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The Long Way to XXI Century Cataract Surgery

AOI – Firenze 2005. The Long Way to XXI Century Cataract Surgery. Rafael I. Barraquer MD, PhD Director, “Joaquín Barraquer” Chair for Eye Research - Barraquer Institute Autonomous University of Barcelona. Can we learn about the future from the past?. Bi/Mf. Couching. PMMA. Extraction

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The Long Way to XXI Century Cataract Surgery

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  1. AOI – Firenze 2005 The Long Wayto XXI CenturyCataract Surgery Rafael I. Barraquer MD, PhD Director, “Joaquín Barraquer” Chair for Eye Research - Barraquer Institute Autonomous University of Barcelona

  2. Can we learn about the future from the past?

  3. Bi/Mf Couching PMMA Extraction (extracapsular) Acc In Toto Extr. (intracapsular) Aq Mics Soft Phaco Microsurgery (extracap. + IOL) Ls Ph-E Major Periods ?

  4. Sushruta operating, by Robert Athom (Courtesy Dr. Anil Pande, Chennai) Bronze instruments of the roman period (1st century AD) for cataract couching, found at Montbellet, France 3000 years of Couching • India: Sushruta • Traditional(legendary?) • Mentioned in Mahabharatha (c 1000 BC) • Sushruta samhita manuscript by Nagarjuna (c 4-2nd cent. BC) • Historic Sushruta(Gupta period, c 2-4th cent. AD) • Influence on: • Greco-Roman? Celsus’ De Medicina,vol.VII (c28-48 AD) • Arab translations: Kitab-I-Susrurd (8th cent.) • Arab to Latin  Medieval Europe

  5. History of Tobit(Tb. 11:12-14)A Biblic account of a (self)-couching?

  6. Brisseau, 1703 Cunier & Abréu, 1844 Modern Age Couching Ophthalmodoyleia (Bartisch, 1583) XIXth century, today?

  7. Cataract extraction (Extracapsular = partial) Precursor: Ammar ibn Ali al-Mawsili (Mosul   Egypt c1000 AD)  Couching surgeon  Metallic hollow needle (Al-Miqdah) cataract aspiration !! J. Daviel(1745-48) Cataract extraction  a complication of lens couching !! (AC dislocation)

  8. in toto Extraction (intracapsular) • Samuel Sharp, London 1753 The Ideal Instrument ? • A thumb (Colonel Smith, India c1870) • Capsular forceps (H. Arruga, etc.) The erysiphake (Phacoerysis) (Ignacio Barraquer, 1917)

  9. 1917 Phacoerysisby Ignacio Barraquer

  10. XXth Century: Microsurgery Anesthesia • topical (cocaine): Koller (1884) • retrobulbar: Elschnig (1928) Sutures • silk: Williams (1865) • conjunctival: J.A. Barraquer (1880) • corneoscleral: Kalt (1894) Microscopes • Zeiss (1955) • J. & J. Barraquer (1964-66) Instruments: “micro-” speculum, forceps, needle holders, scissors, etc. Mechanization: I/A machines, U/S (Kelman 1968), Lasers, etc. Fluid instruments: Ach, a-Ch, visco-elastics, gases, silicon oil, PFCL

  11. Enzymatic Zonulolysis 1958(Joaquín Barraquer)

  12. The Era of Intraocular lenses • Pioneers • Chevalier de Tadini (1764-65, acc to the memoirs of G. Casanova) • Johannes Virgilius Casamaata (1795), glass lens  fell into vitreous • Harold Ridley (1949): PC IOL (PMMA lens-shaped lens)

  13. Early Intraocular Lenses (1950s) • Rigid AC IOLs: • Baron (1952) • Strampelli (1953) • Flexible AC IOLs • Danheim (1956): closed loops • J. Barraquer (1958): open loops (J-Loops)

  14. Intraocular Lenses (‘60s-70s) • Pupil support IOLs : • Epstein (“propeller” IOL) • 60-70’s: Binkhorst, Worst • “New” AC IOLs • Choyce • Kelman • Leiske, Azar • Posterior chamber IOLs(back to extracapsular) • Shearing (1976) J-Loop • Sinskey (modif. "J") • Simcoe (C-loop) • Kratz (1980): angulated lens (avoid capture)

  15. More Intraocular Lenses… • Bag design IOLs: Anis, Galand, Charleux, etc. (’80s) • Foldable IOLs • silicone: (Mazzoco "taco“, etc.) • acrylic hydrophilic & hidrophobic, etc. • Bi- / Multifocal IOLs… • Accommodative IOLs... • Phaco-Ersatz…

  16. PMMA Silicone Monofocal Hydrophilic Hydrophobic Phaco-Ersatz Accommodating Bi/Multifocal Microsurgery (extracap. + IOL) Present & Future Manual Phaco Surgical Tech. Lens design ? ? U/S Phaco Laser Phaco MICS Aqualase

  17. Is Phaco-Ersatz feasible? Haefliger et al. Phaco-Ersatz: Cataract surgery designed to preserve accommodation. Graefes Arch Clin Exp Ophthalmol1986, 224:165-173 Parel et al. Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in the old rhesus monkey. Refract Corneal Surg1994, 10:550-555.

  18. EVAS (Miami) CCLSD (Barcelona) Lens Refilling: Challenges • Surgical technique • Materials • PCO prevention • Physiology of accommodation ( quantity to inject)

  19. 1.8 Billion Presybopesby 2010 Source: WHO IEFP survey 1998 The Global Challenges

  20. XXIth Century Cataract Surgery will have to be… • Highly efficient and safe • Universally available • Low cost, simple instrumentation • Able to restore the full functionality of the lens  truly continuous dynamic accommodation

  21. Thank You

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