Vincenz Fukala (1847–1911) and the early history of clear-lens operations in high myopia

Abstract

Vincenz (Wincenty) Fukala, was born in 1847 in Zolkiew at Galicia in Poland, studied medicine and ophthalmology in Vienna in 1871. He was a pioneer in systematically extracting the clear crystalline lens in young patients with high myopia. He demonstrated the benefit to this group of increased visual acuity which enabled them to work and ophthalmologists gradually began to carry out surgery in high myopes worldwide. He persisted in operating despite the vigorous opposition of several authorities but, through sheer determination he convinced skeptics of the efficacy of his surgical method of lens dissection. He performed the first lens discission in 1887 and in 1894, he had successfully treated 44 patients. The late complication of retinal detachment, which was not understood until years later, eventually led surgeons to abandon the procedure until the recent improvements in both lenticular and retinal surgery techniques that led to better prognosis.

Introduction

Fukala is mostly remembered for his work in the promotion of clear-lens excision as early as 1890. However not much is known about his origin and his private life. Hence, we undertook a comprehensive study of the national and university archives in the cities where he lived, including Cracow, Vienna, Pilsen and Karlove Vary, which allowed us to gather additional information.

Vincenz (Wincenty) Fukala was born in a Polish family in Zolkiew (Żółkiew) in Polish Galicia (now Ukraine) on January 22nd, 1847.^1–4 He studied medicine in Vienna. After completing his thesis on February 21st, 1871, he specialized in ophthalmology under the well respected professor, Karl Ferdinand von Arlt. From 1889 to 1894 he worked as an ophthalmologist in Pilsen (Pilsen-Karlsbad) and Karlove Vary. Fukala returned to Vienna in 1895, where he died on October 27th, 1911.

His other clinical achievements, including surgical methods for treating ectropion for chronic blepharitis, orbital surgery and history of ophthalmology studies are presented elsewhere.²

Historical background

The first person to propose clear-lens surgery in high myopia was probably the French Abbé Desmonceaux in 1776. He recommended the operation to Baron Michael Johann de Wenzel. Yet no publication by Wenzel exists, and we do not know whether he ever performed the surgery.^3–5

Fukala’s operation

Fukala’s indications for surgery were very strict. Patients had to have very poor vision, were unable to work and have myopia of −13 D or higher. He only operated on children with progressive myopia and on young adults; the upper age limit was approximately 40 years. In patients with myopia of about −18 D Fukala recommended bilateral surgery to establish binocular vision.⁶ If myopia was progressive in children between five and ten years, Fukala also operated for −10 D of myopia. He opposed surgery on eyes with pathological changes in the fundus, including chorioretinitis.⁶ This point of view was supported by Barnes⁷ Höpner,⁸ Thompson,⁹ Fuchs,¹⁰ Fergus¹¹ and Wyler,¹² and opposed by Gelpke and Bihler,¹³ Sattler,¹⁴ Scheffels,¹⁵ and Vossius.¹⁶

Fukala’s procedure consisted of discission of the clear lens with subsequent needling and extraction of the swollen lens material. Postoperatively, most of his patients had good visual acuity and enjoyed working for the first time in their life. The surgical goal was to observe a clear pupil at the end of surgery. After antiseptic treatment of the anterior eye with a solution of sublimate (1:5000), he dissected the lens and waited several days until the lens fragments were swollen before washing out the lens material.^17,18 Postoperatively, he treated the eye with atropine. When intraocular inflammation, pain or photophobia occurred, he removed any remaining swollen lens material by needling. He performed iridectomy for the rare cases of increased intraocular pressure. In 1890 he had successfully treated 19 patients who were between 8 and 23 years old.¹⁸ In the book published in 1891 (Fig. 1A), he reported on his surgical procedure involving careful discission of the lens capsule via crosswise sections.¹⁹ Fukala feared that excessive lens swelling after discission may lead to iritis, increased intraocular pressure, and pain.²¹ To avoid these complications, he recommended, making small, crosswise incisions in the capsule when carrying out his initial surgeries. He later changed his mind because multiple needling intervention was cumbersome for the surgeon and the patient.²⁰

Figure 1.

