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The oldest written record of eye diseases dates back to the year 1500 B.C.: numerous diseases of the eye are referred to in the Ebers Papyrus discovered be- tween the legs of a mummy in the Theban Necropolis in Egypt by the German professor Georg Ebers in 1872. And does the de- scription “rising water in the eye“ – as Albertus Magnus says – refer to cataracts? Julius Hirschberg sees it as likely that the descrip- tion “darkening of the pupil and whitening disease of the eye” al- so includes cataracts; even Martin Luther, in his Bible translation of the Book of Tobias into German, translated leucoma, i. e. white coloring, as “Star” (the word used for ‘cataract’ in modern German). The First Eye Operation – Cataract Surgery What are cataracts? The ancient study of cataracts has prevailed in ancient medicine since its roots in the Alexandrine era. Prior Hippocrates, the operable cataract Medicine began in Ancient Greece to this, different types of opacity was a liquid that had congealed in the with Hippocrates. Yet the Hippocrat- seen in the pupil, which presumably pupil. This development and the im- ics – Hippocrates and his pupils included cataracts, were still grouped portance of the ideas concerning the – could know nothing of a disease together. The Medical Schools of study of cataracts are made particu- that matched the modern concept Alexandria knew of the existence of larly clear by Rufus of Ephesus (1st/2nd of cataracts as they had insuffi- the lens. The usual name given to it century): “Glaucoma and hypochyma cient knowledge of the anatomical for a long time was the “crystalline were regarded by the ancients as one existence of the lens. None of the body”. and the same thing. Later genera- ideas of Democritus, Hippocrates From this point onwards, medi- tions, however, declared that glau- or Aristotle features the lens in the cine went off on the wrong track coma was a complaint affecting the anatomy of the eye. The writings of and did not leave it again around crystalline fluid, which changes from the Hippocratics contain only a few 2000 years later. At that time, the its normal coloring into a watery blue references that would seem to al- lens was regarded as the main or- color, and that hypochyma was an lude to cataracts. The most impor- gan of sight – as the divinum oculi: it effusion of fluid, which (later) coagu- tant of these comes from Hippocra- may become opaque but, because of lates, between the iris and the crys- tes himself, a single word. The list its importance, this problem was re- talline body. All glaucomas are incur- of illnesses and diseases relating to garded as inoperable. However, one able; hypochymas are usually curable, old people in the Aphorisms include particular problem that was operated though not always”. the following: dimness of sight, blu- on by means of a process known as Hypochysis or hypochyma was a ish opacity of the pupil, and dullness cataract couching was seen to be collective term for the great variety of of hearing. The “bluish opacity” is a something quite different. Accord- different pathological changes in the reference to cataracts. ing to the theory on fluids that had region between the cornea, iris and 38 Milestones Innovation 17, Carl Zeiss AG, 2006 “The lens is just an optical medium” lens. Rufus described the eye and was a work that draws heavily on Ali Ibn Strictly speaking, the word cataract Left: Eye with cataract. the first person to put the lens in its Isar and Galen, in which he says: as a term for the opacity of the lens Middle: Cataract couching correct position. Galen’s anatomy of “The condition is a membrane – like is just as inaccurate as the word glau- in the salon. Copper en- the eye in the 2nd century comes even spot in front of the pupil, which im- coma that has been used since the graving from Lorenz Heister. Altdorf, 1713, Erlangen- closer to the reality, although he still pairs sight due to extensive moisture 19th century. Nuremberg University believed that the lens was the main that gradually penetrates the eye and In 1543, in his extensive work library, Germany. organ of sight. His system, which is coagulates because of the cold”. “humani corporis fabrica”, the physi- Right: Modern surgical based on Hippocrates and the theory The term “cataract” first appeared cian and anatomist Andreas Vesalius microscope – OPMI® on fluids, remained uncontested for as a new term in the Middle Ages. continued with the notion that the pico i. Basic microscope more than ten centuries. In the 7th In their translation of the Greek word lens was located in the middle of the for ophthalmologic exami- nations and operations. century, Paul of Aegina in particular “hypochysis”, the Arabs referred eyeball. In 1583, Felix Platter, official followed in the footsteps