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