The Birth of the IOL

THE LITTLE LENS THAT COULD

So where are we are we now and where are we going?

in te early days of IOL” I was accused of malpractice for using an IOL. My response was,””We will soon see that failing to use an IOL is legally indefensible”.

Bob Welch, a distinguished ophthalmologist, saw a few poor outcomes and offered to testify for anyone who had a poor outcome. But he didn’t see what he thought he would. He saw a lot of happy patients. And again, at the podium at a major meeting, he said, “I was wrong about IOLs. IOLs are the way to go.!” They had received an official endorsement..

I started my courses in 1974, and by the end of 1975 IOLs had become the “standard” of treatment. Not, of course, only by my graduates, but a couple of hundred eager and aggressive cataract surgeons can put a lot of energy into what was quickly becoming a major movement.

The adage,“See one, do one, teach one” was very much operative here.

Practices were becoming more or less exclusively devoted to IOLs. Dozens, if not hundreds, of IOLs were designed and soon abandoned in favor of yet another refinement.

What if we could design an IOL that could correct presbyopia? Of course we can ! Guy Knolle has the expertise and the courage to have it done on his most important patient; himself !

It worked perfectlyy well. Back at work in 2 days. No glasses for distance or near. 20/20 OU

For the surgical correction of presbyopia to be acceptable, (and I am sure that it will be) it will be held to a very high standard. Look at Lasix.

Now we are approaching a major sea change. ’Classic’ Refractive surgery with its precise results, has replaced aphakia.

Sir Harold Ridley, after 15 years of IOLs, said, “Removal of the crystalline lens deprives a complex organ of an important part, and is but half way to a cure.”

THE STORY OF THE INTRAOCULAR LENS

by Henry Hirschman, M.D.


When I began my practice in 1963, we Ophthalmologists thought we knew something about the treatment of Cataracts. Actually, we thought we knew pretty much all there was to know about it. (Modesty never was our long suit.) The real truth was that there was no treatment for cataract. We simply waited for it to get bad enough, (about 20/200 in the better eye and then removed it. We prescribed “Coke Bottle” glasses and called ourselves “Surgeons.”

In thinking that we were treating the cataract at all, we were already off in the wrong direction. We were in the Visual Rehabilitation Business, whether we knew it or not, and we weren’t very good at it.

Cataracts were, and still are, a very important problem, since virtually everyone who lived long enough was likely to develop them. Now just what does that mean to patients? and their doctors?

As we grow older, the crystalline lens of the eye gradually loses its clarity. For a time, changing the spectacle prescription will provide adequate vision but at some point the patient needs more help. One major barrier is the 20/40 requirement for a driver’s license. Turning in your drivers license is essentially accepting a life sentence of house arrest. Almost.

The reason that we don’t just operate as soon as the cataract is diagnosed is that the postoperative vision provided by the aforementioned Coke Bottle glasses, is, in a word, dreadful.

Image size was enlarged by 30%. They were very heavy and had to be perfectly adjusted. The field of vision was reduced to “Tunnel Vision.” They were cosmetically unacceptable, giving a “fisheye” look. And then there was the “Jack-in-the-Box” phenomenon, where an object moving to the line of vision would disappear and then startlingly reappear, much larger than life. Driving became hazardous to the patient and others. Navigating stairways was difficult, especially down. A walk in the woods was pretty well out of the question. And more.

As I said, dreadful.

The condition of being Aphakic, (A=without, Phakos = Lens) has been a nasty problem, with limited success, throughout recorded history. Imagine, if you can, seeing things 30% larger with the operated eye. If the other eye was normal, a kind of double vision occurred that was simply impossible for the patient to handle. So we couldn’t do unilateral cases.

There were, of course, attempts to develop alternatives.

Robert Welsh’’s “4-Drop” spectacle lenses were a real improvement, and I used them in the early 60’s. They reduced, but did not eliminate these problems that I just described.

Contact lenses were optically superior to spectacles. Image size was increased only 7%, and the Jack-in-the-Box phenomenon was essentially eliminated. Hard contact lenses were not tolerated as well as myopic cases. They were relatively heavy and difficult for Aphakic patients to handle, ie; insert, remove and reposition Another important development was the Soft Contact lens.

The FDA quickly approved the use of Soft Contact Lenses for the treatment of aphakia. So determined was the FDA to provide an alternative to IOLs that soft contact lenses were promptly approved for extended wear. This did not work out very well. Charles Kelman put it very well when he said,”These new contact lenses are wonderful! Almost perfect. It’s these old, tired, dry eyes and loose lids and fragile lenses that are the problem!” Only a small percentage of patients were successful with contact lens for 5 years or more. Something on the order of 5 or 10%.

excerpt from book ' The Birth of the IOL', available fall 2007