Cataract surgery: Controversies through the ages

From the earliest documentation of cataract surgery, methodology and outcomes have remained a source of passionate debate. Perhaps not surprisingly we have seen the arguments against the acceptance of new techniques and technology often repeated throughout history.

Early history

The debate over acceptance of this new technique was prolonged and heated. Early adopters often became strong proponents of the method based on evidence from their own successful, albeit perhaps limited, experience. Those against continued to argue that patients should undergo the least invasive and technically demanding operation capable of producing acceptable results.

With ongoing development and a growing body of experience, extracapsular surgery however eventually gained widespread acceptance.

Slow progression

In comparison to today's standards, visual and safety outcomes of cataract surgery remained dubious at best with success measured against the relatively modest existing expectations of both surgeons and patients. The potential for visual rehabilitation increased with the continued development of glasses and contact lenses, however despite these advances aphakic correction remained suboptimal with heavy, abberated lenses largely impractical and generally reducing the subjective quality of vision.

Ridley's pioneering presentation at the Oxford Ophthalmological Conference in 1951 on the use of intraocular lenses (IOLs) was largely condemned despite the potential to contribute to improved postoperative visual outcomes and patient quality of life. In retrospect it appears bewildering, however, through to the late 1960's it was still advised that cataract extraction and the use of contact lenses provided visual results sufficient to label any further development of surgical procedures as unwise and a significant gamble.²

The significant developments in IOL technology and weight of evidence eventually superseded the available options. Importantly it was the addition of concurrent technology that helped provide a platform for the enhancement of visual and refractive outcomes.

Adoption of phacoemulsification

The adoption of phacoemulsification into mainstream practice involved a significant investment both financially and in terms of faith in a procedure with unproven foundation. Complementing the addition of the capsulorhexis, phacoemulsification had experienced largely infiltrated mainstream practice prior to emergence of the studies which vindicated it as the technique of choice.^3–5

During its initial implementation a significant learning curve was recognized with surgeons persisting through one hundred or more procedures before reducing complication rates to intracapsular levels.⁶ Despite these hurdles the popularity of the technique continued to grow on the basis of anecdotal evidence. The true potential was only realized with the introduction of foldable lenses, which enabled completion of the procedure through much smaller incisions optimizing infective, inflammatory and astigmatic indices.^7.8

Subsequent large scale studies have demonstrated superiority of phacoemulsification compared to ECCE and ICCE in terms of astigmatism and visual outcomes.^3–5