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Sir Nicholas Harold Ridley, Kt, MD, FRCS, FRS
Contributions in Addition to the Intraocular Lens
David J. Apple, MD;
Rupal H. Trivedi, MD
Arch Ophthalmol. 2002;120:1198-1202.
INTRODUCTION
Sir Harold Ridley, Kt, MD, FRCS, FRS (Figure 1), the inventor of the intraocular lens (IOL)1-16
and one of the founders of the modern subspecialty of cataract and refractive
surgery, passed away on May 25, 2001, just 6 weeks before his 95th birthday,
in a hospital near his wife, Elisabeth, and his retirement cottage in Stapleford,
Wiltshire (near Salisbury), Southwestern England.
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Figure 1. Sir Harold Ridley, Kt, MD, FRCS,
FRS, ca 1990.
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Most obituaries are crafted to provide a brief biographical sketch of
an individual, to list his or her accomplishments and honors, and to express
gratitude to the deceased. In this memorial to Sir Harold as well as another
obituary covering different facts of his life published in the American Journal of Ophthalmology,1
we have chosen a diverse course. Our purpose here is not only to honor him,
but also to discuss the hard time he encountered in gaining acceptance of
the IOL itself as well as to highlight his non–IOL-related accomplishments,
the latter not being well known to ophthalmologists and the general public.
One of us (D.J.A.) first met Sir Harold in 1985, having been referred
to him by 2 of his English colleagues, the late John Pearce, MD, and D. Peter
Choyce, MD. That meeting was the beginning of a 2-decade-long close personal
friendship with Sir Harold. At the first sighting of him in the train station
at Salisbury, it appeared that he was at low ebb physically and especially
psychologically. Having retired to a lovely rural setting, the Ridleys lived
in modest comfort. However, he still recognized that many of his colleagues
and peers frequently treated him and his IOL with severe skepticism and indeed
sometimes scorn. This was the reason that Pearce and Choyce had called his
attention to some IOL-related research results we and our coworkers had just
published.14-15 They believed
Sir Harold would be very appreciative of them because these writings had helped
verify several of his concepts regarding the rationale, safety, and efficacy
of his invention—and indeed he was!
As late as 1985 when I first met him, almost 4 decades after his initial
IOL implantation on November 29, 1949, acceptance of the concept of an implantable
plastic "foreign body" in the eye was far from universal, especially among
some members of the medical establishment. The latter included some of the
most illustrious professors at some of the world's greatest universities,
including his homeland in England as well as in the United States. Not only
did this criticism wear him down, but also he related that one extremely worrying
matter was the fear of a charge of malpractice being brought against him,
against which he probably would have had little defense in those early days
of the still-experimental operation. That partially explains why very little
was heard from him during the period from the mid-1940s until the early 1950s,
as his surgical research proceeded in secrecy.
Acceptance of the IOL was very slow in coming. Several observations
conveyed to me in recent interviews with many of Ridley's contemporaries have
convinced me that Sir Harold provided us a gift that in many ways actually
transcended the IOL itself. Details regarding these have been published in
an obituary elsewhere.1 In short, his invention
of the IOL was not merely the introduction of a piece of refined plastic,
etc, but it was influential in 2 other ways. First, it jarred and disrupted
the apparent long-standing dogma that one "should never put a foreign body
into the delicate tissues of the eye" (seemingly trite now, but a major issue
in the mid-20th century and before17-20).
Ridley had forced a huge paradigm shift and a major rethinking of principles.
This probably explains at least in part why Ridley received such disproportionate
criticism, sometimes bordering on invective, that continued during the past
half century.1
Second, Ridley helped pioneer the general use and worldwide dissemination
of permanent implantable intraocular prosthetics or biodevices, in short,
artificial "tissues or organs" designed to remain permanently in a delicate
tissue or organ of the body. This is taken for granted today but was a "bombshell"
then. The strife that ensued was, in a limited way within his subspecialty,
not unlike that occurring today on a national and international level with
respect to stem cell and cloning research. His invention helped propel not
only ophthalmology but, indeed, general medicine into a new era. It helped
generate a new subspecialty that we now term biomedical
engineering, which has grown rapidly during the past 2 decades. He
himself was probably not aware of this more universal significance of his
invention, but we believe history will show that the introduction of these
broad concepts and innovations were as important as the basic visual rehabilitative
benefits of the IOL itself.
NON–IOL-RELATED CONTRIBUTIONS
A detailed biography and several short works about Ridley have already
been published.1-13
Just before his death, Ridley requested that, in lieu of a classic obituary
or biography, we mention a few of his non–IOL-related activities.
It will surprise many readers that Sir Harold Ridley did pioneering
work in several other fields of ophthalmology besides the IOL. Significant
research and teaching, aids, medical and surgical treatments and techniques,
and biodevices in routine use today—now usually taken for granted—were
either invented or first applied by Ridley. The credit he deserves for these
non–IOL-related contributions has in many instances faded. These are,
however, of sufficient significance that they deserve this documentation,
not just because they are of historic value but also because some have a continuing
practical usefulness today.
