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| GOLDEN JUBILEE SPECIAL ARTICLE |
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| Year : 2003 | Volume
: 51
| Issue : 3 | Page : 211-216 |
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Sir Nicholas Harold Ridley.He Changed the World, So that We Might Better See It.
Rupal H Trivedi, David J Apple, Suresh K Pandey, L Werner, Andrea M Izak, Abhay R Vasavada, J Ram
Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, South Carolina, USA
Correspondence Address:
Rupal H Trivedi
Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, South Carolina
USA
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 14601845 
Cataract surgery with intraocular lens (IOL) implantation has become the most common and most successful of all operations in medicine. Sir Harold Ridley's first cataract extraction with implantation of an IOL marked the beginning of a major change in the practice of ophthalmology. Millions of patients worldwide have benefited from Sir Ridley's invention, and are likely to continue to derive benefit from this device. However, the development of the IOL was not without its share of ups and downs.
Sir Harold Ridley, the inventor of IOL, died at the age of 94, on 25 May 2001, and ophthalmology lost one of its greatest and most influential practitioners. We are happy that he lived to enjoy the fruits of his labour - to see the amazing improvements and the expansive growth that evolved in the cataract-IOL technique, from early and unsatisfactory operations in previous decades, to the superb results attainable today. The invention of the IOL has not been just the addition of one new form of treatment, but rather, Sir Harold's tiny disc-shaped sliver of plastic has changed the world so that our patients may better see it . This article presents a brief biographical sketch of Sir Harold and lists his major inventions and contributions to ophthalmology. Keywords: Sir Harold Ridley, cataract surgery, intraocular lens, pseudophakia, ophthalmology, history.
How to cite this article:
Trivedi RH, Apple DJ, Pandey SK, Werner L, Izak AM, Vasavada AR, Ram J. Sir Nicholas Harold Ridley.He Changed the World, So that We Might Better See It. Indian J Ophthalmol 2003;51:211-6 |
Sir Nicholas Harold Ridley [Figure - 1], MA, MD, Cantab. (Cambridge); FRCS, England; DHL, Medical University of South Carolina, Charleston, SC, USA; DS, City University of London; Fellow of the Royal Society; recipient of the Gullstrand and Gonin Medals; the inventor of the intraocular lens (IOL) and founder of our modern subspecialty of cataract and refractive surgery; passed away in Salisbury, UK, on May 25, 2001. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10]
Ridley was born in Kibworth, Leicestershire, on July 10, 1906. After completing his studies at Cambridge in 1927, he began his medical training at St. Thomas' Hospital, London, where he completed his basic medical education in 1930. By 1938 he had appointments as surgeon and consultant at both Saint Thomas' Hospital and Moorfields' Eye Hospital. It is universally accepted that he invented the IOL and that he was the first surgeon to implant the IOL. The first operation was done at St. Thomas' Hospital [Figure - 2] in London, on November 29, 1949. [1],[2],[3]
Although IOL implantation is now a universally accepted practice, the invention of this implantable prosthesis was indeed a veritable revolution in its time. Young residents and practitioners today implant IOLs routinely and with ease, not realising the extraordinary struggle that Ridley had to endure for many years as he developed his technique. Many of us have very short memories. It took a long time to convince many that his mid-20th century IOL invention marked the beginning of changes that led to the vastly improved treatment we are now able to provide cataract patients. Since the operation was revolutionary rather than merely evolutionary , it seemed inevitable that it would encounter widespread criticism. So Ridley decided to keep the idea secret for a while, between 1947 to 1950. At the time, his surgical research was designated "top secret." He wanted to research it thoroughly, and thus be able to provide as safe and effective a finished product as possible when he introduced it publicly. Ridley was not concerned about the financial issues (he did not patent the lens), but he wanted secrecy in order to keep other interested, but often-inexperienced surgeons from using the lens before he had thoroughly tested it. He was afraid that surgeons would, without proper instruction, possibly experience complications that might give the IOL a bad name. Unfortunately, that is precisely what happened, and was probably responsible for a delay in the acceptance of the IOL.
