367
TRENDS IN CATARACT SURGERY JOSEPH W. EICHENBAUM, M.D. Assistant Clinical Professor Department of Ophthalmology The Mount Sinai School of Medicine New York, New York
RECENT EPIDEMIOLOGY
C ATARACTS, OR LENS OPACITIES, are present in about 10% of all Americans. Between the ages of 65 and 74 the prevalence of cataracts increases to about 50%, and for those over the age of 75 it increases to 70%.' In the United States cataracts are the major cause of self reported visual impairment. They are the third leading cause of preventable blindness. Although the impact of cataracts at the early stages can be lessened to some degree with glasses or contact lenses, surgery today, with lens implant, is the ultimate therapy that can be provided.' Based on current life expectancy, a person is more likely to undergo cataract operation than almost any other surgical procedure. This makes cataract surgery the leading therapeutic surgical procedure for Americans over the age of 65. It is estimated that about 1.25 million cataract extractions were performed during 1988 in the United States. More than one million cataract procedures are paid for each year by Medicare. The annual cost for cataract surgery and all associated care approximates $3 billion." 2 About 10% of all cataract surgery is done on an inpatient basis, resulting in about 125,000 hospitalizations annually. Ophthalmology is the leading category of surgical procedures in free-standing outpatient surgery centers. It accounts for 25% of all the surgery in these centers. The vast majority of the outpatient operations are cataract extractions with implantation of intraocular lenses under local anesthesia.1'3'4 COUCHING AND THE VISION OF THE OLD WORLD
Susruta, the first eye surgeon, who lived thousands of years ago in India, first described couching of cataracts. George Gorin's History ofOphthalmology provides a succinct surgical description: "It was done during the moderate Address for reprint requests: 1050 Park Avenue, New York, NY 10028
Vol. 68, No. 3, July 1992
Bull. N.Y. Acad. Med.
368
368
J. W. EICHENBAUM FICHENBAUM
Fig. 1. Couching of cataract in second half of the 16th century. Reproduced by permission from Gorin G.: History of Ophthalmology. New York, Publish or Perish (Raven), 1982, p. 36.
season, preceded the day before by purgatives. The patient is seated and should look toward the nose. The point of puncture should be just outside the junction of the black and white on the temporal side.... The surgeon should hold the needle steadily and should puncture through the natural aperture [the pupil]. A correct puncture is indicated by exudation of a drop of water. An incorrect puncture will be followed by bleeding. After the cataract is reached it should be scarified with the needle till it is dislodged out of the visual field." (Figures 1 and 2)5 Although couching (or merely the displacing with a needle) of cataracts was the method of choice throughout Europe well into the 18th century, Arab surgeons of Baghdad had begun extracting cataracts back in the 13th century. Arab surgeons increased the Greek surgical armamentarium to 36 instruments, as described by Halifa in a text from 1266. They had devised a hollow needle knife as well as a glass tube to suck out cataracts. The ancient Arabians used corneal or scleral puncture with a Bull. N.Y. Acad. Med.
CATAR ACT qTTR(FRV
IAQ JU7
I B A Fig. 2. Needle entry and contact sites in couching. A: anterior approach; B: posterior approach. Reproduced by permission from Gorin G.: History of Ophthalmology. New York, Publish or Perish (Raven), 1982, p. 26.
sharpened glass tube inserted into the cataract. Using the mouth, suction was applied to such out the cataract.5'6 The ancients, including Galen, perpetuated the notion that the cataract was a condensation of fluid located in front of the pupil but emanating from the brain. The word cataract is Greek in origin. It is a down-rushing of water, a waterfall. Ibn Rushd Averoes, a Spanish Arab who was an Aristotelian scholar in the mid 1 OOs, was the first to suggest that the lens or cataract was not the photoreceptor organ of vision. He suggested that the retina contained the elements of visual perception.7 As early as the 11th century, Alhazen's Book of Optics, written by Ibn alHaitham in Cairo, rejected the ancient and pervasive emanation hypothesis. Because of the support of Plato and most of the ancient world for the emanation hypothesis, it was widely believed that the act of vision emanated from visual rays from the eyes. The visual rays traveled like sun rays or spider web threads to objects from the eyes. The skepticism of Aristotle and only a few others was ignored. Alhazen, a physicist during the 1 1th century, proposed the "camera obscura" or pinhole camera analogy to the eye. In his concept, light traveled from an object to the retina. The front segment of the eye focused the light on the retina. The retina then sent information to be assimilated into the brain. His treatise has the oldest diagrams of the visual system showing its components in relation to the brain. (Figure 3)7 Unfortunately, this level of sophistication in comprehension and methodology was not to resurface for nearly another 700 years. In 1543 Vesalius and others argued with the prevailing European wisdom. Vol. 68, No. 3, July 1992
370
370
J. J. W.
01
EICHENBAUM
114.. LIS-,-j
Fig. 3. The oldest diagram of the visual system showing its components and its relation to the brain. From the Book of Optics of Ibnal-Haitham (Alhazen), 1083; Reproduced by permission from Polyak S.L.: The Human Eye in Anatomical Transparencies, Kronfeld P.C. and McHugh G., editors. Rochester, NY, Bausch and Lomb, 1943, p. 82.
