The World’s Most Common Surgery: Cataract Surgery Overview Cataract surgery has evolved over 4,000 years from a primitive practice using thorn instruments to a modern 20-minute procedure with over 95% success. Despite these advances, broad access remains the key future challenge. Historical Context Ancient Origins The term cataract comes from Latin and Greek words meaning “waterfall,” symbolizing the cloudy lens. First surgical description by Indian physician Maharshi Sushruta (~600 BCE) detailed couching, a procedure pushing the clouded lens out of the pupil line without removal. Couching was widely practiced for centuries (India, Persia, Europe, Islamic world) but left patients with blurry vision and was rudimentary. Greco-Roman Era 29 BCE: Aulus Cornelius Celsus described couching in De Medicina. Instruments from excavations confirm widespread use. Techniques were proliferated but not significantly improved. Islamic Golden Age Between the 9th-14th centuries, ophthalmology flourished in cities like Baghdad, Cairo, and Córdoba. Ammar ibn Ali al-Mawsili (10th century) innovated a suction method, using a hollow needle to remove rather than displace the cataract—marking a conceptual leap. Surgical Advances Extraction Techniques 1747: Jacques Daviel introduced extracapsular cataract extraction (ECCE), removing cataracts while preserving the posterior lens capsule. 1750: Samuel Sharp proposed intracapsular cataract extraction (ICCE), removing the entire lens and capsule, simpler mechanically but causing inflammation. Both methods left patients without natural lenses, causing severe farsightedness; vision correction was via thick convex spectacles. Intraocular Lens (IOL) Implantation WWII era: Harold Ridley, inspired by RAF pilot injuries involving PMMA (polymethyl methacrylate), developed the first intraocular lens implant. First implantation in 1949 restored partial vision; many refinements followed. Early reception was skeptical, especially in Britain, facing opposition from established ophthalmologists. By the 1970s, thousands of successful implants globally, with growing acceptance. Precision Era and Modern Techniques 1960s: Charles D. Kelman developed phacoemulsification, using ultrasonic vibrations (40,000 times/sec) to emulsify and remove cataracts via tiny incisions (<3mm), enabling faster recovery and less trauma. Subsequent decades saw improvements in instruments, foldable IOLs, fluidics, and integrated computer control. 2008: First Femtosecond-Laser-Assisted Cataract Surgery (FLACS) introduced, using computer-guided laser for precise steps though traditional phaco remains standard. Current Procedure Patient receives local/topical anesthesia. Small corneal incision is made. Ultrasonic probe emulsifies cataract; fragments are suctioned out. Foldable IOL implanted in preserved capsular bag. Surgery lasts about 20 minutes; rapid visual improvement occurs. Access and Challenges Global Inequities Cataract remains the leading cause of blindness worldwide, notably impacting low-resource regions. Cataract Surgical Rate (CSR) varies: High-income countries: 5,000–10,000 surgeries/million people/year. Sub-Saharan Africa: often <500/million/year. Barriers include: Limited infrastructure and trained personnel. Financial costs including hidden expenses (travel, lost income). Gender disparities limiting women’s access. Productivity loss from vision impairment is estimated at $411 billion annually. Innovations to Increase Access Aravind Eye Hospital (founded 1976), India: Hybrid business model: paid patients subsidize free/low-cost surgeries. Produces affordable IOLs (<$10) via Aurolab, providing quality lenses to >140 countries. Organized outreach screening camps identifying underserved patients. Efficient “assembly line” surgery