Recently, one of us (DJA) had the opportunity to visit Ms. Doreen Ogg [Figure - 3][Figure - 4]. Ms. Ogg is the only surviving member of Sir Harold Ridley's first implant operation team, and one of his most respected nurses, and as such is an important source of information regarding Ridley's early work. According to Ridley himself, Ms. Ogg played a very important role in the research projects and events that led up to the invention of the IOL. She had a major role in record keeping, basic operating room nursing duties, as well as with dressings and patient follow-up. It seems very archaic now, but in those times it was a crucial task to hold the manual hand-guided light system that provided the correct lighting for an operating field. Ridley specifically chose her, among others, to perform this and other tasks because of her reliability. She made several interesting observations regarding the original IOL operation, and provided written follow-up regarding these surgeries.
At a memorial service held in honor of Sir Harold on September 6, 2001, in London, Ms. Ogg was "surprised" to hear it stated that the initial lens implant did not occur until February of 1950. She strongly disagreed and went on to explain that in fact the first implantation of an IOL was performed on November 29, 1949. In written records, the operation on that date was referred to only as "lens extraction." Mention of an IOL was purposely omitted in order to retain the secrecy that Sir Harold had requested. She also recalls vividly that in December 1949, very soon after the extraction, and definitely "before Christmas", the patient's refraction was very unusual: Sir Harold and the other opticians were "horrified" by the inappropriate pseudophakic correction. The patient was rendered highly myopic (-14 Diopters). She noted that the initial lens was then replaced by another lens at a later time. It is quite possible that this latter event may have been the lens implantation noted in the operative note occurring on February 8, 1950. The specificity of these dates is only of historical interest. This indeed is a historic date, both actually and symbolically representing the launch of a new era. We accept the initial implant date as November 29, 1949, not only because of the evidence, but perhaps more importantly, this was the date indicated in numerous writings and discussions by Sir Harold himself. It is interesting to note that if Ms. Ogg's recollections are correct, this case would represent not only the first case of an IOL implantation, but also the first case of an IOL explantation , as well as the first case of an IOL exchange.
As mentioned earlier, early reaction to his IOL invention ranged from skepticism and scorn, to outright virulence. [11],[12],[13],[14] Ridley subsequently related several negative encounters to one of us (DJA), some of which were subsequently presented and published as comments during the Gullstrand Lecture presented in Stockholm, Sweden in 1993.[12] Excerpts of some comments follow:
'Dr. Ridley, Why don't you… GO HOME!' (Philadelphia).
'Would you have one of THESE THINGS put in your son's eye?' (Oxford).
'As long as I remain in charge of this department no implant will ever be done' (European Professor of Ophthalmology).
'This operation should never be done' (Chicago).
'It offends the first principle of ophthalmic surgery and could cause malignant disease' (USA).
'Rayners should be prosecuted for supplying intraocular lenses'.
Sir Harold presented his very first patient at the Oxford Congress in 1951, and received severe criticism. He immediately withdrew from the Oxford meeting and drove back to London. Sir Stewart Duke-Elder, a highly influential author and respected leader in ophthalmology, was especially critical at this Oxford meeting, and also on many other occasions until his death in 1978. Ridley himself stated that the pressure was so intense that one morning he collapsed in the hospital with depression, and had to take medication for months. Ridley also recalled that one extremely worrying matter was the fear of a charge of malpractice being brought against him, for which he probably would have had little defense in those early days of what was still an experimental surgery.
This well-known series of conflicts, and the long delay in Ridley's receipt of appropriate honors, was based largely on three major factors. (1) His mid-20th century invention of the implantable IOL was not merely the introduction of a piece of plastic. Rather, it was a break from tradition, necessitating a major paradigm shift. The practice of ophthalmology at that time was largely based on "taking things out of the eye." It was a groundbreaking introduction of the new concept of an "implantable intraocular prosthesis" that required time, education and understanding to accept and assimilate. (2) There were in fact IOL-related complications. Some surgeons referred to the IOL as a "time bomb." Government funding sources showed little interest in the devices, as there was little available experimental or animal data, and little analysis of the material in those early years. Therefore, valid criticisms from a medical, experimental and pathological viewpoint were warranted. Unfortunately, many criticisms were based on jealousy or prejudice, and not on the scientific facts; many of the criticisms had nothing to do with Sir Harold himself, but rather were related to complications experienced by other surgeons. He himself was an excellent surgeon. We have had an opportunity to analyse several pseudophakic human eyes obtained postmortem, implanted with Ridley's original Rayner IOL [Figure - 6].[15],[16] The techniques of that time were not fully developed for the IOL procedure; in many instances the techniques and instruments used were of 19th century vintage, and many surgeons were not yet skilled. Sir Harold was also a brilliant surgeon and scientist, what we would call a "modest genius." This modesty contributed to his decision, conscious or otherwise, to not act as a "politician" in the negative sense that we sometimes use the term today. He was non-confrontational and not a debater; therefore, he sometimes found himself physically fearful of criticism.
