History of Cataract Surgery

Key Points at a Glance

1. History of Cataract Surgery

Cataract is a disease in which the lens becomes cloudy, causing vision loss. The word originates from the Latin “cataracta” (waterfall). This is based on the ancient belief that an opaque fluid flows within the lens, or that severe cataracts resemble a waterfall.

Cataract is the leading cause of blindness worldwide. As of 2010, over 20 million people were affected, and the prevalence continues to increase with the aging population. For cataracts with visual impairment, surgical intervention is the only curative treatment.

The history of cataract surgery dates back to ancient times. It has been a continuous series of technological innovations, starting with ancient couching, followed by extracapsular cataract extraction in the 18th century, intraocular lenses and phacoemulsification in the 20th century, and laser surgery in the 21st century.

Couching: The oldest cataract surgery

Couching is the oldest surgical technique for cataracts. The term comes from the French word “coucher” (to lay down). It involved puncturing the eye near the corneal edge with a sharp needle and dislodging the cloudy lens out of the visual axis.

The following ancient records are known:

Chrysippus of Soli (c. 279–206 BC): Mentioned couching for cataracts.
Sushruta Samhita (ancient Sanskrit text): The third volume “Uttara Tantra” describes the couching method.

However, in an era without the concept of aseptic technique, the prognosis was extremely poor. Major complications included secondary glaucoma, hyphema, and endophthalmitis, often leading to blindness. Couching is still practiced in northern Nigeria and parts of West Africa today.

Q Why did couching often fail?

There was no concept of aseptic technique, and the procedure was crude. Since the lens was only displaced from the visual axis and not removed, complications such as secondary glaucoma, hyphema, and endophthalmitis frequently occurred.

Birth of Extracapsular Cataract Extraction

Archaeological evidence suggests that aspiration of soft cataracts may have been performed in ancient Greek and Roman times. In medieval Arabia (10th–17th centuries), cataract extraction via tube aspiration was definitely performed.

The founder of modern extracapsular cataract extraction is the French surgeon Jacques Daviel. In 1745 (or 1750 according to some sources), Daviel performed the first planned extracapsular cataract extraction through an inferior incision.

Daviel’s technique was as follows:

Make a corneal incision of 10 mm or more with a corneal knife
Puncture the lens capsule with a blunt needle
Remove the lens with a spatula and curette
Cover the eye with a cotton bandage soaked in wine after surgery

Although it was a significant improvement over couching, complications such as posterior capsule opacification, retained lens material, and infection remained prevalent.

Period	Procedure	Characteristics
Ancient–18th century	Couching	Dislocation of the lens out of the visual axis
1745–	Extracapsular cataract extraction	Removal of the lens through a corneal incision
1753–	ICCE	Removal of the entire lens within the capsule

Intracapsular Cataract Extraction

In 1753, London surgeon Samuel Sharp first recorded intracapsular cataract extraction (ICCE). This technique removes the cloudy lens and its surrounding capsule as a single unit. The zonular fibers are severed, and the lens capsule complex is extracted through a large corneal incision.

In the 1850s, von Graefe performed extracapsular cataract extraction using a linear knife through a superior incision, and also performed intracapsular extraction using capsule forceps.

The main problems with ICCE were as follows:

Vitreous prolapse: Loss of the barrier between the anterior and posterior chambers due to removal of the lens capsule
Retinal detachment: Secondary to vitreous prolapse
Large incision: prolonged healing time and increased infection rate

Introduction of local anesthesia

In 1884, Austrian physician Carl Koller introduced topical cocaine anesthesia for eye surgery. This greatly improved pain management during cataract surgery. In 1919, Elschnig introduced retrobulbar anesthesia, and in 1993, Fishman reported the use of topical anesthesia.

2. Development of intraocular lenses

After lens removal, patients become aphakic. Before IOLs, high-power bulky glasses were needed, greatly reducing visual quality.

Early attempts

In 1797, Casamata of Dresden attempted to place a glass intraocular lens after cataract surgery. However, the lens fell to the back of the eye, resulting in failure.

Ridley’s PMMA IOL

In 1949, Sir Harold Ridley performed the world’s first IOL implantation at St. Thomas’ Hospital in London. Stating that “removal alone is only half the treatment for cataracts,” Ridley observed during World War II that plastic fragments (PMMA) retained in the eyes of British Royal Air Force pilots caused almost no reaction. This finding led to the development of the PMMA IOL.

The initial IOLs were larger and heavier than current ones, often causing them to sink into the eye.

