History of Cataract Surgery
`
`Norman S. Jaffe, MD
`
`Several philosophers have reminded us that those who
`forget the mistakes of the past are destined to repeat them
`in the future. In this historical survey, it is hoped that the
`knowledge we inherited will be an incentive for us to con-
`tinue to strive to improve the quality of life of our patients.
`The earliest recorded ophthalmologic reference to be
`found dates back to Babylonia-Assyria (2250 B.C.) in the
`Code of Hammaurabi. which is a legal document con-
`cerned with civil laws administered by the Babylonian
`king, Hammurabi.
`The origin of the term cataract is interesting, but ac-
`cording to Celsus,' the tenn is logical because it means a
`waterfall or flowing down. It was believed that a cataract
`was an inspissated humor that had seeped from the brain
`into the space between the cornea and the iris. Rufus}
`the author of the earliest anatomy book (On Naming the
`Parts of the Human Body) was the first to use the term
`crystalline lens.
`Jacques Daviel3 (Fig I) started a revolution in
`ophthalmic surgery on April 8, 1747. A couching pro-
`cedure failed, so through an inferior corneal incision, he
`inserted a needle behind the lens and delivered it with
`some loss of vitreous. This was the first report of cataract
`extraction from its normal position behind the iris. In
`1753, he presented one of the landmark articles‘ in
`ophthalmic history to the Royal Academy of Surgery. He
`reported 1 l5 cataract extractions with 100 successes. By
`1756. he had performed 434 extractions with only 50 fail-
`ures.5 Because Daviel opened the anterior capsule, this
`was an extraeapsular extraction. It is remarkable that the
`intracapsular method was born during this same period.
`Samuel Sharp° (1753) of London and George de la Faye7
`(1752) are credited with the first such procedures. Sharp
`expelled the lens from the eye by pressure of his thumb.
`Shortly thereafter, a more direct method was adopted by
`Richter” (1773), who pushed the lens out after impaling
`its posterior pole with a needle thrust through the sclera.
`This method was also used by Beer” and von Canstatt.'°
`A. and H. Pagenstecher' '-'3 (1866-I871) introduced the
`method of removing the lens with a spoon. Alternate
`techniques included pressure on the globe by instruments,
`
`From Bascom Palmer Eye lnstitute. University of Miami School of
`Medicine, Miami.
`
`Reprint requests to Norman S. Jaffc. MD. 5130 Linton Blvd. Delray
`Beach. Fl. 33484.
`
`Page 1 of 12
`
`such as a eurette,” a spoon.” or a strabismus hook, a
`method popularized by Col. Henry Smith” (1900-1926).
`Many distinguished surgeons of that time continued
`to use the old procedure of couching (Fig 2), a technique
`that did not die easily. It continued to be used well into
`the second half of the l9th century, primarily because of
`the technical complexity of the new procedures and the
`high rate of postoperative infections.
`Although the extracapsular and intracapsular methods
`were developed at nearly the same time,
`it took much
`longer for the latter to gain popularity. The earlier intra-
`capsular techniques involved expression of the entire lens
`with its capsule intact by some form of pressure on the
`globe, either with a thumb or with an instrument, but
`because of the high rate of vitreous loss, techniques were
`designed to remove the lens using traction.
`Mention should be made also of the first attempt at
`intraocular lens implantation. It has been reported'‘’'”‘
`that Casanova (1725-1798) referred in his memoirs to
`the Italian oculist Tadini, who discussed with him the
`idea of implanting an artificial lens after a cataract surgery
`in 1764 to 1765. Casanova is said to have passed this idea
`on to the Dresden court ophthalmologist Casaamata.
`Around 1795, Casaamata did. indeed. attempt to intro-
`duce a glass lens into an eye after a cataract surgery. but
`the lens immediately slid posteriorly toward the retina.
`But despite this problem, it is still remarkable that this
`attempt preceded Rid|ey’s first case by more than 150
`years.
