This document provides a history of cataract surgery procedures from ancient times to modern techniques. It begins with couching procedures from 300 BC and describes the introduction of incisional extraction in 1753. Modern developments include extracapsular cataract extraction (ECCE) and phacoemulsification. ECCE involves removing the nucleus and cortex through an anterior capsulotomy while leaving the posterior capsule intact, allowing for intraocular lens implantation. While obsolete today, intracapsular cataract extraction (ICCE) remains an option for markedly subluxated lenses in under-resourced areas due to less sophisticated equipment requirements.

1. Cataract Surgery-History,
ICCE,ECCE,SICS
Dr. Ramesh Bhandari
Resident, Ophthalmology
BPKLCOS, MMC, IOM

2. CONTENTS
History of Cataract Surgery
Introduction
Major Indications
Procedures-at a glance
Advantages and Disadvantages
Complications
References
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3. History- The Ancient Era
 Early writings say that cataract surgery used to
be performed as early as 300 BC with no
description of methods and techniques.
 For more than 20 centuries, couching was the
primary method for dislodging the cataract away
from the pupil.
 The first written description of couching came
from Sushruta, an ancient Indian surgeon (600
BC)
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4. 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 patient sees shapes or movement, the
procedure is stopped
 The patient is left without a lens (aphakic)
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5. 9/16/2022 5
Bronze instruments of the roman period
(1st century AD) for cataract couching,
found at Montbellet, France

6. The Modern Era
• The father of modern cataract surgery, Jacques
Daviel, introduced the incisional extraction of the
cataract (extracapsular catract extraction)in 1753.
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7.  Between 1753 and 1862, three milestones took place
that profoundly affected the direction of cataract
surgery:
1. Pierre–Francois–Benezet Pamard of Avignon shifted
the surgical incision to the upper part of the eye. He had
the patient lie on his or her back and operated from the
head of the table.
2. Carl Himly, a German oculist, improved the surgeon's
view by introducing pharmacologic mydriasis.
3. Albert Mooren of Düsseldorf added a preliminary
iridectomy to combat the complication of pupillary block.
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8. Introduction of ICCE
• Samuel Sharp (1753) described surgery that introduced
the subject of taking the entire lens out of the eye with
the capsule intact through limbal incision using
pressure from his thumb.
• Albrecht von Graefe (1867) devised his long, thin,
sword-like corneal knife that created better apposed
incision.
• Christiaen (1845) wrote on breaking the zonules with a
curved blunt probe passed into the anterior chamber
(AC).
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9. Techniques (ICCE)
Smith’s method
Arruga’s method
Erysiphakes
Cryo surgery
Chemical dissolution of zonular
fibers
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10. The return to ECCE
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During World war II, Ridley
treated pilots with
perforated foreign body
injuries to the eyes that
had occurred through
splinters of the Plexiglas
domes in the cockpits. He
learned that these
splinters remained
relatively inert in the
internal eye.