(A) Fukala’s book on cure of high-degree myopia by removal of the lens (1891); (B) Translation of Fukala’s first comprehensive publication from Graefe’s Archive of Ophthalmology by Casey A. Wood (Chicago) (1890); (C) Translation of Fukala’s Publication from 1891.⁸²

Opponents and proponents of Fukala’s operation

Despite the vigorous opposition from renowned specialists, especially Donders, Fuchs and von Graefe, Fukala pushed through his ideas and continued operating on myopic eyes. Donders argued, at an ophthalmological meeting in 1894 in Edinburgh, that extraction of the lens in high myopia would be a “punishable presumption” because the aphakic eye would be put at a disadvantage in comparison to its preoperative condition.²¹ Donders also feared that aphakic patients would lose their accommodation completely. Fukala thought, however, that Donders was arguing theoretically, not from practical experience. He emphasized that preoperative accommodation in a highly myopic eye is inconsequential.^34,35 He also observed that his patients were able to do work at close up and at a normal distance without difficulty postoperatively. Hübner confirmed Fukala’s experience that postoperative vision of myopic patients was much better.²² Lawford argued: “The loss of the power of accommodation, which was thought by Donders to be a serious objection to this treatment of myopia, has proved to be no objection at all. The range of distinct vision for reading is greater and infinitely more useful in these highly myopic eyes, after removal of the crystalline lens, than that which they previously possessed by reason of their power of accommodation”.²³ Fukala calculated the increase of the retinal images, demonstrating that an aphakic eye reveals a reduced optic system without lens reflexes as an additional explanation for the better postoperative sight of the patients he treated.²⁴

Fukala performed the first lens discission on April 3rd, 1887 and in 1889 the first lecture on the surgical treatment of high myopia was presented.²⁵ In the discussion to that report, Fuchs criticized Fukala, maintaining that clear-lens removal in high myopia was not only a waste of time, it could even be dangerous under certain circumstances.²⁶ Ten years later, Fuchs had changed his opinion on the indication for surgery. He wrote that he did not oppose surgery in high myopic patients in principle. In 1899 Fuchs reported that 10 patients in his clinic with high myopia had been successfully surgically treated.¹⁰ By the end of 1889, Fukala had successfully treated 14 patients.²⁶ Postoperatively, most of his patients had good visual acuity and enjoyed working for the first time in their life. 1890, Fukala operated on 19 eyes¹⁸ Fukala also observed postoperatively that retinal images were about one-third larger and that visual acuity improved four- to eightfold compared to preoperatively.²⁷

Fukala’s idea to treat patients with high myopia by removal of the clear lens was mainly supported by the opinion of Ludwig Mauthner. He emphasized in his textbook that the vision of patients with high myopia may improve if the lens was removed.²⁸ Fukala’s teacher Karl Ferdinand v. Arlt supported Mauthner’s idea, however, he said he would not have the courage to carry out clear-lens extraction because of the fear of surgical complications.²⁵

Two years after Fukala’s first operation,²⁹ Louis Vacher also treated patients with high myopia independently from Fukala. Vacher, however, mainly treated patients who were older than 30 years, in contrast to Fukala who only treated young people with high myopia. Vacher thought that clear-lens extraction constituted a prophylactic procedure against retinal detachment, and had successfully treated seven patients with clear-lens extraction. He wrote: “My operated patients are almost all over the age of 30 years.... I believe that crystalline-lens extraction has, despite the surgical difficulty and dangers of a similar intervention, become at this time the best therapy with which to prevent the terrible complications associated with progressive choroidal myopia; it suppresses the most definitive cause of atrophic choroiditis and probably retinal detachment”²⁹ Vacher performed a direct extraction of the lens in contrast to Fukala, who carried out discission of the lens with consecutive repetition of discussions.^17,18

Reports on Fukala’s operation

Casey A. Wood translated Fukala’s publication from Graefe´s Archive of Ophthalmology¹⁸ for the American Journal of Ophthalmology [Fig. 1B]. In this comprehensive article, Fukala reported having treated 19 eyes with 13 D and higher during the previous three years. The patients on whom Fukala operated showed at least a fourfold improvement in vision. They could read Jaeger No. 1 at their punctum remotum. Fukala emphasized the advantages of aphakia in his patients: sharp distance vision, and enlarged retinal images. He also found that the excessive accommodation strain had disappeared, and that his myopic patients no longer bent over during work.