`
`The Last 100 Years
`
`The Centennial anniversary of the American Academy of
`Ophthalmology (formerly known as the American Academy
`of Ophthalmology and Oto-laryngology) is celebrated in
`1996. No other surgical specialty has been so dominated by
`a single surgery as has ophthalmology by cataract extraction.
`Old concepts change, and new ideas are plentiful in all fields
`of science and medicine; cataract surgery is no exception.
`However, when one considers the progress in cataract surgery
`during the past l()0 years. it is clear that the previous 8000
`years produced few dynamic changes. except for the switch
`from couching to cataract extraction.
`In the first decade of the Academy. what was known
`as simple cataract extraction (i.e.. extracapsular) was the
`procedure of choice. This is despite the fact that the in-
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`Ophthalmology Volume 103, Number 8, August Supplement 1996
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`Preliminary lridectomy
`
`During the first 20 years of Academy history, the question
`of whether an iridectomy done a few days or weeks before
`lens extraction was advantageous in the average case re-
`mained unanswered. Reber” gave an excellent summary
`of the views of ophthalmologists on this subject in 1907.
`He sent letters to 160 American ophthalmologists asking
`whether they did a preliminary iridectomy, and, if so,
`why. Well over one half of the respondents favored the
`preliminary iridectomy.
`
`Preliminary Capsulotomy
`
`The main advantage of a preliminary capsulotomy per-
`formed hours, days. or even weeks before lens extraction
`was in cases of immature cataract. In the senile form,
`mature referred to the condition of the lens cortex. It was
`well known that nuclear cataracts often progressed slowly,
`leaving many patients with a prolonged period of visual
`disability. Some ophthalmologists of that era used a needle
`or a knife-needle to open the anterior capsule and allow
`
`.1/
`, "7
`4
`'/
`Z’ /1
`
`I
`
`Figure 2. Couching for cataract as performed in Medieval Europe and
`practiced by Bartisch. (Reprinted with permission from Bartisch G.
`Ophrhaimodouleia, das ist. Augendienst. Dresden: Marthes Stocke, 1583.)
`
`Figure 1. Daviel’s first surgery for cataract. Daviel is seen ready to per-
`form surgery on Brother Felix, the hermit of Aiguill en Provence, on
`April 8. 1745. (Reprinted with pemiission from Duke-Elder S. System of
`()ph:halmology. Vol. XI. St. Louis: CV Mosby Co, XI;Z53.)
`
`tracapsular method was gaining favor among the more
`experienced cataract surgeons of the time. No matter the
`method favored. considerable attention was directed to-
`ward improving the success rate of the surgery. Surgeons
`of today should appreciate the statement made by DW
`Greene” at the 1905 Academy meeting, a statement that
`still applies in I996:
`“A well conceived and properly executed extraction is
`probably the acme of surgical skill. No other surgery ap-
`proaches it in definiteness of conception. delicacy of ex-
`ecution. in the nicety with which the different steps are
`carried out, the object to be attained, and lastly, the con-
`tentment and joy it has brought to humanity. Other sur-
`geries relieve suffering, some prolong life, and some correct
`deformity, but the extraction of the opaque lens does all
`of these and more.”
`
`The simple cataract extraction consisted of opening the
`anterior capsule and expressing the nucleus. This is the es-
`sence ofa planned extracapsular cataract extraction (ECCE)
`as perfonned today, but the similarity ends. There were doz-
`ens of methods for the anterior capsulectomy, but none were
`considered ideal. H. Knapp” stated at the 1905 Academy
`meeting, “I saw that the capsule was the most difficult factor
`in the cataract operation. In one of the periodical statistical
`reports of my cataract operations,
`I said: ‘The man who
`invents a safe method of removing the central part of the
`anterior capsule will be the greatest benefactor of the hosts
`of countless old blind people.‘ ” Homer Smith" echoed
`these comments during the 1906 Academy meeting “It is
`admitted that the latter (capsulotomy) is the most difficult
`and dangerous step in the operation."