However, these controversies are now largely relics of the past. His work is almost universally accepted. Our patients can now enjoy the success that is currently achievable with these devices. Colleagues in those early years, including Ridley himself, would be thoroughly amased to see the rapid advances in implant technology.
With few exceptions, almost all of Ridley's recognitions and honors came in the last 15 years of his life, between 1986 until his death in 2001. If Ridley had died any time sooner, he would probably be on the verge of being a forgotten man today. His first major public recognition was his election to the Royal Society, London, in 1986. His first academic honor was an honorary doctorate degree, Doctor of Humane Letters, (DHL) conferred in 1989, by the Medical University of South Carolina, Charleston, SC, USA [Figure - 7]. His detailed biography was prepared by one of us (DJA) and published in the Survey of Ophthalmology in 1996.[4] In April 1999, at the annual meeting of the American Society of Cataract and Refractive Surgery in Seattle, Washington, Ridley was honored in a special anniversary session as one of the most outstanding ophthalmologists of the 20th Century. In February 2000, knighthood was conferred on him by Queen Elizabeth II [Figure - 8].[7],[8] These honours finally helped erase what had indeed been a very difficult memories for him, for most of his professional life. Prior to these honours and recognitions, Ridley was indeed a classic example of a "prophet -without- honour" in his own country.
Almost all of Ridley's public honours were related to the IOL. Because of the huge impact of the IOL, almost all his non-IOL related medical discoveries have drawn little attention. Even taken alone, these related discoveries would elevate him to the highest rank as the one of the greatest ophthalmologists of all time. Sir Harold's real genius becomes obvious when one surveys the scope of his accomplishments and innovations. He surely would have been considered as "high tech" in his time. Removing the cloak of the IOL reveals the following partial listing of several documented ideas that originated from Ridley. We have classified these into three categories and have included some illustrations of historical interest related to these endeavours. Most of these are now long forgotten and some are previously unpublished. These are: Category 1, clinically-related (medical/surgical); Category 2, pioneering attempts at applications of the newly-emerging post-World War II technology termed "electronics" at that time, termed "high-tech" today; and Category 3, non-scientific innovations not at all intended by Ridley himself, basically an unintentional but radical shift in the realm of medical economics.
Clinical (medical/surgical) achievements
1.Definitive characterisation of onchocerciasis (River Blindness) in 1945. Onchocerciasis is one of the most common causes of blindness worldwide. These studies were based on work carried out during his wartime station in Ghana.[17]
2.Treatment of ocular leprosy, a disease commonly regarded as incurable. He performed what he felt may have been the first successful corneal graft on a leprosy patient.
3.Pioneered recognition of the multivitamin therapies in tropical countries to treat nutritional amblyopia.[18] Finally, his experience with Vitamin A was utilized in the treatment of keratomalasia (xerophthalmia) in tropical countries. He applied this treatment on a small scale (but with great success) during his wartime period in Ghana. Unfortunately, Sir Harold has received almost no credit for these efforts performed in rural regions in wartime.
4.Pioneered clinical research in non-enucleation treatment of uveal (especially choroidal) malignant melanoma.
5.Was an early pioneer (with D. Peter Choyce) in keratorefractive surgery, especially intrastromal corneal implants. He also designed one of the first keratoprosthetic biodevices.[19]
Electronic ("hi-tech") ophthalmology
Just as he derived IOL biocompatibility information from World War II experiences when plastic 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 the war, to the field of ophthalmology and visual sciences. As he had done with the IOL in collaboration with Rayner Intraocular Lenses Ltd., Sir Harold developed close relationships with other members of the corporate sector to accomplish these applications (e.g., the Marconi Wireless Electronic Company, London; and the Pye Electronics Company, Cambridge, both leaders in the electronics at that time).
