history in the l11aking

Father of the Intraocular Lens

Harold Ridley, MD, FReS, FRS

T he road the pioneer treads-no matter the field­is never uneventful and frequently rocky. This was

certainly true for Harold Ridley, the man credited with the first intraocular lens (10 L) implantation in a cataract patient 48 years ago. The road he traveled to that moment, with its many byways and occasional culs-de­sac, began with his birth as Nicholas Harold Lloyd Ridley in Ribworth, Leicestershire, United Kingdom, on July 10,1906.

One does not have to dig too deeply to find Ridley's medical and ophthalmological roots, since his father Nicholas was a consultant ophthalmologist in Leicester.

Like his father, Harold Ridley served as a ship's surgeon and began his ophthalmological career at Moorfields Eye Hospital, London. At the time, 1934, the status of Moorfields as an important teaching center had weak­ened because of the loss of so many of its promising young ophthalmologists in World War I.

Ridley felt the decline in teaching standards deeply and views his help in reinstating Moorfields' earlier repuration as one of his greatest contributions to oph­thalmology. He did so by encouraging the appointment of a dean and the creation of a medical school in which clinicians would do the teaching and residents' training would be increased to 3 years.

Although his name is most closely linked to his groundbreakingwork on the IOL, Ridley is also remem­bered for his contributions to the field of tropical medi­cine, a result of his World War II service as a major in the Royal Army Medical Corps in Africa and India. He established guidelines for the treatment of ocular onchocerciasis, performed the first corneal transplant on a patient with ocular leprosis, and provided new insight into the nutritional amblyopia that afflicted many pris­oners of war, some of whom had been forced to work on the Burma railway.

After the war, Ridley resumed work as an ophthal­mologist at Moorfields and St. Thomas' Hospital and established consulting rooms on Harley Street, London. In the following years, he became the first ophthalmolo­gist to televise eye surgery in both black and white and color (1949); he also developed new electronic tech­niques for visualizing retinochoroidal abnormalities.

Ridley had been contemplating the development of an intraocular prosthesis since the 1930s when he was still under the tutelage of A. Cyril Hudson, whom he has always acknowledged as one of his greatest influences. As David Apple and John Sims note in their biographical article,1 Ridley concluded that "the cataract operation without a replacement lens was an incomplete, only half-finished operation."

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HISTORY IN THE MAKING

At the time, the idea of implanting an artificial lens in the eye of a patient was anathema to large segments of the ophthalmological profession. Some maintained that the surgery required to implant an IOL would be too complicated to contemplate, and even if it could be done, there would be severe complications, including rejection of the IOL by the body's immune defenses. Others were concerned about inflammation, other patho­logical reactions, and the possibility that sympathetic ophthalmia might ensue.

With John Pike, an optical scientist in London, Ridley calculated that if an IOL were to be practical, it should be biconvex, made of an inert material such as poly(methyl methacrylate), and implanted in the poste­rior capsule. They selected PMMA as the material and were able to convince Imperial Chemical Industries to make a high-purity clinical grade.

Under great secrecy, Ridley implanted his first IOL on November 29, 1949, in a 42-year-old woman after removing the cataract by extracapsular cataract extrac­tion (ECCE), a procedure that was still not popular among his fellow eye surgeons. The two procedures were separated by 3 months to allow the eye to settle. The 10 L was placed behind the iris, on the anterior part of the posterior capsule. Ridley later realized that the initial 10 L was too thick and did not account for the difference in refractive index between the human lens protein and the artificial lens. Therefore, although the woman's central visual acuity after surgery improved to 20/200, there was a myopic overcorrection of more than 14 diopters.

With new methods for calculating the dioptric power of the IOL, postoperative visual acuity was sig­nificantly improved and the level of myopia decreased to an acceptable amount. Over the next few years, Ridley implanted about 100 IOLs, and most patients showed excellent and in some cases very long-term visual reha­bilitation. One woman in whom Ridley implanted a lens in 1953 was found to have a visual acuity of20/25 with no lens opacity 30 years later. However, in many eyes there were complications, including dislocated IOLs, some of which had to be removed.

Ridley formally announced his experiences with his 10 L in 1951, two years after the first implantation. The delay was atrributed to the fact that he was concerned about maintaining the priority of his discovery and because he hoped to have at least 2 years of follow-up on

his patients. Some speculate that he was worried other surgeons might begin implanting the IOLs prematurely without the necessary training and experience.

Ridley's reports on his IOL were greeted with a mixture of enthusiam and skepticism in the United Kingdom and the United States. One U.S. critic charac­terized the operation as "reckless" with risks that far outweighed its benefits. For a combination of reasons, including the high level of angry criticism and the fear of litigation, Ridley abandoned his original posterior cham­ber lens design.

For the next 10 years, the number ofIOL implan­tations continued to grow at a slow but steady pace. However, even as late as the early 1970s, few distin­guished ophthalmologists had any time for Ridley's original concept. Nonetheless, Ridley had laid a firm foundation that has matured into a field that offers previously unattainable benefits to millions of cataract patients throughout the world.

Ridley's innovations led to an enormous array of new monofocal, multifocal, and foldable IOL designs, some intended for implantation in the anterior cham­ber, some for implantation with iris support, as well as a return to Ridley's conviction that the posterior chamber was the best place to put the IOL. New surgical tech­niques have emerged, including in-the-bag implanta­tion, phacoemulsification, and continuous curvilinear capsulorhexis, all of which improved patients' visual acuity with few complications. Just as important, an entirely new and profitable industry emerged that might not exist if Harold Ridley and other forward thinkers such as Cornelius Binkhorst and Peter Choyce had not recognized the enormously beneficial possibilities of placing a tiny piece of plastic in a cataract patient's eye.

Today, with his wife Elisabeth, Harold Ridley is

enjoying his 91st year in their thatched cottage by the riverside near Salisbury, England. He receives many visitors who cannot fail to be impressed with his memo­ries oflong-past events, his eloquence, and his kindness. Whereas he once admitted to being "alone in the world," he has lived long enough to see his prophecy of a real cure for aphakia become a reality.

Reference 1. Apple D], Sims ]. Remembrances of things past. Surv

OphthalmoI1996; 40:279-292

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