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Modern History | Sep 2005

The Infancy of Modern Cataract Surgery

"Change your thoughts and you change the world.” —Harold R. McAlindon

The sentiment of the earlier quotation dominated the philosophy of all the pioneers who changed the world of vision for patients suffering from cataracts. Mark Twain once said that people with vision (he meant a different kind) could see the future before mere mortals. The pioneers in cataract surgery obviously envisioned a profoundly different clinical course pre-, intra-, and postoperatively for cataract patients. They imagined ambulatory surgery under local anesthesia with the insertion of an intraocular implant that would allow the patient to leave the OR and resume virtually all reasonable activities that same day.

If any one of these pioneers had described his vision to the rest of the ophthalmic community in the late 1950s, he probably would have been subjected to a sobriety test. Nevertheless, each of the pioneers profiled in this and future editions of the column played a vital role in the evolution of modern cataract surgery.

When operating on patients with cataracts during my residency in 1959, I wore an operating loupe that provided 3.5X magnification, and I stood hunched over an anesthetized patient lying on an operating table illuminated by a large, round, overhead source. All surgical specialties in hospital ORs used the same lighting. Obviously, standing fatigued many important spinal muscles, which affected ophthalmologists' necks, shoulders, arms, hands, and lower backs. The stress of not being able to see finite details intraoperatively because of the lack of magnification and adequate lighting compounded the surgeon's overall fatigue. Very few cataract surgeons could effectively perform more than several operations on a given day.

At that time, I also used rather crude surgical instruments that did not permit me to use exquisitely sensitive fingertip control. Moreover, the sutures were 4–0 to 5–0 in diameter and were individually threaded on needles, most of which were less than perfect in shape or sharpness. I knew that there must be better ways to perform this challenging surgical procedure.

At one of the AAO meetings in Chicago in the early 1960s, I met Richard Perritt, MD, one of the leading eye surgeons in that city. I had heard that he used a microscope during cataract surgery. The concept fascinated me, because the much greater magnification would markedly improve operative results. I watched him perform surgery while using the microscope and instantly realized that this technique was a giant step forward in the evolution of cataract surgery. To the best of my knowledge, he was the first ophthalmologist to describe the advantages of using the operating microscope, although it was a crude instrument at the time.

Several years later, Richard Troutman, MD, who was Chief Surgeon at the Manhattan Eye, Ear, Nose and Throat Hospital, designed a much more functional and sophisticated operating microscope. It featured built-in illumination with variable magnification controlled by either a hand-switch or foot control. It was the most commonly used microscope for many years. The instrument allowed the surgeon to see anatomic details inside the eye and thus facilitated the transition from intracapsular to extracapsular extractions as well as the insertion of intraocular implants.

One of my teachers at the New York Eye and Ear Infirmary was an exceedingly innovative surgeon by the name of David Kimmelman, MD. While observing him operating on many occasions, I noticed that he sat during the procedure and placed his wrists on arm supports to stabilize them. He encouraged me to try that technique, which improved the steadiness of my hands and relieved the stress on my lower back. After operating in this manner a few times, I never stood up at the OR table again. As a result, I also found it natural and easy to transition to using the operating microscope (instead of the primitive operating loupe) when it became available. These changes represented another major step forward in the evolution of modern cataract surgery.

The initial rumblings of major changes in ophthalmology in the US started several years later, when a few surgeons began to implant IOLs at New York Medi-

cal College. As one of those surgeons, I had intimate contact with all of the early pioneers, whose personal stories are fascinating and, for the most part, unpublished. These individuals will describe their experiences in future installments of this column. I hope that their stories will encourage younger ophthalmic surgeons to play a role in making cataract surgery the best operation ever performed on humans. 

Section Editor Herve M. Byron, MD, is Clinical Professor for the Department of Ophthalmology at the New York University School of Medicine in New York. Dr. Byron may be reached at (212) 249-8494;
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