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Up Front | Sep 2007

José Ignacio Barraquer: The Father of Refractive Surgery

A tribute to my brother, who dedicated his life to the development of refractive surgery.

My brother, José Ignacio Barraquer, MD (Figure 1), was born in Barcelona, Spain, on January 24, 1916. He represented the third generation in a dynasty of famous Spanish ophthalmologists.

One year after José Ignacio’s birth, our father, Ignacio Barraquer, MD—founder of the Clinica Barraquer (Barcelona, Spain 1941)—invented the phacoerysis, a surgical procedure using a motor-driven vacuum device (ie, erysiphake) for intracapsular lens removal. Our grandfather, Professor José Antonio Barraquer-Roviralta, MD, held the first Chair of Ophthalmology in Barcelona.

Following the family tradition, José Ignacio Barraquer specialized in ophthalmology immediately after beginning medical school in 1932. Apart from his interest in experimenting with new surgical techniques and improving classic procedures, the greatest challenge for him was trying to correct refractive errors through modifying the shape of the cornea. He considered that the corneal curvature played an important part in creating the dioptric power of the eye.

At that time, many of Professor José Ignacio Barraquer’s colleagues thought it ludicrous to consider myopia something that should be treated. Eyes with myopia were thought to be healthy eyes, and the only thing to do for these patients was to prescribe spectacles to improve their vision. Professor José Ignacio Barraquer was the first to argue that refractive errors were a disease. His logic was that if an organ did not function correctly, this must be regarded as a disease. Therefore, it required a treatment/cure. Spectacles and contact lenses were considered prosthetics, not a cure. It was Professor José Ignacio Barraquer’s lifelong desire to cure myopia so that people would not have to be spectacle- or contact lens-dependent. He felt that such prosthetics reduced quality of life (eg, fear of losing/breaking optical aids, stress of finding/picking up optical aids in emergency situations).

In l949, Professor José Ignacio Barraquer published a preliminary note on the correction of ametropia, including aphakia, by surgically modifying the cornea (Figures 2 through 5).1 He proposed that the term refractive keratoplasty be added to the list of classifications according to purpose, which from then on included (1) optical, (2) reconstructive, (3) cosmetic, (4) therapeutic, and (5) refractive keratoplasty. This was indeed the birth of refractive surgery.

Although Professor José Ignacio Barraquer’s research on refractive surgery originated in Spain, he actually conducted most of the work in Bogotá, Colombia. There, he established himself in 1953 and founded the Instituto Barraquer de America in 1964 and the Clínica Barraquer de Bogotá in 1968.

PRINCIPLE CONTRIBUTIONS

After many years of continuous investigation into modification of the cornea (eg, corneal resections for the management of astigmatism, refractive lamellar grafts with and without freezing, the use of a cryolathe),2 two of Professor José Ignacio Barraquer’s principle contributions to refractive keratoplasty occurred. In 1964, he introduced keratomileusis (ie, Greek for sculptured cornea)3 and an even more sophisticated technique, keratophakia (ie, Greek for corneal lens).4

Keratomileusis. This is an autoplastic procedure for the correction of ametropia (Figures 6 and 7). The basis of the operation is to remove, modify, and reinsert the corneal disc into the patient’s eye. After fixation with a pneumatic fixation ring, a special microkeratome (Figure 8) separates a parallel-faced corneal disk from the anterior layers of the cornea. The microkeratome operates on the principle of a carpenter’s plane, shaving the parallel-faced corneal disk,5 which is then frozen and carved with a special lathe according to computer measurements.

Professor José Ignacio Barraquer’s operation represented the first time in human surgery that part of an organ was separated from the organism to modify its function—in this case the refraction—and replaced in its original position. It was also the first time that a computer-generated electronic calculation helped to determine the required grade of surgical action needed to compensate for an organic defect.

For keratomileusis, the carved disk must be of the same power—but of the opposed sign—as the ametropia to be corrected. This means that a positive lenticle has to be carved to correct myopia and a negative lenticle to correct hypermetropia. Subsequently, the disk, thus converted into a lenticle, is unfrozen and washed with balanced salt solution. It is then placed into the recipient bed and sutured into place. The refractive power of the modified reconstructed cornea increases or diminishes exactly as previously calculated. The cornea is thinned in the center to correct myopia. Consequently, as the anterior surface flattens, the refractive power decreases. For correction of hypermetropia the central corneal thickness is respected, and the periphery around the optic vertex is thinned. The curvature of the anterior corneal surface increases, and so does its dioptric power.

