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The First Eye Operation Cataract Surgery

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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

								
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