David Warmflash, MD
Cataract removal is the most common surgical procedure in the United States, with roughly 3.8 million of the operations performed each year. Routine, quick, and highly successful, patients are in and out of the office in hours, bringing home millimeter-scale incisions and vastly improved eyesight. Yet you may know little of its history, stretching back millennia and punctuated with breakthroughs, some of them happening earlier than you might expect.
In couching, the surgeon inserted a sharp needle through the pars plana of the eye. Angled forward, the tip of the needle passed between the iris and the cloudy lens, which it pushed backward into the vitreous cavity, where it could no longer block light entering the pupil. While this procedure left only the cornea refracting the light, it often gave the person a little bit of vision. But when, where, and how did it start?
Bronze Age relics, such as an Egyptian 5th Dynasty statue showing a white pupillary reflex (c. 2450 BCE) , the Code of Hammurabi (c. 1755-1750 BCE) , and the Ebers Papyrus (c. 1550 BCE ), tell us ocular disease and surgical procedures affecting the eyes were of interest to scribes of that period. As for couching, however, the origins are murky. While scholars generally believe the procedure was well established for cataracts in India and Egypt by the first millennium BCE, the temporal and geographic origin is difficult to pin down since the Sanskrit text that describes couching, the Sushruta Samhita, went through various rewritings, while many of the Egyptian descriptions came to us by way of the Greeks.
Carvings on the Egyptian tomb of Ipuy at Thebes depicts what looks like a couching procedure circa 1200 BCE, in the Late Bronze Age. While this sounds impressive for the era, it raises the question of what would make someone think a poke in the eye with a sharp object would be a way to treat blindness.
One possible explanation, according to Christopher Leffler, MD, was a serendipitous encounter with a spiky bush.
Christopher Leffler, MD
“It’s entirely possible that this could have started with just an accidental injury,” said Leffler, associate professor of ophthalmology at Virginia Commonwealth University in Richmond and author of the book A New History of Cataract Surgery (Wayenborgh Publishing, 2024; https://kugler.pub/editors/christopher-t-leffler/). “It’s possible for a thorn to penetrate the eye and displace a cataract, leading to improved vision.”
Supporting the thorn hypothesis, Leffler cites a myth handed down in the Greek world that a goat invented cataract surgery when it accidentally ran into a thorn bush and a thorn penetrated its eye. “This is the myth, but it was repeated by four different authors associated with the Alexandrian tradition,” he said.
Middle Ages Advances
During the Middle Ages (c. 500-1500 CE), surgeons improved on couching by replacing the sharp needle with two instruments: a lancet to penetrate the sclera and a blunter needle to do the dislodging of the cataract. The combination reduced the risk the surgeon would damage the iris. Also by the Middle Ages, specifically in the Arabic-speaking world, some clinicians began extracting soft cataracts using suction — often with their own mouth, although tube devices were sometimes at hand.
“Some people have tried to attribute these suction methods to the ancient Greeks, and it’s not impossible, but when you really look at it, we can’t say for sure that it was in the ancient Greek period, but it was definitely happening in the Medieval Arabic period,” Leffler said.
As for documentation of such methods, the Persian surgeon Abu Bakr al-Razi (865-925 CE) described such a tube device in his medical text, Kitāb al-Hāwī fī al-tibb, whereas a later surgeon, Ammar ibn Ali al-Mawsili, mentioned a similar operation in his treatise, Kitāb al-muntakhab fī ʿilm al-ʿayn.
Suction techniques, like those of al-Razi and al-Mawsili, were limited to soft types of cataracts typical of those occurring in children and sometimes younger adults, Leffler said. “Aspiration just doesn’t work for the hard cataracts that older people get. That’s why Charles Kelman, in 1967, introduced phacoemulsification, the use of ultrasound to liquify the cataract so that it can be aspirated.”
But since ultrasound would not be invented until the 20th century, something else had to be done. That’s where the French ophthalmologist Jacques Daviel (1696 –1762), enters the story.
