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Couching: The Earliest Step Towards Neuro-Ophthalmology

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Couching: The Earliest Step Towards Neuro-Ophthalmology

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Couching is the earliest known surgical method of lens manipulation that attempted to relieve the blurry vision of countless patients who had a common ocular condition now known as cataracts. Despite the high risk posed toward each affected eye compounded with numerous possible postoperative side effects, couching was still renowned as the best cataracts treatment for centuries after 0 AD, as patients remained willing to take the chance despite many unfortunate cases¹. Early surgeons most commonly aimed to push the lens down into the eyeball with a needle to shift the clouded structure away from patients' visual axis; however, some patients were left with a completely unfocused path of vision even if the couching procedure partially restored their light detection ability¹.

The 16th century illustration above is what you might find if you stepped into Dr. George Bartisch's office in the late 1500s². Bartisch was a famous German opthamologist known for his work Ophthalmodouleia: das ist Augendienst (1583), the first Renaissance opthamology text written in a "modern language", which was a dialect of Early New High German at the time, that elaborated on eye diseases, dissections, and couching methodology3,4. Ophthalmodouleia describes the best position of the surgeon as taking a seat facing the patient in a well lit room to minimize the risk of couching's blind approach, then carefully navigating the needle behind the iris to reach the lens which required intense focus and an ambidextrous skillset3,4.

Source:

(1)

https://www.pbs.org/video/gross-science-ancient-cataract-surgery/

(2)

https://www.aao.org/exhibition-detail/cataract-surgery-couching-to-phaco

(3)

https://jamanetwork.com/journals/jamaophthalmology/fullarticle/267992

(4)

https://publicdomainreview.org/collection/georg-bartisch-s-ophthalmodouleia-1583

(5) (Image)

https://www.researchgate.net/figure/During-cataract-couching-as-depicted-by-George-Bartisch-in-1583-Notes-The-patient_fig5_301251974

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Important fundamental conclusions on cranial and ocular anatomy were established by Felix Platter, a Swiss physician in the late 1500s who is suggested to be best known for mapping the lens significantly closer to its true position1,2. Platter was the first physician to accurately identify the function of the lens as the organ of vision that focused light, and to correctly separate the function of the lens from the retina, the ocular organ of visual perception, which was successfully achieved through Platter's intricate analysis of the optic nerve drawn in the left-hand image1,2. Notably, Platter understood the importance of the lens's convex structure which was also integral to drawing more accurate conclusions on the characteristics and role of the lens that contributed to the refinement of couching techniques1,3.

The center image above is the cover of Platter's widely influential publication of anatomical illustrations, De corporis humani structura et usu, which significantly advanced the 16th century medical world's knowledge of eye anatomy and positively influenced the development of future surgical techniques given more accurate representations of the eye were available for surgeons to reference in the following years1,4.

Source:

(1) (Image)

https://neuroportraits.eu/portrait/felix-platter.html

(2)

https://www.eurotimes.org/escrs-heritage-lecture-2019/

(3)

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673699903860.pdf

(4)

https://pubmed.ncbi.nlm.nih.gov/2184100/

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Many of the earliest physicians who believed in couching continued to tackle case after case of patients with generically described "blurry vision" until French physician Michael Brisseau began to investigate the physiological implications of that general diagnosis in the early 1700s. Brisseau correctly distinguished cataracts from glaucoma, and noted glaucoma was a condition involving the vitreous humor as opposed to the lens1,2. He went onto accurately attribute standard cataracts to the opacification of the lens rather than to a deficit of a more anterior membrane in 17052. With a large body of dissection work focused on the vitreous humor, Brisseau later pinpointed vitreous discoloration from a medical peer's dissection in 1709 and pioneered the understanding of green cataracts that has also been approved by contemporary physicians and exists today².

The image above shows an early 18th century illustration from the masterful work Traité de la Cataracte et du Glaucoma created by Brisseau that was published in 17093,4. Dissection work was some of the most rewarding work in medicine at the time as physicians and surgeons were generally directing their analyses to smaller structures. Brisseau was also an anatomy and botany professor at the University of Douai that supports how important his discoveries through dissection were to the future development of intraocular surgical procedures1,3.