While this wisdom conceived of the lens as the site of vision, Vesalius and others maintained that the function of the lens was only to focus incoming light. Kepler, through mathematical analysis, Pater Scheiner, through direct observation, and Athanasius Kircher and Descartes independently demonstrated that the image was formed on the retina after being focused through the lens. They confirmed the hypothesis postulated by Alhazen centuries before.7 Georg Bartisch, according to some historians, was the "Father of Modem Ophthalmology." In 1583 he published the first printed textbook of ophthalmology. Bartisch portrayed in atlas format the anatomy of a model eye. He traveled extensively, using handbills to extol the virtue ofhis work in couching cataracts. Although he presumably enjoyed great success in his couching technique in many European cities as well as at the Vienna annual fair, the Bull. N.Y. Acad. Med.
qTVZUTTC CATARACT TRC.FRV rA I A^ArT a _xX
I
171 171
Fig. 4. Daviel's cataract extraction. Reproduced by permission from Gorin G.: History of Ophthalmology. New York, Publish or Perish (Raven), 1982, p. 47.
guild of barber surgeons of Vienna intervened there. They refused to grant him a license and forced him to leave town.5 CATARACT EXTRACTION
There were sporadic efforts in cataract extraction throughout the next century. These efforts included Blankaart (1669-1702) speaking of forceps removal through a superior corneal incision, circa 1700, and Charles St. Yves' spooning out of the lens through an inferior corneal incision in 1707.5 Despite these isolated attempts, it was Daviel who revolutionized the art of cataract extraction. In 1749, as the story goes, Jacques Daviel removed the lens of a steer in the presence of the king. Daviel used a knife incision in the inferior cornea, right and left corneal scissors (to enlarge the opening in the corneal scleral margin), a sharp needle to cut open the anterior lens capsule (just beneath the iris), a gold spatula to remove the lens nucleus, and a spoon and forceps to remove lens cortical remnants. Daviel left the posterior lens capsule in place still attached to the zonules (fine specialized connective tissue strands from posterior lens capsule to the ciliary body), and removed only the anterior lens capsule, the lens nucleus, and lens cortex, performing one of the first planned extracapsular cataract extractions (Figures 4, 5, and 6 for anatomic considerations).5 King Louis XV subsequently chose Daviel as his personal physician and established the first chair in ophthalmology, in Paris.5 Vol. 68, No. 3, July 1992
372
372
EICHENBAUM J. W. BICHENBAUM
Fig. 5. American Academy of Ophthalmology clinical instruction slide showing extracapsular cataract technique. The cataract back capsule remains attached to zonular fibers, emanating black curved lines running to the more peripheral, darker ciliary body, behind the iris. The cataract also consists of the nucleus, central region, and cortex, stippled areas circumferentially around central area. In this diagram the cataract nucleus and cortex are removed linearly and the back capsule remains intact as the site for lens implant, vide infra. Reproduced by permission from San Francisco, American Academy of Ophthalmology, 1992, p. 41.
In the 1750s Daviel and, separately, de la Faye, who in 1752 designed the first cataract knife, removed cataracts and their capsule together (intracapsular cataract extraction). (Figures 5 and 6)5 They used gentle pressure from above and below, breaking the zonular attachments and extracting the cataract through an inferior corneal section. While in Rheims in 1751 Daviel performed 43 cataract extractions in three weeks. In 1752 he published a textbook on cataract extraction. By the end of 1756 Daviel had done 434 cataract extractions. Twelve percent had poor visual results. He cautioned against exerting excess pressure on the eye, vitreous loss, and iris prolapse.5 In London in 1753 Samuel Sharp is actually credited with the first performed intracapsular cataract extraction.8 However, this technique was not widely used until the early 1940s. Major advances in instrumentation and surgical sophistication in intracapsular technique developed after that early 1940s period.8 During the 1800s a number of ostensibly smaller advances facilitated the cataract extraction methodology. In 1801 Karl Himly described pupillary dilation to abet linear extraction.5 Pomard contributed three improvements to the Daviel procedure: the patient was operated on lying on his back, rather Bull. N.Y. Acad. Med.