11. • Harold Ridley performed his first artificial lens
implant at St Thomas’ Hospital in London on
Nov 29, 1949.
• After trying only two posterior chamber lenses
in patients after ICCE; he put all the rest in
ECCE patients.
• Lens luxation- major problem
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12. • Harold Scheie described a procedure for aspirating
a soft congenital cataract from the eye through
small incisions.He performed aspiration through a
single needle and irrigation with AC maintenance
through a separate needle.
• In 1967, Kelman introduced Phacoemulsification.
 Technically difficult and dangerous :high risk of
corneal damage, capsular rupture, vitreous loss,
and nucleus dislocation into the vitreous
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13. • William Simcoe (1977) introduced his Simcoe curved 23-
gauge cannula connected to a small irrigating bulb.
• In1980, Miller and Stegman use Healon to stabilize AC.
• Gimbel and Neuhann described CCC which allowed safe in-
the-bag nuclear emulsification.
• In 1990, McFarland demonstrated that a properly created
scleral tunnel would make a corneal valve effect that sealed
any egress of AC fluid.
• Fine in February 1992 described a planar temporal clear-
corneal sutureless incision,which was a self-sealing.
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14. • In 1998 ,Amar Agarwal described Phaconit
using bare phaco tip & irrigating chopper
through 0.9mm clear corneal incision.
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15. 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.
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16. • Preferred surgical technique before the
refinement of modern ECCE surgery
• However there remained 5% rate of potentially
blinding complications including:
 Infection
 Hemorrhage
 RD
 CME
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17. Indications of ICCE
Operating microscopes not available
Unstable / luxated cataracts
Week zonular support
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18. Advantages of ICCE
• Entire lens removed with no capsule left behind to:
 Opacify
Require additional surgery
• Less sophisticated instrumentation required
• Non automated extraction devices:
 Cryoprobes
 Capsular forceps
 Erysiphakes
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19. Disadvantages of ICCE
• Large ICCE incision 12 – 14 mm (160° - 180°)
Delayed healing
Iris incarceration
Delayed visual rehabilitation
Vitreous incarceration
• Postoperative wound leaks with inadvertent filteration
• Endothelial cell loss > following ICCE than ECCE
• Corneal / endothelial cell trauma from lifting / folding
of the cornea (lens delivery / cryprobe)
• Cystoid macular edema (transient 50%, persistent 2%-
4%)
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20. • Vitreous complications:
• In young patients PC is firmly adherent to anterior hyaloid; attempted ICCE will usually result in
vitreous loss
• Intact vitreous face may opacify and decrease vision
• Adherence to corneal endothelium (corneal edema)
• Adherence to iris (pupillary block glaucoma)
• Broken vitreous face may incarcerate in the wound with vitreous traction causing:
RD
CME
Vitreous in AC causing open angle glaucoma
• IOL implantation problematic since posterior capsular support is missing
• IOL choices include:
ACL /Sutured PC IOL (Iris fixation IOLs no longer available)
These significant disadvantages and risks led to loss of popularity of ICCE
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21. Procedure
 Patient preparation:
- Informed consent
- Dilation of pupil
- Local anaesthesia and orbital massage
- Cleaning of periocular skin & ocular surface
- Draping
-Eyelid speculum
Superior rectus bridle suture
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22.  Incision:
- Fornix based or limbal based conjunctival flap.
- Wet-field cautery used for homeostasis.
- Partial thickness groove or gutter made through about
2/3rd depth of anterior limbal area from 9:30 to 2:30
O’clock with razor blade knife.
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23. 9/16/2022 23
 -AC entered with razor blade knife or with 3.2mm
keratome.
- Corneoscleral section completed with scissors.
- α-chymotrypsin injected via a cannula through the
pupillary space into the posterior chamber.

24. • Iris retractor used to expose the superior surface of the
lens.
• Cellulose sponge is used to dry the anterior capsule.
• Cryoprobe placed on the lens surface & foot pedal
pressed. After formation of iceball, gentle maneuvers
used to deliver lens.
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25.  Iris reposited into AC & chamber formed by injecting BSS.
 After instillation of acetylcholine, ACIOL or PCIOL with iris
or scleral fixation can be inserted.
 Conjunctival flap secured. Subconj or subtenon antibiotics
& steroids given.
 Patch or shield.
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26. ICCE Today
• Though obsolete today, ICCE is still performed:
1. Markedly subluxated or dislocated lens
2. In less previledged part of world, this has
some role because of the following:
- Less sophisticated instrumentation required
- Visual rehabilitation with temporary aphakic
spectacles is usually possible soon after
surgery.
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27. Extracapsular cataract
extraction (ECCE)
• Extracapsular cataract extraction (ECCE) has replaced
ICCE, almost entirely in most parts of the world:
1. Better operating microscopes
2. More sophisticated surgical aspiration systems
3. More sophisticated IOL implants
• ECCE involves removal of the nucleus and cortex
through an opening in the anterior capsule (anterior
capsulotomy), leaving the posterior capsule in place.
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28. Methods:
ECCE
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Phacoemulsification
Conventional ECCE

29. Merits of ECCE
• A posterior chamber IOL is usually implanted along
with ECCE,which is an ideal Intraocular lens.
• Chances of vitreous loss is very minimal.
• The occurrence of vitreous-related anterior
segment complication is negligible.
• Less chance of cystoid macular edema due to intact
posterior capsule.
• Less chance of retinal detachment.
• An intact posterior capsule guards against infection
(like endophthalmitis) for a prolonged period.
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30. Demerits of ECCE
• A difficult microsurgical technique,costly and takes
time to master.
• Iridocyclitis and glaucoma due to lens particles are
common.
• Opacification of posterior capsule(after cataract)
occurs in a significant number of cases,requiring
YAG-Laser capsulotomy
• ECCE cannot be done in dislocation and is difficult
in subluxation of the lens.
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31. Conventional ECCE-Procedures
• Patient preparation
• Superior rectus bridle suture
• Fornix based conjunctival flap made and homeostasis achieved by wet-
field cautery.
• A groove incision- 11 or 12mm , made in sclera behind the posterior
limbal margin using a diamond knife, round-tipped steel blade or sharp
microknife.
• AC is entered with razor blade knife or keratome.
• Viscoelastic substance is injected into the AC.
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32. • Anterior capsulotomy:
1) Can-opener’s technique: Irrigating cystitome or a
bent tipped, 1 inch, 22 gauge needle is introduced
into AC
Series of connected radial cuts made in anterior
capsule for 360°.
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33. 2) Envelope technique:
Several punctures are made horizontally in the anterior
capsule at 6 O’clock position.
A puncture is made at 10 O’clock & incision extended to
2- O’clock position. After expression of nucleus &
insertion of PCIOL, diagonal incision made on the right
which connects with the end of can-opener incision at 6
o’clock. Similar incision made on the left.
Anterior capsule is grasped with smooth forceps , torn
free & removed.
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34. 3) Continuous curvilinear capsulorhexis (CCC):
- A puncture or small tear is made at the center of
the lens, the edge of which is grasped with
cystotome tip or with forceps & pulled around
smoothly, removing a circular portion of anterior
capsule.
• The fragment of the anterior capsule
is removed with forceps.
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35. 9/16/2022 35
• Hydrodissection:
of the lamellar planes may be performed using a cannula.
• Nucleus may be maneuvered in several directions to
separate it from cortex.