of Hippo- to the condition as “Nuzulelma”, doctor to the city of Basel, wrote in crates, his ideas based on the writ- “downflow of water”. To this very his book “de corporis humani struc- ings of Galen. The Arabs translated day, the Arabs call cataracts “the blue tura” one crucially significant sen- his writings about cataracts and cata- water”. It is generally accepted that tence: “The lens is just an optical ract couching. When the Roman Em- the Catharginian monk Constantine medium”. Yet, despite this, clinicians pire collapsed, the Arabs became the the African (1015-1087), one of the continued for the time being to keep custodians of the Greek heritage and most famous pupils of the School of faith with the old ideas. protected the Hippocratic-Galenic Salerno, who in Monte Cassino also The second half of the 17th century medicine from the West. translated the “Ten treatises on the finally brought the required change in It was not until centuries later, in eye” of Abu Zaid Hunain (808-873) thinking. In 1656, the German anato- 1363, that the personal physician into medieval Latin, rendered the mist Werner Rolfinck revealed that to the popes at Avignon, Guy de Arabic expression as “cataracta” (wa- cataracts were the consequence of Chauliac, wrote his Chirurgia Magna, terfall) in his work “Liber de oculis”. lens opacity. In 1682, the renowned Milestones Innovation 17, Carl Zeiss AG, 2006 39 “I understand real cataracts to be opacified humorem crystallinum and not a layer of skin” Left: Modern intraocular French ophthalmologist Antoine Mai- lished in 1722, that “I understand re- ract operations since the middle of lens (IOL). tre-Jan observed, when couching the al cataracts to be opacified humorem the last century. Middle: Medieval depiction cataract, that it was not a thickened crystallinum and not a layer of skin”. Cataract couching is apparently of cataract couching by membrane that appeared in the ante- Any final traces of doubt were elimi- first described in Ancient Hindustan Georg Bartisch from the 16th century. rior chamber but a thick round body, nated by Jacques Daviel in 1753 with in the period around 500 years be- the lens. On April 6, 1705 the French his work on operating on cataracts. fore Christ by the legendary Indian Right: Eye with artificial doctor Pierre Brisseau made the same doctor Susruta. The first documented lens implant. observation. Despite the misgivings The cataract operation evidence of cataract couching can be of his teacher Duverney, he present- found in the writings of Chrysippos, ed his findings to the Royal Academy The main operating method for a the Stoic philosopher from Soli, in the of Sciences in Paris on November 12, very long time – from the 5th century 3rd century before the birth of Christ. 1705, after which he lost his position B.C. until the 19th century A.D. – in- Cataract couching was unheard-of in at the academy. volved a technique known as cata- Ancient Egypt and Classical Greece. However, it was now no longer ract couching. This was joined from The first, more or less accurate de- possible to restrain this new thinking. around 1750 until into the 20th cen- scription is attributed to Aulus Cor- Too great was the authority enjoyed tury by extracapsular cataract extrac- nelius Celsus from the 1st century and by the surgeon Maitre-Jan, who in tion. The arrival of the 20th century can be found in the chapter “De ocu- 1707 published his “Tracté des mala- saw more and more surgeons switch- lorum vitiis quae scalpello et manu dies des yeux” and declared that in ing to the technique of intracapsular curantur”. actual fact cataracts were an opacity cataract extraction, which involves Cataract couching involved prick- and hardening of the crystal. Charles the full removal of the lens, i.e. in- ing the sclera temporal with a needle de Saint-Yves also writes in his trea- cluding the lens capsule. Artificial (scleronyxis) and pushing the cata- tise on the diseases of the eye, pub- lenses have been implanted in cata- ract into the vitreous body (depres- 40 Milestones Innovation 17, Carl Zeiss AG, 2006 sio lentis). Interestingly, the Indians were followed in the 2nd half of the method is particularly associated with practiced a somewhat safer method: 18th century by the itinerant cataract the name Choice. At the end of the they opened up the sclera with a cutters, who applied Daviel’s method. 