One means of looking at his non–IOL-related accomplishments is
to ask the question: What might this man's legacy have been if he had not
invented the IOL, but had otherwise completed his professional life as it
unfolded? In our opinion, if one sets aside the IOL from his list of professional
accomplishments, what emerges is surprising. A glimpse of Ridley's other discoveries
in ophthalmology reveals an array of important innovations that reflect an
interest and expertise in almost all components and tissues of the eye. Some
of these taken alone would have ensured a solid legacy.
Almost all of his innovative activities, including the invention of
the IOL, occurred between about 1945 and about 1955. It is ironic that if
this chain of other non-IOL research endeavors had not been thrust into the
background by the widespread publicity given to the IOL, his acceptance by
the academic medical establishment at that time would almost surely have been
immediate and highly positive. Why? Because almost without exception the non–IOL-related
issues offered solid, noncontroversial, and clinically relevant advances in
clinical ophthalmology that would not have required the above-mentioned paradigm
shift. Without the IOL there is no doubt that his career would have been far
less controversial and stressful. The evolution of the non-IOL discoveries
he made would have been easy for all to accept, and some of them taken alone
might represent a lifetime of productive work for most of us. However, the
legacy gained from his non–IOL-related inventions would probably have
been "short-term"—during his lifetime. Each of these represented baseline
discoveries of concepts and techniques that he made by using the rudimentary
gadgetry and technology available to him at that time. Therefore, this work
has been built upon, improved, and superseded many times through the years,
and at first glance the essence of his original work is hardly visible today.
In sharp contrast, the IOL led to a revolution that shoved most of his other
discoveries into the background. A 5-decade-long period of turmoil ensued
that caused a degree of controversy unprecedented in our specialty. However,
as is often the case with things of value, the lack of acceptance of the IOL
by many during much of Ridley's lifetime was followed, as the history was
written, by the permanent positive reorganization that he clearly deserves.
Removing the cloak of the IOL discloses the following partial listing
of several documented ideas that originated with Ridley. These are ideas and
innovations that have not yet been systemically categorized and submitted
to the public. Most are by now long forgotten or previously unpublished. These
ideas can be classified into 3 categories: (1) clinical (medical/surgical)
applications; (2) pioneering attempts at application of the newly emerging
post–World War II technology, termed electronics
at that time and termed high tech today; and (3)
nonscientific innovations, not intended by Ridley himself, leading to an unintentional
but radical shift in the realm of medical economics.
CLINICAL (MEDICAL/SURGICAL) APPLICATIONS
1. Ridley performed definitive characterization of onchocerciasis (river
blindness). This is one of the most common causes of blindness in the world.
Ridley's studies were based on work carried out during his wartime service
in Ghana, West Africa, in 1943. He gathered sufficient facilities to perform
histopathological analysis of the microorganisms (Figure 2). This work resulted in the presentation of his classic
monograph, "Ocular Onchocerciasis," in 1945.21
He himself painted a figure showing fundus changes in this disease, now universally
called the Ridley fundus. This work helped establish
a basis for later treatment of this disease, including today's ongoing World
Health Organization–sponsored treatments.
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Figure 2. An early photomicrograph of Onchocercus organisms, prepared by Ridley in Ghana, ca 1943.
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2. Ridley applied various multivitamin therapies to patients in tropical
countries. He treated nutritional amblyopia in released World War II prisoners.
These efforts represent, in an indirect way, a forerunner of today's use of
"multivitamins" for several eye diseases, eg, macular degeneration.22
He also developed a keen interest in treating patients (especially children)
with beta carotene to combat keratomalacia (xerophthalmia). He applied this
treatment on a small scale (but with great success) during his wartime period
in Ghana. He did not publish results regarding this condition, but he spoke
of it often and emphasized it in his private writings.
Although he has received almost no credit for these efforts, they have
no doubt been influential in helping attain today's huge public health successes
achieved by administration of beta carotene to affected populations. His accomplishments
in this field were a source of great pride to him. In some discussions he
would speak of these efforts with much more enthusiasm than the IOL.
3. While treating ocular leprosy in Ghana in 1941, a disease commonly
regarded as incurable, Ridley performed what he believed may have been the
first successful penetrating keratoplasty on a leper (cited by Apple and Sims6). Unfortunately, he did not published this, but his
claim is probably correct, since, to our knowledge, there are no earlier published
reports in the literature.
He pioneered clinical research in local (nonenucleation) treatment of
uveal malignant melanoma. Figure 3
shows an example of an irradiated choroidal neoplasm.
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Figure 3. A pigmented fundus tumor treated
by irradiation, presented by Ridley at the meeting of the European Society
of Ophthalmology, Budapest, Hungary, in 1971. The actual work began in the
1950s. This documents his early clinical research in local, nonenucleation
treatment of intraocular neoplasm.
