Harold Ridley and the invention of the intraocular lens: a reappraisal

Ophthalmic thought leaders opposed IOL implantation in the decades after its invention because of the secrecy of its development, the lack of preclinical studies, and poor clinical results.

Abstract

Harold Ridley permanently implanted the first intraocular lens (IOL) in 1950. The widely accepted narrative is that Ridley and his invention received a hostile reception from Stewart Duke-Elder and other ophthalmic thought leaders. Ridley suffered greatly but was eventually vindicated because later IOL designs were widely accepted. This narrative casts Ridley as a prophetic innovator who suffered and eventually triumphed against the forces of animosity, jealousy, and close-mindedness arrayed against him. We argue that this narrative is biased because it was told by Ridley himself and amplified by his biographer and close friend, David Apple. There were good reasons to be skeptical of Ridley's invention. Ridley had not performed preclinical studies, so his first patients suffered avoidable complications. He worked in secret at a time when openness was the norm. Ridley's IOL had a high percentage of poor outcomes. The cautious approach that Duke-Elder and others had toward IOLs is understandable. The accurate history is a story of a clash of worldviews between an inventor who was focused on innovating quickly to solve a major clinical problem and established leaders who were concerned about the harm to patients from a flawed invention. The skepticism of established thought leaders remains a valuable check on aggressive innovation today.

On February 8, 1950, Harold Ridley stood at the head of the operating table at St. Thomas' Hospital in London.^1,2 Wearing loupes, he made a 180 degrees cornea-conjunctival section with a Graefe knife and implanted the first permanent intraocular lens (IOL) in an eye.³

Ridley kept his new IOL secret until the Oxford Congress in July 1951.⁴ There he presented his first 8 cases. He brought two live patients for the conference attendees to examine, one of whom had 20/20 uncorrected acuity. Many of the conference participants were awed; one called it “one of the most significant advances in the ophthalmic surgical field of this half century.”⁴

Ridley was the first to intentionally implant a foreign body in the eye, so he was prepared for controversy. He was unprepared for what he interpreted as naked hostility. Present at the Congress was Sir Stewart Duke-Elder, the Director of Research of the Institute of Ophthalmology in London and Britain's most famous and powerful ophthalmologist.^5(p.155) According to Ridley, Duke-Elder “firmly refused repeated requests to look at the patients, so confirming his hostility even at that very early stage.”⁶ Ridley was so upset that he left the conference early.

This year ophthalmologists celebrate the 75th anniversary of Ridley's first implant and its impact on cataract surgery worldwide. In this article, we reexamine the circumstances surrounding the invention of the IOL and its chilly reception by Duke-Elder and other ophthalmic leaders. We argue that the existing narrative about its reception is incomplete, biased, and simplistic.

HAROLD RIDLEY: THE CANONICAL NARRATIVE

Nicholas Harold Lloyd Ridley was born in Leicestershire in 1906, the son of an ophthalmologist (Figure 1). He completed his ophthalmology training at Moorfields Eye Hospital in London in 1935. During World War II, he served as a major in the Royal Army Medical Corps. Ridley returned from the war and started a private practice in Harley Street in 1946.

Figure 1.

Sir Harold Ridley (Reprinted with permission from the Ridley Eye Foundation)

The standard of care in cataract surgery then was to perform an intracapsular extraction and leave the eye aphakic. One day, a medical student observing Ridley perform cataract surgery asked him why he did not replace the crystalline lens with an artificial lens. Ridley decided to try.⁶ He knew that the eyes of fighter pilots in World War II had at times been pierced by fragments of poly(methyl methacrylate) (PMMA) from shattered aircraft canopies. The PMMA fragments were well tolerated in these eyes years later.^7,8 Ridley enlisted John Pike from Rayner and Keeler to make a lens out of PMMA. The two men met surreptitiously in Ridley's Bentley automobile in Cavendish Square, London, and sketched out a design for a posterior chamber IOL. Ridley implanted the new lens in a 45-year-old nurse with a unilateral cataract.

