Cataract Surgery Across Time

Cataract Surgery: A Historical Background

Each year, cataract surgery permits millions of people to improve and recover their vision.  This eye surgery has been conducted since ancient times, but has undergone significantly advanced developments over the past fifty years in order to become a common and effective procedure.  The word “cataract” stems from the Greek word for “waterfall,” because prior to the 1700s, people believed that cataracts were comprised of an “opaque material flowing, like a waterfall, into the eye.”(1)  It is now recognized that the obscuring of the ordinarily “transparent crystalline lens within the eye, suspended in place by thousands of strands called zonules, is a result of aging, metabolic changes, injury, radiation, toxic chemicals or drugs.”  In antiquity, as early as 5th century BC (as determined from Sanskrit manuscripts), the first form of a cataract operation was performed, known as “couching”.  This method consisted of dislocating the cataractous lens, moving it away from the pupil, and letting it sit in the vitreous cavity towards the rear of the eye.  Unfortunately, due to the absence of corrective lenses, images still appeared blurry for the patient.  Diggings in countries such as Iran, Greece, and Egypt, have allowed scientists to discover the utensils that ancient doctors would have used when performing cataract surgeries.  It has been revealed that in 29 A.D., a method called “needling” or “discussion” was used in De Medicinae.  This procedure slices the cataract into multiple particles, allowing for them to be easily absorbed.(2)

The style of cataract surgery where the cataract is actually removed was introduced in 1748 by Jacques Daniel in Paris.  In this form of surgery, the substances from the inner lens are extracted, yet part of the outer covering remains.  Shortly after, Samuel Sharp of London developed a strategy to extract the full unbroken lens via an incision by placing pressure with his thumb.  Tools to grasp the lens such as forceps and suction cups were developed by 1902.  Throughout the 1950s and 1960s, lens removal techniques continued to markedly improve.  Although the surgery had widespread success, the procedure still did not provide the patient with the lens necessary to focus an image onto the retina.  A huge breakthrough occurred in the 1940s in England when Harold Ridley created the intraocular lens.  The IOL is a long-lasting plastic lens fixed inside the eye as a substitute for the crystalline lens.  Recently, there has been a swift growth of projects, resources, and embedding methods for intraocular lenses, deeming them a safe and realistic technique to restore vision after surgery.  In the future, doctors are hoping to significantly decrease the frequency of cataracts due to growing information regarding “toxic chemicals, cataract-causing drugs, and harmful radiation.”  The remarkable methods and tools created historically have been tremendously improved and refined, allowing for such a safe and effective cataract surgery today.(3)

Types of Cataract Surgeries

What is a cataract?

In the past several decades, cataract surgery has undergone rapid development and has improved tremendously.  In order to fully comprehend the differences between the various surgeries, it is critical to first recognize the basics of what a cataract is and the way in which it impairs vision.  Essentially, the eye operates as a camera with two lenses: one is the cornea, a translucent layer casing the front of the eye, and the other is the crystalline lens, which is secured by a capsule situated behind the pupil.  The cornea’s function is to focus the image (approximately 70% of the way), and the natural lens further refines it.  As a person ages, the natural lens can start to become blurry and cloudy, preventing light from passing through, or altering the rays so that vision is unclear and obscured.  A “cataract” is the term for this hazy lens.(4)  Cataract surgery aims to extract this out-of-focus lens so that the patient’s vision can be restored to its natural ability.  In the surgeries performed today, a plastic prescription lens is implanted into the eye as a substitute for the natural one that has been removed.
Here, we will examine the different variations of cataract surgeries as the procedure has continued to change and evolve.

