic shunned the notion
that poor hand hygiene was contributing to the spread of disease
in maternity wards.12 Joseph Lister13 furthered the cause of antisepsis by recognizing the role of microorganisms in the etiology
of infection. Influenced by the work of Louis Pasteur, he set out
on a quest to find a substance capable of eradicating ‘‘septic germs.’’
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213
Martin et al
Asia-Pacific Journal of Ophthalmology
He first assessed the effect of packing carbolic acidYinfused cloths
into the wounds of patients with compound fractures. Generally
condemned to amputation with high perioperative and postoperative mortality and morbidity, these patients began to survive
without disabling disfigurement. 13 Lister’s prioritization of education led to widespread circulation of his ideas. He reported
his findings in a series of publications in The Lancet and British
Medical Journal and presented them at a landmark meeting of
the British Medical Association in Dublin in 1867.13 Alfred
Graefe14 was first to record his experience with the new precautions as they pertained to cataract surgery. Loss of eyes following implementation of his antiseptic regimen dropped from
4% to 10% to 1% to 2% when instruments, lids, and conjunctival sac were treated preoperatively, perioperatively, and postoperatively. His technique incorporated the use of 2% carbolic acid
for ocular surface treatment, alcohol treatment of instruments utilized, and boric acidYinfused cloths to drape and bandage.14 Over
the century that followed, antiseptic methods evolved, and improved surgical technique continued a downward trend in infection rates. However, as with most evolving practices in the medical
realm, change was slow. As a case in point, iodine was first noted
to reduce ocular flora in 1951.15 Yet, it took 40 years for a study
demonstrating reduced endophthalmitis rates with the use of 5%
povidone-iodine to be published.16 Preoperative antisepsis with
povidone-iodine is now a routine step in ophthalmic surgeries.
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FROM APHAKIA TO PSEUDOPHAKIA
expected foreign body response when they became lodged in
patients’ eyes. Using similar material, he proceeded to perform
the first IOL replacement and subsequently presented his operation to colleagues at the Oxford Ophthalmological conference
on July 9, 1951.22 Despite having already accumulated several
positive, relatively long-term results, his surgery was condemned
by some of the most respected academics of the time as unnecessary and even reckless. Owing to the apathetic reception received, these devices did not come into mainstream practice until
the 1970s to 1980s.
Charles Kelman23 was visiting his dentist in the 1960s when
he came across the seed of an idea that would spawn arguably
the most significant advance in 20th-century cataract surgery. Like
Kelman, his dentist Larry Kuhn, was an innovator using a new
ultrasonic device to remove dental plaque.23 Kelman immediately
recognized its potential for cataract surgery. He had long been
considering methods to fragment the lens to facilitate its removal through smaller orifices than were being used at the time,
thus reducing the antecedent inflammatory, infective, and astigmatic effects of large incisions. In 1967, the first human procedure was performed on a blind eye resulting in endophthalmitis
and phthisis bulbi.23 Undeterred, Kelman persisted, with subsequent ventures proving more successful. He proceeded to teach
the method to interested parties. Converting established and proficient intracapsular surgeons to this technically challenging, as
yet unproven technique was an uphill struggle. Many sought to
find fault with the new procedure. Initial concerns centered on
several valid observations. The new operation had a prolonged
learning trajectory with newly initiated surgeons taking 100 cases
to reduce their complication rates to intracapsular levels.24 The
machine and instrumentation represented a significant initial outlay, and with intracapsular extraction boasting complication rates
of only 3% to 5% and initial studies demonstrating no significant
advantage from the perspective of visual outcome, the debate as
to whether this was a justifiable investment remained valid for
many years after its first inception.25 Phacoemulsification had
largely infiltrated mainstream practice within the developed world
before the emergence of research exonerating it as the procedure of choice. Review articles comparing phacoemulsification
to alternative methods of extraction have found that it consistently provides the best outcomes in terms of vision and complication rates.26,27
In 1984, the Food Drug Authority approval of Mazzocco’s28
foldable IOL allowed phacoemulsification to showcase its true
potential. Before this, the operation would be completed through
a 3-mm incision to the point of IOL introduction, at which stage
the wound required enlargement to 6 to 8 mm, negating the effort
of operating through the smaller incision.28 With the introduction of the foldable lens, 3 mm incisions became achievable.
More recently, the trend has moved toward microincisions, with
the main wound measuring just 1.8 mm.29
Procedures to remove cataracts have been available for centuries. However, the success of these operations, if measured in
terms of visual restoration, has been dubious, at best, for most of
this time.
Although the introduction of spectacles and subsequent advent of contact lenses provided life-changing visual improvement
for those with refractive errors, aphakic refractive correction was
fraught with complications. Lenses required were cumbersome
and produced significant and disabling aberrations.
An incidental observation was responsible for the first truly
inspired means of refractive correction following lensectomy.
When Harold Ridley22 served as ophthalmologist to the fighter
pilots of World War II, he noticed that shards of the polymethylmethacrylate/glass hybrid windscreen material did not elicit the
Laser technology has carved a niche as a treatment adjunct
across many ophthalmic subspecialties. Dr Aron-Rosa and colleagues’ introduction of noninvasive yttrium aluminum garnet
(YAG) laser capsulotomies in 1978 made posterior capsular
opacification a far less significant concern.30 Dodick and
Christiansen31 developed the use of the Nd:YAG laser to fragment the lens in 1989. Kanellopoulos’32 multicenter trial of 1000
cases provided promising safety and efficacy data. The shorter
pulse duration of femtosecond laser offered enhanced precision
with a reduced risk of damage to adjacent tissue. Zoltan Nagy33
was the first to perform LCS in Hungary in 2008.