The chilly reception Ridley received at the Oxford Congress left him shaken but undeterred. He continued implanting IOLs. Ridley maintained that Duke-Elder was hostile to IOLs throughout his life.^6,9 Ridley soon found that other powerful figures were also critical of his work. Ridley presented results of his first 63 cases at the American Academy of Ophthalmology meeting in Chicago in 1952. The discussant was Derrick Vail, editor-in-chief of the American Journal of Ophthalmology. Vail said, “The operation is one of considerable recklessness and… its hazards far exceed the little that is gained in the way of ocular comfort.”¹⁰ Ridley reports other charged comments that he received after conference presentations: “This operation should never be done”; “As long as I remain in charge of this department, no implant will ever be done”; and “Would you have one of THESE THINGS put in your son's eye?”⁶

Part of the canonical narrative is that Duke-Elder's opposition to the IOL was a clash of personalities, with the powerful Duke-Elder hounding Ridley because of jealousy or personal animosity. Ridley suggested that Duke-Elder may have been angry at him for complaining 10 years previously that Duke-Elder was not attending his assigned clinics at Moorfields.^5(p.157) Ridley's biographer, David Apple MD, claims that Duke-Elder was jealous that he had not conceived of the IOL himself.^5(p.160)

At one point, Ridley was hospitalized with depression that he attributed to the criticism directed at him.⁶ Although Ridley eventually abandoned his original IOL, he inspired a generation of ophthalmic surgeons to develop newer models of lenses. Ridley wrote that the continuing controversy “deprived a whole generation of cataract patients throughout the world of restoration of their natural sight.”⁶ According to David Apple, “For over three decades he was supported by a very few visionary individuals, but defamed by many. Fortunately, he has lived to see the vast benefits he has provided to humanity with his invention.”⁹ Ridley eventually received a knighthood and was inducted into the Royal Society.¹¹ He was honored with the Gullstrand Medal, given every 10 years to the individual who has made the greatest contribution to ophthalmology.⁹

THE CANONICAL NARRATIVE IS ONE-SIDED

The canonical narrative about the invention of the IOL is this: A visionary young inventor with a brilliant idea was opposed at every turn by powerful reactionary individuals who were driven by jealousy, animosity, or lack of imagination. The inventor suffered greatly but persevered in his vision, and his invention eventually changed the lives of millions. It is a gripping and satisfying narrative.

Unfortunately, it is incomplete, and as we shall see, biased. It was told almost entirely by Ridley himself, through his Gullstrand medal lecture and interviews he gave to his primary biographer, Dr. David Apple, in the 1990s.^5,6 We should expect that story to be biased toward Ridley's point of view. Nowhere is Duke-Elder's point of view mentioned in any of the writings of Ridley or Apple.

One aim of this article was to understand Stewart Duke-Elder's view of Harold Ridley's IOL. This is not an easy task. Duke-Elder never told his side of the story. Ridley left behind recorded interviews, but Duke-Elder did not. The first modern IOL, the Shearing J-loop posterior chamber lens, was not introduced until 1977.¹² When Duke-Elder died in 1978, IOLs were still not generally accepted, so no one had thought to interview him about IOLs.

Duke-Elder's only published references to IOLs are 3 pages in System of Ophthalmology and a brief mention in another book.^13,14 A thorough search of the archives of the Institute of Ophthalmology in London, the institution that Duke-Elder founded and led for 17 years, revealed no material referencing Ridley or IOLs. Contemporaneous archives from St. Thomas' Hospital, where Ridley performed many of his lens implants, apparently no longer exist except for formal annual reports.

Nevertheless, it is possible still to develop a portrait of Duke-Elder that provides a perspective on his point of view. That perspective makes clear that the canonical narrative is simplistic, incomplete, and biased. To explain why, we need to introduce the alleged villain.

WILLIAM STEWART DUKE-ELDER

William Stewart Duke-Elder was born in Scotland in 1898 (Figure 2). He rode 5 miles to high school in Dundee, Scotland, by horse and open carriage each day, carrying feed for the horse and lunch money. He skipped lunch and used the money to buy candles, so he could read at night at home. Duke-Elder attended the University of St. Andrews. He finished his ophthalmology training at Moorfields in 1928, 7 years before Harold Ridley.¹⁵

Figure 2.

