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Diamond jubilee of the first intraocular lens implantation?

2009; Lippincott Williams & Wilkins; Volume: 35; Issue: 12 Linguagem: Inglês

10.1016/j.jcrs.2009.10.014

1873-4502

David J. Spalton,

Intraocular Surgery and Lenses

November 29, 2009, was the 60th anniversary and Diamond Jubilee of Harold Ridley's first intraocular lens (IOL) implantation—or was it? The lead-up to the first implantation is well described in David Apple's book,1 but controversy surrounds the actual operation. Harold Ridley retired from St. Thomas' in 1973, and I was appointed a consultant at St Thomas' 10 years later. When we moved departments some years later, the operating theater register for 1948, 1949, and 1950 turned up, an old exercise book (World War II had not long finished and paper was in short supply) with each operation entered by the theater sister in beautifully neat pen-and-ink handwriting. On November 29, 1949, Ridley performed 4 operations listed as “intracapsular extraction, extracapsular extraction, linear extraction, and a lateral tarsorrhaphy” with no mention of anything unusual. Turning forward to February 8, 1950, we see that one patient—Emily Attfield, then aged 46 and the patient who had had the extracapsular extraction the previous November—had a “lenticular graft” procedure under topical and retrobulbar anesthesia with a facial block to the left eye (Figure 1). On February 11, 1950, the patient returned to the operating theater for “first dressing and reposition of iris prolapse.” We have no further details until an outpatient record in 1975, when Attfield was seen with an early cataract in the right eye and counting fingers (CF) vision in the left eye. A longstanding iris prolapse was present, and the pupil was elliptical; no mention was made of the cornea or fundus (Figure 2).Figure 1: The entry from the theater record of February 8, 1950.Figure 2: The clinical note from 1975.So, when was the first IOL implanted? Peter Choyce, a registrar and acolyte of Ridley at the time, told me that Ridley had implanted the IOL on November 29, 1949, but decided to remove it immediately and before reoperating as a secondary procedure. The only other person still alive from that time was Doreen Ogg, the operating theater sister and long since retired. I wrote to her, now an elderly lady, and she replied, “I think I can now put things straight. The Attfield extraction on 29/11/49, Harold was determined to keep this quiet. Hence the entry. I only wish I had made a secret mark by it. Harold did not take out the lens immediately. I recall that her correction with glasses was such that the poor soul could hardly hold her head up! And a lot more work had to be done on the actual lens. This would account for the lenticular graft entered on 8/2/50. The cat was out of the bag so no need for secrecy and he did the first dressing himself as was usual for the surgeon to do after an extraction.” This might imply that the patient had an IOL exchange in February 1950, which seems a bit unlikely. However, in Ridley's first report of the event to the Oxford Ophthalmic Congress in July 1951, he reports “no serious complications have been experienced in 8 cases… this lens has remained in the eye for 17 months,”2 correlating with a surgery date of February 1950. Furthermore, the clinic note and letter from the ophthalmologist to the patient's family doctor following the consultation in 1975 says, “In the past she has had a left cataract extraction in 1949 and the following year a prosthetic lens was implanted” (Figure 2). The circumstantial evidence therefore suggests the operating theater sister's recollection might not be accurate and the implantation was done as a secondary procedure on February 8, 1950. It is interesting to speculate why Ridley might have been happy to gloss over the fact that the procedure was done as a secondary event. The refractive correction of unilateral aphakia at this time was problematic, the only option being a contact lens, which would be a highly unsatisfactory large scleral lens, difficult to fit, and very uncomfortable to wear. Because of these problems and the disadvantages of aphakic spectacles, most surgeons would only operate on bilateral cataracts severe enough to reduce the acuity in each eye to 20/200 or CF. Unilateral cataracts were removed only when mature. Might it have been easier to convince a patient with unilateral aphakia that her vision could be restored by a new operation? One must remember, too, that in those days with poor lighting, no microscope, and crude instrumentation, intraocular surgery carried a significant risk for visual loss and blindness. To operate on an eye a second time without very good reason would place the patient in double jeopardy, and when the balloon finally went up and criticism rolled in, it was perhaps better not to dwell on this. Ridley was a consultant (ie, staff surgeon) at both Moorfields and St. Thomas' Hospital. St Thomas' had 2 consultant ophthalmic surgeons, Moorfields probably about 10. Most of the Moorfields surgeons were old, relicts from the 1930s, poorly trained, and out of date, being too old to be called up for military service. At that time, feelings ran high; one London teaching hospital refusing after the war to appoint doctors to the staff “who had not worn the King's uniform.” Ridley held them in contempt. At that time, St. Thomas', the hospital uniquely associated with Florence Nightingale, was a London teaching hospital at the peak of its power and prestige; a St. Thomas' surgeon walked on the right hand side of God or at least the left hand side of the hospital matron and it offered some secrecy. It was widely acknowledged that Ridley was a superb surgeon at a time when manual dexterity was of crucial importance. No one, however, could accuse him of being a team player in a modern sense. He was known to say he earned more money than any other St. Thomas' surgeon, something unlikely to endear him to his colleagues. Perhaps Ridley's greatest error, however, was to exclude Sir Stewart Duke Elder from the implant work. Duke Elder was a man of immense power and political influence but known to be a ham-fisted surgeon. Most likely motivated by jealousy of Ridley's work and clinical abilities, he refused to see or examine Ridley's patient at the Oxford Congress in 1951, thereby initiating a feud at Moorfields that lasted 30 years, although this could later be justified to some extent by Ridley's poor judgment and management of patient selection. Ridley was known to say to patients “I have done my part… now it's up to you,” and many young residents in the 1970s, such as myself, will recall seeing patients such as a 30-year-old woman who was going blind from bullous keratopathy, peripheral anterior synechiae, and angle-closure glaucoma, which were largely untreatable with the technology of the time. Although interesting, the date of the first implantation is really immaterial—it is the achievement that counts. Ridley's development of the IOL was undoubtedly the greatest advance in ophthalmology in the 20th century. We put up a plaque at St. Thomas' to commemorate his achievement (Figure 3). Controversy remained to the end though, with one of my senior colleagues saying we should put up another by its side to commemorate the patients who gave their sight in the process.Figure 3: The plaque at St. Thomas' Hospital, London.