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The Evolution of Cataract Surgery

by Geetha Davis, MD

Cataract surgery may be Abstract has evolved over time, to its current
considered one of the most Cataract surgery is one of meaning of a visual acuity of 20/40 or
successful treatments in all the most common procedures worse.³ When cataract surgery was in
of medicine. performed worldwide. It is also its the infancy, a “visually significant”
one of the oldest. Alongside cataract was likely used to describe
advancements in cataract an advanced or mature cataract,
surgical techniques have been with vision impairment approaching
improvements in intraocular lens blindness (see Figure 2). Thanks to
replacement technology. Cataract amazing advancements in surgical
surgery may be considered among techniques and improved safety
the most successful treatments profiles, the indications and threshold
in all of medicine. This article for cataract surgery clearly have shifted
discusses the fascinating evolution to cataract removal at a much earlier
of cataract surgery, from the stage of development.
earliest approach of couching to
modern day phacoemulsification Couching and Mature Cataract
and lens replacement. The earliest known method
of treating a cataract is couching,
Introduction which dates back to the fifth century
The normal crystalline lens of the BC (see Figure 3).4 The word
eye is a clear structure suspended in “couching” comes from the French
its natural position by zonular fibers verb “coucher,” which means “to
from the ciliary body (see Figure
put to bed.” Couching was typically
1). The lens contains a capsule, lens
performed on mature cataracts. The
epithelium, cortex, and nucleus.
cataract was not removed from the
Functions of the lens include refracting
light to focus a clear image on the eye. Instead, the mature cataract was
retina and providing accommodation. purposefully dislodged out of the
A cataract is an opacification of the visual axis with a needle. The cataract
crystalline lens, leading to visual remained in the eye but was no longer
impairment. Many conditions can blocking light, producing instantaneous
cause cataract formation. Aging, improvement in vision. Indeed, in the
however, is the most common cause very immediate postoperative period,
which is multifactorial in nature.¹ couching was considered a success,
Avoidable risk factors for cataract but the retained cataractous lens and
include use of tobacco products and the lack of aseptic technique soon had
Geetha Davis, MD, MSMA member since exposure to ultraviolet radiation.² deleterious effects on the eye, often
2010, is assistant professor of ophthalmology
and director of the ophthalmology residency When a cataract becomes visually resulting in blindness shortly after the
program at Mason Eye Institute, Department significant, cataract surgery is the procedure. Unfortunately, couching
of Ophthalmology at the University of is still in practice in some developing
Missouri.
only established method of treatment.
Contact: [email protected] The definition of “visually significant” countries.5

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 science oF Medicine | School of Medicine
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Extracapsular Cataract Extraction Figure 1

Sectional view showing the layers of the lens.
As knowledge of ocular anatomy and eye disease
expanded, so did the approach to cataract surgery. While
couching is generally thought to have been the predominant
method of cataract treatment until the 18th century, ancient
literature suggests that as early as 600 BC, an Indian surgeon,
named Sushruta, may have been the first to perform some
type of extracapsular cataract extraction (ECCE).6 The
procedure is termed “extracapsular” because the lens
capsule is left in place. The first true cataract extraction was
performed in 1747, in Paris, by the French surgeon Jacques
Daviel. His procedure was more effective than couching,
with an overall success rate of 50%.7 Daviel’s procedure
basically involved making a large corneal incision (more
than 10 mm), puncturing the lens capsule, expressing the
nucleus, and then extracting the lens cortex by curettage. the cataract is gently evacuated from the eye. The success
Although this procedure represented great progress of ICCE grew with the advent of modern anesthetic and
compared to couching, postoperative complications were sterilization techniques, but its popularity rapidly declined as
considerable, including poor wound healing, retained lens improvements were made in ECCE techniques. The major
remnants, posterior capsular opacification, and infection. drawbacks of ICCE are related to removing the lens and
Despite the risks of Daviel’s procedure, it remained the lens capsule in its entirety. The lens capsule serves as a wall
accepted approach for cataract extraction for over 100 years, between the anterior and posterior structures of the eye.
until the 19th century, when intracapsular cataract extraction
Potentially blinding complications from ICCE, such as retinal
(ICCE) became, for a time, the preferred method of cataract
detachment, macular edema, and corneal decompensation,
removal. However, improvements in operative methods
are more likely to occur when this wall is not in place to
and surgical tools eventually led to the reemergence, in
prevent the vitreous from prolapsing forward. Furthermore,
the 1970s, of ECCE as the preferred approach over ICCE,
ICCE requires larger incisions to remove a cataract, leading
which fell out of favor because of high rates of blinding
complications. Modern day versions of ECCE and manual to slow healing and a greater amount of surgically induced
small incision cataract surgery (MSICS) are now used astigmatism. Despite the drawbacks of ICCE, it remained
in many parts of the world, including the United States. the primary approach for cataract extraction in the United
Techniques for performing extracapsular cataract removal States, well into the 1970s, and modern ICCE is still in
have dramatically improved over time, to the point where practice in developing countries.
the overall success rate is now 90% to 95%.8
Modern Cataract Extraction
Intracapsular Cataract Extraction and Phacoemulsification
In 1753, Samuel Sharp performed the first documented As improvements in surgical techniques, anesthesia,
intracapsular cataract extraction (ICCE).9 With ICCE, and equipment evolved, ICCE fell out of favor and was
the entire lens, including the lens capsule, is removed supplanted by ECCE as the standard of care for cataract
through a large limbal incision. Samuel Sharp used his extraction. ECCE has proved to be an extremely effective
thumb to expel the cataract from the eye. Fracturing the method of cataract removal, with considerably better visual
zonular fibers that suspend the lens to the eye was a vital outcomes than with ICCE. The advent of an intraocular lens
part of the ICCE procedure. The mechanism by which (IOL) to replace the cataractous lens has led to improved
the zonules were broken has evolved from the early use of refractive results after surgery. The arrival in 1972 of
forceps to hold the lens capsule and manually disrupt the ophthalmic viscosurgical devices (OVDs) improved the
zonules. In 1957 Joaquin Barraquer was the first surgeon facility and safety of the operation as well. An OVD is a gel-
to utilize the enzyme alpha-chymotrypsin to dissolve the like substance used during cataract surgery to maintain space
lens zonules.10 Cryoextraction also proved to be a successful in the eye, preventing deflation of the globe and protecting
method for ICCE. With cryoextraction, a frozen probe is the structures inside the eye without interfering with the
applied to the cataract, which adheres to the probe, and steps of the operation.

