In 1980, Randall J. Olson, MD, and I (Figure 1) founded our biodevice research center, The Center for Intraocular Lens Research. Unfortunately, during the past few years, I have had a series of illnesses, and many friends and colleagues have thought I retired. Instead, I am pleased to inform the ophthalmic community that the Apple lab is alive and well, re-established in its original home in Salt Lake City. It seems appropriate to pause for reflection now that the center has reached its 25th anniversary.

THE BEGINNING

I first joined Dr. Randy Olson's Department of Ophthalmology in Salt Lake City in 1980 as a general ocular pathologist. Shortly thereafter, a unique specimen arrived on my desk—an enucleated eye containing an early J-loop PCIOL. The eye was blind secondary to numerous IOL-related complications. The specimen was courtesy of John Lyman, MD, and I. Howard Fine, MD, of Eugene, Oregon, who, incidentally, were not the implanters of the lens. Labeled IOL No. 1, the specimen marked a turning point in the field of IOL research/pathology and the study of IOL-related complications. It also dramatically changed my professional life.

My colleagues and I studied the eye and its myriad complications and submitted our report to Ophthalmology.1 I was surprised when the editors immediately accepted the article. We learned later that they were strongly anti-IOL, as were many in the academic establishment of the time. The editors believed that our article—with its numerous pictures of blood, erosions, a severely malpositioned lens, etc.—would help kill IOLs. On the contrary, surgeons worldwide read the piece with interest and found our results to be helpful in recognizing and minimizing these complications. Shortly after this initial case report, we published a comprehensive article on IOL-related complications. This article was and perhaps still is the most reprinted and circulated article in its field.2 Quite soon thereafter, the use of IOLs paradoxically increased.

Figure 2 shows the dismal lack of growth in the use of IOLs for the 30 years after Sir Harold Ridley invented the implant in 1949/1950. As a result, an entire generation of patients between 1950 and 1980 was deprived of the value of his invention. Certainly, the quality of IOLs overall and implantation techniques of that era were not yet perfect, but surgeons could achieve good results with some of the lenses by carefully inserting them, even with the less-than-optimal, large-incision, extracapsular-cataract-extraction techniques that were then available.

Unfortunately, much of the delay in IOLs' use was caused by various ophthalmologists' antagonism toward Ridley and his “radical” new invention. As late as the early 1990s, many physicians considered it inappropriate to insert a foreign body into the eye. Numerous surgeons doubted the future of the subspecialty of cataract/IOL surgery. Although many ophthalmologists, especially in the private sector, clearly saw the advantages of pseudophakia, those with seats of power did not. Fortunately, the cataract/IOL procedure really began to gain in popularity around 1980 (Figure 2).

In 1984, we submitted a request for a grant from the National Institutes of Health (now the National Eye Institute) to study IOLs. The agency turned us down, largely because some of the reviewers felt that IOLs were not important and would probably not remain a valid option. This thinking, of course, was blatantly wrong, but, in retrospect, the decision turned out to be a wonderful stroke of luck for us. Instead of depending on federal funding, we began to confine all of our funding requests to the private sector, especially industry. Since then, we have received generous funding from virtually all IOL companies, to the great enhancement of our research.

In addition to the application of new instrumentation, operating microscopes, and phacoemulsification, my colleagues and I are proud that many of our research studies, projects, and evaluations of autopsic eyes in the 1980s helped improve the overall success of IOL implantation as well as perk up the results illustrated in Figure 2. In addition to biomaterial analyses, our studies included pathologic examinations of many surgical techniques that are taken for granted today (eg, symmetric in-the-bag fixation of PCIOLs, hydrodissection-enhanced cortical cleanup, continuous curvilinear capsulorhexis, and many others).

THE CENTER GROWS

The center grew rapidly in Salt Lake City, best evidenced by the marked increased in the number of specimens sent to us, both explants and eyes with IOLs obtained postmortem. By 1988, we had studied more than 1,000 of both types of specimens.