`
`$6
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`Page 2 of 12
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`Jafie - History of Cataract Surgery
`
`the relatively clear lens cortex to opacify. This was best
`done with an ab externo puncture so that the anterior
`chamber remained formed. The capsulotomy occasionally
`was combined with a preliminary iridectomy. However,
`many ophthalmologists shied away from this. among them
`DW Greene.” who stated at the 1908 Academy meeting.
`“For the extraction of immature cataract, the method
`(Smith’s intracapsular cataract extraction [ICCE] opera-
`tion) is superior to any process of artificial ripening and
`extraction afterward.”
`
`It was agreed by many ophthalmologists that a sec-
`ondary cataract was inevitable. and that no matter which
`technique was used for the anterior capsulectomy, there
`was no way to prevent it. Among these were C. Barck“
`at the 1903 Academy meeting, and I-lotz” and H. Knapp”
`at the 1905 Academy meeting. As a result, some surgeons
`performed a puncture of the posterior capsule as a routine
`procedure, whereas others did a posterior capsulotomy
`only if a central opacity in the capsule was observed during
`the surgery. It was considered an advantage if this was
`associated with a forward pressure of the vitreous to realign
`the wound margins. If vitreous was seen at the incision,
`it merely was snipped off.
`After the anterior capsulectomy, expression of the nu-
`cleus was performed. One method consisted of retracting
`the upper eyelid with an instrument held in the surgeon’s
`left hand. while the thumb of the right hand pressed
`against the globe at the inferior limbus in an anteropos-
`terior direction. When the edge of the nucleus presented
`through the incision, an assistant rolled the nucleus out
`of the eye with a spatula.
`An interesting comment was made by DW Greene“
`at the l9l0 Academy meeting. Keep in mind that this
`was said in I9 I 0. One cannot hear such a statement today.
`This statement was:
`
`.men who discuss this subject seem to think the
`.
`question of the future of the cataract operation is settled.
`So far as the old operation (i.e., ECCE) is concerned, this
`may be true, it having been practiced since 1753, now
`157 years. it has probably reached its limits of improve-
`ment in technic and visual results.”
`
`As noted previously, the intracapsular method was de-
`veloped at nearly the same time as was the extracapsular
`technique. but it never enjoyed much popularity because
`it was considered to be too technically demanding and
`was associated with a high incidence of vitreous loss and
`postoperative infection. Results did improve. however,
`when techniques were introduced that allowed intracap-
`sular lens extraction using traction.
`Various methods of applying traction gained pop-
`ularity. Phacoeresis involved lens extraction with a
`suction cup, as originally used by Stoewer” (1902) and
`Hulenz“ (I910). This technique became more sophis-
`ticated when l. Barraquer3"“'” (l9l7—l924) designed
`an erisophake controlled by an electric pump. This
`was later simplified by Dimitry” (1933). who used
`suction with a syringe, and Bell“ (1948), who designed
`a stiff rubber bulb for this purpose. Another method
`was that of LaCarrére35 (1932). who used diathermo-
`coagulation with a double-pronged needle. Finally. the
`
`Page 3 of 12
`
`very popular cryoextraction technique was introduced
`by Krwawicz“ (I961).
`Early meetings of the American Academy of Oph-
`thalmology and Oto-laryngology included many presen-
`tations that contributed to the progress of intracapsular
`lens extraction. Many of these built on the work of Henry
`Smith, who in 1960 had published an article in the Indian
`Medical Gazette of Calcutta.” Smith was a civil surgeon
`at Jullundur, Punjab, North India. He advised a return
`to the method of extracting the lens in its capsule by ex-
`ternal manipulation.
`At the l906 Academy meeting, DW Greene” lamented
`the fact that one had to wait for ripening of a cataract
`before surgery (i.e.. ECCE) could be done. After a pre-
`sentation by Smith on a visit to the United States. Greene.