36. • The incision is enlarged using corneoscleral scissors along
the entire length of the previously prepared groove .
 Nucleus delivery
The most popular method- scleral depression.
• Irrigating wire vectis method.
• Injecting viscoelastic material will act as a cushion from the
nucleus to prevent corneal endothelial cell damage.
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37. • Aspiration of cortex: The I/A handpiece with
0.3mm aspiration port passed into AC.The orifice is
directed medially or laterally to engage the cortex
in the periphery.
• It is drawn towards the center of the pupil and
aspirated
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38. • The posterior capsule is then polished with low
aspiration pressure & with port directed against
posterior capsule.
• If the posterior capsule inadvertently becomes
engaged into the aspiration port, aspiration must
be quickly disengaged and the reflex system
employed
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39. • PCIOL implantation:
1)In-the-bag:
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40. 9/16/2022 40
• Viscoelastic injected behind the iris compressing
anterior capsule to posterior capsule.
• Superior haptic is passed behind the superior
portion of the iris. IOL rotated- haptics lie
horizontally & no iris retractions.
• Inferior haptic going beneath
the iris in the sulcus.

41. • Sutured PCIOL
- In ICCE
-Zonular dialysis or PCR
where PCIOL couldn’t be supported.
• Nonabsorbable sutures passed through eyelets.
• Partial thickness flaps
• Sutures are passed underneath the iris into the sulcus and
out into the bed of the previously made scleral flaps
• The IOL is placed gently into position as the sutures are
drawn out through the openings.
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42. • Wound closure
By several radial sutures placed in an interrupted
or in a running fashion.
Tissues brought into approximation without
excessive tissue compression.
 Suture depth of somewhat less than the full
thickness of the wound
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43. Advantages of ECCE over ICCE
• Posterior chamber IOL can be implanted after ECCE, while it
cannot be implanted after ICCE.
• Postoperative vitreous related problems (such as herniation in
anterior chamber, pupillary block and vitreous touch syndrome)
associated with
ICCE are not seen after ECCE.
• Incidence of postoperative complications such as
endophthalmitis, cystoid macular oedema and
• Retinal detachment are much less after ECCE.
• Postoperative astigmatism is less, as the incision is smaller.
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44. Small Incision cataract
Surgery(SICS)
Brief history of SICS
• The scleral tunnel incision was introduced in early eighties in
an attempt to provide better wound healing with less
surgically induced astigmatism.
• This became the most favoured incision technique in the
recent past for sutureless, small incision, non-phaco cataract
surgery.
• Richard Kratz, in 1983 was the first surgeon to move the
cataract incision from the limbus to the sclera thereby
increasing the surfaces of apposed wound to produce
enhanced wound healing and less astigmatism.
• Girard and Hoffman in 1984 were the pioneer to call this
posterior incision as scleral tunnel incision.
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45. • Jack A Singer in 1991 conducted a prospective
clinical trial to evaluate induced astigmatism with
PMMA IOL implantation through a modified pocket
incision, curved opposite to the limbus, which was
named, “Frown incision”, because of its appearance
to the surgeon
• The purpose of the frown configuration was to
reduce wound induced astigmatism
• Paul H Ernest introduced the concept of an internal
corneal lip (triplanar incision); acting as a one-way
valve and imparting selfsealing wound properties
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46. Procedures-
• 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
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47. • Superior rectus (bridle) suture
• Conjunctival flap and exposure of sclera
-Fornix based conjunctival flap is made along the
limbus from 10 to 2 O’clock positions.
-Conjunctiva and the Tenon's capsule are dissected,
separated from the underlying sclera and retracted to
expose about 4mm strip of sclera along the entire
incision length.
• Hemostasis maintained with wet-field cautery.
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48. • Sclero-corneal tunnel incision
1)External scleral incision:
- A one-third to halfthickness external scleral groove
is made about 1.5 to 2mm behind the limbus.
-5.5mm to 7.5 mm in length.
- straight, frown shaped or chevron in configuration.
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49. 2)Sclero-corneal tunnel
-It is made with the help of a crescent knife.
- Extends 1-1.5mm into the clear cornea.
3) Internal corneal incision
- Made with a sharp 3.2 mm
angled keratome.
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50. • Side-port entry of about 1.5-mm valvular corneal
incision is made at 9 o'clock position.
• Anterior capsulotomy:
 Can-opener, envelope or CCC.
• Hydrodissection
 to separate corticonuclear mass from the
posterior capsule
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51. • Nucleus delivery:
-Prolapse of nucleus into AC initiated during
hydrodissection & completed by rotating it with
sinskey’s hook.
- Delivery of nucleus outside done by
* Irrigating wire vectis
* Fish hook
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52. • Aspiration of cortex:
-The remaining cortex is aspirated out using a two-way
irrigation and aspiration cannula from the main incision
and/or side port entry.
• IOL implantation:
- A posterior chamber IOL is implanted in
the capsular bag after filling the bag with
viscoelastic substance.
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53. • Removal of viscoelastic material:
-done thoroughly from the anterior chamber and capsular
bag with the help of two-way irrigation aspiration cannula.
• Wound closure:
-The AC is deepened with BSS injected through side port
entry. This leads to self sealing of the sclero-corneal tunnel
incision due to valve effect. Rarely, a single infinity suture may
be required to seal the wound.
-The conjunctival flap is reposited back and is anchored with
the help of wet-field cautery.
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54. 9/16/2022 54