Intracapsular Cataract Extraction (ICCE)

This type of surgery was created and widely used in the 1980s, but is rarely still used due to the newer and more effective methods that have since been developed.  The ICCE technique involves taking out the total natural lens of the eye, along with the capsule that usually stabilizes it.  Compared to the more advanced techniques that are used today, this method requires an incision that is much larger and more intrusive.  In this surgery, the physician creates a large incision in the eyeball and inserts medicine, allowing the “zonular fibers” that are securing the lens in place to soften.  Liquid nitrogen is then smeared on the lens in order to freeze it by using a probe.  This probe is then gradually pulled off of the eye, removing the natural lens along with it.  An intraocular lens is then placed in front of the iris, and a number of stitches are required to close the eye until it heals.  Intracapsular Cataract Extraction is used sparingly today because the incision is quite large, and there is high risk for retinal detachment and inflammation.(5)

Extracapsular Cataract Extraction (ECCE)

In Extracapsular Cataract Extraction, the natural lens of the eye is taken out, but the back of the capsule that stabilizes the lens in its place remains intact.  The incision is significantly less intrusive than the intracapsular procedure (which extracted the lens and complete capsule), yet not as concise as the later-developed phacoemulsification.(6) The ECCE procedure consists of creating a minuscule incision near the cornea’s external edge, and then entering the eye via this opening.  The front of the lens capsule, which holds the lens in place, is then carefully opened through “capsulorrhexis,” or a small circular tear.  The hard nucleus of the lens is then extracted by carefully applying pressure with specific tools.  Suction is then used by the surgeon in order to eliminate the soft lens cortex.  Viscoelastic material is inserted into the empty lens capsule to maintain its form as the intraocular lens is being implanted, which is then removed after the IOL is successfully placed.  The back of the lens capsule remains intact within the eye and assists in firmly supporting the newly placed intraocular lens.  The incision is then sealed and protected using two to three stitches.(7)  Today, extracapsular cataract extraction is not used as commonly as phacoemulsification, but is helpful when removing extremely advanced cataracts that can be difficult to break up through phaco, or in patients with numerous eye problems that could be worsened by phaco.  Visual recovery after ECCE is often longer than phaco, and because the cataract is removed in one singular piece, the incision is much larger, which can cause greater discomfort.(8)

Phacoemulsification

Phacoemulsification is a refinement of extracapsular cataract extraction.  The procedure was initially created in the 1960s by Charles Kelman.  It was discovered that by using an ultrasound tip, a cataract could be fragmented before removal (instead of removing it in one singular piece).  Phacoemulsification can be a complicated process for doctors to learn, but because of its remarkable success rates, surgeons have gradually acquired the technique.  Across time, surgeons have continued to develop and perfect phacoemulsification, allowing it to become even lower risk and more effective.  For example, “innovations in technology such as the foldable IOL have helped improve outcomes by allowing surgeons to make smaller incisions.”(9)

When performing the surgery, the surgeon anesthetizes the region of the eye.  Pressure is applied in order to prevent any bleeding, and then an incision is made on the side of the cornea.  In recent years, it has been found that the temporal location is the least intrusive area for the incision to be made.  Viscoelastic fluid is inserted through the incision opening in order to decrease shock in the intraocular matter.  Capsulorhexis is performed, as a tiny rounded incision is made in the tissue neighboring the cataract.  The cataract is separated from the cortex by using a water stream, and a sharp needle with ultrasound waves is injected into the cornea.  This emulsifies the cataract, which is then suctioned out (starting with the central nucleus because this is the densest part).  As the cataract is being emulsified, it is concurrently being extracted through a slight hole at the point of the phaco probe.  The cortex is taken out, but the posterior capsule is left to stabilize the intraocular lens after it is inserted.