In his second publication in the American Journal of Ophthalmology [Fig. 1C], he argued: “the loss of the power of accommodation in myopes of the highest degree is not a disadvantage, but is of a considerable advantage”.⁸² He explained also that accommodation raises intraocular pressure and worsens myopia.⁸²

Many surgeons advocated operating on young patients.^{3,11,12,16,30–32} Bonnefon³¹ argued that complications in older patients were more frequent, including glaucoma and retinal detachment. Pause⁸¹ compared visual acuity in a younger group of nine patients (mean age: 17.3 years) to an older group of 10 patients (mean age: 28.7 years) and found better results with the first group.

Barnes argued that the “operation of the lens in high degree of myopia is justifiable when vision cannot be improved by glasses, there are no serious fundus lesions, the myopia amounts to 15 D or more, and there is evidence that the degree of myopia, already high, is rapidly increasing”.⁷ Barnes concluded his article: “...it, however, appears that the large majority, particularly of European ophthalmologists, believe that the Fukala operation, in spite of its not being ideal in all respects, is, within certain limitations, indicated, and that it constitutes a very great advance in eye surgery”.⁷ Wyler wrote that the “...following indications seem to warrant the procedure: a myopia of at least 14 diopters, this is the minimum, for 18–20 D give better results; the degenerations of the fundus must not be very far advanced or the vitreous greatly diseased, for under such circumstances a good vision can hardly be expected; if the patient can follow his daily occupation without discomfort nothing should be done; patients over 40 years should not be operated upon, unless absolutely imperative, for after this age a needling and linear extraction will not meet the requirements, and a simple extraction in a high myope is not only exceedingly difficult, but hazardous”.¹²

In 1894, Fukala³³ reported on 44 patients who successfully underwent surgery from 1887 to 1894, observing a three- to fivefold increase in visual acuity in his patients. In 1896, Fukala reported that several surgeons had also routinely operated on highly myopic patients, namely Schweigger in Berlin, Pflüger in Bern, Thier in Aachen (each about 100 patients), and v. Hippel in Halle and Sattler in Leipzig (each about 80 patients).²¹ There were more surgeons operating on highly myopic patients by clear lens excision, but Fukala did not mention them all; on the whole, about 1000 patients underwent surgery at that time.

Fukala’s drive and competence ultimately convinced his skeptical colleagues of the efficacy of his surgical method of lens discission. Those who supported him early were Pflüger,³⁰ von Hippel,^35–38 Haab,³⁹ Sattler,¹⁴ Thier,^40,41 von Schröder,⁴² Hirschberg,⁴³ von Grosz,⁴⁴ and Blumenthal.⁴⁵ Some of his proponents modified his operation technique into direct lens extraction.¹⁴ Von Hippel wrote: “Fukala´s operation was initially regarded with suspicion, yet within a short time more and more ophthalmologists came out in favor of this surgical procedure ... perhaps those of you who are sceptical or reject it could abandon your theoretical doubts to enable patients (who for so long had to do without both) to work and enjoy life”.³⁸

After Fukala’s first successful reports, highly myopic patients were gradually operated on by ophthalmologists in Europe (mainly Switzerland, Germany, Austria, France, Poland, England, Sweden, Hungary, and Russia). Lawford²³ argued that the treatment of high degree myopia by removal of the crystalline lens is “one of great and probably increasing importance”. This operation was, however, rarely carried out in the USA.⁷ Barnes⁷ wrote: “Up to this writing, there have been about 2500 of the operations reported from abroad, while, after a painstaking search of the literature of this subject, I have found not quite fifty cases reported in America”. Wilmer⁴⁸ presented one case of the operation with which the visual acuity improved in Archives of Ophthalmology in 1898. Ophthalmologists took Fukala´s surgical advice, and their patients enjoyed postoperative visual progress as a distinct improvement in visual acuity and visual field enlargement. We may assume that over 3000 patients with high myopia underwent surgery in Europe at the turn of the century.