1.Ridley was the first to televise eye operations, both in black and white (B&W) and colour (1949). This of course opened the floodgates to our universal use of surgical videos in research and teaching and the establishment of "Film Festivals" at our meetings. Ridley was the first to use television in ophthalmology to image intraocular tissues on a monitor (B&W and colour) as early as 1949. This represented the forerunner of such applications as televised video-conferencing and video-diagnosis.
2.Ridley was the first to initiate a form of electronic ophthalmoscopy,[21],[22] which was instrumental in directly establishing the basic principles of modern confocal microscopy and scanning laser ophthalmoscopy, now a very important clinical and research tool.[23]
Medical economics
Last but not least, and perhaps unintentionally, 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. This 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/scientific components that our forerunners had seen.
A careful look at each one of the items listed here taken alone would be a discovery or innovation of a lifetime for most of us. Taken together (even without the IOL) these, in our opinion, would distinguish Ridley as a major figure in our specialty in the 20th century. Because the IOL overwhelmed all of these, Ridley received very little recognition during his lifetime for these other highly significant innovations.
Helping ophthalmology in the developing world
For several years Sir Harold Ridley had a close relationship with ophthalmology in the developing world. Later entering the Royal Army Medical Corps in 1941, Ridley was sent to Ghana in the Gold Coast of West Africa in 1943. Later, he was ordered to fly to Poona, India, then by train to Calcutta, and finally to Paraganas near Calcutta. Following this, he was transferred to Rangoon, Burma. During these years, he worked extensively on onchocerciasis and amblyopia. His 1945 monograph entitled Ocular Onchocerciasis published as a supplement to the British Journal of Ophthalmology, was a landmark.[17]
Forty million people in developing countries are functionally blind - over half of them from cataract. Without exaggeration - and there are very few doubters today - Sir Harold's IOL invention has both directly and indirectly led to visual restoration and cure for multi-millions of visually handicapped people worldwide, a huge step towards the eradication of cataract blindness. Because of Sir Harold's early work, implantation of IOLs on a broad scale in the rural areas of these countries is now a definite possibility. It would be a spectacular legacy to Harold Ridley - whose heart and intellect was strongly devoted to the problems of tropical medicine and blindness in the developing world - to accelerate and expand efforts to provide the benefits of IOLs to needy individuals throughout the world.[24],[25]
Cataract removal and IOL implantation is by far the most common and most successful of all operations in medicine. We are pleased that Sir Harold Ridley lived to enjoy the fruits of his labour, to see the amazing improvements and the expansive growth that has evolved in the cataract-IOL technique, from early and unsatis-factory operations in previous decades, to the superb results attainable today. Our challenge is to "cure aphakia" on a global basis; and we are pleased that concerted efforts now are being made toward achieving widespread "pseudophakia" in the developing world. The advantages of an IOL implant over aphakic spectacles have also been confirmed in recent studies done in leading ophthalmic centers in developing countries.[26]
As we say good-bye to Sir Harold Ridley, we hope that all of us who have shared the experiences of relatives or friends (even ourselves!) regarding IOL implants after cataract surgery, will reflect back in history on his tiny piece of plastic and be grateful for his sight-saving invention. The year 1949 began a new era, the formative years of the IOL. The intermediate years represented the period of growth of the cataract-IOL procedure. His death came at a time of near perfection of his invention, indeed during a period of maturation of not only IOLs, but also of other hi-tech implantable biodevices, many of which he pioneered. The second-half of the 20th century has truly benefited from Ridley's contributions, and we are likely to continue deriving benefits from his work. As noted by our friend, I. Howard Fine, himself a pioneer, innovator and practitioner of cataract-IOL surgery, the IOL has not been just the addition of one new form of treatment, but rather, Ridley and his tiny disc-shaped sliver of plastic have literally "changed the world." Indeed, Sir Harold Ridley has changed the world so that our patients may better see it . Only rarely has an individual in the field of ophthalmology provided so much intellect, effort, and vision that have led to such great benefits for so many.