Because the IOL can be folded in this procedure before insertion, the incision is much smaller.  The exact methods of the surgery can differ depending on the compactness and magnitude of the cataract being removed.  The surgeon can concentrate on different parts of the nucleus at different times, and different techniques for emulsification exist. The cataract can be constantly chopped, or it can be methodically divided into sections for removal.  Technology is continuously being developed, and the required size for the incision is continuing to decrease.(10) 

Small Incision Cataract Surgery (SICS)

While phacoemulsification is by far the most widely used procedure in the developed world, many ophthalmologists use non-phaco small incision surgery in developing countries, which is just as effective when done correctly.  This “sutureless non-phaco cataract surgery” has three essential parts to it.  The procedure creates a small, self-sealing incision that provides low risk for developing astigmatism.  However, the incision must also be sufficiently sizable to fit the entire lens nucleus in order to remove it.  The nucleus is prepared within the eye for extraction, and then must be taken out extremely carefully so as not to harm the cornea and posterior lens capsule.(11)  Manual SICS in comparison to phaco has several advantages, as it requires less resources, can be conducted with virtually any variation of cataract, and involves less training in comparison to Phaco.(12)

Artists and Eye Diseases

In order to better understand the effects of eye diseases, it is interesting to examine the alterations that they cause to the way in which people view the world.  The later works of the famous artists Degas and Monet have been observed as being “strangely coarse and garish” and altogether incongruent with their typical art personalities.  These transformations occurred as a result of eye diseases, and their paintings provide us with insight into the ways in which eye problems can largely distort and obscure vision.  In a study by Michael Marmor, images of a “near acuity test card” were modified in order to mimic the effects of the artists’ eye conditions.  Alterations such as “Gaussian blur, brunescence, darkening, blur, and filter settings” were made to photographs of things the artists’ saw and painted in real life.(13)

Degas (1834 – 1917)

Degas suffered from an advanced retinal disease that led to central damage to his eye, resulting in blurred vision.  Degas complained of the “infirmity of sight” beginning in the 1880’s.  Throughout this decade, he commonly mentioned his struggles with daily tasks such as reading and writing, and his difficulty was exemplified by his huge and lopsided style of handwriting.  Alterations in Degas’ signature painting approach were strongly associated with the deterioration of his vision. While his 1870s pieces included exact detail and meticulous shading of objects, by the 1880s and 1890s the identical topics were being depicted with much less detail. For example, his paintings of ballet costumes that once revealed every miniscule fold and wrinkle of fabric became pointedly less polished and perfected.  By post-1900, the evidence of visual damage was fairly severe, as many pieces from this era seem to be “mere shadows of his customary style,” with shaky outlines, bizarre color splotches, and sparse detail.  Degas’ primary interest was always the “shape and posture of his subjects and their setting in space,” features that are still apparent even with reduced vision abilities.  While it is speculated that Degas must have realized that his lines were significantly rougher and harsher than they used to be, his models and dancers still appeared well-shaded and well-rounded to him when he looked at the overall appearance of his works from a distance.  To Degas, his late works seemed quite comparable to his earlier ones.(14)
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The three figures of nude bathers on the top row show the shift in Degas’ style (less detail and less refined) from 1885 to 1910.  The figures on the bottom row are how Degas saw the figures.  Note how the third figure appeared to be shaded naturally and smoothly to Degas, but to us appears coarse and drastically different from his earlier works.(15)

Monet (1840 – 1926)

Through medical records and exploration of historical correspondence, it has been determined that Monet had cataracts that progressively developed across time between 1912 and 1922.  This form of “nuclear sclerosis” is linked to age, and “manifest[s] as [a] yellowing and darkening of the lens,” which is easily identified by ophthalmologists and has a significant impact on color sensitivity and visual accuracy.  Although surgery was suggested to Monet immediately after his diagnosis, he remained ambivalent because he feared his abilities as an artist could be compromised by the procedure.  In reality, this concern was ironic because the removal of a cataract would restore his visual acuity to its former glory.  When reflecting on the experience of his vision deteriorating in 1914 and 1915, Monet recalled, “colors no longer had the same intensity for me…reds had begun to look muddy…my painting was getting more and more darkened.”(16)  A comparison between Monet’s works with and without cataracts reveals the “overriding yellowing cast and loss of subtle color discriminations.”(17) 
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<http://archopht.ama-assn.org/cgi/reprint/124/12/1764.>

