10 years By Nick Lane PhD Pioneers Past and Present – But where are the boundaries of the justifiable? heir names justly echo down the halls Elder, his colleagues walked out of early example was the supplanting of horse- “I don’t think for a moment that we’re Tof fame of ophthalmology – Sir presentations; the very concept of IOL drawn carriages by cars; there were many going to see the end of LASIK or corneal Harold Ridley, Peter Choyce, Cornelius implantations was openly repudiated, and people at the time who could see no refractive surgery in general, but as the Binkhorst, Edward Epstein, Svyatoslav dismissed by the AAO as “not sufficiently advantages of cars over horses,” Dr Fine new generations of accommodating IOLs Fyodorov, Charles Kelman, Benedetto proven for use in the US”. Ridley spent told EuroTimes. come into their own, we’re likely to see Strampelli, José Barraquer, Luis Ruiz,Theo years terrified that his early failures would Of course pioneers need more than just more and more people in their fifties and Seiler, Ioannis Pallikaris, to take just a few. come back to haunt him through the vision to succeed; they also need the sixties opting for lens exchange, maybe Their techniques transformed the world courts. In Barcelona, in 1970, Joachim ability to see a technical way through the even before they’ve developed the first and restored sight for millions. But had it Barraquer was forced to explant half of problem, to convert their vision into signs of a cataract.This is not really a not been for their failures, the successes the anterior IOLs that he had implanted in action.And they need to be able to get it technical leap, at least not surgically – it is of today might never have been possible. 500 patients, as a result of corneal across to their colleagues in an intelligible in terms of lens technology – but it is Failure is an occupational hazard in decompensation.And despite his way, so that other people can test their certainly a major sea-change in attitudes,” surgery, but how much failure is too successful anterior IOL designs, the name ideas properly, and refine the technology. said Dr McDonald.“ much? of Peter Choyce is muddied by the Horses didn’t give way to cars before unlicensed manufacture of shoddily there’d been a lot of engineering Innovation versus clinical data produced copies (inadequately sized and improvements. Even so, refractive lens exchange is only finished, and prone to warpage).After In cataract and refractive surgery, one way through the quagmire, and herein “In society in general 100,000 defective implants in the 1970s, Ridley’s concept of implanting an IOL was lies the problem.What of phakic IOLs? many of which caused the so-called UGH the first such leap. Implanting anything into What of the use of advancing wavefront there have been many syndrome (uveitis, glaucoma and the eye went against the ethos of the technology in laser ablations, reducing the hyphaema) they were finally withdrawn times, when ophthalmologists were taught risk of glare and haloes in more highly such leaps. Mechanical from the market. only to remove things from the eye. myopic patients? These and other Charles Kelman, too, was subject to Phacoemulsification was a similar leap, techniques are advancing rapidly, and it is typewriters were scathing criticism for his pioneering of making modern microincision cataract phacoemulsification, not altogether surgery possible; improved to the surprisingly given the secretive failure of and the use of his first case.After 4? hours in a room the excimer laser electric version, but marked ‘contaminated’, with an hour and was another 19 minutes of ultrasound using his bulky lateral leap, then were prototype phacoemulsifier, the patient which solved developed endophthalmitis, lost vitreous many of the unexpectedly fluid, and finally had his eye enucleated the problems following day. Of course, the cumulative associated with supplanted altogether technical improvements of radial phacoemulsification ultimately enabled the keratotomy, by computers.” successful development of modern notably the lack microincision cataract surgery, with of predictive Howard Fine MD implantation of foldable intracapsular power and the “You can tell the pioneers from the lenses. Ironically – even pioneers get set in (small but arrows in their backs” joked Marguerite their ways – Ridley and Choyce never serious) risk of McDonald, MD, clinical professor of accepted intracapsular IOL implantation. traumatic globe ophthalmology at Tulane University, to rupture. EuroTimes. The conceptual leap of innovation How much comfort Certainly the greatest advances in So is there a common theme to these The refractive do you want ? cataract and refractive surgery have met pioneers? According to Howard Fine, MD, lens exchange with vituperative criticism from peers. Dr clinical professor of ophthalmology at revolution McDonald herself, after performing the Casey Eye Institute, Oregon Health & So which of the It‘s your decision ! first photorefractive keratectomy (PRK) Science University, true innovation comes numerous on a normally-sighted myopic patient in from a conceptual leap, when the current techniques and LDWIDE 1987 (following years of research on eye- techniques have run up against an ideas being SOLE WOR bank eyes and animals), was accused by a image inversion immovable barrier.The breakthrough is tested today will • electrically switched s senior colleague, in the letters pages of a often an inspired lateral leap from an be seen as a • microscope independent motorized focu journal, of either being irresponsible or unexpected quarter, which might seem pioneering leap, • ergonomics well-proved for 20 years lying.And that was the barbed reward for obvious with the benefit of hindsight.The with the benefit immediate success; initial failure is far first attempts may be technically of hindsight? Oculus BIOM 3c /SDI 3c – more commonly the fate of successful rudimentary, but the conceptual leap Interestingly, The fully motorized and most versatile version. innovation. forwards is the beginning of a completely both Dr Fine and Fits to the common microscopes used for vitreo- History furnishes many examples of new path leading to refinements, until the Dr McDonald retinal surgery. Not depending on microscope’s brand. Also available for cost-effective retrofi tting. how far the disavowal of peers can go, 110 years next barrier blocks the way again. agreed that the 110 years even when an innovative technique proves “In society in general there have been most important Trust in 20 years experience of the world leader in non contact wide angle observation. enormously beneficial in the end (or not many such leaps. Mechanical typewriters current as the case may be – see the side bar). were improved to the electric version, but conceptual leap Ridley’s own troubles are the stuff of then were unexpectedly supplanted is refractive lens Oculus Optikgeraete GmbH • D-35549 Wetzlar legend. Castigated by Sir Stewart Duke altogether by computers.Another exchange. Tel. +49-641-20 05-0 • Fax +49-641-20 05-295 • www.oculus.de EuroTimes January 2006 7 10 years hard to say which will provide the best successful but ultimately limiting treatment “This is the closest we’ve got so far to our profession, and is a violation of the long-term solution. Unless we pursue is drawn too soon, then the negative the crystalline lens. It can be custom made, implied pact between physician and them all, we’ll never know; but equally, comparisons may stifle successful using MRI measurements of the exact size patient.” some rapidly advancing innovations are innovation.What if Kelman’s early of the capsular bag, and implanted through Wise words.Yet patient choice is also likely to do as much harm as good. attempts at phacoemulsification had been an incision as small as 1.0 mm.” ultimately the answer, so long as patients According to Roger Steinert, MD, data on dismissed as disastrous, as well they Personalising medicine to individual are well informed. phakic IOLs (published in AJO, November could? His lasting testament, like Ridley’s, patients in this way is achievable in 2004) “shine a bright yellow caution light” was the proof of a concept, not its surgery, but goes against the grain of on angle-fixated anterior-chamber IOLs perfection. It is his vision that stood the evidence-based medicine, which insists on pigeonholing patients into comparable “Given that refractive groups with high statistical power. No doubt cataract and refractive surgeons will surgery affects quality- “As the new generations of accommodating IOLs continue to earn the opprobrium of colleagues in other disciplines. But while of-life, it’s reasonable come into their own, we’re likely to see more monolithic medicine served 20th century science well, it may be that its days are that patients should and more people in their fifties and sixties numbered, as the impact of genomics makes itself felt. choose, and pay. But opting for lens exchange, maybe even before The human genome project is set to revolutionise the practice of clinical trials we have a they’ve developed the first signs of a cataract. through the application of pharmac- Marguerite McDonald MD ogenomics – the tailoring of drug therapies responsibility to to the genetic makeup of individual and posterior-chamber IOLs. But perhaps test of time; and the early data were best patients. By searching for individual single educate the patients this rap across the knuckles is just the ignored. nucleotide polymorphisms (known as stimulus for better innovative design. Some modern examples are more ‘snips’) that influence the pharmacology as honestly as we can.” On the other hand, cataract and subtle, but still hinge on the playoff and pharmacokinetics of drugs, and by Howard Fine MD refractive surgeons sometimes seem between data, on the one hand, and long- tailoring therapies to the specific genotype almost incorrigibly innovative.There are term potential on the other.