PROFILE Nathan Efron

Charismatic academic returns to Australia

Clin Exp Optom 2005; 88: 6: 430-433

Barry L Cole levels of hypoxia beneath all forms of Professor Emeritus contact lenses in open and closed eye con- The ditiom2This work formed an important part of the rationale for developing high Nathan Efron will take up an appointment oxygen performance silicone hydrogel as Research Professor in the School of lenses, which have become available in optometry at the Queensland University recent years and provide a much more of Technology in January 2006. He is satisfactory ocular response. returning to Australia after 16 years as After completing his PhD, Nathan held Professor of Clinical Optometry at the two 12-month postdoctoral appointments, Institute of one with Professor Ken Polse at the Uni- Science and Technology (UMIST) in the versity of California and the other with United Kingdom. Professor Brien Holden at the University of NSW. The highlight of this period was Early years at Melbourne co-authorship of the ‘Gothenburg Study’,’% Nathan Efron is a graduate in optometry which documented the long-term effects from The University of Melbourne. His un- of extended wear contact lenses on the dergraduate studies between 1973 and cornea and defined key requirements for 1976 coincided with the very early years the future development of contact lenses: of the commercial development of soft that they should be replaced regularly and contact lenses, an area that captured his made from materials of higher oxygen imagination and drew him into research Nathan Efron PhD DSc performance. The current dominance in as soon as he graduated. Professor Leo the marketplace of disposable contact Carney had just returned to Melbourne lenses and super oxygen-permeable sili- following post-doctoral studies with Pro- be applied to the human eye. cone hydrogel materials attests to the fessor Richard Hill at the Ohio State Uni- Nathan’s first refereed article,’ pub- prescience of the Gothenburg Study. versity in the USA and had established the lished in 1979 and co-authored with Leo Nathan returned to The University of Corneal Biophysics Laboratory. Nathan Carney, is one of his most cited works. It Melbourne in 1984 to take up an appoint- commenced PhD studies with Leo, work- defined the level of oxygen at the corneal ment as Lecturer in the Department of ing in the field of corneal oxygenation surface beneath the closed eyelid (it is Optometry where he established a fruit- during contact lens wear. This was an im- about one-third of that available to the ful and prolific collaboration with Dr Noel portant topic because it was the key to open eye). This was a critical finding for Brennan. Their work concentrated on the explaining the clinical performance of accurate modelling of corneal oxygena- hydration characteristics of soft lenses and rigid and soft contact lenses during open tion while wearing contact lenses over- methods for measuring contact lens gas and closed eye lens wear. Nathan adapted night, a topic that is still of considerable permeability. They developed an optical the ‘equivalent oxygen percentage’ (EOP) interest today. His doctoral studies also instrument for measuring the water con- technique-previously developed by Rich- resulted in the publication of a series of tent of hydrogel lenses, the Soft Contact ard Hill for use in rabbit eyes-so it could models that demonstrated significant Lens Refractometer, which was commer-

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cially produced by Atago. They also puh- The move to Manchester highlighting a number of potential appli- lished an important series of papers on the In 1990, Nathan was appointed Professor cations for ocular thermography, includ- methodology for determining the oxygen of Clinical Optometry in the Department ing monitoring the pre-corneal tear film performance of contact lenses, which re- of Ophthalmic Optics (renamed in 1992 in dry eye, assessing post-herpetic neural- sulted in the contact lens industry adopt- as the ‘Department of Optometry and gia, quantifying the extent of ocular in- ing a more standardised approach to the Vision Sciences’ and renamed yet again in flammation in anterior eye disease and reporting of contact lens oxygen perme- 1997 as the ‘Department of Optometry assessing the thermal impact of various ability and transmissibility.