Modern History | Aug 2005
A Tribute to David Apple, MD
Colleagues share their thoughts on his legacy.
Randall J. Olson, MD; Gerd U. Auffarth, MD, PhD; Kensaku Miyake, MD;Nick Mamalis, MD; Okihiro Nishi, MD; Manfred Tetz, MD; Ehud Assia, MD; Luis G. Vargas, MD; Suresh K. Pandey, MD; Liliana Werner, MD, PhD; and Kerry D. Solomon, MD
RANDALL J. OLSON, MD
When David Apple first was recruited to our institution in 1981, I was involved in a few complicated cases with autopsic eyes in association with early IOLs. I asked David, as a renowned ophthalmic pathologist who was also an ophthalmologist, to help decipher just what was going on in these eyes. At the time, he was particularly interested in understanding the full embryology of the extraocular muscles. Seeing the incredible intellect, skill, and insight that he brought to the autopsic eyes, I suggested that he consider focusing on the complications of IOLs, and the rest is history.
Not long after, the Center for Intraocular Lens Research was founded. From that humble beginning, more work in this field has been done by the group under the direction of Dr. Apple than by any other individual in ophthalmology. The number and seminal nature of these publications, I think, are unheralded.
Dr. Apple has truly been a pioneer, and we owe him a great debt of gratitude for the part he has played in the success story that is modern cataract surgery. He proceeded independently as a researcher and pathologist so that, without any ax to grind, he could gather the information and provide the data that all of us clinicians desperately needed. I am most pleased that Cataract & Refractive Surgery Today has honored this unique and outstanding individual in our field.
Gerd U. Auffarth, MD, PhD
We are celebrating a man and his vision to improve IOL technology, cataract surgical techniques, and patient care throughout the world. David Apple has been like my scientific father and mentor who has shown me how to do research in this area. I owe him so much, and ophthalmology has benefited from his uncountable contributions. Even major personal health problems have not stopped his vision, his motivation, and his wisdom; perhaps these characteristics have defeated his illness.
With his fellows, David Apple has planted a seed in so many countries in the industrialized as well as in the developing world that his legacy will continue globally. I am extremely proud to belong to the Apple Korps, as he likes to call his fellows.
Kensaku Miyake, MD
In the field of IOL implantology, there is a tendency toward being too practical, too clinical. The laboratory of David Apple and his group has compensated for this shortcoming and produced an abundance of results. Their experimental studies using the techniques of histopathology and morphology and their examinations of numerous autopsic eyes with IOL implants have been essential to the progress of safe IOL implantology.
The posterior video technique that I developed (the so-called Miyake View) was also improved in his laboratory, and today has become an important tool in the preclinical assessment of various types of IOLs, operative techniques, and complications. I therefore proposed to Dr. Apple that we call this the Miyake-Apple view. It is my hope that his laboratory will continue to play a leading role in the field of implantology.
Nick Mamalis, MD
In 1981, I was a fourth-year medical student eager to learn about ophthalmology when I heard about a well-known ophthalmic pathologist named David Apple who was going to be joining the faculty at the University of Utah. Following a 12-week student research elective, I spent 1 year as a preresidency fellow with David and was a founding member of the Apple Korps. At that time, many ophthalmic surgeons were beginning the transition from intracapsular to extracapsular cataract extraction. Closed-loop ACIOLs were coming into widespread use, iris-fixated IOLs were still being used, and PCIOLs were in their infancy. Surgeons who were removing these IOLs due to complications were often simply placing the lenses in a drawer and forgetting about them.
David Apple recognized the need to study these explanted lenses and worked with Randy Olson to establish a center at the University of Utah for the study of IOL-related complications. David used his extensive training in pathology to evaluate the effects of various IOL designs and materials on intraocular tissues. This was relatively uncharted territory at that time, and the laboratory pioneered the use of extensive analyses of IOLs by means of scanning electron microscopy as well as light microscopy and new applications of the Miyake technique. The knowledge gained from extensive analyses of IOLs in Salt Lake City as well as in Charleston, South Carolina, was responsible for many unsafe or poorly designed IOLs' being pulled off the market, and it helped result in a better design and finish of both ACIOLs and PCIOLs.
David has trained a large group of dedicated fellows and has been responsible for launching the careers of many successful academic ophthalmologists (myself included) worldwide. As an interesting side note, when he first applied for a major NEI grant for IOL research, he was turned down, and one of the reviewers commented that there were simply not enough specimens available to study in order to justify such work. More than 16,000 analyzed IOLs prove the need for such study. David Apple is truly a pioneer in the area of IOLs and their complications.
Okihiro Nishi, MD
Every ophthalmologist is aware of David Apple's incomparable contribution to modern cataract/IOL surgery. The development of surgical technique, IOL design and material, and methods of overcoming various complications in the last 3 decades would not have been possible without his deep insight as a pathologist. I not only learned a lot from his numerous publications and lectures, which greatly helped me in research and practice, but also benefited from his laboratory science using the Miyake-Apple view, histopathology, animal studies, and observations in postmortem eyes.
