1. 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 AOI – Firenze 2005

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

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

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

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

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

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

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 Phacoerysis by 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,  -Ch, visco- elastics, gases, silicon oil, PFCL

11. Enzymatic Zonulolysis 1958 (Joaquín Barraquer)

12. The Era of Intraocular lenses Pioneers 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) Harold Ridley (1949): PC IOL (PMMA lens-shaped lens)

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

14. Intraocular Lenses (‘60s- 70s) Pupil support IOLs : Pupil support IOLs : ► Epstein (“propeller” IOL) ► 60-70’s: Binkhorst, Worst “New” AC IOLs “New” AC IOLs ► Choyce ► Kelman ► Leiske, Azar Posterior chamber IOLs (back to extracapsular) 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) Bag design IOLs: Anis, Galand, Charleux, etc. (’80s) Foldable IOLs Foldable IOLs ► silicone: (Mazzoco "taco“, etc.) ► acrylic hydrophilic & hidrophobic, etc. Bi- / Multifocal IOLs… Bi- / Multifocal IOLs… Accommodative IOLs... Accommodative IOLs... Phaco-Ersatz… Phaco-Ersatz…

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

17. Haefliger et al. Phaco-Ersatz: Cataract surgery designed to preserve accommodation. Graefes Arch Clin Exp Ophthalmol 1986, 224:165-173 Parel et al. Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in the old rhesus monkey. Refract Corneal Surg 1994, 10:550-555. Is Phaco-Ersatz feasible?

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

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

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

21. Thank You