Von Graefe knife

The von Graefe knife in cataract surgery - an historical note:

Until the acceptability of the keratome and scissors method after the early 1940s, an essential part of cataract surgery was mastery of the von Graefe knife. With increased popularity of sutures - especially pre-placed scleral groove (McLean) sutures, it became difficult for the occasional surgeon to develop the skill required to make an acceptable von Graefe incision. If the surgeon was not ambidextrous, the use of the von Graefe knife might be even more difficult with the non-dominant hand. . With his right hand, he introduced the knife into the anterior chamber of the OD at 9 . He would then perforate the limbal area at 3. An upward sweep was then made for the completion of the incision. Most frequently, there was no conjunctival flap. However, some especially skilled eye surgeons would form a conjunctival flap as they were completing the upward sweep. Normally, the ambidextrous von Graefe surgeon would switch to his left hand so that he could enter the left eye at 3 and exit at 9. If he used his dominant right hand for the left eye, the nose became an impediment when he attempted to enter the eye at 9 and attempted to counter perforate at 3. Oftentimes, poor results could have been prevented by the use of post-placed sutures. Unfortunately, in the earlier years of cataract surgery, suitable sutures and needles were not in the armamentarium of many cataract surgeons.:

Of course, in the1980s, with the ever-increasing popularity of the Kelman phacoemulsification technique that emphasized a small incision and extra-capsular cataract extraction (ECCE) , the keratome-and-scissors, large incision surgery technique combined with intracapsular cataract extraction (ICCE) was relegated to the obsolete. It should be pointed out that the use of the von Graefe knife in cataract surgery in India continued well-beyond that in the West. Sutures had limited if any use in routine cataract surgery in the high-volume rural cataract camps so common in India. Formally trained Indian ophthalmologists were and are among the most experienced and skilled eye surgeons in the world. Their experience and skill could result in outstanding deftness with the von Graefe knife. Ultraviolet-rich India with its vast rural and underclass population afflicted with nutritional eye diseases and with those related to a multitude of public health problems was and still is the “Land of Eye Disease and Eye Surgery“. Few Western ophthalmologists have the daily volume of eye pathology and eye surgery that faces their Indian counterpart.

How could an eye recover from an intracapsular cataract operation that entailed a 170 to 180 degree superior corneal or limbal incision without the closure of the incisional wound by means of sutures? Recovery was significantly dependent on the quality of a well-made von Graefe knife incision with a well-honed and well-maintained knife. Unlike the keratome and scissors incision, the well-performed von Graefe knife maneuver produced a corneal or limbal incision with well-apposed edges that resulted in rapid healing and a scar that was almost invisible to the naked eye. Contrariwise, a poorly made von Graefe knife incision could lead to horrendous disasters.

Fortunately for the modern ophthalmologist, Dr. Charles Kelman’s revolutionary modifications of cataract surgery through phacoemulsification eliminated the use of the von Graefe knife - a bete noir for many earlier aspirants to be skilled cataract surgeons. References:

( 1. ) : The following URL will provide a photograph and catalogue description of a classic von Graefe cataract knife. : [http://www.amblersurgical.com/store/product.cfm?pID=1073] ( 2. ) : Google: von Graefe knife incision: [http://www.google.com/search?sourceid=navclient&aq=t&ie=UTF-8&rls=GGLD,GGLD:2004-05,GGLD:en&q=von+graefe+knife+incision ] :

( 3, ) : Google: cataract surgery sutures: [http://www.medrounds.org/cataract-surgery-greenhorns/2005/09/chapter-3-old-school.html ] :

( 4. ) : Prof. Derrick Vail’s experiences in India: [http://archopht.ama-assn.org/cgi/content/full/121/5/720 ] :

( 5. ) : Photographs of some results of von Graefe knife cataract surgery. The photographs are to be found in the University of Iowa Eye Atlas whose Search Form URL is:http://webeye.ophth.uiowa.edu/eyeforum/atlassearch1.htm?appSession=52924685551717] :

After the Search form of The University of Iowa Eye Atlas appears , type “von Graefe “ in the “Diagnosis” space . Click “Run Query”. Several appropriate photographs should appear.