More than 1.3 million operations are performed annually in the United States to correct cataracts, a clouding of the optic lens that occurs mostly among the elderly. This surgery has been common throughout history.
By 1000 BC, for instance, the surgery was performed routinely in India. It spread west to Mesopotamia, where it was mentioned in the Code of Hammurabi. The Greek physician Hippocrates and the Roman doctor Celsus mentioned it many times. Even in the Middle Ages, when medical progress sometimes took a giant step backward, oculists regularly performed the surgery. French surgeon Charles de Saint-Yves (1667-1733) was reported to have done 571 cataract procedures in the year 1708. James Peter Mettauer (1785-1875) of Prince Edward County, Va., performed more than 800 cataract operations in his long career.
Notes from the Massachusetts General Hospital in 1822 suggest the routine nature of the procedure:
"A woman of 75 years entered the hospital Nov. 4th. From then until the 27th, when the operation was performed, she was purged and dieted. The eyelids, which were somewhat irritated, were treated, and the pupils kept well dilated by the external application of a preparation of belladonna. The operation was done by breaking up the cataracts with a needle and pushing the fragments into the anterior chamber. This was accomplished without much pain to the patient. Later, as the right eye did not clear up satisfactorily, the operation was repeated, and the cataract, which was very firm, depressed into the vitreous. A successful result occurred."
To be sure, the type of surgery on cataracts (from the Latin cataracta meaning the slamming down of a sluice gate or stemming of water in a waterfall) varied considerably over the course of history. The ancients saw the eye as operating primarily through the cornea and pupil or through the entire outer fibrous capsule enveloping the lens. It was believed that this fluid-filled capsule developed a sluice gate, or cataract, when excess fluid arose, blocking the lens and impairing sight. In reality, vision also depends on the back inner lining of the eye, or retina.
Early surgeons dealt with this opaque condition of the lens by couching, depression or reclination, that is, pushing the cataract-affected lens away from the line of vision. They used an awl-like needle, often bronze or gold, to move the cataract. It was a delicate operation, requiring an ambidextrous surgeon, as Celsus made clear in the first century AD:
" . . . the patient . . . is to be seated opposite the surgeon in a light room facing the light, while the surgeon sits on a slightly higher seat; the assistant from behind holds the head so that the patient does not move; for vision can be destroyed permanently by a slight movement. In order also that the eye to be treated may be held more still, wool is put over the opposite eye and bandaged on: further, the left eye should be operated upon with the right hand, and the right eye with the left hand. . . .
"When the spot is reached, the needle is to be sloped against the suffusion itelf and should gently rotate there and little by little guide it below the region of the pupil; when the cataract has passed below the pupil, it is pressed upon more firmly in order that it may settle below. If it sticks there, the cure is accomplished; if it returns to some extent, it is to be cut up with the same needle and separated into several pieces, which can be more easily stowed away singly and form smaller obstacles to vision. After this, the needle is drawn straight out; and soft wool soaked in white of egg is to be put on, and above this something to check inflammation; and then bandages."
If the cataract-affected lens were suppressed or broken up, vision would have insufficient focusing. But that was thought preferable to the pre-surgery situation, in which only light could be distinguished if the cataract blocked the entire lens. The cataract also could return to its original location, with subsequent surgery increasing the risk of infection and loss of vision. Little wonder that many prominent scientists had nothing to do with the procedure, resorting instead to nonsurgical concoctions for relief. British physicist and chemist Robert Boyle (1627-1691), for instance, proposed putting powdered human excrement into the affected eyes. He did not explain why.
In 1753, French physician Jacques Daviel (1696-1762) found a better way to deal with cataracts. Failing to couch a cataract of a patient, Daviel decided to remove the lens itself, which had the same result as couching, except for the likelihood of clouding returning. Within years, Daviel developed instruments for the procedure (Daviel's spoon is so named and still employed) and traveled throughout the continent to perform the surgery on rich and common folk alike. Remarkably, patients in this era were fully conscious during surgery. But Daviel soon learned that wide-awake patients naturally rolled their eyes upward, making his incision on the lower part of the cornea easier.
Daviel's technique would arouse controversy for about a century, with some practitioners preferring the traditional couching and others deciding to remove the entire lens and capsule. The result, like Daviel's procedure, was to restore vision. The approaches of Daviel and the innovators prevailed over the coucher's, but each contributed a distinct procedure that would serve as the basis of 20th-century surgery. Daviel's method would become known as extracapsular extraction, the others as intracapsular. Extracapsular surgery, by limiting extraction to the lens, left behind a support system that limited complications; intracapsular minimized the likelihood of subsequent clouding that required additional surgery.
Still, both procedures waited for decades for advances in technology that would allow expansion of the size of the incision and the number of sutures and progress in microscopic surgery. Hospitalization was lengthy, with the patient's head immobilized for days as healing began; recovery at home lasted two to three months, with restrictions on bending and lifting. Then came thick glasses, hopefully to restore normal vision.
Only in the last quarter-century would technological strides make the surgery less traumatic. Joining Daviel's extracapsular surgery was a new technique, phacoemulsification, employing ultrasound waves to break up cataracts (invented by American doctor Charles D. Kelman). They would become the two leading choices for ophthalmologists, who found they needed dexterity with their feet as well as hands to operate the pedals of high-tech microscopes and suction tools. Opthalmalogists would also benefit from the no-stitch incision invented by Samuel Pallin, although the Sun City, Ariz., physician, who holds a patent on the frown-shaped cut, is suing some eye surgeons for patent infringement, demanding royalties for use of his technique.
Today, the outpatient procedure, under local anesthesia, takes less than an hour; a lens implant restores near normal sight. Although 95 percent of surgical cases result in improved vision, complications occasionally arise, such as thickening of the lens capsule, in which subsequent laser surgery is often employed. The question facing potential surgery patients today is whether the procedure is necessary. Some lens cloudiness can be detected in 40 percent of individuals aged 55 to 64 and in 75 percent aged 65 to 74, but for many people the ability to engage in normal activities is not impaired. Moreover, precipitating conditions such as smoking and exposure to sunlight can be avoided, and recent research has suggested that diets rich in vitamins E and C may help in slowing the onset of blinding cataracts. Thomas V. DiBacco is a historian at The American University. CAPTION: Operation on a cataract, copper engraving from 1598 by J. Guillemeau.