Sir William Stewart Duke-Elder (Reprinted with permission from the Institute of Ophthalmology)

Duke-Elder was the unchallenged leader of British ophthalmology, and likely the most famous ophthalmologist in the world.^16(p.100) He was knighted at age 35. In 1936, at the age of 38, he was appointed surgeon oculist to King Edward VIII, a remarkable honor for someone so young. He was best known for the System of Ophthalmology, a massive nineteen-volume multiauthor work that was a comprehensive survey of all that was known about the subject. Before that he had written the single-author, seven-volume Textbook of Ophthalmology, published between 1932 and 1954. He received innumerable international awards, including the Gullstrand medal in 1952, 40 years before Ridley.¹⁵

A core belief of Duke-Elder was that laboratory research was central to curing disease. He wrote in the introduction to Textbook of Ophthalmology, “This first volume is entirely devoted to the fundamental sciences upon which alone a thorough understanding of clinical ophthalmology can rest, and upon which any advances in the treatment of disease must be based.”¹⁷ Nearly 30 years later, his faith in the laboratory was unshaken: “Those who will be leaders in the new ophthalmology of the next century of progress will…be men and women capable of analyzing, criticizing, and weighing the significance of the findings of the scientist… and applying this knowledge to the sick patient in the ordinary practice of everyday life.”¹⁸

Duke-Elder's professional work reflects this belief. Of the 48 peer-reviewed articles he published prior to the onset of World War II, 34 articles reported on laboratory work and its relevance to ophthalmic disease, particularly glaucoma (based on PubMed database search using the term “Duke-Elder[author]”).

Duke-Elder's vision that laboratory research is a prerequisite for high-quality clinical care was clear when he created the Institute of Ophthalmology in London, an affiliate of Moorfields Eye Hospital and the University of London. The Institute was created in 1948 by an Act of Parliament which Duke-Elder skillfully engineered. On 18 February 1946, he wrote a letter to Aneurin Bevan, MP, the Secretary of State for Health, lobbying for the Institute

[The Americans] are doing nothing fundamentally important…To get on in an American teaching school—Harvard, Cornell, Columbia, Johns Hopkins, Philadelphia and so on—the young surgeon invents a new method of stitching for a cataract operation (technically their surgical standard is high): but they do not require to think very much and most of the fundamental research in eyes was being done by…refugees [from WW II], undoubtedly the most valuable import that America has ever made…so far as real medical progress is concerned we can beat them hands down.

His Institute would “arrange the marriage of the clinician with the scientist out of whose union alone progress in the fundamental sense can emerge.”¹⁹

The first half of the 20th century was a time when laboratory science had come into its own as the foundation of major advances in medicine. Stewart Duke-Elder was a product of that period and an heir to the belief in the importance of careful laboratory science. That belief likely informed his attitude to Ridley's new invention.

COMPLICATIONS OF RIDLEY'S LENS AND OTHER EARLY IOLS

Harold Ridley designed his IOL to be the same size and shape as the crystalline lens but he did not account for the difference in index of refraction between PMMA and the crystalline lens.^7,20,21 As a result, the first implant caused extreme myopia of −21 diopters spherical equivalent.²² Alvar Gullstrand had won a Nobel Prize in 1911 for his research on the optics of the eye.²³ A simple calculation before surgery would have revealed the error in IOL power. In 1950, Duke-Elder's Institute of Ophthalmology was conducting research in ophthalmic optics.^24(p.19) Ridley could have obtained help at the Institute in calculating the power of his IOL, but he did not, nor apparently did he attempt to calculate the power himself.

Ridley did not do animal testing before the first implantation. Ridley sterilized the lens implants in cetrimide. The first patients developed a significant inflammatory reaction from adsorption of cetrimide on the surface of the lens.^9,25,26 The Institute of Ophthalmology performed research in rabbits, cats, and dogs, so Ridley could have tested the sterilized material in animals before implanting it in human eyes.²⁴ The IOLs were made of Perspex CQ, a slightly different formulation than the PMMA that was used in aircraft canopies, so animal testing would have been prudent regardless.⁶ Preclinical testing was expected in 1949. The Nuremberg Code in 1947 called for animal testing before human use, and Duke-Elder criticized Ridley for not testing in animals.^26,27

In brief, Ridley made little effort to ensure his new lens was safe before implantation. Had he made such an effort, serious complications could have been avoided in his early patients.