| References | |  |
| 1. | Ridley NHL. Intraocular acrylic lenses. Trans Ophthalmol Soc UK & Oxford Ophthalmol Congress . 1951;LXXI:617-21.  |
| 2. | Ridley NHL. Further observations on intraocular acrylic lenses in cataract surgery. Trans Am Acad Ophthalmol Otolaryngol . 1953;57:98-106. |
| 3. | Ridley NHL. Intraocular acrylic lenses after cataract extraction. Lancet . 1952;1:118-19. |
| 4. | Apple DJ, Sims J. Harold Ridley and the invention of the intraocular lens. Surv Ophthalmol . 1996;40:279-92. [ PUBMED] [ FULLTEXT] |
| 5. | Apple DJ. Harold Ridley MA, MD, FRCS: A golden anniversary celebration and a golden age. Arch Ophthalmol . 1999;117:827-28. [ PUBMED] [ FULLTEXT] |
| 6. | Apple DJ, Peng Q, Ram J. The 50th anniversary of the intraocular lens and a quiet revolution. Ophthalmology . 1999;106:1861-62. [ PUBMED] [ FULLTEXT] |
| 7. | Apple DJ. Sir Harold Ridley receives England's highest honor. Surv Ophthalmol . 2000;44:542. [ PUBMED] [ FULLTEXT] |
| 8. | Apple DJ, Peng Q. Harold Ridley knighted. Ophthalmology 2000;107:412-13. |
| 9. | Apple DJ. Sir Nicholas Harold Ridley: All's well that ends well. Am J Ophthalmol . 2002;133:131-33. |
| 10. | Williams HP. Sir Harold Ridley's vision. Br J Ophthalmol 2001; 85:1022-1023. |
| 11. | Duke-Elder S. System of Ophthalmology: Diseases of the Lens and Vitreous, Glaucoma and Hypotony . St Louis, MO: CV Mosby, 1969; Vol XI. pp 1-291. |
| 12. | Ridley H. Gullstrand Lecture: Mr. Harold Ridley, Stockholm, 1992. Eur J Implant Ref Surg . 1993; 5:4-7. |
| 13. | Vail D. A dream cometh through a multitude of business. Am J Ophthalmol . 1952;35:1701-3. |
| 14. | Vail D. Discussion of Ridley H: Further observations on intraocular acrylic lenses. Trans Am Acad Ophthalmol Otolaryngol 1953;57:104. |
| 15. | Apple DJ, Mamalis N, Loftfield K, Googe JM, Novak LC, Kavka-Van Norman D, et al. Complications of intraocular lenses: A historical and histopathological review. Surv Ophthalmol 1984;29:1-54. |
| 16. | Apple DJ, Kincaid MC, Mamalis N, Olson RJ. Intraocular lenses; evolution, designs, complications, and pathology . Baltimore, MD: Williams & Wilkins. 1989. pp 370-377. |
| 17. | Ridley NHL. Ocular onchocerciasis. Br J Ophthalmol . 1945;29(Suppl). |
| 18. | Ridley H. Ocular manifestations of malnutrition in released prisoners of war from Thailand. Br J Ophthalmol . 1945; 29:613-18. |
| 19. | Choyce DP. Intraocular Lenses and Implants . London, UK: HK Lewis & Co. 1964. pp 1-211. |
| 20. | Ridley NHL. Television in ophthalmology. Proc XVI Intern Congress Ophthalmol . 1950; pp 1397-1404. |
| 21. | Ridley NHL. Recent methods of fundus examination including electronic ophthalmoscopy. Trans Ophthalmol Soc UK . 1952; LXXII:497-509. |
| 22. | Ridley H. The improved flying spot electronic ophthalmoscope. Trans Ophthalmol Soc UK . 1960;79:585-89. |
| 23. | Masters BR. SPIE Milestone Series of Selected Reprints: Confocal Microscopy . Bellingham, WA: SPIE Optical Engineering Press. 1996; Vol MS131. |
| 24. | Apple DJ, Ram J, Foster A, Peng Q. Elimination of cataract blindness: A global perspective entering the new millennium. Surv Ophthalmol 2000;45(Suppl):S1-S196. |
| 25. | World Health Organization. Use of intraocular lenses in cataract surgery in developing countries: Memorandum from a WHO meeting. Bull WHO . 1991; 69:657-666. |
| 26. | Natchiar GN, Thulasiraj RD, Negrel AD, Bangdiwala S, Rahmathallah R, Prajna NV et al. The Madurai Intraocular Lens Study. I: A randomized clinical trial comparing complications and vision outcomes of intracapsular cataract extraction and extracapsular cataract extraction with posterior chamber intraocular lens. Am J Ophthalmol 1998;125:1-13. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]
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