Spanish Cataract Surgery in the 20th Century
In approximately 600 BC, Susruta provided the first written communication on cataract operation and postoperative care. In the 18th century, extracapsular extraction (ECCE) and intracapsular cataract extraction (ICCE) was first reported by Daviel in 1745 and then by Sharpe and Richter in 1773. There is no doubt, however, that the most important cataract advances in the quest of vision recuperation were made during the 20th century.
Modern anesthesia, controlled ocular hypotension, antibiotic medication, sophisticated instrumentation, refined suture material, surgical microscopes with incorporated slit-lamp attachment, viscosurgery and substitution of the opaque crystalline lens with an artificial IOL, represent the basis of the constant brilliant results obtained in modern cataract surgery. Many techniques (eg, intracapsular extraction, using a suction cup or forceps with or without enzymatic zonulolysis; cryoextraction; extracapsular extraction; hydrodissection; phacoemulsification; self-closing incision; radial sutures; continuous sutures) permit comparable results. Each surgeon considers that their technique of choice — which provides them with their best results — is the most perfect. Thus, as Derrick Vail pointed out in 1957, cataract surgery has been more written and argued about than any other subject except the weather, religion or politics.
FIVE GENERATIONS
The purpose of this article is to present the evolution of cataract surgery as experienced in our clinic, Centro de Oftalmología Barraquer, in Barcelona, Spain, during the last century. There have been five generations of ocular surgeons in my family.
My grandfather, Professor José Antonio Barraquer-Roviralta (Figure 1), removed the cataract by ECCE extraction without a microscope or viscoelastics. Cocaine eyedrops was the form of local anesthesia. My grandfather's technique took about 1 minute and included incision, opening the lens capsule and removing the nucleus. Both the capsule and lens matter were left in the eye. Frequently, a secondary cataract developed and spoiled the visual result.
My father, Professor Ignacio Barraquer (Figure 2), designed a special suction cup device (the phacoerysis; based on the Greek roots phacos [lens] and eresis [to grasp]) that grasped a large portion of the lens and removed the cataract in toto. At that time (1917), intracapsular cataract extraction was usually performed with forceps. Because the area grasped with the forceps was rather small, capsule rupture was fairly frequent. Often the procedure, planned as ICCE, was concluded extracapsularly. My father's innovation represented a revolution of contemporary surgical techniques, and many Spanish surgeons as well as other surgeons across the world adopted this new procedure (Figure 3).
LENS REMOVAL, MINIMAL TRAUMA
I, as the third generation of Barraquer surgeons, also contributed to cataract surgery this past century. In 1957, I developed an enzymatic lytic procedure (enzymatic zonulolysis) that facilitated lens removal with minimal trauma. The technique was simple: Following opening of the anterior chamber, several drops of a 1/5,000 alphachymotrypsin solution were applied in the posterior chamber. After 2 minutes, the lens was removed without any traction (Figure 4). Alphachymotrypsin represents a true enzymatic bistoury for ICCE. The lytic action of alphachymotrypsin in a solution of 1/5,000 is limited to the zonular fibers, and the surrounding ocular tissues are not affected.
ICCE IS SAFER
I presented this technique, after 1 year of experimentation, at the 1958 Royal Academy of Medicine of Barcelona. Enzymatic zonulolysis was considered a great discovery, although it produced controversy. It was thought that the use of enzymatic zonulolysis was related to an increase in certain complications (ie, delayed wound healing, ocular hypertension and retinal detachment). These complications, however, were not directly due to the use of the enzyme. They were caused by insufficient adaptation of the surgical technique to the conditions created by the zonulolysis prior to lens removal.
Six months after the first published article, >600 scientific articles surfaced. For years, the procedure occupied a place of honor in ophthalmology and made ICCE safer for the patient and easier for the surgeon. Cataract removal is now done as an ECCE, however, enzymatic zonulolysis is still considered in special cases when ICCE is indicated.
Best optical correction of aphakia is important for restoring the patient's quality of vision, and, consequently, quality of life. My brother, Professor José Ignacio Barraquer (Figure 5) developed a technique to correct aphakia by introducing a homograft of corneal stroma into the patient's previously split cornea (ie, sandwich graft). This increased the positive dioptric power of the cornea and avoided correction with 12.00-D to 15.00-D spectacle glasses (Figure 6). The refraction was individually adapted, and each graft was calculated and prepared specially for each patient. The graft was made of stroma; because it did not contain epithelium nor endothelium, consequently there was no danger of immunologic reactions.
IOL IMPLANTATION
Optical correction of aphakia after cataract surgery is also achieved with IOL implantation. In 1949, Sir Harold Ridley (Figure 7) was the first to implant an artificial PCIOL as an alternate to spectacles. Although it has been alleged that Chevalier de Tadini referred to a glass lens to replace the opaque crystalline lens, Harold Ridley opened the door for practical IOL use to correct aphakia after cataract surgery. In our clinic, we started implanting IOLs in 1950. We obtained some encouraging results, but there were many failures. The first lenses were too large, too heavy and too difficult to fixate.
