Harold Ridley

Harold Ridley was a 20^th century English ophthalmologist. His experience in Britain during World War II, and later in Africa and Burma, led him to launch a revolutionary new approach to cataract surgery. He implanted the world’s first intraocular lens (IOL), the start of an era of innovation, inspiration and challenge in the field of ophthalmology. His work, against a hostile background and the disdain and outright opposition of professional colleagues, was to prove hugely influential at a practical level. His treatment would, directly and indirectly, save the sight of at least 50 million people. It was said, “He changed the world, so that we might better see it”.

Early years and education

Sir Nicholas Harold Lloyd Ridley (as he was later to become) was born in the village of Kibworth Harcourt, Leicestershire, on 10^th July 1906. His father was Nicholas Charles Ridley, a naval surgeon who specialised in ophthalmology. His mother was Margaret, née Parker. Harold was the family’s eldest son. His younger brother, perhaps curiously, was called Olden. Young Harold had a stammer which he was largely able to manage. As a child he supposedly met and sat on the lap of Florence Nightingale, a close friend of his mother. A poor communicator but with a strong practical bent, it seems he usually asked the right questions and ended up finding practical solutions. He made several toys as a child and when aged seven told his mother he wanted to be an inventor.

Moorfields Eye Hospital

He was sent to the public school, Charterhouse, and then went to university at Pembroke College, Cambridge from 1924 to 1927, where he read natural science. He followed this with medical training at the major London teaching hospital, St Thomas’. Harold completed his studies in medicine there in 1930. He specialised in his father’s discipline, ophthalmology, and went on to work as a surgeon at both St Thomas’ and the specialist Moorfields Eye Hospital in London. One of his patients was a skilled worker whose career was threatened by a traumatic cataract. Ridley told his mentor Mr A Cyril Hudson, “How nice it would be to put a new lens in his eye”.

Eye surgeon

Ridley had six months of experience as a casualty officer, a year of general surgery, then a year as ship’s surgeon in different vessels, followed by an 18 months formal ophthalmology residency training at Moorfields. In 1938 he was promoted, gaining the coveted post of full surgeon and permanent consultant at Moorfields. At age 32, it was what he had long wanted and what his background and career had been leading up to.

With World War II starting a year later, Ridley treated many patients, notably RAF pilots with eye injuries. In August 1940 pilot Ft. Lieut. Gordon ‘Mouse’ Cleaver forgot to pick up his goggles when changing his damaged Hurricane for a replacement during a Luftwaffe attack. He was then shot down and with no protection, was blinded as Perspex fragments from the cockpit canopy penetrated both his eyes. The first words Cleaver spoke to a friend visiting him at the military hospital were, “Jack, tell them to wear their goggles”.

Perspex pieces from a German plane

Under treatment for several years at Moorfields, Cleaver had about 18 surgical procedures on his eyes and face, to try to preserve some vision. Many of these were performed by Ridley, mainly to remove Perspex pieces that had gone in his eyes or embedded in the ocular coats. Eventually Cleaver’s left eye was saved. This was when Ridley made the historic observation that the acrylic pieces did not seem to elicit any inflammatory reaction as did glass. He saw the same in other pilots’ eyes with similar injuries. His earlier idea of implanting a lens came back. It was probably the Eureka moment.

War service and wider experience

In May 1941 Ridley married Elisabeth Jane Weatherill, who was 10 years younger than him. But there was no opportunity to settle down, as he was temporarily assigned to the Royal Army Medical Corps, and posted first to the Gold Coast (Ghana) in West Africa. The location was free of war action which depressed Ridley as he realised his surgical experience would be wasted there. He also believed that Sir Stewart Duke Elder, doyen of British ophthalmology, and later a fierce opponent of Ridley’s methods, was behind the transfer. It may be that Elder was keen to remove Ridley from London, where he might have more freedom to try out his ideas.

While in Africa, Ridley led important research into onchocerciasis (river blindness) an endemic disease in parts of the country. Having had his interest in the problem stimulated by Brig. GM Findlay, he travelled north overland with Cpt. John Holden, examining patients.  90% had onchocerciasis and 10% were blind. Ridley recorded his observations of the retinal fundus in primitive conditions using water colour painting and photography. Back in Accra he finished the work. Biographer David Apple said, “The attention he called to this disease constitutes one of Ridley’s major contributions. His monograph “Ocular onchocerciasis”, published in 1945 in a supplement to the British Journal of Ophthalmology, was a landmark.”