1970s, the second era of posterior sharp lancet and then introduced a In Halle in 1806, Wilhelm Heinrich chamber lenses began. The so-called blunt instrument to push it down, Buchhorn described cataract couch- „J-loop lens“, first presented by which meant that the risk of injury ing through the cornea, calling it Shearing in 1977, which was fixed was smaller than with the use of just keratonyxis. In the second half of the in place in the ciliary sulcus follow- a sharp needle. Arab physicians even 19th century, extracapsular cataract ing an extracapsular operation, soon seem to have performed suction on extraction finally won the day once found universal appeal. It became the soft forms of cataract. Friedrich Jaeger had introduced the prototype for all subsequent lenses. Particularly impressive are the ac- cataract operation technique of an Of crucial importance to this devel- counts of cataracts by Georg Bartisch upper incision in the cornea. This opment was the phacoemulsification in his eye manual “Augendienst”, triumph was also aided by improve- process introduced by Kelmann in published in Dresden in 1583 [ac- ments in the instruments that were 1970. In the last two decades of the count from the surgeon, patient and used and the local anesthetic that 20th century, the main focus was on assistant], and by the surgeon Lorenz was administered. developing new types of lenses, im- Heister from Frankfurt in 1713. In 1922, Professor Anton Elschnig proving the operating technique and, The extracapsular cataract opera- from Prague declared that in special above all, making it safer. Implanta- tion, in which the lens of the capsule cases the lens could be removed in its tion in the capsular sac replaced sul- is opened, was born in 1745: for entirety, i.e. intracapsular extraction. cus fixation. Of vital importance for the first time ever, Jacques Daviel Within a matter of decades, the int- ensuring a safe capsule implantation removed a cataract through an inci- racapsular cataract operation had be- is the precise opening of the ante- sion in the cornea because blood and come an accepted practice. To avoid rior lens capsule. This only became lens residue had entered the anterior a prolapse of the vitreous humor, possible with the help of the circular chamber as a result of an unsuccess- glycerin was given before the opera- capsulorrhexis technique indicated by ful couching operation. tion and oculopression was later ap- Thomas Neuhann in 1985. The 18th century was also known plied. The removal of the lens was The development of foldable lenses as the age of the oculists, because performed using capsule forceps. To made of silicone and acrylic together cataracts were treated not just by prevent any laceration of the capsule, with small incision surgery were the hospital surgeons but itinerant oc- a suction cup was later used. Finally, real advances made in the 1990s. The ulists as well. One such cataract cryoextraction became the method latest developments include multi- couching oculist of the 18th century of choice. The operation was further focal lenses, toric intraocular lenses was Joseph Hillmer from Vienna. He facilitated by means of the enzymatic to correct astigmatism and the in- traveled across Europe, from Por- zonulolysis introduced by Barraquer. corporation of tiny sensors in the in- tugal to Russia. Frederick the Great traocular lenses (IOL) to continuously appointed him a Professor of Oph- Artificial lenses measure intraocular pressure. thalmology at the Berlin Collegium The story of cataracts will continue Medico-Chirurgicum in 1748. Three Harold Ridley is regarded as the pio- and maybe one day the ophthalmolo- years later, Hillmer was exposed as neer of lens implantation: in 1949, gist‘s dream of refilling a completely a charlatan. Even more well-known, he inserted the first artificial lens as emptied capsular sac with a flexible but likewise of dubious character, a posterior chamber lens in the cap- material, thereby restoring not just was the itinerant “chevalier” John sular bag. 1952 to 1962 is the era sight but also accommodation, will Taylor: on his carriage stood in bold of early anterior chamber lenses. become a reality. letters “Qui dat videre dat vivere”. Then came the Dutchman Cornelius In Leipzig, in 1750, he performed a Binkhorst with his iris clip lens, which cataract operation on both of Johann he first used in 1958, though it took Sebastian Bach‘s eyes, but without around another 15 years for the iris- success. Bach went completely blind supported lens to gain wider appeal. and died four months later. A further development was the me- The same fate befell Georg Frie- dallion lens. Parallel to the iris-sup- Gerhard Holland, History of Medicine drich Handel in London in 1758. He ported lens, experiments were being and Pharmacy Collection, Christian Albrechts University Kiel, Germany too completely lost his sight follow- conducted into further developing Dieter Brocksch, Carl Zeiss AG ing an operation carried out by Tay- implantation in the anterior cham- www.med-hist.uni-kiel.de lor. The itinerant cataract couchers ber. Between 1963 and 1978, this www.snof.org/histoire/histoire.html Milestones Innovation 17, Carl Zeiss AG, 2006 41
"The First Eye Operation Cataract Surgery"