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In 1967, an American ophthalmologist, Charles

Kelman, revolutionized cataract surgery when he introduced
phacoemulsification (often referred to as “phaco”) as an
alternative approach to ECCE.11 With conventional ECCE,
the entire nucleus of the lens is removed from the eye
through a large (10 mm) incision. In phacoemulsification,
an ultrasound-driven needle emulsifies and aspirates the
lens through a considerably smaller (3 to 4 mm) incision.
Phacoemulsification was initially met with resistance,
but this procedure is now considered the safest and the
preferred method of cataract surgery in the developed
world. The smaller incision results in a more stable anterior
chamber throughout surgery, shorter recovery time, and less Figure 2
surgically induced astigmatism. Hypermature age-related corticonuclear cataract with a brunescent
(brown) nucleus.
The current phacoemulsification procedure is
performed in the following manner. Pupillary dilation with
topical medications usually takes place in the preoperative experienced phaco surgeons, the above-outlined steps of
holding area. Topical anesthetic agents, introduced by cataract surgery are extremely controlled and consistent, so
Fischman in 1993,12 are commonly administered before that surgical outcomes are predictable with a good degree of
the procedure. In the operating room, after sterile reliability. However, in medicine, there is always room for
preparation of the eye with povidone-iodine and draping, improvement. In 2001, femtosecond laser technology was
the eye is adequately exposed using a lid speculum, the applied to LASIK refractive surgery to create the corneal
surgical microscope is positioned, and the surgery begins. flap, resulting in a more precise LASIK flap. This technology
A paracentesis, or sideport incision (1 mm), is made in the was utilized in cataract surgery for the first time, in 2008,
cornea. Through this small incision, OVD is injected into when the first femtosecond laser-assisted cataract surgery
the anterior chamber to protect the ocular structures as well was performed in Budapest, Hungary.13 The laser does
as stabilize the globe in preparation for the main incision. not obviate the need for phacoemulsification. Instead, the
The main incision is then made, which can range from laser performs many of the steps of the cataract procedure,
1.8 mm to 2.75 mm in size, depending on the instrument including constructing the main wound, creating the
used. This wound is constructed in a multiplanar fashion capsulorrhexis, and fragmenting the lens. Limbal relaxing
to promote self-sealing at the conclusion of the procedure incisions to correct astigmatism are often also performed
(“stitchless cataract surgery”). Next, a continuous circular with the laser. With femtosecond laser technology,
opening is made in the anterior lens capsule (capsulorrhexis) visual acuity outcomes are thought to be more precise,
to gain exposure of the contents of the lens. The predictable, and reproducible compared to conventional
phacoemulsification handpiece is then introduced into the cataract extraction. However, data do not demonstrate that
eye to emulsify and aspirate the lens. After removal of all femtosecond laser–assisted cataract surgery yields outcomes
of the lens contents, all but the anterior portion of the lens superior to those of manual phacoemulsification surgery.
capsule is then removed during capsulorrhexis. The anterior Thus far, the two approaches appear to be equally safe and
portion of the lens capsule, or capsular bag, remains intact effective.14 Although many cataract surgeons worldwide
and will serve to house the IOL. All of the lens contents have adopted femtosecond laser technology, there are still
are moved by phaco thorugh an opening made in the lens many phaco surgeons who do not believe this technology is
capsule (capsulorrhexis). All that remains after phaco is the beneficial or cost-effective.15
lens capsule (minus the anterior portion that was removed
during capsulorrhexis). The remaining lens capsule, or Intraocular Lenses
capsular gag, will serve to house the IOL. The incredible success of cataract surgery would
Phacoemulsification techniques and technology not have been possible without the development of
continue to be refined. Precision is paramount. Cataract intraocular lenses (IOL). In 1949 Sir Harold Ridley, a
surgery in developed parts of the world has evolved British ophthalmologist, implanted the first IOL. Prior to
into a refractive procedure, in which expectations of the introduction of IOLs, patients were aphakic (without
spectacle independence are commonplace. In the hands of a lens) after cataract surgery. Postoperatively the aphakic