After Sir Harold Ridley, the Italian ophthalmologist Benedetto Strampelli (Figure 8) designed an anterior chamber lens. This IOL could be implanted after ICCE (Figure 9), the common procedure of the time and the technique I learned from my father. In the beginning, I was enthusiastic about the Strampelli lens.
With this technique, immediate results were good. In 1959, I designed an ACIOL model that later inspired modern PCIOL designs (Figure 10). Long-term results with the ACIOL were not as good, and there were serious late complications, even after years of good tolerance. In certain cases, the eye had to be enucleated.
We stopped IOL implantation in 1961. For many years, I insisted that the risk of complications was directly related to IOLs. Over the years, many IOLs (eg, lenses fixed to the iris, such as iris-clip lenses; lenses with iridocapsular support; ACIOLs; PCIOLs) appear and disappear. In 1989, after having closely followed the evolution of the PCIOL, I finally reconsidered IOL implantation.
In our clinic, my daughter, Dr. Elena Barraquer, performed the first IOL implantation of the new era. I assisted her operation, and I was very satisfied with the result. Subsequently, my son, Dr. Rafael Barraquer, myself, and gradually the other members of our team, reinitiated IOL implantation for correction of aphakia after cataract surgery.
VISCO SUBSTANCES AND SIMULTANEOUS OPERATIONS
Toward the end of the 20th century, indications for IOL implantation extended to patients who had previously been considered poor candidates (eg, coexisting cornea guttata, iridocyclitis, anterior synechiae, pseudoexfoliation of the lens capsule, glaucoma, high myopia, previous surgery for glaucoma or retinal detachment, important trauma). The use of viscoelastic substances (eg, sodium hyaluronate) facilitated this expansion because it protected the intraocular structures, especially the endothelium. In cases of severe destruction of the anterior segment or capsule rupture, the IOL would be applied into the sulcus and sutured to the sclera through the sulcus, after preparing two scleral trap incisions to avoid erosion of the sutures through the conjunctiva.
Technical advances also increased the indications for combined simultaneous cataract operations. It was no longer considered unusual or impossible to perform a penetrating keratoplasty with synechiotomy, ECCE with IOL implantation and reconstruction of the iris diaphragm, trabeculectomy and vitrectomy.
PHACO-ERSATZ
After entering the 21st century, there is no doubt that the future evolution of cataract surgery will be conditioned by the challenge of achieving better postcataract vision. My son, our surgical team and I collaborate with the Bascom Palmer Eye Institute, in Miami, Florida, on the project Phaco-Ersatz 2001. Based on my studies to restore the crystalline lens, filling the capsular bag with Healon (Advanced Medical Optics, Santa Ana, California) (Figures 11 and 12), demonstrated the possibility of permanent restoration of the lens. Simultaneously, Parel et al1,2 published experimental studies on endocapsular lens restoration with recuperation of accommodation. The research in Miami was carried out using a silicone gel with a refraction index of 1.4, which facilitated adequate observation of the eye fundus. In monkeys, 4.00 D of accommodation have been obtained after injection of pilocarpine in the anterior chamber (Figure 13).3
Three principal problems have to be resolved before the Phaco-Ersatz project can be adopted for clinical use. (1) Instruments must be updated or modified to perform microcapsulorhexis (ie, a circular 1-mm capsulotomy) and for phacoextraction through this opening. Laser/phaco devices using optic fibers are being investigated. (2) To avoid the development of secondary cataract, the epithelial lens cells must be eliminated. The results obtained with photodynamic techniques, combined with endocapsular irradiation with a green dye laser have been encouraging (Figures 14 and 15).4,5 (3) A biocompatible substance must be selected, with a consistency and transparency similar to the natural lens content, and the exact quantity must be calculated to ensure emetropy and an adequate accommodation range.
To resolve these problems, the Accommodation Club was founded in 1989 (See sidebar entitled The Accommodation Club). Ophthalmologists interested in improving postcataract quality of vision as well as specialists in biopolymers and photodynamic techniques and instrument designers are members.
Due to the technical advances in ocular surgery, and specifically in cataract surgery, the indications for cataract extraction with IOL implantation have been extended considerably. Results achieved with simple or combined simultaneous operations are very encouraging. We are undertaking the challenge of more sophisticated correction of aphakia. There is a potential to restore perfect quality of vision and recuperate accommodation.
Joaquín Barraquer, MD, FASC, FRCOphth is the chairman of ocular surgery at the Autonomous University of Barcelona, and the chief-surgeon director of the Centro de Oftalmología Barraquer, both in Barcelona, Spain. Professor Barraquer states that he has no financial interest in the products or companies mentioned. He may be reached at jbm@co-barraquer.es; + 34 93 4142319 (telephone); or + 34 93 2099977 (fax).
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