There were many reports indicating advantages of the operation and its safety. Wyler wrote that “the conclusions which I draw are firstly — that the operation is no tone of choice, but rather of indication. Secondly, that it is not an exceedingly dangerous procedure, in fact the dangers have been exaggerated. Thirdly, that the advantages are many, and any relief in a position of this kind is well worthy of a careful consideration”.¹² Elschnig reported in 1920 that many treated patients spoke with joy that after surgery they noticed the beauty of the world for the first time in their lives.⁴⁹ Thompson,⁹ who operated by himself on 19 patients with high myopia, reported a 3 year old child operated by his tutor, who after 10 years was “6/12 in the operated eye with hypermetropia of + 1.5 D. “He added also that in the unoperated eye the myopia had grown to −20 D”.⁹ Other authors such as Gelpke and Bihler,¹³ Gelpke⁵⁶ Horn,⁵¹ Magen,⁵² Otto,⁵³ Scheffels¹⁵ praised Fukala´s operation as a great innovation in ophthalmology.

Complications of Fukala´s operation

After statistical evaluation of surgical results in the first decades of the 20th century, ophthalmologists became aware of complications of clear-lens extraction. Scott wrote that “in view of the inflammatory risks with their far-reaching consequences which the myopic patient would have to incur, quite apart from the possibility of the occurrence of retinal detachment, etc., the surgeon in the present state of our knowledge should wholly abstain from recommending the operation of removal of the lens in cases of high myopia”.⁵⁴ Barnes⁷ enumerated dangers of the clear-lens extraction, including hemorrhage and loss of vitreous humor, retinal detachment, incarceration of the iris or capsule, glaucoma, iritis, and infection. Barnes⁷ also stated that retinal detachment occurred “according to European authorities” in only three to five percent of cases. He also argued that glaucoma could be “avoided by extraction within a proper interval after operation, and it should not occur in a carefully watched case”.⁷ Sidler-Huguenin⁵⁵ was one of the first authors who reported already in 1906 on poor surgical results in patients with high myopia. He evaluated data on 75 patients with high myopia who had undergone surgery years earlier by Haab in Zürich.³⁹ The first operations had been carried out 20 years earlier, the other 12 years prior to the study. Sidler-Huguenin⁵⁵ found that out of 50 examined patients, macular hemorrhages occurred in 18, retinal hemorrhages in 11, and retinal detachments in 13. Sidler-Huguenin⁵⁵ concluded that the original enthusiasm for the surgical procedure was unwarranted.

Soon, it became recognized that retinal detachment was a major sight-threatening complication of the surgery.^{54,67,69,72,74–76,78,80,83} Gelpke⁵⁶ was the first to note that the retinal periphery should be examined in patients with high myopia, stating that peripheral retinal changes indicate a risk for retinal detachment. In the discussion following Fukala´s presentation,⁵⁷ Valude reported on the postoperative binocular retinal detachment in a 10-year-old child with −15 D.⁵⁷ Von Hippel,⁵⁸ who operated on 275 eyes with high myopia between 1893 and 1905, reported retinal detachments in 9.5%. Huber⁵⁹ reported on late follow-up complications in more than 100 eyes operated on by Otto Haab, including new macular disease in 14.7%, vitreous opacifications in 16%, retinal hemorrhages in 14.7%, retinal detachment in 6.7% (two occurring after ocular trauma), optic atrophy in 2.7%, ocular infection leading to blindness in 1.3% and glaucoma in 1.3% of the patients. Eperon estimated a frequency of retinal detachment of about 10% in the operated patients.⁶⁰ Vossius⁶¹ reported that visual acuity decreased over time in 24 of 60 operated eyes: in 10% due to secondary cataract, in 5% due to glaucoma, and in 18.3% due to retinal detachment. Retinal detachment was most frequently observed after primary extraction of the lens. Fröhlich⁶² reported that 3.3% patients out of 572 operated had retinal detachment and 2.2% became blind due to the ocular infection. Fischer calculated that the risk of retinal detachment in 1280 unoperated eyes with high myopia was far less than 0.5%, which he compared to the cumulated risk of blindness due to both retinal detachment and infection, which totaled 5.5%.⁶³ Fischer indicated an 11-fold higher risk of blindness in patients who underwent clear-lens surgery.⁶³ De Font-Réaulx analyzed about 1620 case histories in the literature published before 1900, and found that in 92% vision improved, and in 3.4% did not change.⁶⁴ Imai evaluated the results of operations in 974 patients with high myopia in the literature, finding good results in 923 patients, ocular infection in 1.4%, and retinal detachment in 3.8%.⁶⁵ The percentage of retinal detachment in the Gießen clinic was at that time about 18.3%, and results were worse after primary extraction of the lens than after discission.

