Sarah Knows Eyes

Last month, having possibly scared the living daylights out of anyone facing the prospect of cataract surgery, I thought I’d better try to redeem myself, by pointing out that it’s really not THAT bad! Medicine has indeed moved on significantly since the 18th century and, certainly in the Western world, the brutal “couching” is by far a thing of the past. Today, surgeries in which cataracts are removed and the lens replaced are among ophthalmology's (and medicine's!) most successful procedures.

Firstly, let’s start by explaining what exactly a cataract is. As briefly touched upon in my blog “The Truth About UV Protection”, a cataract is the opacification (clouding) of the lens in the eye.

I’m a little ashamed to admit, but it wasn’t until researching this blog that I realised just how many different types of cataract there are! The most common is ‘age-related’, caused by prolonged exposure to ‘incident’ (present in the environment) ultraviolet radiation. Most people will develop cataracts as they get older – more than one in two people aged 65 and older have some signs of cataract, and they are present in almost everyone over 75.

Some people are born with them – these are known as ‘congenital’ cataracts. A trauma to the eye can cause a cataract, as can certain metabolic disorders, such as uncontrolled diabetics, galactosemia, Wilson disease, and Myotonic dystrophy.

NHS guidelines concerning referral for cataract surgery are very prudent and basically tie-in with the DVLA’s driving standards: -

“You must be able to read (with glasses or contact lenses, if necessary) a car number plate made after 1 September 2001 from 20 metres.

You must also meet the minimum eyesight standard for driving by having a visual acuity of at least decimal 0.5 (6/12) measure on the Snellen Scale (with glasses or contact lenses, if necessary) using both eyes together or, if you have sight in one eye only, in that eye.”

/via https://www.gov.uk/driving-eyesight-rules

As result, we wait until the cataracts are “ripe”, i.e. the Optometrist can no longer correct your vision to comply with these driving standards. There are exceptions to this rule, for instance, a patient who experiences disabling glare due to cataract when driving may still achieve a visual acuity of better than 6/9 under ideal conditions of illumination, or where anisometropia is causing symptoms. On occasions, cataract surgery may be performed primarily to aid the management of other eye conditions, for instance to facilitate surveillance or treatment of diabetic retinopathy or to improve intraocular pressure control in primary angle closure glaucoma.

 

Just kidding!!!

The procedure itself is usually done under local anaesthetic. You will be awake, but the ophthalmologist will make sure you do not feel the area around your eye. You should (hopefully!) hear the ophthalmologist explaining what he/she is doing, and you may see some vague movements around your eye. The ophthalmologist will make a tiny cut in your eye to remove the cataract - they basically blast the clouded lens with ultrasound and then suck out the remnants. They will normally then insert a plastic replacement lens so that you can see clearly again. This will usually take between 15-45 minutes. The procedure generally does not require stiches, but your eye will be covered to protect it from knocks after the operation. You will be allowed to go home the same day, but you should have someone go with you to the appointment, and to look after you for the following 24 hours. You must not drive.

Now, I absolutely hate the thought of somebody poking about in my eyes, I’d rather have a Ceti eel crawl in my ear, but having been working in Optics for 14 years now (yes, I’m THAT old!) I have seen many a patient before and after having their cataracts done, and they all assure me that there is absolutely nothing to be nervous about. And that the results are amazing!

If any of you are waiting to have your cataracts done, I hope this blog post has gone, even just a little way, to putting your mind at rest, but as always, if you have any questions, or would like any further information about this topic, then please do not hesitate to contact me using the “Ask Away” link above.

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Okay, so the title may be a little overdramatic and not strictly true, but it stems from a conversation I (unwittingly) overheard in practice the other day that peaked SarahKnowsEyes curiosity – I had to investigate further! Delving deeper, I discovered a fascinating and gruesome tale that I couldn’t wait to share with you all (aren’t I nice?!).

 

 Johann Sebastian Bach

In 1749, at the age of 64, it is safe to assume that Bach’s vision had deteriorated naturally with age, he was undoubtedly presbyopic and hence required some form of magnification for reading, but it would seem that he had also developed cataracts, at a reasonably young age it has to said. (Of course, he could have been born with them, but I’m going slightly off at a tangent now…)

Although it would appear that cold hard facts are somewhat difficult to come by, we do know that Bach had either one or both of his eyes operated upon during the final days of March 1750 by a traveling British eye surgeon, or "oculist", the (self-appointed) Chevalier, John Taylor, and that at least one (possibly both) had to be operated on again a week later. This second operation left Bach totally blind. He was blind when he dictated his final work (The Art of Fugue), and he died a few months later on the 28th July 1750, from what was described as a “painful eye condition”.

