Great Insights in Ophthalmology
The foundation of modern medicine began in the 19th Century with advancements in the knowledge of disease and bacteriology, together with the introduction of instrumentation, drugs, and new practices. During this period ophthalmology emerged as a distinct medical and surgical discipline as well as a science. The transformation was brought on by the inventive minds, comprehensive researchers, and skilled hands of ophthalmologists who sought to better understand the human eye and improve the quality of vision. Here we highlight seven ophthalmologists and their advancements that created turning points in history.
German physician and physicist, Hermann von Helmholtz, MD (1821-1894) published his paper on the ophthalmoscope in 1850 and revolutionized modern ophthalmology by demonstrating how to visualize the fundus of the living eye. One historian commented that after the invention “every look into the eye became a discovery.”
Helmholtz first formally reported his findings in a paper delivered to the Berlin Physical Society on December 6, 1850 by his friend Du-Bois-Reymond. Helmholtz then sent one of his instruments to Sir William Bowman in London. It is said that notable ophthalmologists Albrecht von Graefe and Franciscus Donders visited Bowman and while London was buzzing about the scientific progress on display at the Great Exhibition of 1851, these three ophthalmologist could not stop discussing Helmholtz's ophthalmoscope.
How It Works
Helmholtz’s instrument showed that light entering the pupil is reflected back to its source. Furthermore, the light follows the same path out of the eye as it took entering the pupil. Using his ophthalmoscope, Helmholtz could place his eye in the path of the light rays entering and leaving the patient’s eye, thereby projecting an image of a living retina. The ophthalmoscope allows physicians to closely examine the interior structures of the eye, diagnose eye diseases, determine refractive errors.
Carl Koller, MD (1858-1944) modernized the medical field while he was still in school at the University of Vienna, Royal General Hospital. It was a period of experimentation for Koller and his friend, Sigmund Freud. Both were looking to make a name for themselves in the medical field and their research into the properties and uses of cocaine seemed extremely promising.
When Freud began researching cocaine’s general physiological effects, Koller would occasionally joined in his experiments. In the summer of 1884 Koller had an epiphany. Cocaine was known to have a numbing effect on the tongue, what if it was placed in a water-based solution and dropped into the eye? Topical anesthetic, a subject Koller had already researched to no fruition, was suddenly a reality. Koller’s observations were quickly disseminated around the world, giving him instant fame in the ophthalmic community. Freud was delighted for his friend, flippantly calling him “Coca Koller” in their personal correspondence.
Albrecht von Graefe, MD (1828-1870) is often credited as a founder of modern ophthalmology for his many contributions to the field. Among his achievements Graefe developed a treatment for chronic iridocyclitis with iridectomy, crafted a special knife for extracapsular cataract extraction, and was among the first to use the ophthalmoscope.
Graefe studied glaucoma in depth. He distinguished three stages of glaucoma: acute, chronic and simple. He also described how to use the ophthalmoscope to see the pulsation of the retinal arteries, providing ophthalmologists with a reliable indicator of elevated intraocular pressure. His observations helped put ophthalmology on the path of understanding of this disease.
In 1911 Allvar Gullstrand, MD (1862-1930) became the first ophthalmologist and first Swedish National to receive the Nobel Prize in Medicine or Physiology for his work on the dioptrics of the human eye. That is, the study of a series of transparent lenses for the gathering and refraction of light. Gullstand was both a mathematician and ophthalmologist, who made numerous contributions to ophthalmic subspecialties.
During his career, Gullstrand contributed to the theory of astigmatism, worked on aspherical lenses, and the function of the cornea. His major contributions to instrumentation were the reflex-free ophthalmoscope and the slit lamp, which used his own mathematical models to avoid reflection from the patient's cornea and lens during examination.
Sir Nicholas Harold Lloyd Ridley (1906-2001) was a House Surgeon and Ophthalmic Consultant at the Royal London Ophthalmic Hospital at Moorfields in 1939 when England declared war on Germany. During the Battle of Britain, as a member of the Emergency Medical Service, Ridley treated Royal Air Force pilots who suffered from eye injuries. Many of these injuries included fragments of airplane canopies which were made of polymethyl methacrylate (aka PMMA or Perspex). Only after the war ended did Ridley reflect on his observations of the Perspex fragments, noting that they were relatively inert and well-tolerated by the eye. This led him to design a replacement for the lens removed during cataract surgery.
On November 29, 1949, Ridley performed the first intraocular lens implant surgery. The surgery was a success, but over time it was found that the Ridley lens was too thick and too refractive. The ophthalmic community in Europe and the United States rejected his work, branding it reckless. Over the next 30 years individual physicians all over the world took up the cause and slowly improved IOL design until they gained worldwide acclaim for safety and efficacy. Only nearing the end of his life did Ridley receive the recognition he deserved and was conferred the Knighthood by Queen Elizabeth II in February 2000, at the age of 93.
Edward Jackson, MD (1856-1942), a professor of Ophthalmology at the University of Colorado School of Medicine, was a key proponent of standardized medical education in the U.S. In 1914 Jackson was Chair of the American Medical Association Section on Ophthalmology’s Committee of Education which proposed that a national examining board be established. He worked to get the AMA together with two other organizations, the American Ophthalmological Society and the American Academy of Ophthalmology and Otolaryngology to create a board that would superintend the testing of anyone who wished to practice ophthalmology exclusively.
American Board of Ophthalmology
Jackson’s efforts resulted in the establishment of the American Board of Ophthalmology (ABO) in 1916. The ABO was the first medical specialty board in the U.S. Dr. Jackson was named its first President and he presided over the first exams in 1917. The purpose of the board was to raise the competency of those engaged in ophthalmologic practice in the United States. It promoted residency training and specialized graduate programs. It then tested students in a written and oral examination. The certificate of completion awarded to the fully-trained ophthalmologist was designed to let both the public and medical profession know the recipient was qualified to meet the high standards of patient care in ophthalmology. The ABO continues this important work today.
Robert Machemer (1933-2009) was a German educated ophthalmologist with a distinguished career in the field of retinal surgery. He established an experimental model of retinal detachment and then used it to analyze a major complication of the disease called proliferative vitreoretinopathy (PVR). His work in this area is the basis of understanding of the disease today.
Machemer is perhaps best known for the development of the seminal pars plana vitrectomy and the vitreous infusion suction cutter (VISC) in 1970. His VISC instrument removes diseased vitreous and intraocular scar tissue from the eye aiding numerous patients who were previously considered untreatable. His techniques are now the most commonly performed procedure in vitreoretinal surgery.