‘ Nathan’s two and Neuroscience’) at UMIST in Manches- forms of laser refractive surgery on the PhD students at Melbourne, Suzanne ter in the United Kingdom. His formal cornea. Dr Morgan became Research Man- Fleiszig” andJohn Ang,b have gone on to interview for the Professorial Chair was ager of Eurolens Research and has re- develop their own distinguished careers in held immediately following the annual mained Nathan’s closest research collabo- academia and industry, respectively. meeting of the British Contact Lens Asso- rator; together they have co-authored While at Melbourne, Nathan won an ciation, which Nathan attended. At that more than 40 refereed scientific papers. Academic Exchange Award from the Brit- meeting, he was introduced to an engag- Professor Efron’s arrival in the UK cor- ish Council to travel to London for six ing and attractive young woman, Suzanne responded with the introduction of dispos- months to undertake historical research Bloore, who had previously graduated in able contact lenses. One of his first papers with Dr Richard Pearson in the Depart- Optometry from UMIST, by a mutual on this subject focused on the question- ment of Optometry at the City University. friend, the editor of the Optician, Alison able quality of these mass-produced The year 1988 marked the centenary cel- Ewbank, ostensibly so that Nathan would lenses? This was hugely controversial and ebration of Fick’s Line Contactbrilk, which be better informed about UMIST prior to was reported and debated internationally was the first published paper on contact his interview. The ‘ploy’ worked; two years in both the ophthalmic and lay press. Al- lenses. The following year was the 100th later Suzanne became Nathan’s wife and though causing great upheaval at the time, anniversary of August Miiller’s inaugural a further 12 years later she was a research that work is now recognised as a landmark dissertation on contact lenses, which was collaborator and co-author. paper that drew the attention of the con- the first reported attempt to correct myo- The professorial chair at UMIST to tact lens industry to the importance of pia with contact lenses. Nathan and Rich- which Nathan was appointed was spon- contact lens quality and led to significant ard published historical reviews of each of sored by a major contact lens company, improvements in contact lens design and these pioneering works in prominent in- Bausch & Lomb, with the expectation that manufacture. ternational oph thalmicjournalsg~6that pro- the incumbent would engage in research Professor Efron makes a habit of con- vided a nostalgic retrospective analysis of relating to contact lenses and provide gen- troversial pronouncements, such as his 100 years of development of the contact eral support for the UK contact lens in- predictions of the demise of rigid contact lens industry and corrected a number of dustry. Professor Efron had bigger ideas, lensesg and his outspoken criticism of misinterpretations of previous historians. and quickly established a European-wide orthokeratology and fitting rigid lenses to About 15 years after their paper on Muller contact lens research and consultancy arrest the progression of myopia.“’Despite was published-and with the aid of the group known as Eurolens Research (short drawing fire from many quarters, Profes- internet which did not exist at the time of for the European Centre for Contact Lens sor Efron’s arguments are always based on their earlier work in the 1980s-they un- Research). Realising that single-company well marshalled evidence and cogently earthed additional historical material sponsorship of his chair could compro- expressed. It is unlikely that he will he about the optician Otto Himmler, who mise the potential of this venture, Profes- deterred from expressing controversial made the glass lenses used by Miiller and sor Efron sought and obtained ongoing opinions, however politically incorrect who can he credited as being the first sponsorship from 11 other contact lens they may seem; the more politically manufacturer of a contact lens of speci- companies. This provided a support vehi- incorrect the view, the more he enjoys fied dimension and power. They published cle for fundamental research into the espousing it. a short account of thisin Survqr nJOphtha1- cornea and contact lenses in addition to The mid-1990s heralded the clinical molngy.7 commercially-negotiated industrial con- development of the corneal confocal mi- sulting work. croscope, which allows the human cornea One of the first of Professor Efron’s 19 to he imaged in vivo at about 700x magni- PhD students in Manchester was Philip fication and enables the cornea to be Morgan. Together