More than two-and-a-half century's later, prominent Finnish ophthalmologist, Ahti Tarkkanen1, offered what he called a “plausible diagnosis” of the great composer: “Because Bach was blind after the second operation, and suffered from immense pain of the eyes and the body, the symptoms could be compatible with acute intractable secondary glaucoma.” It is also possible that the procedure may have caused retinal detachment(s). It is notable that Tarkkanen refers to Taylor as a “surgeon” in quotation marks, giving you some idea of his lack of respect for the practitioner.

Chevalier John Taylor

Daniel Albert2, the author of Men of Vision, a history of ophthalmology, calls Taylor “the poster child for 18th century quackery” noting that he “practiced in the most flamboyant way, drawing crowds to watch procedures in the town square, and then getting out of town before the patients took their bandages off." In fact, an entire chapter of his book is dedicated to Taylor's colourful, if somewhat gruesome, career. He describes him as "the most infamous of all ophthalmic quacks." His arrival into town would be heralded by placards and handbills, and his coach was decorated with paintings of eyeballs and the motto: "Qui dat videre dat viver" (He who gives sight, gives life).

This just makes me think of James Franco’s Wizard of Oz, in the 2013 film “Oz the Great and Powerful”:

Taylor performed a “couching” on Bach, which is the oldest (dating from 2000 B.C.) and crudest form of cataract surgery. It involves dislocating the cataract lens with a sharp or blunt instrument,such as a needle, which is poked into the eye to effectively push the cataract-clouded lens back into the posterior chamber, out of the field of vision.

/via www.bioline.org.br

At the time, physicians had no concept of bacteria, and no anaesthesia, so the idea was to operate as quickly as possible. "If you had a good result a third of the time, it was par for the course," Albert says of 18th century techniques: "People didn't expect a good outcome; they knew if they put themselves in the hands of an eye surgeon, they were taking a big chance." Of course, the risks may have been greater with a charlatan like Taylor… 

Whilst there is no obvious cause-and-effect relationship between the operations and Bach’s death, Taylor’s postoperative care regime reads more like torture, by which the Orion Syndicate seem like pussy cats in comparison?! It included the use of eye drops of blood from slaughtered pigeons, pulverized with either sugar or baked salt, whilst in the case of serious inflammation Taylor prescribed large doses of mercury. In a 2005 paper examining the same subject, physician Richard Zegers3 notes that “the operations, bloodlettings, and/or purgatives would have weakened him and predisposed him to new infections.” Ultimately, a post-operative infection is the most likely the cause of Bach’s death.

Perhaps most tragically, a more modern method was being tested in a neighboring nation. In 1747 – three years before Bach’s operation – Paris-based ophthalmologist Jacques Daviel conducted the first cataract operation using a new, safer, more effective method. His “extracapsular technique” would soon become the standard procedure for cataract operations, and remain so until the early 20th century. Today, surgeries in which cataracts are removed and the lens replaced are among ophthalmology's most successful procedures.

Sadly, it was too late for Bach, and seemly so for another great composer of that era, George Frederick Handel. In 1751, he, too, underwent the surgery, several times, probably the last one at the hands of Taylor– and, like Bach, none of the surgeries worked and he was left blind. Poignantly, the lyrics to “Samson": "Total eclipse. No sun, no moon, all dark." – were written as Handel's eyesight failed.

George Frederick Handel

Wowsers! Let’s just say it makes me thankful that medicine has moved on somewhat since then! Or has it…

I was shocked to learn that this procedure is still in use in some parts of Africa and India! Tarkkanen points to a 2009 study from Sudan that examined the ultimate outcome of 60 contemporary couching patients. It found 60 percent of them were totally blind, due to glaucoma. Frightening!

 

Bibliography

  1. Tarkkanen, A. (2012). Blindness of Johann Sebastian Bach. Arch Ophthalmol. Mar; 91(2): 191-192.

  2. Zegers, R. H. C. (2005). The Eyes of Johann Sebastian Bach. Arch Ophthalmol. Oct; 123(10).

  3. Albert, D. M. (1994). Men of Vision: Lives of Notable Figures in Ophthalmology. Saunders

 

And special thanks to:

Susan LambertSmith (http://www.med.wisc.edu/news-events/handel-bach-were-blinded-by-18th-century-quackery/25951) and Tom Jacobs (https://psmag.com/why-did-bach-go-blind-5957636c6b41#.gc62182b7) whose articles made for such an inspiring read, and made this blog post possible!

 

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Finally succumbed once all the "the new update is evil" fracas abated, and updated to iOS 9.3.1. This is an interesting little feature, especially following SKE March blog...

P.S. I've set it up and love it BTW! #NightShift

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