I remember how he diagnosed propionibacterium endophthalmitis on histopathological sections for my fellow surgeons and me during the first such case report in Japan. He also confirmed for us that the morphological changes of human lens epithelial cells in cell culture represented fibrous pseudometaplasia, when we began taking cell cultures and sent a sample to him. To my knowledge, he is the first person who pointed out, in the early 1980s, the importance of solving the complications caused specifically by residual lens epithelial cells, thereby providing a clue for our research direction. He has also contributed to ophthalmic pathology in general, as shown in the textbook Pathology of the Eye,1 which I translated into Japanese.
Manfred Tetz, MD
David Apple not only had the foresight to establish a unique ophthalmic pathology laboratory and research center, but, 25 years ago, he provided the incentive for a network of schools worldwide through his mentoring of many pupils. I had the privilege of becoming one of his first international fellows and the first German to work with him in the field of surgical and IOL-related ocular pathology. We began animal research and the Miyake laboratory work during my fellowship between August 1986 and August 1988. My work with him in Utah and South Carolina was supported by the Alexander von Humboldt Foundation, which had also previously granted exclusive stipends to Dr. Apple. Twenty-five years of his laboratory's work represent a quarter of a century of unique mentorship by a great teacher, researcher, and ophthalmologist.
Ehud Assia, MD
I started my fellowship with David Apple in July 1989, soon after the Center for IOL Research moved to Charleston. The laboratory was still in the process of reorganization, David was busy as the new chairman of the Storm Eye Institute, the other fellows and I were new in the field, and there were only a few active projects. I realized that it might take a few months to come up with new ideas and set up original studies. I was patient and enthusiastic.
Then came Hurricane Hugo. On TV, it seemed wider than the entire state of South Carolina, and it headed right toward Charleston. We had to evacuate the city. The restoration of the devastated city took weeks. One should expect disasters when coming to do a fellowship somewhere called the Storm Eye Institute. I was afraid I would return home empty-handed.
A year and a half later, I finished my fellowship with 28 peer-reviewed publications, five book chapters, and numerous abstracts, proceedings, presentations, and courses. This is what having David Apple as a mentor means. I was fortunate to do research under David's guidance during the most exciting era of emerging technologies. Phacoemulsification was only the second most common surgical technique. We investigated the physiology of the capsulorhexis before most surgeons knew what it was, and we studied viscoelastic substances before they were introduced to the market. Our findings on the first foldable lenses were immediately reflected in the new generations of lenses.
David Apple has contributed more to the understanding of the pathophysiology of cataract surgery and IOLs than any other single person, and his research is as active, relevant, and influential as ever. My 2 years with him were the starting point of my professional career, and I am forever grateful. Thank you, David.
Luis G. Vargas, MD
I was working as a fellow on a project involving a new accommodating IOL. We had some difficulties folding and implanting the lens in the capsular bag, and, after the first day working with it, I told Dr. Apple that the IOL did not have a chance. It was complex and bulky, had too many haptics and optics, and was just too different. I was impressed with his alternative view of things. He told me, “Yes, it is a different lens, and it is difficult to implant, but the concept is good. It has a chance to succeed.”
He is a visionary, and his vision is the same that Harold Ridley had in the early 1950s when he developed and implanted the first IOL. David Apple always seems to be the first to see the next thing coming, and he puts his biggest effort, based on science, into proving his convictions. I am now the Medical Director for Visiogen, Inc. (Irvine, CA), the company that has developed that too-difficult lens, the first dual-optic accommodating IOL (Synchrony) implanted in human eyes.
Suresh K. Pandey, MD
I came to work with David Apple in Charleston soon after completing my residency in ophthalmology in India. In my 5 years (1998 to 2003) at the laboratory, I gained a wealth of research experience that led to numerous scientific publications, presentations, and videos (Figure 1). During that time, I found Dr. Apple to be a visionary ophthalmologist, a dedicated researcher, and a great mentor who always encourages young ophthalmologists in ophthalmic research. With the Apple Korps he leads, Dr. Apple has influenced cataract/IOL research worldwide. His example continues to inspire a generation of young ophthalmologists, including myself, to pursue applied research in the field of cataract surgery and IOL implantation.
Despite his international reputation, Dr. Apple remains a modest individual who is always happy to help others. It was a privilege for me to work with him in Charleston and, later, in Salt Lake City, and I am sincerely thankful to him for all of his support. I continue to collaborate with Dr. Apple, Liliana Werner, Nick Mamalis, Randall Olson, and other members of the center.
Liliana Werner, MD, PhD
I came to the US to work with David Apple in January 1999, after my residency in ophthalmology in Brazil and my doctorate in biomaterials in France. He was diagnosed with serious health problems less than 6 months after I arrived in Charleston. At that time, and during the following years, I enjoyed a fruitful collaboration with my colleagues at the Storm Eye Institute. We greatly admire the strength Dr. Apple showed throughout his treatment, and it inspired us to keep the work in the laboratory alive. I became Director of Research of the laboratory, now located in Salt Lake City, in September 2002.
