Harold Ridley’s Brilliant Innovation

One day, perhaps in 1947, a routine list of operations was performed. At the end, a student who had never before seen a cataract said, ‘It’s a pity you can’t replace the cataract with a clear lens.’ He was told that this was not usual, though many people, including myself, had suggested this project. However, no one had the temerity to take action.

– Sir Harold Ridley, inventor of the intraocular lens

Following this encounter, Mr Ridley, as he then was, went forward with the first intraocular lens (IOL). He met with John Pike of Rayner and Keeler and, between them, realised the basic ideas of the project. Mr Ridley had been impressed during World War II by the apparent lack of inflammation caused by fragments of aircraft clear canopies when found in the eyes of injured crew. Pike asked his friend John Holt of Imperial Chemical Industries in the UK to create clinical quality and hopefully biologically inert polymethylmethacrylate (PMMA).

The design he chose for the first IOL mimicked the shape of the human lens. It was inserted into a patient’s eye behind the pupil and hopefully into the capsular bag after an extracapsular cataract extraction. The actual date of the first implantation is not entirely clear. It may have been 29 November 1949, but it was removed and inserted as a secondary operation on 8 February 1950. It produced a gross refractive error of -14 D due to the IOL power calculation conducted in air, not liquid. The error was quickly corrected in subsequent implantations, and the operation promised the first “cure for aphakia,” as Harold Ridley put it.

Mr Ridley wanted to keep his invention a secret until he had sufficient clinical data. However, one of his implanted patients, when going for a follow-up visit, went to see another ophthalmologist with the surname Ridley by mistake. With his secret out, Mr Ridley decided to go public at the Oxford Ophthalmological Congress in July 1951. He brought two of his patients, one with 6/6 vision unaided, to the meeting so colleagues could examine them. At the meeting was Sir Stewart Duke Elder, the doyen of British ophthalmology at the time, who refused to look at Ridley’s patients or watch the coloured movie of one of the implant procedures. This very negative attitude was mirrored by many senior ophthalmologists across the world.

Lacking haptics for support and weighing many times more than current IOLs, the earliest lenses tended to dislocate, sometimes months or even years after surgery. Despite this, some of the early IOLs continued to give good vision 20 years after implantation. About 15% of Ridley lenses were eventually explanted. Stabilising the implant was a problem that took more than 40 years to adequately solve.

Other frequent complications of early IOL surgery included postoperative infections, haemorrhage, inflammation, corneal oedema, peripheral anterior synechiae, raised intraocular pressure, capsule and lens opacification, and residual refractive error.

Focusing on the problems rather than trying to find solutions, much of the global academic ophthalmic establishment vehemently opposed ocular implants for several decades.

However, the status quo was not acceptable. “Spectacles for aphakia were horrendous—they magnified and distorted the image, and many patients never really adapted to them. The gross anisometropia made uniocular surgery impossible to rehabilitate,” said David J Spalton, who, as a trainee in the mid-1970s, was among the last to assist Harold Ridley in an implant procedure.

Implants restored normal vision, and “there was a lot to be said for that. It was just a matter of getting the design and techniques right for it,” Professor Spalton said.

To bring together those interested in lens implantology, Mr Ridley and Peter Choyce, a very early IOL pioneer, formed the Intraocular Implant Club (IIC) in 1966. The founder members of what became the International Intraocular Implant Club (IIIC) came from many countries. In the US, it took another decade before Harold Ridley was recognised for his accomplishments at a meeting of the American Academy of Ophthalmology in 1976. For Mr Ridley, the greatest of all his achievements by way of scientific recognition was admission to The Royal Society of London in 1986. Public recognition eventually came after lobbying of a prime minister’s wife when he was knighted in 2000.

Along the way, enterprising surgeons, researchers, and manufacturers made most of the technical innovations. “It was driven by individuals who put a lot of time and thought into the complications and how you would avoid them,” Prof Spalton said.

“It’s truly remarkable to witness the ongoing evolution of these technologies, underscoring our commitment to providing tailored solutions for each patient’s unique visual needs. Continuous progress in the field not only enhances our surgical capabilities but, more importantly, significantly improves the quality of life for those seeking visual correction after cataract surgery,” incoming ESCRS President Professor Filomena Ribeiro said.