Medieval suction was no solution for hard cataracts, the most common form of the condition in elderly patients. Motivated by concern about the complications of couching — glaucoma, pain, return of the cataract, uveitis, vitreous hemorrhage, to name a few — Daviel developed a procedure involving a large corneal incision greater than 10 mm (and often 12-14 mm), capsular puncture, and removal of lens material with spatulas and curettes. In contrast with previous, less-well documented attempts by others that had produced varying results, including dislocated lenses, Daviel achieved successful outcomes, of which he made a comprehensive report to the French Royal Academy of Surgery in 1752.
Two years prior to that, however, in September 1750, the Gazette de Cologne published a more informal announcement about the surgery in an article that would not be noticed or mentioned for more than 275 years, other than a brief mention in 1804 by the nephew of a competing surgeon. Then, two weeks prior to Leffler’s interview with Medscape, Leffler discovered the Gazette article and days ago submitted an academic paper, currently a preprint going through review, explaining what the article reveals: that Daviel did the surgery at the home of the Gazette’s editor, in front of the medical faculty of Cologne, first operating on a sheep to extract the lens — presumably a healthy lens as a demonstration — then a few days later on a human with a cataract.
Daviel’s work laid the foundation for techniques that improved incrementally, then went through an abrupt advance in the mid-20th century with the advent of artificial intraocular lenses (IOLs).
If the Greek tale of the goat and the thorn has a modern equivalent, it would have to be the story of Harold Ridley. Working as a consulting ophthalmologist for the Royal Air Force, Ridley noticed that World War II pilots who sustained eye injuries when their cockpit canopies, made of the plastic polymethyl methacrylate, shattered often tolerated those fragments in their eyes without severe inflammation or rejection.
As the story goes, Ridley had a lightbulb moment: The absence of inflammation that was common with injuries from metal shrapnel made polymethyl methacrylate — also known as Perspex, acrylic, and Plexiglas — the optimal material for an IOL. Thus, Ridley implanted the first polymethyl methacrylate lens in 1949.
But Leffler said that advance was not quite as serendipitous it often is portrayed in the medical and lay press.
“The general idea that polymethyl methacrylate was biocompatible was by no means a secret,” Leffler said. “The different Air Force doctors knew about the biocompatibility because these injuries were not rare.”
Indeed, in 1948, one such physician, Philip Clermont Livingston — who was both an ophthalmologist and a pioneer in aviation medicine — published a paper in the British Journal of Ophthalmologyshowing Perspex splinters were well-tolerated by the eye. And by then, acrylic was being used for orbital prostheses, Leffler said. “Adolphe Franceschetti even presented the use of acrylic corneal prostheses in London in the spring of 1949, before Ridley started working” on his lenses, he said.
While early IOLs restored refractive power in one step, eliminating the need for heavy aphakic spectacles, they faced skepticism and complications. Uveitis was common after surgery, and dislocation, partly because they were rigid, limited how small the incisions could be.
For Leffler, the major revolution in cataract surgery would come in 1967, when Kelman, inspired by dentists using cavitrons to liquify hardened tartar, developed phacoemulsification. This technique allowed for the dissolution of hard cataracts, allowing them to be aspirated away through much smaller incisions than with previous methods. Phacoemulsification meant the incision size was dictated no longer by the space needed to pull the cataract out but by the space needed to insert the new lens.
Gradually, thanks to new materials, lens designs, and refinements in techniques, IOLs were able to be inserted through smaller and smaller incisions with good outcomes. Over the years, the field progressed with continuous curvilinear capsulorhexis, viscoelastic agents, and continuously improving topical anesthesia.
An important aside here is the is the realization tamsulosin and other alpha-blockers, used in managing benign prostatic hyperplasia, are strongly associated with intraoperative floppy iris syndrome, which complicates cataract surgery. Leffler said primary care physicians should keep this link in mind for their patients with enlarged prostates who require cataract removal and refer them for the procedure before starting the alpha-blocker.
That caveat is another good reminder, too, that cataract surgery did not arrive fully formed. Today’s quick, low-risk procedures stand on centuries of trial and error. When millions of Americans regain clear sight each year, they benefit from a history worth remembering — so we do not mistake a modern routine for something that was ever simple to achieve.
David Warmflash, MD, has been a contributor to Medscape Medical News on various topics since 2019.