Conjoint RANZCO / RVEEH Museum

Intracapsular Cataract Extraction

In 1745 Daviel was the first surgeon to treat cataract by extraction rather than couching.

Following this the extracapsular method of extraction was the operation of choice. However, the problems associated with retained lens matter and the delay in obtaining satisfactory vision led to thoughts to remove the lens in its capsule.

Extraction of a lens within its capsule can be performed in four ways:-

1. By pressure applied to the outside of the globe.

First performed by Samuel Sharp of London in 1753 who expelled the lens from the eye through a lower incision by pressure of his thumb against the inferior part of the globe.

Gradual but slow progress was made over the following years with the eventual adoption of a superior incision. Some surgeons dislocated the lens into the anterior chamber by impaling it with a needle or the zonule was ruptured by pushing back on the lens with a flat instrument.

A lens with a large opaque nucleus gave best results when using this expression technique.

In 1894 surgeons of the Indian Medical Service (I.M.S) developed a method of expression for all types of lenses to what became known as the Smith Indian Operation after Col. Smith of I.M.S.

This operation was the preferred one, with or without iridectomy, in many centres in the early years of the 20th century.

A large 180 degree section was made and pressure was applied over the lower one third of the cornea by a smooth hook or spatula. The lens was delivered "straight" with the upper pole presenting if the upper zonule ruptured first, or tumbled with the lower pole presenting first following rupture of the lower zonule (see diagrams 1 and 2).

Loss of vitreous occurred in between seven and ten percent of cases with this method.

2. Passage of an instrument behind the lens to aid delivery.

Pargenstecher in 1866 used a flat spoon which he slipped behind the lens combined with pressure from below.
Later a loop or vectis was used for this purpose.

3. Application of an instrument to the anterior capsule and rupture of the zonule by rotating or rocking lens.

Forceps

Terson (1871) used toothed forceps for this purpose but later forceps designed by Kalt (Circa 1900) were smooth.

The lens was extracted by a combination of traction by the forceps gripping the anterior capsule, and separation of the zonular fibres by pressure over the periphery of the cornea producing counter traction.

The forceps may be applied at the twelve o'clock position or at six o'clock, the lens being tumbled with this latter application.

Diagram 3: Various capsule forceps

Duthie, Arruga, Castroviejo, Sinclair (the latter two are cross-action).

Diagram 4: Lens Expressors, right and left

Suction Devices

Vard Hulen (1910) designed a suction cup or erisiphake to be applied to the lens capsule. This was powered by a mechanical pump.

For a diagram of the Vard Hulen Vacuum Extractor and Pump please contact the library.

Ignacio Barraquer of Barcelona (Circa 1920) improved this by the use of an electric pump which was further modified by Geoffrey Sutherland of Melbourne (Circa 1960).

Diagram 7: Mechanical Erisiphake

Designed by Geoffrey Sutherland based on Erisiphake by Ignacio Barraquer of Barcelona.

Electric pump with foot control.

Diagram 5: Barraquer Brush - Made of marten hair. Useful for removing
blood clots from wound or iris surface.

Various small hand erisiphakes operated by a rubber bulb were designed from 1948 onwards.

Diagram 8: Simple Erisphake

Silicone rubber bulb

Cryoprobes

Krwawiez of Poland designed a cryosurgical probe in 1961. This adhered to the lens capsule and produced an ice ball in the substance of the lens itself giving a very firm grip. Various types of cryoprobes followed.

Diagram 9: Kelman Cryostylet Cryoprobe

circa 1960-1970. Loss of heat in the probe is produced by the Peltier effect. In this process, loss of heat occurs when a current is passed in the reverse direction across a termocouple, probably bismuth and antimony. Excess heat is removed by passage of cold water pumped theough the probe from a water tank.

Diagram 12: Kelman MK.II Cryoprobe

A single use freon gas cartridge which fits into the handle of the probe.

Disposable Cryoprobes Diagram 10: Alcon Microphake

Operating Instructions: To activate hold MICROPHAKE with metal tip pointing down and press button at top all the way in until top of button is leverl with barrel. When a thin coat of frost appears on probe, Micrphake is ready for use. To loosen adhesion, direct saline to tip of probe.

Diagrams 11 a& b: Cataract Cryoxtractor and charge, with instruction sheet.
4. Zonular destruction. Various mechanical methods were tried. A Zonulotome was described by Gradenico in 1902. This was passed around the periphery of the lens thereby breaking zonular fibres. Joaquin Barraquer (1958) developed a technique of chemically dissolving the zonule by a solution of the enzyme alpha-chymotrypsin. This was injected through a peripheral iridectomy. Following the separation of the zonular fibres, the lens could easily be removed by forceps or erisiphake, and later preferably by means of a cryoprobe. (See diagrams 13-17)
Diagram 13: Quimotrase (Alpha-chymotrysin) P.E.V.Y.A Laboratories, Barcelona.	Original enzyme developed by J Barraquer. Purchased 1958 in Barcelona by Dr K. G. Howsam at 2nd International course of the Barraquer Institute.
Alpha-Chymotripsin by various makers (Diagrams 14-16)
Diagram 14: Chymo-Trypure Novo Industries Denmark.	Diagram 15: Catarase Smith, Miller & Patch, USA.
Diagram 16: Zolyse Alcon Laboratories, USA.	Diagram 17: Olive tip canulae for injecting Chymotrypsin
All material illustrated is part of the Conjoint Museum Collection.