Von Graefe Knife - History

History

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 right eye 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.

In the 1980s, 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) became obsolete, although the use of the von Graefe knife still continued in India. Sutures had limited if any use in routine cataract surgery in the high-volume most experienced and skilled eye surgeons in the world. Their experience and skill could result in outstanding rural cataract camps so common in India. Formally trained Indian ophthalmologists were and are among the 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.

It is possible for 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.

Dr. Charles Kelman’s revolutionary modifications of cataract surgery through phacoemulsification eliminated the use of the von Graefe knife—a bête noire for many earlier aspirants to be skilled cataract surgeons.