cataract history 05
TRANSCRIPT
The Long WayThe Long Wayto XXI Centuryto XXI Century
Cataract Cataract SurgerySurgery
Rafael I. Barraquer MD, PhD
Director, “Joaquín Barraquer” Chair for Eye Research - Barraquer Institute
Autonomous University of Barcelona
AOI – Firenze AOI – Firenze 20052005
Can we learn Can we learn about the about the
future from future from the past?the past?
Major PeriodsMajor PeriodsCouchingCouching
ExtractionExtraction(extracapsular)(extracapsular)
In Toto In Toto Extr.Extr. (intracapsular)(intracapsular)
MicrosurgeryMicrosurgery(extracap. + IOL)(extracap. + IOL)
PhacoPhacoLsLs
AqAq MicsMics
PMMAPMMA
SoftSoftBi/MfBi/Mf
AccAccPh-EPh-E
??
3000 years of 3000 years of CouchingCouching India: SushrutaIndia: Sushruta
► TraditionalTraditional (legendary?)(legendary?)► Mentioned in Mentioned in MahabharathaMahabharatha
(c 1000 BC)(c 1000 BC)► Sushruta samhitaSushruta samhita
manuscript by Nagarjuna manuscript by Nagarjuna (c 4-2(c 4-2ndnd cent. BC) cent. BC)
► Historic SushrutaHistoric Sushruta (Gupta period, c 2-4(Gupta period, c 2-4thth cent. AD) cent. AD)
Influence on:Influence on:► Greco-Roman? Celsus’ Greco-Roman? Celsus’
De Medicina,De Medicina, vol.VII (c28-48 ADvol.VII (c28-48 AD))► Arab translations: Arab translations:
Kitab-I-Susrurd Kitab-I-Susrurd (8(8thth cent.) cent.)► Arab to Latin Arab to Latin Medieval Medieval
EuropeEurope
Sushruta operating, by Robert Athom (Courtesy Dr. Anil Pande, Chennai) Sushruta operating, by Robert Athom (Courtesy Dr. Anil Pande, Chennai)
Bronze instruments of the roman period (1Bronze instruments of the roman period (1stst century AD) for cataract couching, found at Montbellet, France century AD) for cataract couching, found at Montbellet, France
History of History of TobitTobit(Tb. 11:12-14)(Tb. 11:12-14) A Biblic A Biblic account of a account of a (self)-(self)-couching?couching?
Modern Age Modern Age CouchingCouching
OphthalmodoyleiaOphthalmodoyleia
(Bartisch, 1583)(Bartisch, 1583)
XIXXIXthth century, today? century, today?
Brisseau, 1703Brisseau, 1703Cunier & Abréu, 1844Cunier & Abréu, 1844
Cataract extraction Cataract extraction (Extracapsular = partial)(Extracapsular = partial)
J. DavielJ. Daviel (1745-48)(1745-48)Cataract extraction Cataract extraction a complication of a complication of
lens couching !! lens couching !! (AC (AC dislocation)dislocation)
Precursor: Precursor: Ammar ibn Ali al-Mawsili Ammar ibn Ali al-Mawsili (Mosul (Mosul Egypt c1000 AD) Egypt c1000 AD)
Couching surgeonCouching surgeon Metallic hollow needle Metallic hollow needle (Al-Miqdah)(Al-Miqdah) cataract cataract aspiration !!aspiration !!
in totoin toto Extraction Extraction (intracapsular)(intracapsular)► Samuel Sharp, London 1753Samuel Sharp, London 1753
The Ideal Instrument ?► A thumb A thumb (Colonel Smith, India c1870)(Colonel Smith, India c1870)► Capsular forceps Capsular forceps (H. Arruga, etc.)(H. Arruga, etc.)
