DAVID APPLE - A PIONEER IN OPHTHALMOLOGY

 Today everyone knows that a sharp, square edge on an intraocular lens (IOL) helps delay posterior capsule opacification (PCO) by blocking proliferation of latent lens epithelial cells across the optic zone. It was the pioneering work of the late David Apple MD in IOL pathology that led to this and other insights that have made lens implants safer and more effective for millions of patients worldwide, Steve A Arshinoff MD FRCSC, Toronto, Canada, told the XXX Congress of the ESCRS. As the first pathologist to systematically study how ocular tissues respond to implants, Dr Apple transformed IOL design and implantation from an art based largely on individual clinical observation and surgical insight into a science based on rigorous research, said Dr Arshinoff, who delivered the Apple Commemorative Lecture as president of the International Intraocular Implant Club. Yet his most valuable contribution may have been to remind implant surgeons that they need to be cautious in adopting new technology.

“Sir Harold Ridley gave us the intraocular lens but it was really David Apple who made implantology a science. David was recognised quickly by Dr Ridley as a brilliant young innovator, and in 1985, when Sir Harold was 79 years old he summoned David to England to meet him. They met pretty much three times a year after that to discuss quality issues and what should be done,†Dr Arshinoff said. In a characteristic display of devotion to the field, Dr Apple wrote a paper during his last days that summarised his life’s work and thoughts that was published in December 2011 in Survey of Ophthalmology, Dr Arshinoff recalled. “In it he said, ‘please, surgeons, always under promise and over deliver in intraocular lenses’. The companies, he felt, always emphasise and promise bestcase scenarios.†All IOLs perform well in the first five years, Dr Apple wrote. It is the longterm complications that must be watched.

Dr Apple remained convinced that the most significant long-term IOL complication is LEC proliferation. It can lead to PCO, which can often be resolved with YAG capsulotomy. But erratic proliferations with variable types and degrees of fibrosis also may affect IOL position, causing tilt, decentration, phimosis and other issues less easily addressed, Dr Arshinoff noted. Dr Apple also warned that recent studies show that PCO rates are much higher than previously thought, and LEC proliferation, in the form of Soemmerring’s rings, occur in 100 per cent of IOL cases after three to six years. All IOL designs are subject to break out of cells from the Soemmerring’s rings after 10 to 15 years, and up to 50 per cent of cases experience a breakout. As a result, he advocated much longer test periods for “premium†IOLs both because they are more sensitive to dislocation and Soemmerring’s rings-related distortions, and because, for refractive reasons, they are being implanted in younger patients with a commensurate increase in risk of future problems, Dr Arshinoff added.

“He suggested many changes in the lenses that we use. Today’s lenses represent great advances, but David felt there are still many issues to be addressed,†Dr Arshinoff said. Dr Arshinoff met Dr Apple in 1980 when both sat for the oral portion of the US ophthalmology boards. They were sequestered in a room together for five days because both were known personally to the board examiners; Dr Apple because of his lectures and publishing in ocular pathology and Dr Arshinoff for papers and publications he had delivered and published relating to gyrate atrophy and metabolic ocular inherited disorders .

“We were forced to sit and talk for five days, and we became very good friends.†We passed, though neither of us was required to because we did not practice ophthalmology in the US – a fact noted by the examiners who were impressed with our willingness to sit the exam, Dr Arshinoff said. The commemorative lecture also included taped remembrances from colleagues including Randall Olson MD, who recruited Dr Apple to the University of Utah; Gerd Aufarth MD, who took possession of many of Dr Apple’s records and specimens to continue his work; industry leader Donnie Munro, president of Rayner; and Dr Apple’s wife and constant companion, Ann.

Dr Apple mentored many young ophthalmologists and researchers, who became known as the “Apple Korps.†“David was a friend of everyone he met and taught,†Dr Arshinoff said. “He taught us to respect our heritage; that those who struggle to innovate enrich our abilities to care for our patients, but to remember: most innovations fail. He taught us to be cautious with the latest innovation and to study the long-term effects of each new IOL design or gadget before fully accepting it,†Dr Arshinoff said. “He made ‘implantology’ a science and we will all miss his leadership and input.â€