Harold Ridley in the Gold Coast (Ghana) 1943

In 1944 he published a short paper in the same journal on spitting snakes and the composition and action of snake venom in general. From his Gold Coast experience, Ridley described snake venom ophthalmia in a rural labourer caused by a Black-necked cobra. Ridley treated the man and followed through until after a week the eye had fully recovered. He discussed the therapeutic use of snake venom and speculated that in future diluted venom could be used in some cases of ophthalmic surgery.

After 18 months in Africa, in 1944 Ridley was transferred to India. In his own words, “In Calcutta we basically had nothing to do with no assignments…Finally I was transferred to Rangoon, Burma, where life began again. I treated over 200 released allied prisoner of war, who suffered from nutritional amblyopia. Many had worked on the Burma railway. Starved and ill-treated, they had developed sudden central scotoma, relieved by good diet if available”. Some made a partial recovery in six weeks, but advanced ones proved irreversible. His therapy anticipated today’s use of multivitamins in such patients. The Burma theatre offered the first large population study of nutritional amblyopia. Of 500 cases, Ridley personally treated 200.

Lens replacement question

Back in post war London, a student watching Ridley perform a cataract surgery in 1947 said it was a pity it couldn’t be replaced with a clear lens. The old heretical question had returned. Ridley knew it was time to change the answer. There was now no holding back.

In 1948 at an apparently undercover meeting in a car off London’s Cavendish Square, Harold Ridley and his friend John Pike, an optical scientist at lens specialists Rayner and Keeler, agreed the principles of the first IOL surgery. Perspex would be the material and for the implant site Ridley rejected the more accessible anterior chamber, insisting it should be “just where nature had placed a biconvex lens throughout the animal kingdom”.  Pike roped in his friend Dr. John Holt from ICI to make some pure high quality Perspex. And critically the three agreed on no patent - they would forgo any financial reward.

A posterior chamber IOL (with haptics)

It took Ridley a year to find the right guinea pig. The subjectt had to have a unilateral cataract. The other eye should be working well. The patient needed to understand the risks and, should the operation fail, be prepared to lose the defective eye. At last a 45 year old nurse, Elizabeth Attfield, with a cataract in her left eye, agreed and was selected. The lens was a simple disc with a peripheral groove made by Rayner from Perspex clinical quality (CQ). It cost Ridley under £1. 

Controversial implantation treatment

History was made in the afternoon of November 29^th, 1949. The procedure for which Harold Ridley had been preparing for years was finally carried out in secrecy at St Thomas’ Hospital. It was the first part of a two stage exercise, and the IOL implantation actually took place at the second stage on February 8^th 1950. The early lenses were too accurate in copying the radii of curvature of the human lens and the first patients became highly myopic. But this problem was soon corrected and later implants were adjusted accordingly. Eight were done, with three at Moorfields, without publicity over the next year.

Why the secrecy? Ridley knew the procedure would be controversial and the treatment would face professional opposition. He’d hoped to maintain secrecy for two years until he thought he’d be sure of the results. But the news got out, so he published first in the low profile ‘St Thomas Hospital Reports’, then later in the Lancet and BJO. But the head of research at Moorfields, and the most powerful figure in British Ophthalmology, Sir Stewart Duke Elder, had been kept in the dark. Ridley told Elder he saw no reason to inform him. An attenuated row ensued and Ridley was never forgiven.    

Ridley posterior chamber IOL

In July 1951 he presented his work at the Oxford Ophthalmological Conference. He was accompanied by two implant patients whose vision had recovered and he’d prepared a cine film of one of the operations. But the lecture was badly received. Some senior audience members refused even to look at the patients and the film was not shown. Ridley’s group drove back quietly, missing a planned dinner. There was an even more hostile US reaction at the 1952 American Academy of Ophthalmology session in Chicago, where comments from some senior professional figures were particularly scathing.

30 years of ostracism 

Ridley hoped the Oxford meeting would be a landmark in the history of Ophthalmology. Says Apple, “Indeed, it was a landmark day, but not in the way he expected. Instead it was the beginning of more than 30 years of trials and tribulations leading to health problems that plagued him for the rest of his life”. Some leading ophthalmologists repeated the simplistic mantra that ‘our job was to take things out of eyes, not put things into them’. The long period of abuse, ridicule and ostracism caused Ridley depression, for which he needed medication. 