`accompanied by D. Vail, left for India. There they worked
`with Smith and performed the Indian surgery under the
`tutelage of the master. Upon their return, Greene pub-
`lished a paper (in l9l0)3° on the Smith surgery. Vail, at
`the l9 l0 Academy meeting, presented a paper“ and gave
`a detailed lantern demonstration of the unmodified Smith
`surgery (Figs 3-6). Clark, who had arrived in India 2 weeks
`before Greene and Vail. also reported on the Smith sur-
`gery_4i
`At approximately this same time, there also was some
`discussion as to whether a mature unilateral cataract
`
`should be removed. The advantages of such surgery in-
`cluded removal of cosmetic blemish (in the case of a white
`cataract). increased visual field. and avoidance of the se-
`quelae of a hypermature cataract.
`Because of the relatively high incidence of postoperative
`iris prolapse. there was renewed interest in using a corneal
`
`
`
`Figure 3. Smith surgery for cataract. The operator's left hand is shown
`in the act of grasping the conjunctiva below the cornea before section,
`while he is steadying his hand on the side of the patient's nose and,
`incidentally, steadying the patient’s face. At this stage. the assistant applies
`the thumb of his right hand to the eyebrow to keep it under control
`during the section about to be made. (Reprinted with permission from
`Vail DT. Lantern demonstration of the unmodified Smith surgery for
`cataract. 15th Meeting of the Transactions of the American Academy of
`Ophthalmology and Otolaryngology 1910; 72-97.)
`
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`Ophthalmology Volume 103, Number 8. August Supplement 1996
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`
`
`Figure 4. Sketched at Jullundur, India. Notice the straight position of
`all the fingers of the right hand. the hook being held between the thumb
`and index finger and elbow high. The thumb of the left hand is flexed
`in depressing the lower lid. while the palm of the left hand and the
`fingers are grasping the cheek and jaw to steady the patient's head. The
`handle of the instrument is directed a little toward the crown of the
`patient's head. (Reprinted with permission from Vail DT. Lantern dem—
`onstration of the unmodified Smith surgery for cataract. 15th Meeting of
`the Transactions of the American Academy of Ophthalmology and Om-
`laryngology l9l0;72—97.)
`
`suture (silk or cotton at that time) to close the wound.
`Williamsf’ Kaltf” and Suarez de Mendoza“ advocated
`sutures in the 1890s. EC Ellett“ addressed this subject at
`the 191 1 Academy meeting. where he reviewed previous
`techniques and presented his own. Kalt“ modified the
`suture technique and reported on 2000 cases. He stated
`that prolapse of the iris occurred in l0% to 12% of cases
`after simple extraction (i.e., ECCE) without a suture in
`the hands of excellent surgeons. In his earlier cases with
`a suture. Kalt reported the incidence was 6%, but with
`his improved technique, this dropped to 3% in his last
`1 I00 cases.
`
`At the same 191 1 Academy meeting, GF Keiper“ pre-
`sented an interesting paper on cataract surgeries in the
`eyes of aged patients. Surgeons of today might be amused
`to learn that such surgery among the elderly was consid-
`ered rather risky because the prolonged forced bed rest
`and occlusion of the eyes often led to delirium, prostatic
`obstruction, and pulmonary problems. He addressed let-
`ters to approximately 300 ophthalmologists around the
`country and found that only 7 patients older than I00
`years of age had undergone cataract surgery. All seven
`were women. To appreciate the changes in life span during
`the past 75 years, actuarial data from 1911 are listed in
`Table I; consider the incidence of surgery in these age
`groups today.
`Discussions regarding the cataract surgery of choice
`continued for the next 20 years. It was generally agreed
`on that the intracapsular method was preferable if the
`incidence of intraoperative loss of vitreous could be low-
`
`S8
`
`Page 4 of 12
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`ered. The next evolutionary step beyond the Smith Indian
`method was ofi‘ercd by Stanculeanu“ of Bucharest. Ex-
`perience with this method was reported by WL Simpson”
`at the 1912 Academy meeting. Using smooth, curved
`capsule forceps, the anterior capsule was grasped, and
`movements were made from side to side and up and down
`until the zonular fibers gave way. The forceps then were
`opened and removed, and the lens was expressed by pres-
`sure with a spoon over the cornea slightly below the center,
`with slight counter pressure above the wound. If the cap-
`sule ruptured, the older method of nuclear expression was
`used.