Even had Ridley avoided these initial complications by adequate testing, a design flaw made his IOL unsafe in the long run. His IOL was inserted in the posterior chamber, but it had no haptics or other method of fixation. He designed the IOL with the same dimensions as the crystalline lens in the hope that it would remain stable in the empty capsular bag.²¹ Remarkably, many of the Ridley lenses did remain stable, apparently because of posterior synechiae between the anterior lens capsule and iris.²⁰ However, Ridley reported that 21% of eyes had poor vision resulting from dislocation or from glaucoma caused by dislocation.²⁵ This statistic did not even include patients with corneal decompensation. Ridley eventually abandoned his original IOL because of the complications.²⁸

The results of succeeding generations of IOL implants were not sufficiently improved to mollify the skeptics. Opponents of IOLs in the 1960s said that “there are two kinds of implant surgeons: those who put them in and those who take them out.”²⁹ More than 300 of the 510 IOLs implanted at the Barraquer Institute between 1954 and 1961 had to be explanted.³⁰

Ridley kept the invention secret until he announced it at the Oxford Congress.⁶ Such secrecy was out of place in the 1940s when intellectual property rights went unclaimed by medical innovators. Ridley claimed he kept the IOL project secret out of concern that “it seemed sure to encounter wide-spread criticism.”⁶ Duke-Elder was transparent about his own research. Each year, he published an interim summary of the progress on his various research projects.²⁴ Ridley's atypical secrecy may have rankled Duke-Elder.²¹

Duke-Elder was quite skeptical and possibly hostile toward IOLs. He was faced with a new invention that was radical in character, developed in secrecy, not tested before clinical use, and that caused significant complications both in the short run and in the long run. It is to be expected that he and other leaders who were responsible for teaching the next generation of eye surgeons would have been reluctant to offer their support or endorsement.

BIAS IN THE CANONICAL NARRATIVE

Harold Ridley told his side of the story in his Gullstrand lecture.⁶ David Apple amplified this narrative in a book and no fewer than 12 biographical articles in various ophthalmology journals (based on a PubMed database search using the term “Apple DJ[author] AND Ridley”).⁵ We must question Apple's objectivity when he says of Ridley, “We remained dear friends until the end.”^5(p.59) The titles of Apple's writing suggest hagiography: “Sir Harold Ridley and his fight for sight,” and “A pioneer in the quest to eradicate world blindness,” and “Sir Nicholas Harold Ridley: he changed the world so that we might better see it.”^5,31,32 He likens Ridley to a persecuted biblical prophet, “A prophet is not without honor, except in his own country, among his own relatives, and in his own house.”^5(p.152)

Apple was not objective, and his bias is evident in his narration. He barely acknowledges the early challenges of Ridley's IOL. In his 316-page biography of Ridley, he never mentions inflammation due to cetramide.⁵ He blames the error in lens power on John Pike.^5(p.147) He excuses the lack of preclinical studies by claiming that PMMA shards in pilots' eyes were effectively a preclinical study.^5(p.122-124)

Apple's claim that Duke-Elder was jealous rests on the flimsiest of evidence. He found a 1-page clinic note of a patient seen by Duke-Elder in 1940 with PMMA shards in an eye. Based on that clinic note alone, Apple claims that “it tormented [Duke-Elder] that he had lacked the foresight and genius to have brought [IOLs] to the world.”^5(p.160-161) The narrative that casts Ridley as a hero beleaguered by his skeptics is largely a creation of David Apple.

THE LANGUAGE OF THE CONFLICT

The canonical narrative portrays the IOL skeptics with emotionally loaded language. In describing Duke-Elder, Ridley says, “Perhaps there was considerable jealousy,” and Duke-Elder's refusal to examine the patients was “hostility.” Apple describes Duke-Elder as “one of the most vehement of Ridley's detractors.”⁹ Other leading surgeons “treated Ridley and his lens with severe disdain” and “defamed” him.⁹ The opposition to the lens was “prejudice.”⁹ Ridley's IOL was rejected because of “intense jealousies and animosities.”^5(p.162)

The use of these emotionally loaded words encourages the uncritical reader to side with Ridley and to doubt the veracity and integrity of the critics of the IOL. It is a subtle ad hominem argument. Apple brushes aside the problems of the early IOLs when he writes, “This delay [in developing modern IOL surgery], largely caused by non-medical reasons, deprived an entire generation of the benefits of this procedure” [italics added].^5(p.154) Apple also implicitly criticizes the skeptics for failing to see the revolution that would grow out of Ridley's work. An unbiased biographer would judge the opponents of IOL implantation in the context of their time, when they had no knowledge of what the future would bring.

