REWARDING PROCEDURE

Cataract surgery is one of the most important and rewarding surgical procedures ever devised. Its evolution has been a story of amazing human achievement, tarnished sometimes by arrogance and jealousy. Cataract surgery started in India 1000-600 BC when Sushruta described a procedure to rupture the anterior capsule of a white mature cataract then asking the patient to express the liquefied lens matter by performing a Valsalva manoeuvre by holding his nose and breathing out. This evolved into couching where a lance was used to push the opaque lens backwards into the vitreous. Couching was probably introduced to western Europe by the conquests of Alexander the Great whose campaigns penetrated into the Hindu Kush in 350 BC and is still performed in some remote parts of western Africa today.

The next great advance came from the French surgeon Daviel who pioneered extracapsular cataract extraction (ECCE) in 1745. In 1756 he reported on 434 operations with only 50 (12 per cent) failures and ECCE rapidly became the treatment of choice. It is remarkable that this surgery was performed without any anaesthesia until the introduction of cocaine over 100 years later in 1884. A notable proponent was the flamboyant charlatan ‘Chevalier’ John Taylor who toured Europe as the self-styled oculist to King George II, the Pope and sundry European royalty. He had the distinction of blinding both Bach and Handel in the same year and eventually died in poverty.

Method of choice
ECCE was a relatively safe and easy operation to perform but required a hard lens or mature cataract and hence there were a lot of problems with secondary membrane and inflammation post-surgery. On the other hand intracapsular cataract extraction (ICCE), with complete removal of the lens, could be performed on more immature cataracts with less risk of membrane and inflammation. However, it was a much more difficult operation requiring increased surgical expertise, larger incisions and the risk of capsular rupture and vitreous loss. Through the pioneering work of Col Henry Smith, a British army doctor in India, it gradually became the method of choice by the mid-20th century.

Surgical safety was greatly improved by Barraquer who used alpha chymotrypsin to break the zonule and it is not widely known that Charlie Kelman’s first contribution to ophthalmology was the invention of a cryo probe for extraction of the lens which unfortunately was never fully commercialised. By 1960 ICCE was the operation of choice. I carried out many of these operations myself as a training resident in the mid-1970s at Moorfields Eye Hospital.

The next major advance in cataract surgery was the development of the lens implant by Harold Ridley at St Thomas’ Hospital. He designed and inserted an intraocular lens (IOL) made of Perspex, after a medical student suggested the idea to him. Surgical records from St Thomas’ show that the patient had routine ECCE in November 1949 and the first implant was actually performed in February 1950 as a secondary procedure on a unilateral aphake. In hindsight, this was the ideal situation as by three months postsurgery the capsule would have thickened and supported the heavy IOL, leading to an anatomical (but not visual) success.

Design advances
Later operations when the heavy implant was inserted at the initial surgery lead to posterior dislocation and it is interesting to speculate how events might have turned out if the first case had been done as a primary procedure. Primary posterior chamber implantation was soon abandoned in favour of AC and iris-supported IOLs, frequently with devastating complications from corneal endothelial damage, uveitis and glaucoma. IOL design has since progressed with innumerable advances in design and surgical technique but one of the most important was the return to posterior chamber fixation pioneered by Shearing with the development of his posterior chamber IOL with flexible haptics. In tandem Charlie Kelman was pioneering phaco emulsification. His first operation was performed in 1967 with a phaco time of 79 minutes, the eye being enucleated two days later.

We forget today the trials, tribulations and controversy surrounding these pioneers and the development of cataract surgery into the successful procedure we have today. It took 30 years from the 1950s to the 1980s to establish implant surgery as a safe procedure and about 20 years for phaco to be accepted as the technique of choice. Looking forwards, the only certainty is that the operation will continue to change and improve and I am sure the United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) will be there pioneering the future.