This document provides an overview of the history and evolution of cataract surgery techniques from ancient times to modern techniques. It discusses early techniques like couching and intracapsular cataract extraction. It then covers the development of extracapsular cataract extraction and intraocular lens implantation. More recent advances discussed include small incision cataract surgery, phacoemulsification, microincision cataract surgery, femtosecond laser-assisted cataract surgery, and research into zero-energy cataract surgery. The document traces the progression of cataract surgery from early crude techniques to the highly precise procedures used today and under development for the future.

1. CATARACT SURGERY
PAST-PRESENT-FUTURE
Presenter- Moderator -
Dr. Rohit Agrawal Dr. Sachin Daigavane Sir
Conductor-
Dr. Archana Thool Ma’am
31/07/2017

2. PAST PRESENT FUTURE

3. INTRODUCTION
• HISTORY OF CATARACT SURGERY
• COUCHING
• ICCE
• CONVENTIONAL ECCE
• ERA OF IOL
• SICS
• PHACOEMULSIFICATION
• MICS
• FEMTO SECOND LASER CATARACT SURGERY
• ZERO ENERGY CATARACT SURGERY
• FUTURE ON-GOING RESEARCH

4. HISTORY OF CATARACT SURGERY
 4000 YEARS BACK- SHUSHURUTA - COUCHING
 1600 A.D.- DEVIES - ICCE
 20th CENTURY- ECCE
 40 YEARS BACK- SUTURES + ICCE WITH IOL
 20 YEARS BACK- SUTURES + ECCE WITH IOL
 15 YEARS BACK- PHACO EMULSIFICATION
 RECENTLY- TOPICAL TORSIONAL MICROPHACO WITH
FOLDABLE MULTIFOCAL/TORIC LENSES
 NOW & FUTURE - FEMTO CATARACT

5. COUCHING
• Also known as “LENS DEPRESSION”
• Involves using a sharp instrument to push the cloudy lens to the bottom of the
eye
• It was done “WITHOUT A MICROSCOPE”
• A sharp instrument, such as a thorn or needle, is used to pierce the eye either at
the edge of the cornea or the sclera, near the limbus
• The opaque lens is pushed downwards, allowing light to enter the eye.
• Once the patients sees shapes or movement, the procedure is stopped
• The patient is left without a lens (aphakic)

7. ICCE- INTRACAPSULAR CATARACT
EXTRACTION
• In this technique, the entire cataractous lens along with the intact capsule is
removed.
• Weak and degenerated zonules are a pre-requisite for this method.
• A cryoprobe is used to remove the lens complete with its capsule
• After which anterior chamber IOLs are implanted
• It has been almost entirely replaced by planned extracapsular technique
• At present the only indications of ICCE is markedly subluxated and dislocated
lens.

9. • ADVANTAGES OF ICCE:
• Simple, cheap, easy and does not need sophisticated microinstruments
• ICCE is less time consuming
• Can be done in dislocated or subluxated lens
• DISADVANTAGES OF ICCE:
• PCIOL cannot be implanted
• Post-op complications like C.M.E., R.D., endophthalmitis are more

10. CONVENTIONAL EXTRA CAPSULAR
CATARACT EXTRACTION-
• In this technique cataract is extracted by making an opening in the anterior
capsule of the lens known as anterior capsulotomy.
• Corneo-scleral section from 10-2 o’ clock is made for cataract extraction
• In this type of operation rigid PCIOL is inserted in the capsular bag.
• And corneo-scleral section is then sutured with 9-0 or 10-0 sutures

12. Types of Capsulotomy-
• CAN OPENER CAPSULOTOMY
• CONTINUOUS CURVILINEAR CAPSULORRHEXIS

13. • LINEAR CAPSULOTOMY (ENVELOPE TECHNIQUE)

14. ERA OF IOLs-
• Sir Harold Ridley was the first to successfully implant an intraocular lens on
November 29, 1949, at St Thomas' Hospital , London.
• That first intraocular lens was manufactured from Polymethylmethacrylate
(PMMA)

15. TYPES OF IOL-
ACIOL PCIOL

16. EVOLUTION OF IOLs
1. First generation IOLs
• Ridley lenses
• Disadvantages – posterior dislocation
poor surgical technique
2. Second generation IOLs
• Rigid and semi-rigid anterior chamber IOLs
• Advantages – reduce posterior dislocation
• Disadvantage – corneal decompensation
UGH syndrome

17. 3. Third generation IOLs
• Iris supported lens
• Advantages- less corneal decompensation
• Disadvantages – iris chaffing
pupillary distortion
inflammation

18. 4. Fourth generation IOLs
• Modern anterior chamber lens
• Flexible loops and multiple point fixation
• Advantages – more stable, better design, less complications
• Disadvantages – anterior chamber is not the physiological site for IOL

19. 5. Fifth generation IOLs
• PMMA lenses
• Rigid posterior chamber iol

20. 6. Sixth generation IOLs
Foldable IOL
7. Seventh generation IOLs
Multifocal IOL

21. 8. Eighth generation IOLs
Accomodative IOL
Phakic refractive IOL

22. SICS- MANUAL SMALL INCISION CATARACT
SURGERY
• In this technique ECCE with intraocular lens implantation is
performed through a sutureless self-sealing valvular
sclerocorneo tunnel incision.
• Types of incision in SICS-
1. Frown incision
2. Straight incision