I can affirm without any doubts that this time has been the most significant in my career so far. I enjoy the work related to IOLs and other implantable devices as well as collaborating with other colleagues such as Suresh Pandey, Nick Mamalis, Randall Olson, and Alan Crandall. I am sure that, wherever I may go, I will always carry with me the lessons learned from this period of my life. I cannot thank Dr. Apple enough for that.
Kerry D. Solomon, MD
The word that comes to mind with the mention of Dr. David Apple is respect. As an academic clinician, professor, and chairman, David has always instilled the highest ethical and moral standards in those who train under him as well as in his colleagues. As a researcher, David is always interested in pursuing new ideas and new concepts, and he gives the credit to all of those individuals who have been involved with specific concepts and techniques along the way.
Like myself, many ophthalmologists in practice today would not be in the field were it not for David Apple. He not only inspired us to pursue a field that is progressive and dynamic, but he allowed many of us to see, understand, and share his passion for this field. We are the Apple Korps.
David Apple has spent the last few years ensuring the recognition of Sir Harold Ridley's place in history. His own humble demeanor belies his vast, similarly pioneering accomplishments. He has helped stimulate and develop a field of ocular pathology. His IOL research and pathology affect our daily lives as ophthalmologists and touches more of our patients than any other subspecialty of ophthalmology.
David is my close friend, mentor, and role model. He has risen to the difficult challenges related to his health with the same degree of boldness and determination that he has visibly demonstrated in all aspects of his life. I wish him well and look forward to his next contributions to the field of ophthalmology and his continued friendship for a long time in the future.
Ehud Assia, MD, is Chairman of the Department of Ophthalmology at Meir Medical Center in Kfar-Saba, Israel, and he is Associate Professor for the Sackler School of Medicine at Tel-Aviv University in Israel. Dr. Assia may be reached at +972 9 7471527 or +972 9 7472511; assia@netvision.net.il.
Gerd U. Auffarth, MD, PhD, is Professor of Ophthalmology and Vice-Chairman of the Department of Ophthalmology at Ruprecht-Karls-University in Heidelberg, Germany, Head of the Heidelberg IOL & Refractive Surgery Research Group, and Secretary for the German Society for IOL Implantation and Refractive Surgery. Professor Auffarth may be reached at +49 6221 5636631; auffarthg@aol.com.
Nick Mamalis, MD, is Professor of Ophthalmology for the John A. Moran Eye Center at University of Utah Health Sciences in Salt Lake City. Dr. Mamalis may be reached at (801) 581-6586; nick.mamalis@hsc.utah.edu.
Kensaku Miyake, MD, is Director and Head, Shohzankai Medical Foundation, Miyake Eye Hospital, Nagoya, Japan. He is also Visiting Professor, Fujita Health University, Toyoake, Japan. Dr. Miyake may be reached at +81 52 915 8001; miyake@spice.or.jp.
Okihiro Nishi, MD, is Director of the Jinshikai Medical Foundation at Nishi Eye Hospital in Osaka, Japan.
Dr. Nishi may be reached at +81 6 6981 1132; okihiro@nishi-ganka.or.jp.
Randall J. Olson, MD, is the John A. Moran Presidential Professor, Chair of Ophthalmology, and Director of the John A. Moran Eye Center at University of Utah Health Sciences in Salt Lake City. Dr. Olson may be reached at (801) 585-6622 or (801) 581-8703; randall.olson@hsc.utah.edu.
Suresh K. Pandey, MD, is Ophthalmologist at the Intraocular Implant Unit, Sydney Eye Hospital, Save Sight Institute, University of Sydney, and is Adjunct Assistant Professor for the John A. Moran Eye Center at University of Utah Health Sciences in Salt Lake City. Dr. Pandey may be reached at +61 2 9382 7433; suresh.pandey@gmail.com.
Kerry D. Solomon, MD, is Professor of Ophthalmology, Medical Director of the Magill Laser Center, and Director of the Magill Research Center, all at the Storm Eye Institute, Medical University of South Carolina, Charleston.
Dr. Solomon may be reached at 843-792-8854; solomonk@musc.edu.
Manfred R. Tetz, MD, is Professor of Ophthalmology and Director of his private surgical Eye-Center-Spreebogen Berlin. He is also Scientific Director of the newly founded Berlin Eye Research Institute (BERI). Professor Tetz may be reached at +49 30 3980980; info@augentagesklinik-spreebogen.de or beri@atk-spreebogen.de.
Luis G. Vargas, MD, is Medical Director of Visiogen, Inc. Dr. Vargas may be reached at (949) 341-0700 ext. 292; lvargas@visiogeninc.com.
Liliana Werner, MD, PhD, is Assistant Professor for the John A. Moran Eye Center at University of Utah Health Sciences in Salt Lake City. Dr. Werner may be reached at (801) 581-8136; liliana.werner@hsc.utah.edu.
1. Naumann GOH, Apple DJ. Pathology of the Eye. New York, NY: Springer-Verlag; 1986.