they embarked on a viewed in vivo at a cellular level. Professor a. Suzanne Fleiszig is Professor of Optometry and Vision Science and Associate Dean for Basic research project that had received little Efron acquired an early-generation instru- Sciences in the School of Optometry at the prior attention, the mapping of ocular ment and embarked on a wide-ranging University of California, Berkeley, USA. temperature of the eye using highly sensi- series of studies, elucidating the response b. John Ang is Vice-President, Asia-Pacific Pro- tive infra-red thermal imaging. A series of of the cornea to contact lens wear and fessional and Regulatory Af‘Fairs, Johnson and Johnson Vision Care. important papers on this topic followed, refractive surgery, and developing a

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greater understanding of the normal and able output by ordinary standards. His to make yourself known to your lecturer. keratoconic cornea. Professor Efron and work is widely read and debated as evi- The showmanship and enthusiasm Panagiotis Kallinikos were able to show, for denced by his published work having ob- carries over to successful undergraduate the first time, that contact lens wear causes tained more than 600 citations. He has also teaching. UMIST awarded him an Excel- a reduction in the number of keratocytes published six textbooks. His first venture lence in Teaching Award in 1999 and in the corneal stroma, which appears to was International Contact Lens Yearbook, nominated him for a UK National Teach- be due, at least in part, to the mechanical which ran to three editions. His book Con- ing Award. He did not win the award but effects of lens wear. tact Las Complications published in 1999 the ‘consolation prize’ was an invitation A highly significant application of cor- proved so popular that it had to be re- from Prime Minister Tony Blair to 10 neal confocal microscopy developed by printed only three months after it was Downing Street to join a celebration of Professor Efron’s team is the detection of launched and a second edition appeared excellence in UK higher education. diabetic neuropathy and monitoring its in 2004. A Spanish translation was pub- Nathan recalls being unimpressed by the severity.” This is achieved by observing the lished in 2005. Figuring that he had a few Prime Minister and the Prime Minister sub-basal nerve plexus; patients with dia- more books in him, Nathan arranged to being unimpressed by him. Nathan intro- betic neuropathy-and indeed other take 12 months sabbatical leave at the duced himself as a Professor of Optom- forms of small fibre neuropathy-show a School of Optometry at QUT in 2000-2001 etry to which the Prime Minister replied degeneration of this layer, as evidenced by with the express purpose of writing these ‘So is that what you do?’ and moved on. a reduction in the number of nerves, re- books. The mission succeeded and in that He remembers having a more engaging duced nerve branching and increased year he wrote three more books: The Cor- conversation with the Prime Minister’s wife nerve tortuosity. This approach will sup nea (2001) , Contact Lens A-actice (2002) and who was at least interested in his bow tie plement current electrophysiological and Contact Lenses A-Z (2002). His sixth title, collection. sensory measurements and may obviate Optometry A-Z, is in press and due to skin biopsy testing of diabetic patients. appear in mid-2006. Organised and an organiser Over the past decade, Professor Efron has Professor Efron is organised and an organ- liaised with consultant diabetic specialists Conference junkie and showman iser. In Melbourne he served on the Board and neurologists and in collaboration with It is said thatjoining the navy is one of the of Continuing Education of the Victorian a number of graduate students has pub- best ways of seeing the world. Enthusias- College of Optometry for 11 years (1977- lished 21 papers on confocal microscopy. tic participation in international academic 1989) and as President of the Contact Lens Professor Efron has interests in practi- conferences and meetings for practition- Society ofAustralia (1981). He was a coun- cal aspects of clinical optometry. One of ers is another. Nathan Efron has lectured cillor of the British Contact Lens Associa- these has been standardisation of gradings at no fewer than 360 conferences in 35 tion for seven years (1992-1999) and its of the severity of contact lens complica- countries. His reputation for translating President in 1996. He was Head of