CATARACT SURGERY
373
CATARACT SURGERY
scdSA i
HOIOROID
4
/f/,
TRENDS IN CATARACT SURGERY JOSEPH W. EICHENBAUM, M.D. Assistant Clinical Professor Department of Ophthalmology The Mount Sinai School of Medicine New York, New York
RECENT EPIDEMIOLOGY
C ATARACTS, OR LENS OPACITIES, are present in about 10% of all Americans. Between the ages of 65 and 74 the prevalence of cataracts increases to about 50%, and for those over the age of 75 it increases to 70%.' In the United States cataracts are the major cause of self reported visual impairment. They are the third leading cause of preventable blindness. Although the impact of cataracts at the early stages can be lessened to some degree with glasses or contact lenses, surgery today, with lens implant, is the ultimate therapy that can be provided.' Based on current life expectancy, a person is more likely to undergo cataract operation than almost any other surgical procedure. This makes cataract surgery the leading therapeutic surgical procedure for Americans over the age of 65. It is estimated that about 1.25 million cataract extractions were performed during 1988 in the United States. More than one million cataract procedures are paid for each year by Medicare. The annual cost for cataract surgery and all associated care approximates $3 billion." 2 About 10% of all cataract surgery is done on an inpatient basis, resulting in about 125,000 hospitalizations annually. Ophthalmology is the leading category of surgical procedures in free-standing outpatient surgery centers. It accounts for 25% of all the surgery in these centers. The vast majority of the outpatient operations are cataract extractions with implantation of intraocular lenses under local anesthesia.1'3'4 COUCHING AND THE VISION OF THE OLD WORLD
Susruta, the first eye surgeon, who lived thousands of years ago in India, first described couching of cataracts. George Gorin's History ofOphthalmology provides a succinct surgical description: "It was done during the moderate Address for reprint requests: 1050 Park Avenue, New York, NY 10028
Vol. 68, No. 3, July 1992
Bull. N.Y. Acad. Med.
368
368
J. W. EICHENBAUM FICHENBAUM
Fig. 1. Couching of cataract in second half of the 16th century. Reproduced by permission from Gorin G.: History of Ophthalmology. New York, Publish or Perish (Raven), 1982, p. 36.
season, preceded the day before by purgatives. The patient is seated and should look toward the nose. The point of puncture should be just outside the junction of the black and white on the temporal side.... The surgeon should hold the needle steadily and should puncture through the natural aperture [the pupil]. A correct puncture is indicated by exudation of a drop of water. An incorrect puncture will be followed by bleeding. After the cataract is reached it should be scarified with the needle till it is dislodged out of the visual field." (Figures 1 and 2)5 Although couching (or merely the displacing with a needle) of cataracts was the method of choice throughout Europe well into the 18th century, Arab surgeons of Baghdad had begun extracting cataracts back in the 13th century. Arab surgeons increased the Greek surgical armamentarium to 36 instruments, as described by Halifa in a text from 1266. They had devised a hollow needle knife as well as a glass tube to suck out cataracts. The ancient Arabians used corneal or scleral puncture with a Bull. N.Y. Acad. Med.
CATAR ACT qTTR(FRV
IAQ JU7
I B A Fig. 2. Needle entry and contact sites in couching. A: anterior approach; B: posterior approach. Reproduced by permission from Gorin G.: History of Ophthalmology. New York, Publish or Perish (Raven), 1982, p. 26.
sharpened glass tube inserted into the cataract. Using the mouth, suction was applied to such out the cataract.5'6 The ancients, including Galen, perpetuated the notion that the cataract was a condensation of fluid located in front of the pupil but emanating from the brain. The word cataract is Greek in origin. It is a down-rushing of water, a waterfall. Ibn Rushd Averoes, a Spanish Arab who was an Aristotelian scholar in the mid 1 OOs, was the first to suggest that the lens or cataract was not the photoreceptor organ of vision. He suggested that the retina contained the elements of visual perception.7 As early as the 11th century, Alhazen's Book of Optics, written by Ibn alHaitham in Cairo, rejected the ancient and pervasive emanation hypothesis. Because of the support of Plato and most of the ancient world for the emanation hypothesis, it was widely believed that the act of vision emanated from visual rays from the eyes. The visual rays traveled like sun rays or spider web threads to objects from the eyes. The skepticism of Aristotle and only a few others was ignored. Alhazen, a physicist during the 1 1th century, proposed the "camera obscura" or pinhole camera analogy to the eye. In his concept, light traveled from an object to the retina. The front segment of the eye focused the light on the retina. The retina then sent information to be assimilated into the brain. His treatise has the oldest diagrams of the visual system showing its components in relation to the brain. (Figure 3)7 Unfortunately, this level of sophistication in comprehension and methodology was not to resurface for nearly another 700 years. In 1543 Vesalius and others argued with the prevailing European wisdom. Vol. 68, No. 3, July 1992
370
370
J. J. W.
01
EICHENBAUM
114.. LIS-,-j
Fig. 3. The oldest diagram of the visual system showing its components and its relation to the brain. From the Book of Optics of Ibnal-Haitham (Alhazen), 1083; Reproduced by permission from Polyak S.L.: The Human Eye in Anatomical Transparencies, Kronfeld P.C. and McHugh G., editors. Rochester, NY, Bausch and Lomb, 1943, p. 82.