`
`During this era, it was in vogue not to remove the
`surgical bandage for several days after the procedure. The
`only useful purpose for occluding the eye was to prevent
`trauma, and by the 1916 Academy meeting. J W Millette”
`was a vocal proponent for not using binocular dressings
`and allowing quicker ambulation.
`Knowledge of the management and consequences of
`vitreous loss was rather meager, as expressed at the I920
`
`Figure 5. Spectator-'s view. The lids are being held by the assistant, and
`the hook for expelling the lens is applied. This provides adequate exposure
`for the surgeon. (Reprinted with permission from Vail DT. Lantern
`demonstration of the unmodified Smith surgery for cataract. 15th Meeting
`of the Transactions of the American Academy of Ophthalmology and Oca-
`laryngology 191 0; 72- 97.)
`
`

`
`jaffe - History of Cataract Surgery
`
`forming capsulectomy with the blunt capsule forceps of
`Kalt, he noted that in many cases, before rupture of the
`capsule occurred, the lens became dislocated. This stim-
`ulated him to pursue the intracapsular surgery with a slight
`modification of the Stanculeanu technique.“ He realized
`that there was no ideal method of cataract extraction and
`recommended that ICCE be performed only in selected
`cases.
`
`During the discussion of Knapp‘s paper, A. Green”
`stated that he induced paralysis of the orbicularis by an
`infraorbital injection of procaine hydrochloride (Novo-
`cain); this was fortified by instilling cocaine hydrochloride
`into the conjunctival sac. He continued that after the in-
`cision was made, a horizontal crease often appeared in
`the cornea, running from Iimbus to Iimbus, reflecting in-
`creased intraocular pressure. In these cases, the intracap-
`sular method should be avoided.
`
`At the 1924 Academy meeting. A. Greenwood“ rec-
`ommended that the term cataracr should be avoided as
`much as possible with patients: ‘‘It strikes terror into the
`soul of some of the timid ones.” Cataract often implied
`impending blindness and a dreadful surgery with uncer-
`tain end results, so it is not surprising that many ophthal-
`mologists recommended nonsurgical treatment to sup-
`press the advancement of cataracts. These included
`dionin, sodium iodide, mercury cyanide, and ionization-
`all of which proved ineffective fell into disuse.
`The surgical treatment of congenital cataract by com-
`plete discission was advocated primarily by Zeigler” in
`l92l. It was used mainly in children younger than 10
`years of age. For older children. linear extraction was ad-
`vocated.
`
`As surgical techniques improved, a tide of enthusiasm
`for ICCE continued well into the 19305. and it became
`the favored technique in the United States. This was sup-
`ported by the two most obvious advantages of the method:
`I) no need to wait for maturity of the cataract and 2) the
`avoidance of the then-serious problem of cataract.
`Davis” advocated the ICCE method at the 1937 Acad-
`emy meeting and outlined the suggested routine postop-
`erative care as follows: The first dressing is done on the
`fourth day in cases in which complete iridectomy has been
`performed and after 48 hours in cases of simple extraction.
`Patients are kept in bed for 4 to 5 days, but a backrest is
`permitted after 48 hours. A soap suds enema is given on
`the fourth day. Sutures are removed on the seventh day
`unless spontaneously extruded. The eye that did not un-
`dergo surgery is uncovered on the fourth day after the
`
`Table 1. Life Span per 100,000 Individuals in 1911
`
`Age (yrs)
`
`80
`85
`90
`95
`100
`
`Number
`
`13,290
`5417
`13 19
`89
`1
`
`Figure 6. Top, this is a “tumbler." This halfisomersault of the lens
`occurs by making traction away from the incision by means of the hook
`caught on the ciliary ridge and pulling directly toward the patient’s feet
`and at the same time not making deep pressure. Bottom, the lens advances
`after it has severed its lower ligamentous attachments and is turning.
