Cataract Surgery from ancient to modern

An article by KAB's Chairman Greg Munton, FRCS, FRCOphth, retired ophthalmic consultant

Cataract is a common cause of impaired vision in old age and sometimes in younger people too. The word ‘cataract' comes from the Latin for waterfall. People used to think it was caused by a flow of fluid from the brain into the pupil of the eye forming a white membrane there. In fact it is the lens of the eye becoming opaque and often hard usually as a result of age. This causes progressively poorer sight and, if untreated, no sight. The treatment is cataract surgery.

Earliest surgery for cataracts

Surgery for cataracts goes back to the ancient Egyptians. Flat, copper needle knives (now in The World Museum, Liverpool) used for ‘needling for cataract' were found in the tomb of King Khasekhemwy, 2700 BC, in Upper Egypt.

Needling

This is surgery where a flat needle knife is inserted into the edge of a person's cornea, the clear window at the front of the eye. The needle is then used to push or lever the opaque lens away from its supports behind the iris into the vitreous gel where it falls down to the lowest part of the eye. Although the result is a clear pupil, the eye is left unfocussed like a camera with no lens.

In a modern eye test, the person would then only be able to see at close range the very largest letters in a test chart. Although poor, this amount of vision would be enough for a man to plough his field.

But needling was not the only method used. Around 2,000 BC, surgeons in Japan were using sharp needle knives and fine tubes made out of gold to suck out soft or liquefied cataracts.

Couching surgery

Hieroglyphs and tomb paintings from Thebes in 1200 BC show what is most probably ‘couching', another early documented type of cataract surgery. Couching is where the opaque cataract is pushed away from its supports by strong finger pressure on the eyeball. There is even a description of someone performing couching on their own eyes in the Book of Tobit from the Apocrypha of the Bible which was written in 612 BC.

“Therefore anoint thou his eyes with the gall, and being pricked therewith, he shall rub, and the whiteness shall fall away, and he shall see thee.”

Remarkably, these ancient surgeries were done with very little knowledge about the anatomy of the eye. Unfortunately, whilst they could be successful in giving people brighter, though unfocussed vision, there was always the risk of infection or complete destruction of the eye.

Cataract surgery in Mediaeval and modern Europe

Knowledge of these ancient treatments made its way via Ancient Rome and then Arabia to Mediaeval Europe and England where it was translated into Latin, Old French and finally English.

In 18th century England, the travelling quack Chevalier Taylor would carry out couching procedures on patients and then quickly move on to the next before the all-too-frequent complications became apparent. The great composer George Frederick Handel was blinded in one eye in this way.

The pre-modern era of cataract surgery dates from Daviel in Paris in 1748, who used purpose made knives and scissors to remove cataracts. In fact, modern corneal scissors are remarkably similar to Daviel's. Von Graefe, in 1860, used long, thin-bladed knives to make upper corneal entry wounds. These Graefe knives needed great dexterity to make a long incision around 180 degrees of the cornea, but they made it possible to remove the entire lens to leave a completely clear pupil.

Modern developments

At this time, high power (10 to 12 dioptre) spectacle lenses, called ‘Cataract glasses' were invented. These provided the focus that was lost with the removal of the lens. They gave a clear, focussed but magnified vision which some patients found uncomfortable.

In the late 19th and the 20th century illumination for surgery and surgical microscopes improved the surgeon's view, whilst progress with surgical stitching improved wound strength and stability.

In 1949, Harold Ridley of St Thomas' Hospital in London, implanted artificial Perspex lenses to replace the removed cataract lens. Although there were problems to begin with, these lens implants are now reliable and standard practise worldwide.

Conducted in outpatient departments using ultrasonic cutting instruments that can make tiny incisions of 1 to 2 mm, cataract surgery is now one of the most frequent surgical procedures offering people a return to almost normal vision.

Greg Munton FRCS, FRC Ophth Chairman of the Trustees of KAB