At that time, the concept of IOL itself was revolutionary, and there was strong criticism against inserting a foreign body into the eye. Complications such as glaucoma, inflammation, IOL dislocation, and difficulty in refractive power adjustment occurred, but Ridley’s innovation became the foundation of modern IOL technology.

PMMA IOL

Material: Polymethyl methacrylate (PMMA)

First implantation: 1949, Sir Harold Ridley

Features: Rigid lens. Requires large incision.

Foldable IOL

Material: Silicone (early), acrylic, etc.

First implantation: 1978, Zhou Kaiyi

Advantages: Can be inserted through a small incision. Postoperative astigmatism and infection are reduced.

Foldable IOLs

In 1978, Kai-yi Zhou performed the first implantation of a silicone foldable IOL. Foldable IOLs allowed insertion through a small incision, providing the following advantages:

Reduced induced astigmatism: Due to smaller incision size
Faster healing: Minimal tissue damage
Fewer infections: Lower risk of contamination due to smaller wound

Q How was vision corrected before intraocular lens implantation?

After lens extraction, aphakic eyes were prescribed high-power convex lens glasses. However, visual quality was greatly reduced due to visual field distortion and image magnification.

3. Modern Cataract Surgery

Phacoemulsification

In 1967, Charles Kelman developed phacoemulsification. This technique uses ultrasound to break up the cataract and aspirate it from the eye. This technological innovation led to the following advances:

Reduced incision size: from 10 mm to typically less than 3 mm
Shorter recovery time: Small incisions lead to faster tissue healing
Lower complication rate: Improved surgical stability

The modern standard procedure is as follows:

Create a small incision of 1–3.0 mm
Perform continuous curvilinear capsulorhexis (CCC)
Release adhesions with the capsule via hydrodissection
Cataract is fragmented and aspirated using phacoemulsification.
A foldable IOL is inserted into the remaining lens capsule.

Surgical technique	Incision size	Main era
Extracapsular cataract extraction (conventional)	10 mm or more	18th century~
ICCE	10mm or more	1753~
Phacoemulsification	Less than 3mm	1967~

Sutureless Small Incision Cataract Surgery

As an evolution of extracapsular cataract extraction, sutureless small incision cataract surgery (MSICS / SICS / SECCE) was developed. The incision is self-sealing and does not require sutures. Compared to phacoemulsification, it is less costly and requires less advanced skills, so it is mainly used in developing countries.

Q What changed most with the advent of phacoemulsification?

The biggest change was that the incision size was reduced from 10 mm to less than 3 mm. This led to a significant reduction in postoperative recovery time and a decrease in complication rates.

4. Latest Research and Future Prospects (Research Stage Reports)

Femtosecond Laser-Assisted Cataract Surgery

FLACS received FDA approval in the United States in 2010. The femtosecond laser is equipped with imaging capabilities for the cornea, lens capsule, and anterior chamber, and automates the following procedures:

Corneal incisions (including astigmatism correction)
Anterior capsulotomy
Lens softening and fragmentation

It is particularly useful when inserting premium lenses such as toric IOLs and multifocal/trifocal IOLs.

Integrated operating room systems and new technologies

Modern cataract surgery is extremely safe and effective, and further refinement is being pursued.

Intraoperative aberrometry: improving IOL power accuracy
Heads-up three-dimensional visualization system: improving intraoperative visibility
New technology IOL: Design to improve postoperative visual range and accuracy

Q Is femtosecond laser surgery superior to conventional phacoemulsification?

FLACS has advantages in precision of corneal incisions and capsulotomy. However, there is currently no definitive conclusion on its superiority over conventional methods, and decisions are made on a case-by-case basis considering cost and indications.

5. References

Leffler CT, Klebanov A, Samara WA, Grzybowski A. The history of cataract surgery: from couching to phacoemulsification. Ann Transl Med. 2020;8(22):1551. doi:10.21037/atm-2019-rcs-04. PMID: 33313296.
Davis G. The Evolution of Cataract Surgery. Mo Med. 2016;113(1):58-62. PMID: 27039493.
Kelman CD. The history and development of phacoemulsification. Int Ophthalmol Clin. 1994;34(2):1-12. doi:10.1097/00004397-199403420-00002. PMID: 8071012.
Awad AA, Alkorbi HA, Abu Serhan H. Charles Kelman: The Father of Phacoemulsification. Cureus. 2024;16(6):e61727. doi:10.7759/cureus.61727. PMID: 38975537.
Kohnen T. How far we have come: from Ridley’s first intraocular lens to modern IOL technology. J Cataract Refract Surg. 2009;35(12):2039. doi:10.1016/j.jcrs.2009.10.019. PMID: 19969203.

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