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He was an early pioneer (with D. Peter Choyce, MD) in keratorefractive
surgery, especially intrastromal corneal implants. He also helped design one
of the first keratoprosthetic biodevices (Figure 4).23 To our knowledge, he
did not attempt phakic IOLs.
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Figure 4. Gross photograph of an early keratoprosthesis,
fabricated from polymethylmethacrylate and designed by Ridley.
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ELECTRONIC (HIGH-TECH) OPHTHALMOLOGY
Just as he derived IOL material biocompatibility data from World War
II experiences when polymethylmethacrylate fragments from shattered cockpit
canopies became embedded in the eyes of injured pilots, Ridley was keen to
apply the new electronics technology that emerged during and after that war
to ophthalmology and the visual sciences. As he had done with the IOL in collaboration
with Rayner Intraocular Lenses, Ltd, Hove, England, Sir Harold also developed
close relationships with other members of the corporate sector to accomplish
these applications, in particular the Marconi Wireless Electronic Company,
London, England, and the Pye Electronics Company, Cambridge, England, both
leaders in the field at that time.
It is likely that very few of us who prepare medical, surgical, diagnostic,
or teaching videos or PowerPoint presentations today realize that Sir Harold
laid some of the groundwork for these techniques.
Ridley was the first to televise eye operations, in both black-and-white
and color. Documented in 1950,24 this of course
opened the floodgates to our almost universal use of videos in research and
teaching presentations, as well as the establishment of "film festivals" that
are now popular and useful components of many of our meetings and conferences,
both large and small.
Ridley was the first to use the nascent technology of the late 1940s
to image intraocular tissues on a monitor in both black-and-white and color
in 1950 (Figure 5). The fundus shown
in Figure 5C is the first such televised
intraocular image ever recorded. It is an image of the eye of his operating
room nurse ("theatre sister") Doreen Ogg, shot in Cambridge in September 1949,
just 2 months before his initial implantation operation on November 29, 1949.
This represented the forerunner of such applications as televised videoconferencing
and videodiagnosis. Telepathology has also been applied to ophthalmic pathology.25
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Figure 5. Documentation of the first use
of television in ophthalmology. The experiments were performed in Cambridge,
England, in 1949.24 A and B, The technical
apparatus. C, The first fundus photograph ever imaged on a television monitor.
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Ridley was the first to initiate various forms of electronic ophthalmoscopy,26-27 which later turned out to have unexpected
uses.28-29 Barly Masters, MD,
a leading authority in this field, has confirmed that Sir Harold's work was
instrumental in directly establishing the basic principles of modern confocal
microscopy and scanning laser ophthalmoscopy, a very important clinical and
research tool.26-29
MEDICAL ECONOMICS
Last but not least, and largely unbeknownst to him, Sir Harold's influence
also spread into the realm of business and finance. The IOL was one of the
first inventions that led to a product manufactured in the corporate private
sector that became a marketable device that was distributed and sold worldwide.
The huge market for such products helped stimulate the very large medical-industrial
complex that exists today. This had a strong influence in adding a business
component to our subspecialty in addition to the classic clinical and scientific
components that our forerunners had experienced. Ridley himself would have
been bewildered, for example, had he been informed that his cataract-IOL operation
became the number one surgical cost to the US Medicare system in all of medicine.
Perhaps he would have been even more surprised to learn that the Nd:YAG laser
secondary posterior capsulotomy treatment for posterior capsule opacification
(secondary cataract) was the second highest cost.30
CONCLUSIONS
Each one of the selected items listed here would constitute a discovery
or innovation of a lifetime for most of us. Taken in their summation (even
without the IOL!), these provide a very significant contribution to ophthalmology
and the visual sciences. After the mid 1950s, Sir Harold's production of other
innovations slowed because he was clearly preoccupied with the IOL. It dominated
his thoughts, not only scientifically, but also in relation to the immense
stress during this entire period.
As we have entered the 21st century, Sir Harold's legacy is ensured.
In our opinion, he ranks with many of ophthalmology's greats, such as Albrecht
von Graefe, Ernst Fuchs, and others, as one of the most influential ophthalmologists
in history. All of us are indeed happy that Sir Harold lived long enough to
see the fruits of his efforts and receive the long list of honors that he
deserved.
AUTHOR INFORMATION
Submitted for publication January 1, 2002; final revision received April
26, 2002; accepted April 30, 2002.
This study was supported in part by an unrestricted grant from Research
to Prevent Blindness Inc, New York, NY.
Corresponding author and reprints: David J. Apple, MD, Storm Eye
Institute, Department of Ophthalmology, Medical University of South Carolina,
167 Ashley Ave, PO Box 250676, Charleston, SC 29425-5536 (e-mail: appledj{at}musc.edu).
From the Center for Research on Ocular Therapeutics and Biodevices,
Storm Eye Institute, Medical University of South Carolina, Charleston.
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