Keratophakia. This is a homoplastic or alloplastic procedure for the correction of high hypermetropia or aphakia (Figures 9 and 10). A lenticle of donor material from an eye bank eye—or biocompatible synthetic material (eg, Permalens hydrogel) once it became available later—is inserted into the cornea to modify the curvature.

For keratophakia, a corneal disk is dissected to create a uniform intracorneal interface. A lenticle of stromal corneal donor tissue or biocompatible synthetic material, having been carved on the computerized lathe specifically set for each case, is placed on the remaining corneal surface. The cornea is then reconstructed, placing the previously removed and stored autoplastic disk on the homoplastic or alloplastic lenticle. This remains included in the central part of the corneal stroma, where it is perfectly tolerated and repopulated by the patient’s cells after a few weeks. The lenticle modifies the radial curvature of the anterior corneal face, increasing the refractive power of the eye and correcting hypermetropia.

The original keratomileusis and keratophakia interventions were complex and rather time-consuming. Each required great surgical experience and had a long learning curve, but the results were stable; there were few intra- and/or postoperative complications.6 Keratomileusis was the first available procedure that modified the refractive power of a myopic eye, preserving its accommodation. Frequently, it was the only way to improve binocular vision.

Professor José Ignacio Barraquer was well aware that his original techniques, which he presented during the LXV Annual Meeting of the Spanish Ophthalmological Society in 1989, would soon be modified.7 He anticipated that better comprehension of and compatibility with biomechanics as well as new technological advances would modify and replace his concepts and techniques, although he recommended caution in adopting “those young techniques of rapid evolution.” In his presentation during the 50th anniversary of the Instituto Barraquer of Barcelona, he concluded: “With the newer techniques, there are still problems that are comparable to those experienced in the early stages of currently more established techniques. In its many and diversified forms, the laser promises to simplify and refine refractive surgery, however, the techniques and equipment involved still require more development and refinement.”8

Professor José Ignacio Barraquer’s conclusions confirmed that he was conscious of the importance that laser application would produce in refractive surgery. He probably would never have imagined, however, that less than 10 years after his death, thousands of eyes are corrected with LASIK, femtosecond lasers, Hansatome microkeratomes, and excimer lasers.

The same applies to most patients who undergo refractive surgery today. They probably will never realize that their improved quality of life, vision, and freedom from thick ugly glasses or uncomfortable contact lenses are owed to a man who devoted himself—for more than half a century—to analyze and treat the most common refractive problems by modifying corneal curvature, thus creating and developing the bases of modern refractive surgery.

Until the day of his death on February 13th, 1998, Professor José Ignacio Barraquer maintained his active involvement in treating patients, inventing instruments, developing new techniques, and teaching his young colleagues. He was planning the celebration of the 30th anniversary of the Clinica Barraquer de America, to be held in Bogotá, Colombia, in March 1998. Despite his age, Professor José Ignacio Barraquer continued to be an important participant and frequently invited guest at refractive surgery and ophthalmic meetings worldwide. Shortly before his untimely death, he was preparing his intervention at the l998 World Refractive Surgery Symposium. Now, in spite of his physical absence, his legacy will continue to influence the future evolution of refractive surgery for many years to come.

Joaquín Barraquer MD, FACS, FRCOphth, is Chairman of Ocular Surgery at the Autonomous University of Barcelona, in Spain, and Chief-Surgeon Director at the Centro de Oftalmología Barraquer, Barcelona. Professor Joaquín Barraquer may be reached at tel: +34 93 4142319; fax: +34 93 2099977; or jbm@co-barraquer.es.

Barraquer JI. Queratoplastia Refractiva. Estudios e Informaciones Oftalmológicas. 1949;10:1-21.

Barraquer JI. Method for cutting lamellar grafts in frozen cornea. New orientation for refractive surgery. Arch Soc Amer Oftal Optom. l958;1:271.

Barraquer JI. Queratomileusis para la corrección de la miopía. Arch Soc Amer Oftal Optom. 1964;5:27.

Barraquer JI. Keratomileusis and keratophakia. In: Rycroft, PV, editor. Transactions of the corneo-plastic surgery. Oxford: Pergamon Press Ltd.;1967:409.

Barraquer JI. El microqueratomo en Cirugía Corneal. Arch Soc Amer Oftal. 1966;6:69.

Barraquer JI. Resultados de la queratomileusis en corrección de miopía y queratofaquia en corrección de afaquia en 1976. An Inst Barraquer. 1978-79;14:351-360.

Barraquer JI. Cirugía Refractiva de la Córnea. Official Report (Ponencia) presented at the LXV Ponencia de la Sociedad EspaÒola de Oftalmología. l989.

Barraquer JI. Refractive Corneal Surgery. Experience and Considerations. An Inst Barraquer. 1993-94;24:113-118.

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