Without these gifted and courageous individuals who were willing to stand alone and endure this struggle, the golden age of cataract surgery could never have occurred. Their path followed a trajectory that was ultimately to transform the very concept of cataract surgery from an extractive procedure — designed solely to address the obstructive visual impairment of lens opacity — to the new, broader paradigm of refractive cataract surgery we all share today.
This then is the background for our story that rightly must begin not 20 but slightly more than 50 years ago with the first of those visionaries who even then could see the refractive potential of cataract surgery, Harold Ridley.
The concept of cataract extraction as opposed to couching had been a revolution in itself when first performed in by the French ophthalmologist Jacques Daviel. Two centuries later Ridley, who was being fiercely criticized for performing the first lens implant in , offered the following elegant explanation that is typical of one able to see something in the future that others yet did not.
Even then, he was able to see its refractive potential, and his lens implant started us on the path toward a procedure that today has achieved a level of refractive accuracy far beyond what he could have imagined. The steady improvement in the refractive accuracy of cataract surgery is the result of several advances in the past 20 years that we shall review, but none was more important than phacoemulsification with its small incision, upon which almost every subsequent innovation depended.
A typical visionary, Charlie Kelman was ahead of his time, and for a while so was phaco. Although the benefits of the small 3-mm phaco incision were increasingly apparent, the large rigid IOL of the time required an incision of 6 mm to 7 mm. For most surgeons, there was simply no compelling reason to change from ECCE, which was steadily improving with the techniques and teaching of Dave McIntyre and others.
I recall participating at a roundtable on the future of phaco in I had been trained in phaco during my fellowship with Richard Kratz a few years earlier and was beginning to teach and write about what I saw as a valuable and underutilized technique. Each participant in that roundtable was asked to predict the maximum utilization of phaco in the future. None of us anticipated what was about to happen. Why was a good ECCE procedure suddenly no longer good enough? What had happened to suddenly make phaco an essential element of cataract surgery?
The answer is the next chapter in our story. Francis J. Clark and our team explore the history of cataract surgery. It is difficult to imagine that ancient physicians would perform cataract surgery, especially since anesthesia had not been invented yet. However, in the interest of restoring clouded vision, couching was performed. This procedure involved using a lancet to push the damaged lens back into the eye.
Evidence of this technique dates back 4, years, back to the ancient Egyptians. Couching was not the only method used to remove cataracts. In the 2 nd century, a Greek physician actually removed the clouded lens from the eye. To do this, a hollow bronze instrument was inserted into the eye, and the lens was removed with suction.
The methods invented in the ancient world were used for centuries. It was not until the first cataract extraction surgery was performed in by French ophthalmologist Jacques Daviel that the couching technique declined in popularity. In the mids, the use of an intraocular lens was introduced during cataract surgery. Lens technology improved even further in with the introduction of multifocal IOLs. These lenses can reduce or even eliminate the need for glasses after surgery.
Charles Kelman developed a technique called phacoemulsification. It utilizes ultrasound to break up the cataract and make it easier to remove without a large incision.
Kelman introduced phacoemulsification in , which meant less pain and a shorter hospital stay for patients. Patricia Bath developed the laserphaco probe in as part of her ongoing quest to prevent blindness.
The probe uses a laser to quickly dissolve the cataract and prepare the eye for IOL insertion. These surgeons used the iris-supported or anterior chamber lenses designed by Cornelius D. This article focuses on the influence that the development of phacoemulsification and IOLs had on each other. Binkhorst and Worst to learn how to implant iridocapsular and iris-supported lenses. IOL use increased, thanks in part to intracapsular surgeons who used the novel technology as part of their fight to keep from losing patients to surgeons performing phacoemulsification.
At the same time, phaco surgeons also began to implant IOLs. The difficulty in learning phacoemulsification led to its decline in the mids, while the Choyce and Binkhorst lenses became the most popular IOL designs. In , I introduced phacoemulsification to surgeons in Rio de Janeiro, Brazil and to surgeons in more than 41 countries during the next 15 to 20 years.
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