the tions. He worked for several years with complex scientific material into easily di- Department of Optometry and Vision acclaimed medical ophthalmic artist Terry gestible, clinically-applicable information Sciences at UMIST from 1992 to 1997. Tarrant to develop and validate a series of for contact lens practitioners, as well as a He has also taken his turn in senior illustrated grading scales.I2 He secured reputation for enthusiastic presentation academic administrative roles at UMIST industry sponsorship to produce these and for stirring controversy, has resulted as university-wide Dean of Undergraduate grading scale charts for clinical use and in 170 invitations as guest lecturer or key Studies (1992-1995), Dean of Quality more than 70,000 have been distributed speaker. (1997-2000) and Dean of Research (2001- world-wide to clinical practices without This is Nathan Efron the showman and 2004). charge. The ‘Efron Grading Scales for entertainer, a role symbolised by his daz- During his time as Head of Department, Contact Lens Complications’ has become zling array of flamboyant and colourful Nathan joined with the Head of Ophthal- a standard tool for assessing and commu- bow ties. His father was a clothing manu- mology at the nearby Victoria University nicating the level of severity of adverse facturer so many of the bow ties were be- of Manchester, Professor David McLeod, events relating to contact lens wear. spoke, hand-made by his father. Confer- to establish the world’s firstjoint Optom- An electronic version, in the form of ence delegates have been known to etry and Ophthalmology higher degree operator-controlled computer morph complain when he does not don his course: the MSc in Investigative Ophthal- movie sequences, has also been developed. famous neckwear. mology and Visual Science. This multidis- I recall the showmanship when he was ciplinary course, shared evenly between Easy writer an undergraduate student. He would al- optometry and ophthalmology, is still run- Nathan Efron enjoys writing and writes ways sit in the front row and would com- ning and has trained numerous optom- with an easy facility. He has published 195 monly go to sleep, ostentatiously sprawled etrists, ophthalmologists, orthoptists and refereed scientific papers, 136 clinical ar- over his student desk, head in arms, even vision scientists from the UK and abroad. ticles and 208 abstracts. That is a remark- before the lecture began. That is one way His department did well at research

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while he was its Head: it attained the high- bridge to speak at an alumnus dinner. He been proud of his native country. He of- est possible research rating in the UK-wide greeted her and thanked her for travel- ten embellishes his lectures with images research assessment, but it ranked well in ling all the way from Cambridge, to which of famous Australians, indigenous wildlife teaching too, getting equal highest rating she replied loudly so all could hear ‘What and Australian landscapes. He claims to with two other UK optometry schools for the (powerful expletive), Nathan; you’re have been continually haunted during his teaching excellence from the UK Quality an Australian, you know that 60 (equally decade and a half in the UK by the lyrics Assurance Agency for Higher Education. powerful expletive) miles is nothing.’ of Peter Allen’s classic anthem I still call Being an organiser, the opportunity to His contributions to his discipline and Australia home. He is now taking the op serve on the General Optical Council, the his enthusiastic participation in both aca- portunity to turn the anthem to reality by national registration body in the UK for demic and professional affairs have not returning to Australia to be an active part optometrists and dispensing opticians, gone unrecognised. He has received nu- of what he sees as the exciting develop- could not be refused. He served two terms merous awards, notable among which are ments taking place in the School of from 1994 to 2005, the first as a representa- the Garland W Clay Award (American Optometry at QUT. tive of the UK schools of optometry and Academy of Optometry, 1980), the Dallos the second as an elected optometric mem- Award (British Contact Lens Association, REFERENCES ber. He was very much involved in the 1993), the Emerson Woodruff Award (Uni- 1. Efron N, Carney LG. Oxygen levels beneath drafting of the new Opticians’ Act, espe- versity of Waterloo, Canada, 1994), the the closed eyelid. Invest Ophthalmol Vis Sci cially those aspects relating to the rules award for Distinguished Research on the 1979; 18: 93-95. 