Source:

(1)

https://jamanetwork.com/journals/jamaophthalmology/fullarticle/417645

(2)

https://www.pbagalleries.com/view-auctions/catalog/id/413/lot/129755/Trait-eacute-de-la-cataracte-et-du-glaucoma

(3)

https://fr.wikipedia.org/wiki/Michel_Brisseau

(4) (Image)

https://vdoc.pub/documents/jakobiecs-principles-practice-of-ophthalmology-3rd-edition-volume-one-23h0692j9i4g (p. 1396)

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At a time when couching was still overwhelmingly considered the premier surgical procedure for addressing cataracts, French ophthalmologist Jacques Daviel became 'the father of modern cataract surgery in 1747 after performing a new procedure which targeted the lens capsule rather than the sclera within couching when moving the lens away from the visual axis, now known as extracapsular extraction¹. Like couching, the extracapsular approach was not perfect. Significant vitreous loss and inflammatory responses from Daviel's new technique were reported which kept the playing field open to new ideas and improvements since the publication of his innovative method in 1753¹.

The 18th century illustrations above walks you through the tools Daviel used that are shown on the lefthand side which included a corneal knife, forceps, scissors, blunted needle, spatula, and spoon to carry out the more detailed maneuvers required for his personalized extraction process depicted in the righthand image². Interestingly, Daviel used his fingers to gently push the cataract into the anterior chamber and onto the cheek in contrast to heavy reliance on the needle for pushing during the days of traditional couching, although in many parts of the world couching was still utilized as the popular go-to method for the common occurrence of cataracts1,2.

Source:

(1)

https://vdoc.pub/documents/jakobiecs-principles-practice-of-ophthalmology-3rd-edition-volume-one-23h0692j9i4g (pp. 1395-1397)

(2)

https://www.aao.org/biographies-detail/jacques-daviel-md

(3) (Image)

https://www.cabinetmagazine.org/issues/40/turner.php

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William Cheselden, an eminent English surgeon, lithotomist, and anatomist at St. Thomas' Hospital in London in the early 1700s, is suggested to be one of the most important physicians of his time¹. Part of Cheselden's work contributed to an important neurological and ocular philosophical idea crafted by the famous late 1600s Irish physicist William Molyneux who is probably best known for the question he posed to John Locke which asked "whether a man who has been born blind and who has learnt to distinguish and name a globe and a cube by touch, would be able to distinguish and name these objects simply by sight, once he had been enabled to see"2,3. Cheselden published the behavior of a congenitally blind patient after cataract removal in 1728 and brought forth evidence supporting the hypothesis that a blind man with restored sight had no immediate ability to see and distinguish between objects but had to learn instead². Although Cheselden's report did not lead to a definitive answer or hypothesis being unanimously ruled true, the surgery associated with Molyneux's question inspired other 18th century surgeons to attempt the replication of Cheselden's work³. Cataract surgery was evolving in a new direction beyond anatomical and technical advancements in which Molyneux's controversial question put extra attention on the field of eye surgery and the abstract extent of its surgical outcomes to treat cataracts³.

Pictured above is a very important, unrestored first edition of Molyneux's Dioptrica nova. A Treatise of Dioptricks, in Two Parts. Wherein the Various Effects and Appearances of Spherick Glasses both convex and concave, single and combined, in telescopes and microscopes, together with their usefulness in many concerns of humane life, are explained ⁴. The English text was published in London in 1692 and contains pivotal ideas on vision elaborated on in the first part of Dioptrica ⁴. Proposition 28 advanced the perspectives of physicians, anatomists, and philosophers of Molyneux's time and in subsequent centuries⁴. For instance, the study of plano-convex, plano-concave, and meniscus lenses helped Molyneux understand the intraocular mechanism of the eye and the lens on a deeper level as separate components, until he synthesized all the pieces of the eye as a composite again, and began to write conclusions on the nature of myopia⁴. In essence, Molyneux's work enabled future surgeons to think about couching, extraction, and surgical outcomes of cataracts treatment in new, more insightful ways.