ANAESTHESIA AND VISUAL AIDS
For centuries, surgeons performed cataract extraction without the assistance of visual aids. Poor visualization was further
exacerbated by the likelihood of a vigorously mobile patient before the discovery of suitable anesthesia. It was an ophthalmologist colleague of Sigmund Freud, Karl Koller, who proposed
topical cocaine as the first plausible solution to the latter dilemma.
His findings were presented to the International Ophthalmology
Meeting in Heidelberg in 1884.17
Hermon von Helmholtz gifted the profession with his invention of the ophthalmoscope. This allowed noninvasive visualization of the retina, greatly broadening the diagnostic scope
of fledgling ophthalmologists.18 Pharmaceutical mydriatics have
continued to evolve since atropine was first synthesized from
Belladonna Atropa in 1831, allowing the ophthalmoscope to
achieve its full diagnostic potential.19 In terms of cataract surgery,
mechanical devices such as iris-retractor hooks, polymethylmethacrylate pupil dilator rings, and Beehler pupil dilators continue to
develop, enabling sustained pupil dilation in particularly resistant
subjects.20 The introduction of ophthalmic viscosurgical devices
to ophthalmology in 1972 has also improved maintenance of
pupil shape and anterior chamber depth perioperatively.21
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THE CONTRIBUTION OF LASER
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DISCUSSION
To quote Max Planck: ‘‘A new scientific truth does not
triumph by convincing its opponents and making them see the
light, but rather because its opponents eventually die, and a new
generation grows up that is familiar with it.’’34
Cynical as his sentiments sound, history would seem to
find resonance with his claim. As described above, many established innovators became cautious of new ideas once installed
in positions of influence.
Proponents of femtosecond argue that enhanced precision
of laser created incisions, capsulorrhexis, and nuclear fragmentation facilitate lens centration and lead to reduced aberrations
and more accurate refractive outcomes for patients.35,36 Studies
have impressively demonstrated the stronger, more reproducible
capsulorrhexis created using the technique.35,36 They have also
provided evidence of the improved lens positioning advertised
in the propaganda.36,37 However, whether these alterations translate to improved patient experience has yet to be proven. Similar to phacoemulsification, initial experiences of skilled cataract
surgeons with the new technology demonstrated a definite learning curve.38,39 This technology, like phacoemulsification, also
demands alterations to be made to facilitate its adoption.35 A
dedicated laser room, trained staff, and the femtosecond machine
itself all necessitate a significant initial financial outlay. With
governments in the midst of global financial turmoil, justifications for heath expenditure are being increasingly scrutinized.
For these reasons, some warn that LCS represents a ‘‘pseudoinnovation’’ of the type lamented of in E. Emanuel’s40 contribution
to The New York Times last May.
Whether this new technology really represents a new era
in mainstream cataract surgery or if it will remain an isolated
enclave for the preferences of a select few remains to be seen.
However, to dismiss the procedure based on the existence of a
satisfactory alternative may be to repeat the errors of the past
in dismissing the visionaries of the present.
Evolution of Cataract Surgery
10. Gass J, Norton E. Follow-up study of cystoid macular edema following
cataract extraction. Trans Am Acad Ophthalmol Otolaryngol.
1969;73:665.
11. Kasner D. The technique of radical anterior vitrectomy in vitreous loss.
In: The New Report on Cataract Surgery: Proceedings of the
First-Biennial Cataract Surgical Congress. Miami, FL: Miami
Educational Press; 1969:1.
12. Lane HJ, Blum N, Fee E. Oliver Wendell Holmes (1809Y1894) and
Ignaz Philipp Semmelweis (1818Y1865): preventing the transmission
of puerperal fever. Am J Public Health. 2010;100:1008Y1009.
13. Lister J. On the antiseptic principle in the practice of surgery.
Br Med J. 1867;2:245Y260. Reprinted in Lister BJ (2010). ‘‘The
Classic: On the Antiseptic Principle in the Practice of Surgery.’’ 1867;9.
14. Graefe A. Die antiseptische wundbehandlung bei cataract-extractionen.
Arch Ophthalmol. 1878;24:223.
15. Maumenee AE, Michler RC. Sterility of the operative field after
ocular surgery. Pac Coast Oto-ophthalmol Soc. 1951;32:172Y183.
16. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with
topical povidone-iodine. Ophthalmology. 1991;98:1769Y1775.
17. Markel H. Über Coca: Sigmund Freud, Carl Koller, and cocaine.
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18. Jaeger W. Hermann von Helmholtz (1821Y1894). On the 100th
anniversary of his death [article in German]. Klin Monbl Augenheilkd.
1994;205:119Y125.
19. Weiner N. Atropine, scopolamine, and related antimuscarinic drugs.
In: Gilman AG, Goodman LS, Rall TW, et al, eds. The Pharmacological
Basis of Therapeutics. 7th ed. New York: MacMillan; 1985:130Y138.
20. Akman A, Yilmaz G, Oto S, et al. Comparison of various pupil
dilatation methods for phacoemulsification in eyes with a small pupil
secondary to pseudoexfoliation. Ophthalmology. 2004;111:1693Y1698.
21. Balazs EA, Freeman MI, Kloti R, et al. Hyaluronic acid and replacement
of vitreous and aqueous humour. Mod Probl Ophthalmol.
1972;10:3Y21.
22. Ridley NHL. Intraocular acrylic lenses. Trans Ophthalmol Soc UK.
1951;LXXI:617Y621, Oxford Ophthalmological Congress.
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V John Milton, Paradise Lost
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