2. Efron N, Carney LG. Models of oxygen and regulations surrounding the fitting Cornea and Contact Lens (University of performance for the static, dynamic and and supply of contact lenses. He was the Houston, USA, 1999), BCLA Gold Medal closed lid wear of hydrogel contact lenses. expert witness for the GOC in its cel- (British Contact Lens Association, 2001), Aust J Optom 1981; 64: 223-233. ebrated case against Vision Direct Ltd, the Peter Abel Award (German Association 3. Holden BA, Sweeney DF, Vannas A, Nilsson which was accused of the unsupervised of Contact Lens Specialists, 2001) and the KT, Efron N. Effects of long-term extended contact lens wear on the human cornea. selling of contact lenses. His evidence was Max Schapero Award (American Academy Invest Ophthalmol VisSci 1985; 26: 1489-1501. a turning-point in the case, as the Magis- of Optometry, 2003). He was awarded the 4. Holden BA, Newton-HowesJ, Winterton L, trate’s written judgment makes clear, and degree of Doctor of Science by UMIST in Fatt I, Hamano H, LaHood D, Brennan NA, Vision Direct Ltd was found guilty, an out- 1995. Efron N. The Dk project: an interlaboratory come that provided important impetus for comparison of Dk/L measurements. Optom Sci 1990; 67: 476-481. subsequent optometric legislation. Time for a Vis change 5. Efron N, Pearson RM. Centenary celebra- An opportunity to give something back In 2002, a decision was made to merge tion of Fick’s Eine Contactbrille. Arch to The University of Melbourne came in UMIST with the nearby Victoria Univer- Ophthalmoll988; 106: 1370-1377. 1993 when the University of Melbourne sity of Manchester, to create a new institu- 6. Pearson RM, Efron N. Hundredth anniver- Alumnus Association decided to become tion, called simply The University of Man- sary of August Mdler’s inaugural disserta- tion on contact lenses. Surv Ophthalmol more international. After attending a re- Chester. As a senior academic at UMIST, 1989; 34: 133-141. ception in London organised by the uni- Professor Efron was conscripted to the 7. Pearson RM, Efron N. Otto Himmler: first versity to address this issue, Nathan vol- joint senior management team of the two manufacturer of lathe cut corneo-scleral unteered to form the United Kingdom predecessor institutions. He co-chaired lenses (sic).Sun, Ophthalmol2004; 49: 374 branch of the association. He has always the committee that developed the frame- 375. been an enthusiastic volunteer. He was work for the Graduate School of the new 8. Efron N, Veys J. Defects in disposable con- tact lenses can compromise ocular integ- elected as inaugural president and, to university and served on the interim board rity. Znt Contact Lens Clin 1992; 19: 8-18. keep it in the family, his sister Nicole, who of the Faculty of Medicine and Human 9. Efron N. Contact lens practice and a very was living in London at the time and was Sciences. Professor Efron regrets that he soft option. Clin Exp Optom 2000; 83: 243- also an alumnus of the university, was was unable to persuade the new univer- 245. elected as secretary. Nathan found him- sity, which formed in October 2004, to in- 10. Efron N. The desperate last gasps of rigid contact lenses. Clin Exp Ophthalmol2005; self travelling frequently to London and clude Optometry as a school in the Fac- 33: 341-342. Oxford to host alumni events and enter- ulty of Medicine and Human Sciences. 11. Malik RA, Kallinikos P, Abbott CA, vanSchie tain the likes of the High Commissioner Instead, because of its association with CHM, Morgan PB, Efron N, Boulton AJM. for Australia, the Vice-Chancellor and neuroscience, Optometry has been as- Corneal confocal microscopy: a non-inva- Chancellor of The University of Mel- signed to the Faculty of Life Sciences, a sive surrogate of nerve fibre damage and repair in diabetic patients. Diabetologza bourne, the Agent General for Victoria single school faculty, where optometry is 2003; 46: 683-688. and even fellow alumnus, Germaine Greer. simply a course without a ‘school’ or ‘de- 12. Efron N. Efron grading scales for contact He recalls greeting Germaine Greer in the partment’ to underpin it. Maybe it was lens complications. In: Contact Lens Com- candlelit formality of an Oxford College time to move on. plications, 2nd ed. Oxford: Butterworth- refectory when she travelled from Cam- Like most Australians, Nathan has always Heinemann; 2004. p 239-243.

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