I moved to Charleston, South Carolina, in 1988 to assume the role of Department Chairman of the Storm Eye Institute. The center continued to flourish there, but we renamed it the Center for Research in Ocular Therapeutics and Biodevices to acknowledge our expansion into other fields besides IOLs (eg, laser technology). The highpoint of our research productivity was between 1994 and 1997. Unfortunately, during these years, my work efforts became especially difficult for me due to developing and increasing symptoms of a serious, life-threatening illness. It took me a couple of years to undergo surgery, chemotherapy, and radiation therapy, and I could not continue with difficult and strenuous activity at that stage. Fortunately, as Chairman, I had just finished a $10 million fundraising campaign to enlarge and rebuild the Storm Eye Institute building. I am, therefore, pleased with my legacy there.

My health and future were uncertain, but, happily, sometimes things go around in circles. I met Randy at a meeting, and we made arrangements for me to return to Utah, where my work had begun. Per his request, our new center in Utah was greatly expanded in preparation for the new Moran Eye Center building that will be dedicated in August 2006. Randy offered me—and, of course, I accepted—the position of Director, David J. Apple, MD, Laboratories for Ophthalmic Biodevices Research.

One of my proudest accomplishments has been the training of more than 210 young research fellows and other researchers. George Wyhinny, MD, from Chicago was the first. Guy Kleinmann, MD, of Rehovot, Israel, is the most recent at No. 210, but I hope not the last. Most have gone on to successful private practices, while some have stayed and flourished in the academic realm.

TODAY
At this point in my career, I have determined that the most effective way I can work and provide the most information to surgeons, and indeed to the field of intraocular biodevices, is to reinstitute the studies of autopsic eyes that my colleagues and I began years ago. Unfortunately, these studies ceased during my illness and move to Salt Lake City. Vast numbers of lenses and other devices are now being implanted with virtually no oversight. Numerous marketing claims regarding various IOLs, especially the hot, specialized IOLs (eg, refractive and accommodative designs), emerge daily—mostly without real proof of the lenses' safety and efficacy.

We have shown throughout the years that the careful examination of autopsic eyes can reveal the truth. These findings do not lie and cannot be spun. Because of the huge increase in the number of lens implants, it will not take long to create a large database. We will then disseminate any relevant information. I expect to build on our similar studies in the 1980s, when we elucidated numerous problems that would not have been exposed without this laboratory research. We have notified most eye banks in the US regarding our intentions, and they are kindly beginning to submit specimens. At present, we have more than 12,000 autopsic globes with IOLs in the laboratory, and their number is growing rapidly.

Many individuals have contributed to the success of our laboratory. Unfortunately, I cannot mention them all, but one gentleman must be singled out—Kensaku Miyake, of Nagoya, Japan. We modified and perfected his original video technique to create the Miyake-Apple posterior video/photographic technique. It has been an indispensable tool for the accurate analysis of research eyes (Figure 3A) and clinical cases (eg, human eyes with IOLs obtained postmortem) (Figure 3B).

CONCLUSION

It has been a tremendous voyage during these 25 years, but I believe that my colleagues and I have provided a clear service to our specialty. It has also been my pleasure and a real satisfaction to help rediscover Sir Harold Ridley, the inventor of the IOL, and to have worked with him and known him personally and professionally for 15 years. I am now writing his official biography, which should be available next year in time for the 100th anniversary of his birth. I believe that this book will be an important contribution to our specialty in terms of positive publicity.

My only concern, really, is that our work continue after I retire. In a sense, the laboratory work requires a specialist at three levels: a board-certified clinical ophthalmologist, a board-certified ocular pathologist, and a biomedical engineer—or their equivalents. Many individuals who hold doctoral degrees could also succeed in work of this type. This combination of talents may be rare today, because most young ophthalmologists move directly toward the clinical path for better security and financial gain. I hope, in the next few years, that my colleagues and I can identify young researchers who will be able to continue what we have started in a manner that continues to serve our specialty. 

David J. Apple, MD, is Professor of Ophthalmology and Pathology, Department of Ophthalmology and Visual Sciences, Moran Eye Center, Salt Lake City. He states that he receives financial support for laboratory research from nearly all of the IOL companies. Dr. Apple may be reached at (801) 581-8757; djapple@comcast.net.

1. Apple DJ, Craythorn JM, Olson RJ, et al. Anterior segment complications and neovascular glaucoma following implantation of a posterior chamber intraocular lens. Ophthalmology. 1984;91:403-419.
2. Apple DJ, Mamalis N, Loftfield K, et al. Complications of intraocular lenses. Surv Ophthalmol. 1984;29:1-54.