The The erysiphakeerysiphake ( (PhacoerysisPhacoerysis))(Ignacio Barraquer, 1917)(Ignacio Barraquer, 1917)
1917 Phacoerysis1917 Phacoerysisby by Ignacio BarraquerIgnacio Barraquer
XXth Century: XXth Century: MicrosurgeryMicrosurgeryAnesthesiaAnesthesia
► topical (cocaine): Koller (1884)topical (cocaine): Koller (1884)► retrobulbar: Elschnig (1928)retrobulbar: Elschnig (1928)SuturesSutures► silk: Williams (1865)silk: Williams (1865)► conjunctival: J.A. Barraquer (1880)conjunctival: J.A. Barraquer (1880)► corneoscleral: Kalt (1894)corneoscleral: Kalt (1894)MicroscopesMicroscopes► Zeiss (1955)Zeiss (1955)► J. & J. Barraquer (1964-66)J. & J. Barraquer (1964-66)Instruments:Instruments: “micro-” speculum, forceps, “micro-” speculum, forceps,
needle holders, scissors, etc.needle holders, scissors, etc.Mechanization:Mechanization: I/A machines, U/S I/A machines, U/S
(Kelman 1968), Lasers, etc.(Kelman 1968), Lasers, etc.Fluid instruments:Fluid instruments: Ach, Ach, -Ch, visco--Ch, visco-
elastics, gases, silicon oil, PFCLelastics, gases, silicon oil, PFCL
Enzymatic Zonulolysis Enzymatic Zonulolysis 19581958(Joaquín Barraquer)(Joaquín Barraquer)
The Era of Intraocular The Era of Intraocular lenseslenses Pioneers Pioneers
► Chevalier de Tadini Chevalier de Tadini (1764-65, acc to the (1764-65, acc to the memoirs of G. Casanova)memoirs of G. Casanova)
► Johannes Virgilius Johannes Virgilius Casamaata (1795), glass Casamaata (1795), glass lens lens fell into vitreous fell into vitreous
Harold RidleyHarold Ridley (1949): (1949): PC IOL (PMMA lens-shaped lens)PC IOL (PMMA lens-shaped lens)
Early Intraocular Lenses Early Intraocular Lenses (1950s)(1950s) Rigid AC IOLs:Rigid AC IOLs:
► Baron (1952) Baron (1952) ► Strampelli (1953)Strampelli (1953)
Flexible AC IOLsFlexible AC IOLs► Danheim (1956): Danheim (1956):
closed loopsclosed loops► J. Barraquer (1958): J. Barraquer (1958):
open loops open loops (J-Loops)(J-Loops)
Intraocular Lenses Intraocular Lenses (‘60s-70s)(‘60s-70s) Pupil support IOLs :Pupil support IOLs :
► Epstein (“propeller” IOL)Epstein (“propeller” IOL)► 60-70’s: Binkhorst, Worst60-70’s: Binkhorst, Worst
““New” AC IOLsNew” AC IOLs► ChoyceChoyce► KelmanKelman► Leiske, AzarLeiske, Azar
Posterior chamber IOLsPosterior chamber IOLs (back to extracapsular)(back to extracapsular)
► Shearing (1976) J-LoopShearing (1976) J-Loop► Sinskey (modif. "J")Sinskey (modif. "J")► Simcoe (C-loop) Simcoe (C-loop) ► Kratz (1980): angulated Kratz (1980): angulated
lens (avoid capture)lens (avoid capture)
More Intraocular More Intraocular Lenses…Lenses…
Bag design IOLsBag design IOLs: : Anis, Anis, Galand, Charleux, etc. (’80s)Galand, Charleux, etc. (’80s)
Foldable IOLsFoldable IOLs► silicone: silicone:
(Mazzoco "taco“, etc.)(Mazzoco "taco“, etc.)► acrylic hydrophilic & acrylic hydrophilic &
hidrophobic, etc.hidrophobic, etc. Bi- / Multifocal IOLs…Bi- / Multifocal IOLs… Accommodative IOLs...Accommodative IOLs... Phaco-Ersatz…Phaco-Ersatz…
Present Present && Future FutureMicrosurgeryMicrosurgery(extracap. + IOL)(extracap. + IOL)
PMMAPMMA
SiliconeSilicone
Surgical Tech.Surgical Tech. Lens designLens design
U/S PhacoU/S Phaco
LaserLaserPhacoPhaco
MICSMICS AqualaseAqualase
Manual PhacoManual Phaco
HydrophilicHydrophilic
HydrophobicHydrophobic
MonofocalMonofocal
Bi/MultifocalBi/Multifocal
AccommodatingAccommodating
Phaco-ErsatzPhaco-Ersatz?? ??
Haefliger et al. Phaco-Ersatz: Cataract surgery designed to preserve accommodation. Graefes Arch Clin Exp Ophthalmol 1986, 224:165-173
Parel et al. Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in the old rhesus monkey. Refract Corneal Surg 1994, 10:550-555.
Is Phaco-Ersatz Is Phaco-Ersatz feasible?feasible?
Lens Refilling: Lens Refilling: ChallengesChallenges Surgical techniqueSurgical technique MaterialsMaterials PCO preventionPCO prevention PhysiologyPhysiology of accommodation of accommodation
(( quantity to inject) quantity to inject)
0 2 4 6 828
29
30
31
32
33
34
35
36
Cyno991312-OD
Le
ns
Po
we
r (D
)
Load (g)
Natural Cured
EVAS (Miami)EVAS (Miami)
CCLSD (Barcelona)CCLSD (Barcelona)
The Global ChallengesThe Global Challenges
1.8 Billion Presybopes by 2010
1.8 Billion Presybopes by 2010
Source: WHO IEFP survey 1998
XXIXXIthth Century Cataract Century Cataract SurgerySurgery will have to will have to
be…be… Highly efficient and safeHighly efficient and safe Universally availableUniversally available Low cost, simple instrumentationLow cost, simple instrumentation Able to restore the full functionality of the lens Able to restore the full functionality of the lens
truly continuous truly continuous dynamic accommodationdynamic accommodation
Thank YouThank You