The Long Way to XXI Century Cataract Surgery

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The Long Wayto XXI CenturyCataract Surgery
AOI Firenze 2005

• Rafael I. Barraquer MD, PhD
• Director, Joaquín Barraquer Chair for Eye
  Research - Barraquer Institute
• Autonomous University of Barcelona

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Can we learn about the future from the past?
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Major Periods
?
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3000 years of Couching

• India Sushruta
• Traditional (legendary?)
• Mentioned in Mahabharatha (c 1000 BC)
• Sushruta samhita manuscript by Nagarjuna
  (c 4-2nd cent. BC)
• Historic Sushruta (Gupta period,
  c 2-4th cent. AD)
• Influence on
• Greco-Roman? Celsus De Medicina, vol.VII
  (c28-48 AD)
• Arab translations Kitab-I-Susrurd
  (8th cent.)
• Arab to Latin ? Medieval Europe

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History of Tobit(Tb. 1112-14) A Biblic account
of a (self)-couching?
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Modern Age Couching

• Ophthalmodoyleia
• (Bartisch, 1583)
• XIXth century, today?

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Cataract extraction (Extracapsular partial)
Precursor Ammar ibn Ali al-Mawsili (Mosul ? ?
Egypt c1000 AD) ? Couching surgeon ? Metallic
hollow needle (Al-Miqdah) cataract aspiration !!

• J. Daviel (1745-48)
• Cataract extraction
• ? a complication of lens couching !!
  (AC dislocation)

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in toto Extraction (intracapsular)

• Samuel Sharp, London 1753
• The Ideal Instrument ?
• A thumb (Colonel Smith, India c1870)
• Capsular forceps (H. Arruga, etc.)
• The erysiphake (Phacoerysis)
• (Ignacio Barraquer, 1917)

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1917 Phacoerysisby Ignacio Barraquer
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XXth Century Microsurgery

• Anesthesia
• topical (cocaine) Koller (1884)
• retrobulbar Elschnig (1928)
• Sutures
• silk Williams (1865)
• conjunctival J.A. Barraquer (1880)
• corneoscleral Kalt (1894)
• Microscopes
• Zeiss (1955)
• J. J. Barraquer (1964-66)
• Instruments micro- speculum, forceps, needle
  holders, scissors, etc.
• Mechanization I/A machines, U/S (Kelman 1968),
  Lasers, etc.
• Fluid instruments Ach, a-Ch, visco-elastics,
  gases, silicon oil, PFCL

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Enzymatic Zonulolysis 1958(Joaquín Barraquer)
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The Era of Intraocular lenses

• Pioneers
• Chevalier de Tadini (1764-65, acc to the memoirs
  of G. Casanova)
• Johannes Virgilius Casamaata (1795), glass lens ?
  fell into vitreous
• Harold Ridley (1949) PC IOL (PMMA lens-shaped
  lens)

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Early Intraocular Lenses (1950s)

• Rigid AC IOLs
• Baron (1952)
• Strampelli (1953)
• Flexible AC IOLs
• Danheim (1956) closed loops
• J. Barraquer (1958) open loops (J-Loops)

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Intraocular Lenses (60s-70s)

• Pupil support IOLs
• Epstein (propeller IOL)
• 60-70s Binkhorst, Worst
• New AC IOLs
• Choyce
• Kelman
• Leiske, Azar
• Posterior chamber IOLs (back to extracapsular)
• Shearing (1976) J-Loop
• Sinskey (modif. "J")
• Simcoe (C-loop)
• Kratz (1980) angulated lens (avoid capture)

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More Intraocular Lenses

• Bag design IOLs Anis, Galand, Charleux, etc.
  (80s)
• Foldable IOLs
• silicone (Mazzoco "taco,
  etc.)
• acrylic hydrophilic hidrophobic, etc.
• Bi- / Multifocal IOLs
• Accommodative IOLs...
• Phaco-Ersatz

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Present Future
Manual Phaco
Surgical Tech.
Lens design
?
?
U/S Phaco
Laser Phaco
MICS
Aqualase
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Is Phaco-Ersatz feasible?
Haefliger et al. Phaco-Ersatz Cataract surgery
designed to preserve accommodation. Graefes Arch
Clin Exp Ophthalmol 1986, 224165-173 Parel et
al. Accommodation of an endocapsular silicone
lens (Phaco-Ersatz) in the old rhesus monkey.
Refract Corneal Surg 1994, 10550-555.
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Lens Refilling Challenges

• Surgical technique
• Materials
• PCO prevention
• Physiology of accommodation (? quantity to
  inject)

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The Global Challenges
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XXIth Century Cataract Surgery will have to be

• Highly efficient and safe
• Universally available
• Low cost, simple instrumentation
• Able to restore the full functionality of the
  lens ? truly continuous dynamic
  accommodation

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Thank You