While this wisdom conceived of the lens as the site of vision, Vesalius and others maintained that the function of the lens was only to focus incoming light. Kepler, through mathematical analysis, Pater Scheiner, through direct observation, and Athanasius Kircher and Descartes independently demonstrated that the image was formed on the retina after being focused through the lens. They confirmed the hypothesis postulated by Alhazen centuries before.7 Georg Bartisch, according to some historians, was the "Father of Modem Ophthalmology." In 1583 he published the first printed textbook of ophthalmology. Bartisch portrayed in atlas format the anatomy of a model eye. He traveled extensively, using handbills to extol the virtue ofhis work in couching cataracts. Although he presumably enjoyed great success in his couching technique in many European cities as well as at the Vienna annual fair, the Bull. N.Y. Acad. Med.
qTVZUTTC CATARACT TRC.FRV rA I A^ArT a _xX
I
171 171
Fig. 4. Daviel's cataract extraction. Reproduced by permission from Gorin G.: History of Ophthalmology. New York, Publish or Perish (Raven), 1982, p. 47.
guild of barber surgeons of Vienna intervened there. They refused to grant him a license and forced him to leave town.5 CATARACT EXTRACTION
There were sporadic efforts in cataract extraction throughout the next century. These efforts included Blankaart (1669-1702) speaking of forceps removal through a superior corneal incision, circa 1700, and Charles St. Yves' spooning out of the lens through an inferior corneal incision in 1707.5 Despite these isolated attempts, it was Daviel who revolutionized the art of cataract extraction. In 1749, as the story goes, Jacques Daviel removed the lens of a steer in the presence of the king. Daviel used a knife incision in the inferior cornea, right and left corneal scissors (to enlarge the opening in the corneal scleral margin), a sharp needle to cut open the anterior lens capsule (just beneath the iris), a gold spatula to remove the lens nucleus, and a spoon and forceps to remove lens cortical remnants. Daviel left the posterior lens capsule in place still attached to the zonules (fine specialized connective tissue strands from posterior lens capsule to the ciliary body), and removed only the anterior lens capsule, the lens nucleus, and lens cortex, performing one of the first planned extracapsular cataract extractions (Figures 4, 5, and 6 for anatomic considerations).5 King Louis XV subsequently chose Daviel as his personal physician and established the first chair in ophthalmology, in Paris.5 Vol. 68, No. 3, July 1992
372
372
EICHENBAUM J. W. BICHENBAUM
Fig. 5. American Academy of Ophthalmology clinical instruction slide showing extracapsular cataract technique. The cataract back capsule remains attached to zonular fibers, emanating black curved lines running to the more peripheral, darker ciliary body, behind the iris. The cataract also consists of the nucleus, central region, and cortex, stippled areas circumferentially around central area. In this diagram the cataract nucleus and cortex are removed linearly and the back capsule remains intact as the site for lens implant, vide infra. Reproduced by permission from San Francisco, American Academy of Ophthalmology, 1992, p. 41.
In the 1750s Daviel and, separately, de la Faye, who in 1752 designed the first cataract knife, removed cataracts and their capsule together (intracapsular cataract extraction). (Figures 5 and 6)5 They used gentle pressure from above and below, breaking the zonular attachments and extracting the cataract through an inferior corneal section. While in Rheims in 1751 Daviel performed 43 cataract extractions in three weeks. In 1752 he published a textbook on cataract extraction. By the end of 1756 Daviel had done 434 cataract extractions. Twelve percent had poor visual results. He cautioned against exerting excess pressure on the eye, vitreous loss, and iris prolapse.5 In London in 1753 Samuel Sharp is actually credited with the first performed intracapsular cataract extraction.8 However, this technique was not widely used until the early 1940s. Major advances in instrumentation and surgical sophistication in intracapsular technique developed after that early 1940s period.8 During the 1800s a number of ostensibly smaller advances facilitated the cataract extraction methodology. In 1801 Karl Himly described pupillary dilation to abet linear extraction.5 Pomard contributed three improvements to the Daviel procedure: the patient was operated on lying on his back, rather Bull. N.Y. Acad. Med.
CATARACT SURGERY
373
CATARACT SURGERY
scdSA i
HOIOROID
4
/f/,