55. Advantages of Manual SICS over ECCE
• Smaller incision & sutureless so less induced
astigmatism.
• No post-operative suture related problems
(irritation, suture abscess)
• No wound leaks, shallowing of AC, iris prolapse.
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57. LITERATURE REVIEW
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60. 9/16/2022 60

61. Original Article Br j ophthal,200:85-18
Corneal thickness and endothelial density before
and after cataract surgery
A C Sobottka Ventura1001,
R Wälti1002 and
M Böhnke1001
Dra A C Sobottka Ventura, Av 11 de Junho 22, apto 73, Vila Clementino, CEP 04041-000, São Paulo, Brazil
• Abstract
• BACKGROUND/AIMS Deturgescence of the corneal stroma is controlled by the pumping action of the
endothelial layer and can be monitored by measurement of central corneal thickness (pachymetry). Loss
or damage of endothelial cells leads to an increase in corneal thickness, which may ultimately induce
corneal decompensation and loss of vision. Little is known about the effect of moderate reductions in
endothelial cell number on the thickness of the corneal stroma. This study aimed to investigate this
matter further using patients who had incurred moderate decreases in their endothelial cell counts as a
result of cataract surgery.
• METHODS Central corneal thickness was measured 1 day before surgery, 1 day after surgery, and again at
3 months or 1 year. Endothelial cell counts were also performed 1 day before surgery and thereafter at 3
months or 1 year after surgery. The relationship between these two parameters was assessed statistically.
Precise measurements of central corneal thickness were made by optical low coherence reflectometry.
For comparative purposes, this parameter was also determined by ultrasonic pachymetry. Central corneal
endothelial cell numerical density was estimated on photomicrographs taken with a specular microscope.
• RESULTS All patients had significant postoperative corneal swelling on the day after surgery; preoperative
values were restored by 3 and 12 months, even though significant endothelial cell losses had occurred. No
correlation existed between central corneal thickness and central corneal endothelial cell numerical
density. Measurements estimated by ultrasonic pachymetry were more variable and significantly higher
than those determined by optical low coherence reflectometry.
• CONCLUSION As long as the numerical density of the corneal endothelial cells does not fall below the
physiological threshold, a moderate decrease in this parameter does not compromise the pumping
activity of the layer as a whole.
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62. 62
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63. PAST PRESENT FUTURE
63

64. References
• Principles and Practice of Ophthalmology , third edition
,Albert Jackobiec’s.
• American Academy of Opthalmology, Basic Techniques of
Ophthalmic Surgery, Third Edition
• Fundamentals of Clinical Ophthalmology, Cataract Surgery,
Andrew Combes and David Gartry.
• Cataract Surgery ,Third Edition , Roger F. Steinert
• Manual Small Incision Cataract Surgery Springer International
,AAO 2016-17
• Kanski’s clinical ophthalmology, a systematic approach- eighth
edition
• Various internet sources and Journals
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65. THANK YOU
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