Source:

(1)

http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC2312162&blobtype=pdf

(2)

https://plato.stanford.edu/entries/molyneux-problem/

(3)

https://www.cabinetmagazine.org/issues/40/turner.php

(4) (Image)

https://www.sophiararebooks.com/pages/books/5246/william-molyneux/dioptrica-nova-a-treatise-of-dioptricks-in-two-parts-wherein-the-various-effects-and-appearances

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Pars Plana Vitrectomies for Vascular Neurosurgery

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Pars Plana Vitrectomies for Vascular Neurosurgery

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WARNING: Medical procedure footage beginning at 1:30.

The video above explains the process of carrying out a pars plana vitrectomy (PPV), a fundamental surgical technique that is typically a component of a wide variety of procedures, including neurosurgical procedures for traumatic brain injuries that lead to intense hemorrhaging within and around the eyeball, or to treat patients diagnosed with Terson's Syndrome triggered by an aneurysm or other form of head trauma1,2.

Without the inception of couching and extraction, the surgical supplementation of PPV may have not been developed. Although the blind approach in couching was very high risk during suffusion removal, the area in which early surgeons were aiming at the back of the eye behind the iris is considered a safe zone today, where surgeons are able to carry out desired manipulations without damaging the retina, crystalline lens, or a patient's previous cataracts implant1,3.

Source:

(1)

https://www.ctretina.net/contents/procedures-surgeries/pars-plana-vitrectomy

(2)

https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.920.3718&rep=rep1&type=pdf

(3)

https://vdoc.pub/documents/jakobiecs-principles-practice-of-ophthalmology-3rd-edition-volume-one-23h0692j9i4g (pp. 1395-1397)

(4) (Video)

https://www.youtube.com/watch?v=tiuttHDKSVc&ab_channel=MoranCORE

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Pars Plana Vitrectomy Surgery and Techniques

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Samuel Sharp will be the best guide to walk you through this exhibit. Sharp was an English surgeon in the 1700s probably best known for his operative literature and introduction of intracapsular cataract surgery¹. Sharp gained one of the highest quality educations of his time in operative surgical methods as the apprentice of William Cheselden². Sharp also studied surgery in France then went onto practice at Guy's Hospital in London for 24 years, retiring on account of a serious illness².

Sharp was dedicated to refining operative methods, studied and mastered couching techniques under Cheselden, and successfully mastered the extracapsular procedure of Jacques Daviel, introducing his latest intracapsular approach soon afterwards¹. Sharp's intracapsular extraction consisted of removing the entire lens while carefully keeping the capsule intact to achieve the same goals couching and extracapsular surgery were pursuing¹. In 1739, Sharp published his most popular technical operation guide, A Treatise on the Operations of Surgery with Descriptions and Representation of the Instruments used in performing them, most likely inspired by the knowledge he acquired under Cheselden that serves as a record of Sharp's exceptional skillset as the very first surgeon in history to make a corneal incision with a single knife during cataract extraction1,2. Although intracapsular surgery was an improvement from the results obtained from couching and extracapsular surgery, both the innovation of "extraction" and traditional "couching" were not free of complications³.

Sharp's deep understanding of couching and pivotal modification of Daviel's initial advancement supports his knowledge of the cutting edge operative techniques during his time by addressing cataracts with a fresh perspective. Based on the evolution of his studies, Sharp would most likely be able to grasp the contemporary surgical techniques ocular medical personnel are familiar with today.

Source:

(1)

https://vdoc.pub/documents/jakobiecs-principles-practice-of-ophthalmology-3rd-edition-volume-one-23h0692j9i4g (pp. 1395-1397)

(2)

http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC2312162&blobtype=pdf

(3)

https://cdn.intechopen.com/pdfs/42710/InTech-The_history_of_cataract_surgery.pdf

(4) (Image)

https://www-jstor-org.proxy.lib.ohio-state.edu/stable/24619195?seq=3