23. Steps in manual SICS
SUPERIOR
RECTUS BRIDLE
SUTURE
CONJUNCTIVAL
FLAP
SCLERAL
INCISION

24. SCLERO-CORNEAL
TUNNEL WITH
CRESENT KNIFE
SIDE PORT ENTRY
AND ANTERIOR
CAPSULOTOMY
ENTRY INTO
ANTERIOR CHAMBER
FROM TUNNEL AND
ITS EXTENSION

25. HYDRODISSECTION
AND
HYDRODELINATION
NUCLEUS PROLAPSE
INTO ANTERIOR
CHAMBER
NUCLEUS DELIVERY

26. IRRIGATION AND
ASPIRATION OF
THE CORTEX
PCIOL
IMPLANTATION IN
THE CAPSULAR
BAG
WOUND CLOSURE

27. PHACOEMULSIFICATION-
• Phacoemulsification, introduced by Kelman in 1967, is
undoubtedly one of the most important innovations in
ophthalmology.
• This allows the removal of cataract through a 3.0 mm incision,
thus eliminating many of the complications of wound healing
related to large incision surgery and greatly shortens the recovery
period.
• Cataract is emulsified using ultra-sonic energy.
• Ultrasonic power is most often produced by enclosed
piezoelectric crystals which convert electricity into mechanical
vibration.
• Normal frequency of various phaco machines ranges from 20,000
to 80,000 (20-80 KHz) Hertz.
• Phaco machines come with a foot switch to control functions of
the machine.

28. STEPS IN PHACOEMULSIFICATION-
CLEAR
CORNEAL
INCISION
SIDE PORT
ENTRY
CAPSULOTOMY

29. INITIAL
TRENCHING
FOUR QUADRANT
DIVIDE AND
CONQUER
PHACO CHOP

30. IRRIGATION AND
ASPIRATION
PCIOL
IMPLANTATION
(MOSTLY
FOLDABLE IOL)
WOUND
APPOSITION BY
HYDRO

31. MICS- MICRO INCISIONAL CATARACT
SURGERY
• Micro incision cataract surgery (MICS) is an approach to cataract surgery
through incision less than 1.8 mm with the purpose of reducing surgical
invasiveness, improving at the same time surgical outcomes.
• The main confirmed advantages of MICS are the control and avoidance of
surgically induced corneal astigmatism and the decrease of postoperative
corneal aberrations.
• Microincision cataract surgery (MICS) was described first time by one of the
authors named Jorge Alió in 2002 in Spain
• Agarwal et al. and Tsuneoka et al. described in parallel this surgical approach to
cataract surgery with other denominations such as Phaconit or bimanual
phacoemulsification-aspiration.

34. Phaco probe tips-
• These are made up to titanium.
• It can have an opening angulation of 0°,
15°, 30°, and 45°.
• Greater angulation facilitates sculpting
whereas lower angle is good for occlusion.
• The tip is covered with silicon sleeve that
insulates and protects the tissue at the
incision site.

35. FEMTO SECOND CATARACT SURGERY-
• Current femtosecond laser technology systems use
neodymium:glass 1053 nm (near-infrared) wavelength light.
• This feature allows the light to be focused at a 3 mm spot size,
accurate within 5 mm in the anterior segment
• It works on the principle of photodisruption.
• Uses-
1. CLEAR CORNEAL INCISION
2. ARCUATE INCISION
3. CCC
4. LENS FRAGMENTATION

36. FEMTOSECOND CATARACT SURGERY Video….

37. ZERO ENERGY CATARACT SURGERY-
• Laser assisted cataract surgery has opened the door towards zero
energy(ultrsonic) cataract surgery.
• Through femtosecond laser it is possible to fragment the nucleus
into very small aspirable particles
• This results in zero or negligible use of phacoenergy for breaking
the nucleus
• Can be done for grade 2-3 cataracts

38. NEW INNOVATIONS-
• VERION
• It is a image guided system for phaco catarct surgery
• It gets linked to the operating microscope
• It takes into consideration keratometry readings of the patient
• Has 3 functions-
• Shows the surgeon exact position for incision which will cause least
astigmatism
• Shows the size of capsulorhexis
• Centration after IOL implantation

40. • CAPSULAR TENSION RINGS
• MALYUGIN RING

41. • The idea of rebuilding the crystalline lens by
filling it with an appropriate substance goes
back at least to Julius Kessler (1959).
• Initial experiments in this field date from
1981, and in 1987 the group led by Jean-
Marie Parel in Miami demonstrated on
primates the viability to recover
accommodation by means of replacement of
the lens material by a transparent gel
• Various laboratories throughout the world
are currently working on a project named
Phaco-Ersatz (substitution of the crystalline
lens)
FUTURE ON GOING RESEARCH

42. References-
• PARSON’S DISEASES OF EYE
• A.K. KHURANA
• KANSKI CLINICAL OPHTHALMOLOGY
• DOS JOURNAL

43. THANK YOU….

44. NEXT PG ACTIVITY
• 01/08/2017
• CASE PRESENTATION
• PRESENTER- DR. SAPAN SIR
• MODERATOR- DR. KAMBLE MADAM
• CONDUCTOR- DR. ARCHANA MADAM