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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.
For diagrams of Smith Extraction
please contact the library.
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 through 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.
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Disposable Cryoprobes
Diagram 10: Alcon Microphake
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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 level 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. |
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Diagrams 11 a& b: Cataract Cryoxtractor
and charge, with instruction
sheet.
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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)
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Diagram 13: Quimotrase (Alpha-chymotrysin)
P.E.V.Y.A Laboratories, Barcelona.
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Original enzyme developed by J Barraquer. Purchased 1958 in Barcelona
by Dr K. G. Howsam at 2nd International course of the Barraquer Institute. |
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Alpha-Chymotripsin by various makers (Diagrams 14-16)
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Diagram 14: Chymo-Trypure Novo Industries
Denmark.
Diagram 15: Catarase Smith, Miller
& Patch, USA.
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Diagram 16: Zolyse Alcon Laboratories,
USA.
Diagram 17: Olive tip
canulae for injecting Chymotrypsin
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All material illustrated is part of the Conjoint Museum Collection.
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