`The pressure is shifted to follow it up and is now no longer toward the
`patient‘s feet, but toward the top of the head to keep all gaps between
`the lens and wound closed to prevent vitreous loss. (Reprinted with
`permission from Vail DT. Lantern demonstration of the unmodified
`Smith surgery for cataract. Transactions of the American Academy of
`Ophthalmology and Otolaryngology I910; 72-97.)
`
`meeting of the Academy. H. Gifl”ord5' recommended ter-
`minating the surgery when vitreous loss was encountered
`before the lens was extracted. The surgery was eventually
`completed at a later date. after the incision had healed.
`He offered this as. “the best way out of a bad hole." To
`do this today would be unthinkable.
`Arnold Knapp.” the son of Hcnnan Knapp. influenced
`many ophthalmologists at the 1928 Academy meeting to
`develop their skill in intracapsular surgery. While per-
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`Page 5 of 12
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`Ophthalmology Volume 103, Number 8, August Supplement 1996
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`surgery and the surgical eye is dressed on alternate days
`until the patient is dismissed, which, in private cases, is
`usually the tenth or twelfth day. Vitreous loss occurred
`in 6% of cases. Gradle,” in 1933, reported vitreous loss
`in 3% of patients during ICCE and in 7% of patients during
`ECCE. Davis“ reported postoperative anterior chamber
`hemorrhage in 7% of patients. These rates for these two
`complications were lower than in most other series re-
`ported at that time.
`Although introduced decades earlier, the importance
`of suture closure of the incision was discussed at the 1941
`
`Academy meeting by Peter,” who advocated the Stallard
`suture, a type of mattress suture. Two prominent surgeons
`ofthe day discussed Peter’s paper. McLean5° had described
`his preplaced comeoscleral suture in Archives of Oph-
`thalmology in 1940, and he thought that interrupted radial
`sutures were more advantageous. The use of sutures was
`supported also by Kirby,“ who stated: “I believe sutures
`are an advance in technique and represent a safety factor
`in the promotion of healing of wounds. reduction of astig-
`matism, prevention of hemorrhage, and prolapse of the
`iris." He favored placing the suture after the limbal section.
`Hughes and Owens,“ at the 1944 Academy meeting,
`presented an excellent paper that reviewed 2086 un-
`complicated cataract surgeries performed at the Wilmer
`Institute between I925 and I943. It compared a variety
`of cataract surgical techniques and strongly supported
`the trend toward round pupil intracapsular surgery with
`comeoscleral sutures. Compared with other contem-
`porary methods, there was a sharp reduction in the in-
`cidence of iris prolapse, hyphema,
`iridocyclitis, sec-
`ondary glaucoma, retinal detachment, and postopera-
`tive astigmatism.
`Although Collins and Cross“ had reported two cases
`of epithelial ingrowth in 1892, Theobold's presentation“
`at the 1947 Academy meeting was the first comprehensive
`report to show histologic evidence of delayed healing of
`the wound. This was the most important paper on this
`subject since Perera’s paper,“ delivered at the I937 Acad-
`emy meeting, in which he classified epithelium in the an-
`terior chamber.
`
`During the late 1940s, ICCE was the procedure of
`choice, and although many types of suture closure were
`reported, the most popular was the postplaced comeo-
`scleral suture. Limbal- and fomix-based conjunctiva] flaps
`were popular at this time also, and the Graefe knife section
`gave way to the kcratome with scissors enlargement, as
`introduced by Daviel. The success of surgery had reached
`an all-time high, but one major obstacle to patient satis-
`faction remained. This was the method of optical correc-
`tion of aphakia. Cataract spectacles often left the patient
`more handicapped for normal daily activities than had
`the decreased vision because of the cataract. Linksz°5
`
`wrote in a chapter concerning optical complications of
`aphakia: “As the editor (Theodore) of this volume has so
`aptly stated, one of the unavoidable complications of cat-
`aract surgery is aphakia." The adjustment to aphakia was
`clearly described by Woods,“ a famous ophthalmologist
`who was himself, aphakic. He stated, “This infinnity can-
`not be cured: it must be endured.” Contact lenses were
`
`S10
`
`Page 6 of 12
`
`in their infancy, but many elderly patients could not
`manage them even later, when contact lens technology
`improved considerably.