Ridley performed around 1000 IOL implants with reasonable success.  But about 20% had complications from poor fixation of the rather heavy lens, and some sub optimal surgery. He was forced to abandon the procedure given professional opposition and fear of litigation. But as Dr. Biju John points out, “Had Dr. Ridley access to things such as viscoelastics, operating microscopes and capsulorhexis principles, the story would have played out differently”. But the delay deprived a whole generation of patients of the benefits from IOL treatment.

Harold Ridley (around 1980)

Fortunately people like Choyce, Epstein, Binkhorst and Fyodrov kept the faith and were keen to carry Ridley’s work forward. Indeed Peter Choyce was Ridley’s favourite protégé. First generation anterior chamber IOLs in the 50s were followed by iris-supported lenses, and finally from 1975 it was back to the posterior chamber IOL design of today. This was Ridley’s original plan with a central disc smaller and much lighter. By 1980 posterior chamber IOLs gained FDA approval and Ridley was vindicated in all respects.  

Reputation recovered

As his original plans, duly modified, became standard treatment, Ridley’s reputation recovered. At a European Intraocular Lens Council meeting in 1986 he’s reported to have said, “All you people have enjoyed your implant work, I’m sure. I suffered for it”. But he began to receive some overdue honours and recognition. In 1986 he was elected to the Royal Society in London and three years later was awarded Doctor of Humane Letters by the Medical University of South Carolina. The Gullstrand Medal was conferred on him in 1992 by the Swedish Society of Medicine, and David Apple’s biography was published in 1996. In 1999 he was honoured in Seattle by the American Society of Cataract and Refractive Surgery.

These are just a few of his international public decorations. He’d retired from NHS hospital service earlier, in 1971. In 1966 he’d founded with Peter Choyce a body later called the International Intra-Ocular Implant Club, to promote research in the field and be a forum to exchange professional ideas. Among his earlier innovations was the televising of operations. Apparently this hadn’t been done before but proved a long term benefit. Some teaching hospitals these days have as standard fibre optic circuits to show operations for student training. 

Modern St Thomas'Hospital

Ridley developed cataracts in both eyes as he grew older. His own 1989 and 1990 lens implantation treatment was at St Thomas’.  Thus he benefited from his own invention and pioneering operational procedure. He was pleased it would be done in the hospital where he’d performed the first operation. He asked for a general anaesthetic, explaining to surgeon Michael Falcon, “Well my boy, if I am awake, I will be telling you what to do all the time”.

Honours

In February 2000 Harold Ridley was awarded a knighthood. It followed years of lobbying by biographer David Apple, leading surgeon friends and Donald Munro, of the Rayner Company in Hove. He was 92 and partly deaf at the investiture. When asked what the Queen had said to him he replied with a smile, “I couldn’t hear a damn thing!” He specified how he wished to be remembered. In his inimitable style he said, “I am going to have on my tombstone: He cured Aphakia. People are then going to say, “Who was Aphakia?” He didn’t get this, but the millions all over the world whose sight was restored will be a pretty adequate tribute.    

Sir Nicholas Harold Lloyd Ridley FRS died aged 94 on 25th May 2001 in Salisbury. He was buried at Swinstead in Lincolnshire. His widow Elisabeth lived on for nine years. They had a happy family life with three children, Margaret, Nicholas and David. Nicholas serves as Chairman of the Ridley Eye Foundation, a charity set up in the 1960s to raise funds for cataract surgery in developing countries and to treat avoidable blindness.   

Plaque recording Ridley's first IOL implant 

A plaque at St Thomas’ marks the first IOL implantation. In 2010 the Royal Mail issued a commemorative series to mark ‘Medical Breakthroughs’. Designed by Howard Brown, the 67p stamp depicted artificial lens implant surgery pioneered by Sir Harold Ridley 1949. A Heritage blue plaque was installed in 2012 at Kibworth Harcourt. A plaque in the gardens of his alma mater Pembroke College, reads ‘RIDLEY’S WALK …placed in memory of Sir Harold Ridley, pioneer of intraocular lens surgery’. 

Commermorative Royal Mail stamp

Ridley was an irrepressible and innovative man who was never short of ideas. A rounded personality with a sense of humour, he used his gifts not to enrich himself, but to benefit humanity.   

 

My two most important sources to whom I’m extremely grateful are:

David J Apple (2006) Sir Harold Ridley and his fight for sight: he changed the world so we might better see it   

Dr. C Biju John, Dept of Ophthalmology, Government Medical College, Thiruvananthapuram, Kerala, India (2020) Sir Harold Ridley and the intraocular foreign body that made history