Advancing IOL design

Early lessons prompted continual improvement in IOL design, said Richard Packard MD. To solve the problem of posterior lens dislocation, Dr Ridley designed anterior chamber lenses, prompting many other surgeons to design angle-supported lenses in the early 1950s.

“Universally, they failed. Not immediately, because there were enough endothelial cells to cope with it, but […] they didn’t understand that the edges of the lenses and the haptics were gradually destroying the back of the cornea,” Mr Packard explained. Implant pioneers including Dr Joaquin Barraquer in Barcelona ended up explanting half or more of their anterior chamber lenses.

In the late 1950s, Dr Cornelius Binkhorst designed what Mr Packard described as the first “successful” IOL, the iris-fixated four loop lens, for use with intracapsular extractions. “He determined that the only way IOLs would work was to be separated enough from vital tissues not to cause problems.”

These and similar lenses continued to be implanted until posterior chamber lenses finally overtook them in the late 20th century. Indeed, Mr Packard’s first IOL in December 1978 was a Fyodorov Mark 1 iris-fixated lens, implanted at London’s Charing Cross Hospital after he served as a senior resident at Moorfields, where he never saw an IOL. The day he arrived at Charing Cross, an IOL and phacoemulsification course was underway.

“This was like Saul’s conversion on the road to Damascus. I’d never seen anything like it,” he said. Around the same time, Roberto Bellucci MD began doing cataract surgery in Italy, where cryoextraction remained the standard of care until the mid-1980s. “I remember Mr [Eric] Arnott giving a lecture about his lens at my university, but my professor was not convinced. He used to say: ‘If the surgery is for your mother, do an intracap! If it is for your mother-in-law, put an intraocular lens in!’ It was very hard to overtake this scepticism, and innovation was pushed by doctors working mainly outside the universities, like Lucio Buratto in Milan and Egidio Dal Fiume in Raven-na.” In 1985, he implanted his first IOL, a Worst Medallion sutured to the iris.

In the 1960s, Prof Binkhorst pioneered using the capsular bag left behind in extracapsular procedures to stabilise the IOL. His two-loop iridocapsular lens optic sat in front of the iris with haptics anchored in the bag. This eventually led to a resurgence of posterior chamber designs, such as Dr Steve Shearing’s 1977 J-loop PC IOL. Based on the Barraquer anterior lens design, it was the first of a new generation of posterior lenses that did not extend into the anterior chamber. The 1960s also saw the introduction of theoretical lens power calculation formulas, pioneered by Prof Svyatoslav N Fyodorov.

Cataract surgery technologies advanced rapidly: This included the invention of phacoemulsification by Charles Kelman, the development of capsulorhexis by Drs Howard Gimbel and Thomas Neuhann, and Prof Robert Stegmann’s innovation of viscoelastics. Subsequent innovations included foldable acrylic IOLs, UV blocking IOLs, and toric IOLs. The procedure also became safer with improved anaesthesia and endophthalmitis prophylaxis.

The cumulative impact of all these technologies was a movement away from intracapsular and even extracapsular procedures to phacoemulsification. This reduced hospital stays from several days to overnight and eventually made cataract surgery mainly an outpatient procedure.

On the horizon are accommodative lenses and even robotic surgery, Oliver Findl MD said. Over the course of his career, “the technology has changed, but in the end, it is still a person doing the procedure. I wonder if in 30 years it will still be a person doing it.”

David J Spalton FRCS, FRCP, FRCOphth is an ophthalmologist in London, UK, and a former ESCRS president. profspalton@gmail.com

Richard B Packard MD, FRCS, FRCOphth, FEBOS-CR is an ophthalmologist in London, UK. eyequack@vossnet.co.uk

Filomena Ribeiro MD, PhD, FEBO is head of ophthalmology at Hospital da Luz Lisboa, Portugal, and ESCRS president. filomenajribeiro@gmail.com

Paul Ursell MBBS, MD, FRCOphth is an ophthalmologist in London, UK, and president of the UKISCRS. paul@cataract-doctor.com

Roberto Bellucci MD is an ophthalmologist in Verona, Italy, and former ESCRS president. roberto.bellucci52@gmail.com

Oliver Findl MD, MBA, FEBO is chair of ophthalmology at Hanusch Hospital, Vienna, Austria, and immediate past president of ESCRS. oliver@findl.at