`At the 1955 Academy meeting, Cordes“ presented data
`that charted the future course of management of congen-
`ital cataracts. He suggested that linear extraction was the
`safest surgery so far as immediate results and avoidance
`of complications were concerned. Multiple needlings
`seemed to be the least desirable of all procedures, because
`his statistics showed that 37.9% of patients subjected to
`this method had late detachment of the retina at an av-
`
`erage of 22.2 years after the last needling.
`The 1956 Academy meeting included a major sym-
`posium on postoperative cataract complications, which
`were discussed by leading American ophthalmologists of
`that time: McLean,“ Hogan,‘’‘’ and Maumenee.7" The
`complications considered included nearly all of those as-
`sociated with both [CCE and ECCE. Many of these
`stemmed from wound healing problems that resulted in
`delayed restoration of the anterior chamber.
`A milestone in cataract surgery occurred in 1957 when
`Joaquin Barraquer discovered that the enzyme a-chy-
`motrypsin could cause zonulysis, thereby facilitating the
`delivery of the lens.7"7’ The Academy organized a com-
`mittee to study the use of this enzyme in cataract surgery,
`and its initial findings were presented at the 1959 Academy
`meeting.
`Chandler and Maumence” presented evidence at the
`1960 Academy meeting that postoperative hypotony in
`the absence of external filtration is because of a serous
`
`detachment of the ciliary body, and that the fluid must
`extend anteriorly to the scleral spur before it affects se-
`cretion of aqueous. Chandler also is credited with using
`digital pressure after the rctrobulbar injection to lower the
`intraocular pressure during cataract surgery. Kirsch and
`Steinman" were the primary investigators who popular-
`ized this technique. This Ied to the introduction of a va-
`riety of devices to be applied to the closed eyelids to lower
`intraocular pressure and reduce orbital volume.
`
`
`
`Figure 7. Intracapsular cataract extraction using cryoprobe.
`
`

`
`Jaffe - History of Cataract Surgery
`
`Krawicz” was the first to introduce cryoextraction of
`cataracts (Fig 7). This sharply reduced the incidence of
`rupture of the anterior capsule when using the forceps or
`erisiphake in intracapsular surgery. A modification of the
`cryoextractor was presented by Kelman and Cooper“ at
`the 1963 Academy meeting.
`At the I968 Academy meeting, Gass and Norton"
`contributed to our understanding of the nature of cystoid
`macular edema after cataract extraction. This was a fol-
`
`low-up of their first study. reported in 1966,73 using flu-
`orescein angiography. They stated that exudate from in-
`competent capillaries forms small puddles in the outer
`plexiform layer of Henle. which acts like a sponge. It is
`ofinterest that Irvine” described this entity clinically in
`1953 and thought it was associated with postoperative
`rupture ofthe anterior hyaloid membrane after ICCE. It
`is now known that it can occur after uncomplicated sur-
`gery and in the presence of an intact anterior hyaloid
`membrane.
`[1 occurs less frequently after ECCE with
`preservation of an intact posterior capsule. which is one
`of the factors that created enthusiasm for modern ECCE.
`
`An important advance in the intraoperative manage-
`ment of vitreous loss was contributed by Kasner.” Partial
`anterior vitrectomy is now universally recommended for
`intraoperative loss of vitreous. Kasner used this technique
`beginning in 1961, first with sponges and later with au-
`tomated devices. This greatly improved the success of cat-
`aract surgery in patients with this complication. Mach-
`emer and co-workers'‘'‘‘‘3 helped usher in the era of mod-
`em vitreous surgery via a pars plana approach, with reports
`at the 1970. 1971. and I972 Academy meetings.