The image on the top left was painted when Monet had a moderately progressed cataract (1915), and the image on the top right provides us with the perspective of how Monet would have seen the picture.  The lower image shows us the great detail and contrast that Monet was capable of seeing, and subsequently creating, once the cataract was removed in 1926.(18)

Because cataracts are an enduring condition, many individuals who have them are oblivious to the reality that their entire world is yellowish (there are no non-yellowish colors to compare to).  This is particularly devastating for an artist, because it is nearly impossible to “self-correct” (meaning corresponding what they paint to what they see). Colors such as white and yellow appear identical through the cataract.  Degas’ and Monet’s eye conditions both caused a change in artistic style, but the two artists were affected in different ways.  Instead of focusing on refined outlines and shadings like Degas, Monet’s technique included the application of larger brush strokes.  Monet could still discern the thickness of his paint, but he had lost the ability to distinguish colors. As Michael Marmor describes, “by 1922, images that are strikingly orange or blue to us were an indistinguishable murky yellow-green to him.”(19)  In 1923 when Monet finally agreed to have his cataracts removed, he was made intensely aware of the changes in how he saw color, and he even demolished some of the works that he had made just prior to the surgery. (20)

Being inflicted with these eye conditions altered these artists’ lives, and Monet’s cataract surgery allowed him to see the world that he loved to paint once again, filled with dynamic beauty and vivid color.  Every person who has an advanced cataract or other eye disease experiences a change in their visual perceptions of their surroundings.

Footnotes

(1) The Foundation of the American Academy of Ophthamology, Ophthalmic Heritage and Museum of Vision.  “Cataract Surgery in Antiquity.”  (2010).  Accessed on 1 July 2010.

(2) Ibid.

(3) Ibid.

(4) VisionRX LLC Eyecare Library.  “Intracapsular Cataract Extraction (ICCE),” (2010).  Accessed on 7 July 2010.

(5) Ibid.

(6) VisionRX LLC Eyecare Library.  “Intracapsular Cataract Extraction (ICCE),” (2010).  Accessed on 7 July 2010.

(7) Frey, R.  “Extracapsular Cataract Extraction.”  Encyclopediea of Surgery, Advameg, (2010).  Accessed on 7 July 2010.

(8) Eye Surgery Education Council.  “Extracapsular Cataract Extraction.” Eye Surgery Education.  (2003). Accessed on 7 July 2010.

(9) Bekker, M.  “Phacoemulsification for cataracts.”  Encyclopediea of Surgery, Advameg, (2010).  Accessed on 8 July 2010.

(10) Bekker, M.  “Phacoemulsification for cataracts.”  Encyclopediea of Surgery, Advameg, (2010).  Accessed on 8 July 2010.

(11) Sandford-Smith, J.  “Sutureless Cataract Surgery: Principles and Steps.”  Community Eye Health, vol 16 no. 48 (2003).  Accessed on 9 July 2010.

(12) “Small Incision Cataract Surgery, Chapter 6.  Accessed on 9 July 2010.

(13) Marmor, M.  “Ophthalmology and Art: Simulation of Monet’s Cataracts and Degas’ Retinal Disease.”  Arch Ophthalmol, vol. 124, (Dec 2006).  Accessed on 8 July 2010.

(14) Ibid.

(15) Marmor, M.  “Ophthalmology and Art: Simulation of Monet’s Cataracts and Degas’ Retinal Disease.”  Arch Ophthalmol, vol. 124, (Dec 2006).  Accessed on 8 July 2010.

(16) Marmor, M.  “Ophthalmology and Art: Simulation of Monet’s Cataracts and Degas’ Retinal Disease.”  Arch Ophthalmol, vol. 124, (Dec 2006).  Accessed on 8 July 2010.

(17) Ibid.

(18) Ibid.

(19) Marmor, M.  “Ophthalmology and Art: Simulation of Monet’s Cataracts and Degas’ Retinal Disease.”  Arch Ophthalmol, vol. 124, (Dec 2006).  Accessed on 8 July 2010.

(20) Ibid.