Duke-Elder uses very different language. In 1959, just eight years after Ridley announced his invention, Duke-Elder wrote, “To obviate the many and obvious disadvantages of aphakia, the ingenious suggestion has been made by Ridley of inserting a small lens of acrylic plastic behind the iris.”^14(p.287) In 1969, in System of Ophthalmology, Duke-Elder wrote, “The pioneer in the development of this technique was H. Ridley (1951-57) who implanted an acrylic lenticulus with the appropriate optical correction within the lens capsule behind the iris some time after an extracapsular extraction.”^13(p.289) Duke-Elder's language does not reveal hostility toward the invention itself: “An intra-ocular lenticulus…results in the best type of optical correction, provided complications do not occur.”^13(p.289) He then reviews the complications of different IOL models in a way that is balanced and objective to a modern reader. Duke-Elder credits Ridley where he has no obligation to do so and uses laudatory words like “ingenious” and “pioneer.” His words suggest thoughtfulness and objectivity rather than hostility or jealousy.

In retrospect, we cannot disentangle to what degree, if any, Duke-Elder and others were hostile to Ridley beyond a reasonable skepticism resulting from the problems of early IOLs. However, it is clear that the emotionally loaded language used to describe the IOL critics encourages belief in the one-sided canonical narrative, a narrative which also implicitly criticizes the skeptics for failing to see the future.

CONCLUSIONS

The narrative we have been told by Apple and by Ridley himself is that the opposition to IOLs of Duke-Elder and other established leaders was the misguided attempt of powerful, short-sighted reactionaries who were motivated by jealousy or personal animosity to suppress the development of an important ophthalmic advance. This simple story is appealing but inaccurate.

Apple's narrative should serve as a cautionary tale to would-be historians. Apple's expertise gave him a valuable perspective on the invention of IOLs. However, he was uncritical as a historian, was biased by his reverence for Ridley, and judged the actors for failing to know what the future would bring. Ophthalmologists who write histories should be aware of their biases and seek alternative sources to validate or challenge their narrative. Similarly, ophthalmologist readers should be wary of histories written by their colleagues that do not explicitly address the reliability of their sources.

Apple's version of history has been widely accepted, which is unfortunate because the real story is richer. The conflict should be understood as a clash of worldviews. Ridley saw a significant clinical problem and sought to solve it expeditiously, recognizing that some people would be hurt in the process of developing an innovation that would help many.⁶ Ridley wrote, “most fortunately for our research, people during the war were accustomed to dangers and a few, for the advancement of science, were prepared to accept some risk which had been fully explained to them.”⁶ Although he acknowledged his complications, he also personally saw many patients with significantly better quality of life because of his IOL implants.³³

On the other side, Duke-Elder and his colleagues were opposed to IOLs not out of personal animosity but because they saw a device that caused significant complications, some of which could have been easily avoided. They did not recommend IOLs to their students or to the world. Their criticism may have been more vociferous because the invention was radical in conception and shoddy in its implementation. Without the benefit of hindsight, they did not think the end goal was worthy enough to justify the injuries to patients treated with an innovation that was far from perfect.

The conflict between medical innovation and patient safety continues to this day. Ridley was right about IOLs. In hindsight, we easily recall other times that brilliant innovators were right, such as phacoemulsification, LASIK surgery, and vitrectomy. On the other hand, we too easily forget the bad ideas that were eventually abandoned after unsuccessful surgery in humans. Hexagonal keratotomy, conductive keratoplasty, anterior ciliary sclerotomy, Intacs for myopia, and the dual-optic accommodating IOL come readily to mind.^34–38 There are far more innovations in the latter category than the former.

The canonical narrative says that patients suffered from the lack of an IOL, not because of it. The implicit message is that the skepticism of established thought leaders obstructs vital innovation. We would argue that the skepticism of experienced leaders is an important check on enthusiastic inventors who might push their ideas to the detriment of their patients' well-being. We cannot rely solely on investigational review boards (IRBs) to check aggressive innovators. IRBs often do not understand the subtleties of research in a particular subspecialty. Formal informed consent is not a check either. Patients often trust deeply in their physician's recommendation, do not understand the nature of the study in which they are participating, and hold out false hopes for benefits.³⁹ Correcting the canonical narrative is important because the explicit message should be this: The skepticism of cautious ophthalmic thought leaders has an important role to play in protecting those patients whose eyes are put at risk in the long process of life-changing discovery.

Ridley was human, and he made very human mistakes. On this 75th anniversary of the invention of the IOL, we can finally tell an accurate history and yet still celebrate a man whose extraordinary vision dramatically improved the lives of tens of millions of people.