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patient required high-powered hyperopic spectacles to be Figure 3

Couching, the earliest known
able to refract light and focus images on the retina. This method of treating cataract.
meant that a patient who was losing vision due to a cloudy
lens would have cataract surgery, only to find that, without
correction, vision remained poor due to the absence of the
lens. A medical student working with Ridley was reported
to have asked, Why not replace the cataractous lens with
a clear lens?16 Sir Harold Ridley realized that wounded
World War II pilots tolerated plastic pieces of shattered
airplane windshields in their anterior chambers,17 and this
observation encouraged him to implant an IOL made of
polymethyl methacrylate (PMMA), also known as acrylic
glass. Initially Ridley’s approach garnered little support,
as there were considerable postoperative complications,
including glaucoma, uveitis, and dislocation of implanted lens.
Remarkable innovations in IOL technology and design
have occurred since Ridley’s groundbreaking work. The goal
of IOL implantation is to achieve the best refractive outcome
while avoiding complications. IOLs can be implanted in
various sites, including in the anterior chamber, tied to the
iris, in the ciliary sulcus (the space between the anterior
lens capsule and iris), and in the capsular bag. When IOL
implantation was introduced, ICCE was the predominant The challenge of correcting presbyopia was taken on
method of cataract extraction, with removal of the entire with the introduction of multifocal IOLs in the 1990s and
lens, including the lens capsule, necessitating placement of of accommodating IOLs in 2000. A multifocal IOL acts
the IOL in the anterior chamber or fixed to the iris. Early like a bifocal inside the eye. It has multiple zones on the
lens designs were not compatible with long-term safety in surface that will focus distance and near at all times. An
the eye. For example, anterior chamber IOLs often spun accommodating IOL attempts to behave like the natural
around in the anterior chamber and damaged the corneal lens: when viewing an intermediate or near target, the lens is
endothelium. Iris-fixated lenses often led to pupillary designed to flex forward to focus on the target.
distortion and uveitis-glaucoma-hyphema (UGH) syndrome. Equally important as lens design is lens power. Just as
When ICCE lost its popularity, IOLs were then designed glasses and contact lens powers need to be measured for
with the intent of posterior chamber implantation. An each individual, so do IOL powers. When determining
American ophthalmologist, Steven Shearing, is credited with IOL power, multiple variables play a role, such as corneal
bringing IOL design into the modern era. In the 1970s he refractive power, anterior chamber depth, length of the eye,
designed a lens that could center itself in the same position and location of the lens when it is placed in the eye. Since
where the natural lens was positioned (behind the iris). As IOL implantation became the standard of care in the 1970s,
advances continued in cataract surgical techniques, a more various mathematical formulas taking these variables into
structurally sound place for the IOL to reside was created: account have been utilized to calculate lens power. During
the capsular bag. In 1980 the first foldable lens arrived on the past 20 years, the developments in IOL calculation
the scene, which further improved outcomes. Foldable IOLs methods and measuring devices have been astonishing
are made of flexible material (acrylic or silicone), allowing and have resulted in more precise postoperative refractive
insertion into the eye through an even smaller incision. outcomes. Freedom from spectacles after cataract surgery is
Since the 1970s, remarkable advances have occurred in now more of an expectation than a mere possibility. Cataract
IOL technology, design, and material. In 1992, astigmatism surgeons are constantly evaluating postoperative data to
correction became possible when the first toric IOL was personalize the lens calculation formulas in order to achieve
developed.18 Since then, improvements in the toric IOL better refractive results. In 2006, a United Kingdom study
model have led to excellent results and increased freedom to establish benchmark standards for refractive outcomes
from spectacle correction. after cataract surgery suggested that over 50% of patients

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University of Missouri Health

with normal eyes should be within 0.5D (diopter) of the improvement, but the future of cataract surgery will be
desired target refraction and 85% should be within 1.0D of incredible as advances continue to evolve.
the desired target refraction.19 Studies show that over 90%
of cataract surgery refractive outcomes can be within 1.0D Acknowledgment
of predicted outcomes and over 70% can be within 0.5D Figure 1 by Stacy Turpin Cheavens, MS, CMI, Medical
of predicted outcome when a surgeon tailors his/her lens Illustrator, University of Missouri School of Medicine. Figure
calculations using prior outcome data.20,21 2 from National Eye Institute, National Institutes of Health.
Even with all of the remarkable technology and Figure 3 from Wellcome Library, London.
mathematical formulas, lens calculations are not perfect.
Residual postoperative refractive error can be common. References
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modern cataract surgery has significantly improved the lives
of many people throughout the world, perfection seems Disclosure
to be an elusive, moving target. There remains room for None reported. MM

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