`Kelman,“ in I967, made one of the most important
`contributions to cataract surgery during the past century
`when he introduced the technique of phacoemulsification.
`As was the case in the past when ICCE became more
`popular than did ECCE. surgeons questioned why they
`should discard what was considered a highly successful
`procedure. New methods often involved radical changes
`in technique and a painful learning curve. and phaeo-
`emulsification was no exception. It was introduced to a
`highly hostile audience that tried in many ways to thwart
`its progress. Surgeons were highly protective of their
`ground and resisted the efforts of Kelman and his early
`disciples. It is to the credit of the Academy that it staged
`a symposium on the subject at the 1973 Academy meeting.
`At the 1974 Academy meeting, the Academy Committee
`on Phacoemulsification reported the results of a survey
`of 400 ophthalmologists comparing intracapsular, extra-
`eapsular, and phacoemulsification techniques. The con-
`clusion was that phacoemulsification did not yield results
`inferior to those of ICCE. In the words of the chairman
`
`of the Committee, the “decision is only a draw.”85 At that
`time, the main advantage of phacoemulsification appeared
`to be the small incision and, therefore, earlier return to
`full activity. However, in later years, it became evident
`that the extracapsular technique (including phaeoemul-
`sification) afforded many other advantages over standard
`ICCE.“ It is of interest, and certainly inaccurate, that the
`chairman of the I973 Academy symposium stated that,
`‘‘It (phacoemulsification) is not, and probably will not
`
`Page 7 of 12
`
`become, a universal replacement for the conventional
`procedure."“7
`One of the most important events in cataract surgery
`during the past century occurred on November 29. I949,
`when Ridley implanted his first intraocular lens. He was
`convinced that. “the proper place for an artificial lenti-
`culus must surely be where nature intended the crystalline
`to be, viz, in the posterior chamber."83 His intraocular
`lens was very heavy ([12 mg in air) and could be used
`only with an ECCE because the posterior capsule was
`necessary for its support. Furthermore, his results were
`far from satisfactory. and his procedure was abandoned
`because of a high incidence of postoperative complica-
`tions.88'°'
`Because of difficulties encountered with secure fixation
`of the Ridley posterior chamber lens, the next chapter in
`the history of intraocular lenses involved fixation in the
`anterior chamber angle. Because the appetite of many
`ophthalmologists for lens implant surgery had been whet-
`ted by Ridley. many anterior chamber lenses and tech-
`niques were introduced. Baron” implanted the first an-
`terior chamber lens on May 13. 1952. It seems incredible
`today that so many excellent ophthalmologists were so
`blinded to the delicacy of the corneal endothelium that
`they expected these crudely manufactured lenses to last
`a lifetime. The early results often were good, but the in-
`evitablc result was corneal edema and glaucoma. The di-
`sastrous experience of Barraquer” with these lenses re-
`sulted in near abandonment of intraocular lenses.
`
`A resurgence in enthusiasm for lens implant surgery
`occurred when lenses that depended on the iris for support
`were designed. The major credit for this goes to Bink-
`horst,“ who developed his iris-clip lens in 1957 and used
`it for the first time on August II. 1958 (Fig 8). Epstein”
`designed a Maltese cross lens in 1953 that also depended
`on iris support. Binkhorst later realized that the ECCE
`technique was advantageous. so he removed the anterior
`
`
`
`Figure 8. Binkhorst four-loop iris-clip intraocular lens implanted on
`December 4, 1967, by N. Jafie. Photograph was taken 24 years after surgery.
`
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`

`
`Ophthalmology Volume 103, Number 8, August Supplement 1996
`
`
`
`Iridocapsular intraocular lens fashioned by excising the two
`Figure 9.
`anterior loops of a four-loop Binkhorst lens. Surgery was performed on
`December 4, 1967, by the extracapsular method by N. Jaffe. Photograph
`was taken 20 years after surgery.
`
`loops from his four-loop iris-clip lens and used it as a
`capsule-supported lens in 1963 (Fig 9). He l