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Cataract Couching Cataract couching Out of the dark and into the light? Shirley Ma, David Kaufman What is Cataract Couching? ❖Cataract couching is one of the oldest surgical procedures. ❖It was in practice as early as 2700 B.C. and was the only method to treat cataracts until close to the 19th century. ❖A sharp instrument is inserted into the anterior chamber at the limbus, The opaque lens is pushed posteriorly into the vitreous, thus eliminating the cataract from the visual axis. This resulted in an aphakic eye. Cataract couching through history ❖The presence of the technique has been inferred as early as 2700 B.C. in ancient Egypt. ❖Copper needles with neither hooks nor eyes have been found amongst other surgical tools in the tomb of King Khasekhemwy (c.2700 B.C) and in the tomb of Skar, the chief physician of one of Egypt’s fifth dynasty rulers. ❖A wall painting in the tomb of the master builder Ipwy at Thebes (c. 1200 B.C) depicted an ocular surgeon treating the eye of a craftsman. Cataract couching through history ❖The first definitive description of cataract couching was by an Indian surgeon Maharshi Sushruta in a medical treatise named Sushruta Samhita, Uttara Tantra (c. 800 B.C). ... a curved needle was used to push the lens into the vitreous and out of the visual axis. The eye would later be soaked with warm clarified butter and then bandaged. ❖The technique was later introduced to Central Asia, Middle East and Europe. ❖The first reference to couching in the West was in De Medicina, by the Roman philosopher Aulus Cornelius Celsus in the 1st Century. ❖Couching remained a widely practiced procedure until the advent of extracapsular cataract extraction in 1747. Text Couching Instruments Current Day Practice ❖Since the advent of extracapsular cataract surgery, couching has largely been relegated to the history pages. ❖However, it is still being practiced in rural and remote areas of sub-Saharan Africa, Sudan, Morocco, India, Nepal, China and Yemen. ❖The practitioners are usually traditional healers or witch doctors who provide negligible post-operative care. Current Day Practice Factors influencing patients to seek traditional healers: ❖ Being cataract blind ❖Rural and remote location/lack of access to modern medicine ❖Lower socio-economic class ❖Lower level of education ❖Entrenched belief system in traditional healers, “fate” and “acts of God” The Issues ❖Crude, ineffective and has high complication rates. ❖No quality control for practitioners, sterility nor appropriate anaesthesia or analgesia. ❖It may be presumed that its prevalence in ancient cultures was due to a lack of an alternative. In 1583, George Bertisch made scathing remarks of the practitioners of couching in his book on ophthalmic eye care: “... Nor is there any lack of old women, vagrant hags, therica sellers, tooth-pullers, ruined shopkeepers, rat and mouse catchers, knaves, tinkers, hog-butchers, hangmen, bum- bailiffs, and other wanton good for nothing vagabonds... All of whom boldly try to perform this noble cure.” The Issues ❖Success is often measured in terms of the patient’s ability to see moving objects immediately after the procedure. ❖The patient would enjoy days of ‘being cured’ before the onset of complications, often in the form of severe eye pain and uveitis. ❖Other complications include corneal scarring, retinal detachment, secondary glaucoma and endophthalmitis. ❖Long term VA post couching found to be very poor. Most studies reported a complete loss of sight for at least 60% of couched patients (VA <3/60) and low patient satisfaction. Acknowledgement ❖ Dr David Kaufman ❖ Dr Heather Mack References 1) F.J. Ascaso and V. Huerva. The History of Cataract Surgery, Chap 6, Cataract Surgery, InTech, ISBN: 978-953-51-0975-4, InTech, DOI: 10.5772/19544. (2013) 2) Gilbert C.E., Murthy, G.V.S., Sivasubramaniam S., Kyari F., Imam A., Rabiu M.M., Abdull M., Tafida, A. “Couching in Nigeria: Prevalence, Risk Factors and Visual Acuity Outcomes.” Ophthalmic Epidemiology. 17.5 (2010): 269-275. 3) Ntim-Amponsah C.T. “Traditional Methods of Treatment of Cataract seen at Korle-Bu Teaching Hospital.” West African Journal of Medicine. 14.2 (1995): 82-87. 4) Schémann, J.F., Bakayoko, S., Coulibaly, S. “Traditional couching is not an Effective Alternative Procedure for Cataract Surgery in Mali.” Ophthalmic Epidemiology. 7.4(2000): 271-283. 5) Ahmed Siddig, Mohamed and Ali Mohamed Ali, Nadir. “Complications of Couching and Visual Outcome After IOL Implantation – a study of 60 patients in Sudan.”Sudanese Journal of Opthamology, 1.1 (2009): 33-36. 6) Negrel, A.D., Chami Khazraji, Y., Azelmat M.“Cataract-related Blindness in Morocco. The Moroccan Group of Epidemiologic Evaluation of Blindness.” Medecine Tropicale” revue du Corps de santé Colonial 55.4 (1995): 421-424. .
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