Doctor's Review: Medicine on the Move

October 19, 2017
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Blinded by science

Well-intentioned physicians tried to banish blurry vision, but the cure for cataracts remained cloudy

The term cataract comes from the Latin word cataracta meaning waterfall and the Greek kataraktes meaning to dash down. Because it was believed that an unknown murky substance flowing into the eye caused the vision problem — and its effects were likened to looking through a wall of falling water — the term is an apt one. Such a beautiful image to describe a harrowing degenerative condition, especially in the days before antisepsis, lasers and artificial lenses...

 

Today, we know that at least 50 percent of people over the age of 65 will end up with some degree of clouding in their lenses, with that number rising to 70 percent by the age of 75. Untreated cataracts is the most common cause of blindness worldwide, accounting for upwards of 50 percent of all cases. Of course, modern treatment options — the most successful one being removing the affected lens and replacing it with a permanently implanted artificial one — are quite effective in restoring eyesight, though this certainly wasn’t always the case.

In millennia past, this confounding condition — closely linked with old age and often occurring with other conditions like diabetes, obesity, alcohol abuse, smoking and trauma — robbed countless sufferers of their vision and independence. Desperate and left with no choice but to turn to well-meaning physicians, barber surgeons and even quacks, patients of the past were forced to contend with a myriad of miserable methods to help counteract the course of cataracts. All too often, these “cures” did more harm than good, leaving them worse off, cursed with infection, pain and possibly even the loss of their eyes.


 

SUSRUTA’S STYLINGS

Instruments that may have been used to surgically remove cataracts have been found among the ancient artifacts of Greece, Egypt and Babylonia. However, cataracts were first officially mentioned in literature in 29 CE by Roman writer and possible physician Celsus in De Medicina. Celsus was a proponent of needling, which was exactly what it sounds like — using a needle or stick to scrape and separate the cataracts into smaller bits in order to promote the particles’ natural reabsorption by the eye. Poking practitioners aside, the first physician who actually tried to cut out cataracts was that ancient Indian surgical star, Susruta.

Of all the Hindu healers, Susruta was deservedly the most famous, perhaps because he achieved a remarkable level of scientific understanding and success for someone practising in the fifth and sixth century. His extraordinary surgical exploits and self-made instruments were recorded in a series of Sanskrit medical texts known as the Sushruta Samhita. Among some of his more impressive firsts were rhinoplasty, prostatectomy and abscess lancing. In the Samhita, Susruta also described the first recorded technique for the surgical treatment of cataracts.

Using an instrument modified for this brand of eye surgery, Susruta made an incision through the edge of the cornea and pushed the lens back into the vitreous cavity, clearing the way for clearer vision. The procedure, known as couching or reclination, improved sufferers’ visual acuity... provided they were among the 40 percent who managed to avoid infection or complications. Still, Susruta’s patients were left with some degree of blurriness since glasses and replacement lenses weren’t available in ancient times. Couching, incidentally, remained a popular form of treatment as late as 50 years ago in various corners of the world, including India, Egypt and Tibet.


 

NO MEDIEVAL MIRACLES

Some 500 years later, an Iraqi physician with an interest in all things ocular invented the hypodermic needle. In Ammar ibn Ali al-Mawsili’s major work, Choice of Eye Diseases circa 1000, he recorded his attempts to remove cataracts by sucking them off the surface of the eye using a hollow glass syringe. Though he claimed to have success with his technique and his invention would go on to take its place among the most important scientific innovations in medical history, the hypodermic needle was eventually discarded after other physicians failed to find it beneficial.

Couching, however, continued to be employed throughout India, though it would take centuries before its use spread to Europe. In addition to the ubiquitous practice of bloodletting, various poultices and balms were among the typical options offered to those suffering from clouded vision in the West. Surely, one of the least likely concoctions to cure was mercury — applied directly onto the surface of the eye. Trepanation was another purported cure, though one wonders whether having a small hole bored in one’s skull was any better than the prospect of total blindness to begin with.

It wasn’t until 1748 that Parisian doctor Jacques Daviel (1693-1762) performed the first extracapsular cataract extraction surgery — a milestone that meant the end of suffering for many. After graduating from medical school from the University of Rouen, the promising young physician opened a practice in Marseille. Eventually, he began specializing in ophthalmology and was quite well regarded by the scientific community, even serving as Louis XV’s eye doctor. He practised the standard forms of cataract removal at the time, but he was frustrated by their lack of success. If only there were a better way to offer relief to the many patients he saw suffering from the failing vision associated with cataracts...


 

THE FIRST CUT IS THE DEEPEST

On April 8, 1748, Dr Daviel prepared to operate on one of his patients, a wigmaker named Mr Garion. When the traditional couching method didn’t work, Daviel decided to try something different. He made an incision through the cornea and then used a spatula-like tool to extract and scrape the cataracts and much of the inner lens out, leaving the posterior lens capsule intact as well as the zonules that secure it. Daviel’s so-called extracapsular procedure was the first advance of note since Susruta had couched his way into the record books 1000 years earlier.

Some physicians tried their hand at improving Daviel’s technique. In 1753, London doctor Samuel Sharp developed the intracapsular procedure by creating an incision and then using pressure applied by his thumb to remove the lens through the hole. Later on, in the early 20th century, various tools including tiny suction cups and forceps were devised for the same purpose — a far better alternative to a doctor’s dirty digits!

A century or so later, two more significant steps meant much more comfort for patients undergoing cataract surgery: the introduction of silk sutures by Harvard-educated Boston physician Henry Willard Williams (1821-1895) in 1867, and ocular anesthesia in the form of cocaine eye drops in 1884. Before this time, cataracts surgery was unpleasant to say the least; an extra man had to usually be on hand to hold the patient’s head in place in order to prevent him or her from flailing about in pain. From about 1840 on, general anesthesia had been an option, but often only the wealthy could afford the upgrade, which often led to more post-operative complications anyway.

By the 1960s, cataract surgery was virtually unrecognizable from its humble beginnings, thanks to effective antibiotics, better instruments and the art of plastic artificial lenses. When ophthalmologist Charles Kelman (1930-2004) pioneered the scalpel-free cataract treatment known as phacoemulsification in 1967, in which the lens is virtually pulverized or emulsified using ultrasound and then sucked off the surface of the eye. Phacoemulsification coupled with the insertion of a permanent intraocular plastic lens quickly became the gold standard of treatment, providing much-needed relief to millions of sufferers worldwide. Sure, it may sound nearly as outlandish or even barbaric as some of the old ways, but with around a 95-percent success rate, it’s a virtual walk in the park compared to mercury eye drops or rusty needles!

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