The slow march of microsurgery into ophthalmology
Looking for the first time at a human eye in a slit lamp is an amazing experience, particularly for a fourteen year old boy. My father was about to start his ophthalmology practice and showed me around on the premises. I vividly remember how one could see the iris move as the slit of ligth moved into the open pupillary area and occasionally also get a glimpse of the (very unsharp) optic disk.
Some twelve years later I encountered binocular slit lamp stereo-biomicroscopy of the eye more seriously; at the beginning of my ophthalmology training. Very quickly I learned all the slit-lamp tricks to handle a foreign body removal instrument, among them the importance of hand support. Of course I also learned how to look pre-operatively at cataracts to decide how to perform the surgery and then look at the results after surgery.
Eventually,when in 1960 I was allowed to start training of cataract surgery for real, there was no longer a microscope! One had to stand and work at 30-40 cm distance with at most a 2x Zeiss loupe to perform the delicate surgery Before and after surgery, yes, you were expected to investigate the situation thoroughly in the slit lamp, but during surgery no such instrument was available. I did not ask at the time why nobody had remodeled a slit lamp for surgery use….dumb as I was.
Of course eye operating microscopes came and conquered in the late sixties; nobody nowadays would dream of performing delicate eye surgery without a stereo microscope. Or without excellent arm and hand support.
Much later, or about now, did I bother to look into the history of eye surgery microscopes. "The concept of magnification evolved from unexplained observations in ancient times to the invention of the microscope by the late 16th century. In the subsequent 3 centuries, scientists made technical advances that greatly improved the power and utility of the microscope. By the early 20th century, otolaryngologists became the first surgeons to use the microscope in clinical surgery." Carl-Olof Nylén of Stockholm is reckoned as one of the founders of microsurgery. In 1921, in the university ear, nose, throat clinic in Stockholm, he built the first operational microscope, a modified monocular Brinell-Leitz microscope for intraoperative use in animals. In November 1921, Nylen used it for a microsurgical operation in a case of chronic otitis with labyrintic fistula. This monocular microscope was rapidly replaced by a binocular microscope developed in 1922 by Gunnar Holmgren. Because of its limited field of vision, very short focal distance, poor light quality, and instability, this microscope was seldom used initially. Despite the development of many different models, it was not until 1951 that a new model appeared, perfected by Littmann and the Zeiss Company. This model replaced all other models progressively, thanks to its ease of use and the possibility of changing the magnification without modifying its focal distance.
It could be that the first to perform serious eye surgery under microscope was one Phinizy Calhoun Jr, MD, Emory Eye Institute; of the famous Georgia Calhoun ophthalmology dynasty. This was in 1947. Very likely Jørn Boberg-Ans of Denmark brougth ophthalmomicrosurgery into Scandinavia, perhaps already in the late fifties.
It remains a mystery why microscope surgery took decades to migrate from ENT to OPHTH, even more why it took at least ten years to move from one room to another within ophthalmology. Just imagine, you removed foreign bodies from the cornea under excellent viewing conditions. But removing delicately a lens from the sometimes firm grip of the zonulae was supposed to be done standing up with almost no enlargement help.
Comments? oh
before surgery
during surgery
after surgery