The origins of cataract surgery

The details of the earliest cataract operations are, unsurprisingly, not clearly recorded, but it is possible that the Babylonians were able to treat the condition using couching of the lens as early as 2000 BC. The code of Hammurabi from this time mandated the rewards for successful operations, but also the amputation of the hands of a surgeon unfortunate enough to blind his patient. It is likely that such reference was to cataract surgery and, if so, this most likely discouraged progress and experiment in the field. It is unclear how the couching was achieved, but was probably digital, although Japanese surgeons developed fine metal instruments for dislocating or aspirating lenses at around the same time.

The father of Indian surgery Sushruta practiced during the 5th century BC, and dedicated a whole volume of work to ophthalmic disease, including treatment of cataract. He made what is taken to be the first description of extracapsular cataract surgery1, and described instruments specifically for this.

References to cataract surgery appear also in the Dead Sea Scrolls from around 600 BC and later in Roman writings. In AD 29, Celsus described the pathology and treatment of the condition, including operative and postoperative management. Understanding of the anatomy of the eye was, however, still rudimentary, and at this time cataract was regarded as some form of pathologic entity which required to be pushed out of the visual axis, rather than being recognized as a change in the natural crystalline lens. Other Roman authors such as Pliny and Galen wrote also about cataract surgery, and it is interesting to note that the Romans had already begun to use antiseptics, applied to the eye using ointment sticks inscribed with the name of the specialist.

Couching continued throughout the Middle Ages in the Western world, with no apparent significant advance in understanding or development of technique. The famous surgeon Georg Bartisch (1535–1606) published his beautiful book Ophthalmodouleia in 15832, which was illustrated with woodcut prints, and described couching in some detail therein, mentioning not only the technique and instrumentation, but also some of the complications which might be expected (Fig. 5.1). In 1752 cataract surgery took a major step forward when the French ophthalmologist Jacques Daviel presented his paper ‘A new method of curing cataract by removing the lens’ to the French Royal Academy of surgery. His approach was via the inferior limbus, extending the wound symmetrically circumferentially on each side to somewhat greater than 180°. Intriguingly he had had very fine left and right cutting scissors constructed to accomplish this, as well as a curette and spatula, even at this early stage of development of his new approach (Fig. 5.2). His address is considered by many to be the defining moment in the history of modern cataract surgery.

Fig. 5.1 Couching a cataract.

Courtesy of Richard Keeler.

Fig. 5.2 Daviel’s diagram of his extracapsular cataract operation.

Courtesy of Richard Keeler.

The development of modern surgery