The frequency of retinal detachment varied between 3% and 10% due to variation in the length of the follow-up of the treated patients, and it was likely related to strict indications for surgery.

Other complications of clear lens surgery in high myopia included corneal opacification after secondary cataract surgery,⁶⁶ subtle corneal changes,¹⁶ incarceration of parts of the capsule in the corneal wound,¹⁶ vitreous prolapse and vitreal incarceration in the corneal wound leading to retinal detachment,³ the increase in pressure noticed after discission and chronic glaucoma⁶⁷ iritis which disappeared after removal of the lens masses within four weeks,⁶⁸ posterior synechiae,⁶² secondary cataract (tight pupillary membranes),⁶⁹ and vitreous opacifications.⁷⁰

Clear-lens extraction in recent decades

At the end of the 20th century clear-lens excision in high myopes was re-discovered. The more detailed review of this is available elsewhere.⁷¹ This was probably due to the fact, that the risk of complications of the operation decreased significantly compared to the reported 100 years before. It was shown in one of the recent studies that the retinal detachment was observed in 0.66% of 763 operated patients after laser photocoagulation.⁷² Colin and Robinet reported, using argon laser photocoagulation before clear-lens excision, the incidence of retinal detachment after 18 months is 1.9% and after seven years – 8.1%.^73–75 Barraquer et al. using different surgical techniques, including intracapsular extraction (3.0%), aspiration (59.4%), and extracapsular extraction (37.6%) reported that RD developed in 7.3% after 30.7 ± 26.6 months postoperatively.⁷⁶ A clear association between postoperative YAG laser/posterior capsulotomy and the incidence of retinal detachment was also shown ⁷⁶. Luis Fernández-Vega et al. reported an incidence of 2.1% of RD incidence at 39 months of follow-up of 190 operated eyes,⁷⁷ whereas Horgan et al. reported 3.2% rate of RD in 5 months of follow-up of 62 patients.⁷⁸ Guell et al. reported no retinal detachment in the 44 operated eyes with four-years of follow-up⁷⁹ However, Alvaro Rodriguez et al.⁸⁰ reported that 30% of patients after clear-lens extraction in axial myopia developed retinal detachment, which was not prevented by prophylactic photocoagulation and cryocoagulation. Comparison and discussion of these studies is tenuous at best as they vary in patient age, inclusion criteria, follow-up and surgical techniques. It is however obvious that complications of the clear-lens excision could nowadays be managed easier and more effectively due to the progress of medical technology, including antiobiotics, vitrectomy, etc. Moreover, progress in lens surgery led to the less invasive procedures, including microincision techniques, viscoprocedures, low-ultrasound power, IOLs producing less PCO, etc. All of these make the clear-lens extraction an interesting alternative for the treatment of high myopia. However, inability to effectively restore accommodation remains a serious weakness of the procedure.

Conclusion

Fukala was an important pioneer in systematically performing clear-lens extraction in patients with high myopia. Due to his thorough knowledge of theory and positive experiences of many patients, he demonstrated the benefit of clear-lens removal in young, high-degree myopia. He “stuck to his guns”, despite the energetic opposition of his well respected colleagues such as Frans Cornelius Donders, Ernst Fuchs, and Albrecht von Graefe. Thanks to his determination, Fukala convinced his skeptical colleagues of the efficacy of his surgical method of lens discission although, several surgeons had risked surgery in high-degree myopia in former decades, most were afraid of the immediate postoperative complications at that time; and surgical treatment failed to become established. The late complication of retinal detachment was not appreciated until much later.