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David J. Apple: premier eye researcher, mentor, lecturer
Dr. Apple has devoted most of his professional life not only to research on IOLs, but also to mentoring hundreds of ophthalmologists in training. His latest endeavor is to honor and ensure the legacy of Sir Harold Ridley.
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A simple research assignment in medical school determined the career direction of David J. Apple, MD. It all began with a research assignment on diabetic retinopathy.
“I picked up a small book on ophthalmology and looked it up. I got so interested in it that I read the whole book that night and made my decision right there,” Dr. Apple said. “From the beginning, I was interested in eye research and the pathology of the eye.”
Since that night, Dr. Apple’s accomplishments have been many. Working for the past decade at the Storm Eye Institute in Charleston, S.C., Dr. Apple has become renowned for his research work in IOLs, their design, safety and associated complications.
But not only has he done pioneering research into IOLs and lens implantation techniques, he has also left his mark internationally through the residents and fellows trained at his research foundations.
He has received numerous honors that have sent him lecturing around the globe. Last year, he received an honorary degree from the China Medical University in Beijing and the Alcon Research Award. This year he was made an honorary member of the German Implant Society in Heidelberg. Those are only the most recent awards; Dr. Apple’s 100-plus page curriculum vitae lists more than 900 lectures to his credit, as well as 15 books, 68 book chapters and 364 journal articles.
Unraveling the intricacies
Dr. Apple’s interest in IOL research began during a 2-year fellowship in Germany in 1975. While working at the Institute for Experimental Eye Research in Bonn, Dr. Apple was influenced by Prof. Ulrich Dardenne, an early exponent in phacoemulsification.
He said the familiarity with the German language that he gained during this period helped him tremendously when he was beginning his ophthalmic career.
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“A huge amount of the ophthalmology literature before World War II is in German, so it really opened up my vistas,” Dr. Apple said.
After his training in Germany, he applied his newly acquired expertise at the University of Utah School of Medicine in Salt Lake City, where he was appointed a professor of ophthalmology and pathology in 1981. There he co-founded the Center for Intraocular Lens Research in 1982 with Randall Olson, MD.
The initial impetus for establishing the center was that they received an enucleated pseudophakic eye and were asked by the surgeon to perform a pathologic analysis of numerous complications that had occurred with the posterior chamber IOL that had been implanted in the eye. They reported their findings in a manuscript that was reviewed by conservative reviewers who were skeptical about IOLs and not yet ready to accept their clinical use.
“I know that the reviewers of the article were not for IOLs. I have always had the feeling that they accepted the paper because it talked about complications. However, after the report was published and read by ophthalmologists worldwide, it stimulated them to start sending IOL-related specimens to the laboratory. It has become a flood of specimens since that time,” Dr. Apple said.
“Regrettably, some of my colleagues in general ocular pathology were not happy that I branched off into IOLs. They thought I was on the fringes. I hope now that they understand the value of our efforts,” he said.
His colleagues were not the only ones who did not welcome the new area of research. In 1983 the National Eye Institute (NEI) denied Drs. Apple and Olson funding for a research grant, stating that there might not be a future for IOLs. Furthermore, the NEI was skeptical that these investigators could obtain the required number of specimens for the project. However, that denial worked for the better, Dr. Apple said, because instead much of his funding has come from private companies, reducing his need to depend on government funding.
Since that initial report in 1982, Dr. Apple has received close to 18,000 specimens, first at Utah and more recently at the Storm Eye Institute at the Medical University of South Carolina where he moved to in 1988.
Drs. Apple and Olson first analyzed IOL design elements such as size and shape, which they were sure were the cause of some complications. Their research was the first to scientifically indicate that placement of the IOL in the capsular bag decreased the risk of several complications such as decentration and posterior capsular opacification.
“One of our first efforts was defining that it should be in the bag. The IOLs in use today are the kind we’ve been advocating over the years – the modified C design with the right amount of haptic compression,” he said.
Dr. Apple moved the Center for Intraocular Lens Research to the Storm Eye Institute at the Medical University of South Carolina in 1988. Thanks to a generous grant from Holly and Arturo Melosi and their family foundation, Drs. Apple and Solomon expanded the center to include research on modern cataract and refractive surgery. The nomenclature of the center has now been changed to the more complicated but more inclusive designation, Center for Research on Ocular Therapeutics and Biodevices and the Arthur and Holly Magill Research Center for Vision Correction.
The future of IOLs
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In recent research, Dr. Apple and his team continue to identify problems with the manufacture of some IOLs. Several lens manufacturers have been working with them to resolve problems with their de signs.
“There are several modern IOLs, surprisingly, that have undergone opacification with biomaterial problems and calcium influx that causes the optic to become opaque. That’s a big problem, especially with IOLs sold overseas, and we’re researching to see if we can help stop that,” he said.
He is also working on problems experienced with refractive IOLs, both phakic posterior chamber lenses and anterior chamber lenses. Some of these IOLs are thought to have caused cataracts in patients implanted with them.
Dr. Apple said that he hopes his line of research will continue to help determine the most appropriate IOL designs for cataract and refractive surgery.
“I think all the various subdivisions that are developing now will be researched in greater detail — refractive lenses, accommodative lenses, multifocal lenses — these are subdivisions of the main types of pseudophakic IOLs that we have now. We’re just waiting to see which one’s the right one,” Dr. Apple said.
International focus
The findings of Dr. Apple’s IOL research have crossed borders and influenced ophthalmologists not only in the developed world, but also in developing countries. In 1976, a trip to operate in a hospital in Nigeria inspired him to ponder the issue of cataract surgery in developing countries. At that time, most ophthalmologists in developing countries did not have the equipment training to perform modern cataract surgery, and the vast majority had no access to lens implants. His observations led him to establish, in conjunction with the World Health Organization in Geneva, the Center for Developing World Ophthalmology at the Storm Eye Institute, where research appropriate to cataract surgery in developing countries is conducted.
“I started working on implants that would be suitable for the developing world, and we continue to work with both governmental and nongovernmental organizations. For example, we analyze specimens they send us,” Dr. Apple said.
He is also a consultant to the Christoffel Blindenmission, a German organization focusing on eye care in developing countries.
Mentor
Dr. Apple’s research has attracted more than 200 ophthalmologists to study or work with him. Some of his first research fellows from Germany coined the name “Apple Korps.” The Korps’ first member came on board in 1975. They spend anywhere from a few months to 2 years; a third of them come from outside the United States, Dr. Apple said. During their stay, their pay is matched by corporate and private donations.
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Dr. Apple’s teaching activities have not only been evident hands-on in the laboratory, but also in two classic books he has authored. Two generations of ophthalmologists (from 1974 to the present) have learned basic ocular pathology from the book authored by Dr. Apple and Dr. Maurice Rabb, entitled Ocular Pathology, Clinical Applications, and Self-Assessment (ed 5), St. Louis, Mosby-Year Book. In addition, he has just completed the second edition of his text on Foldable Intraocular Lenses: Evolution, Clinicopathologic Correlations, Complications, Slack Inc., Thorofare, 2002.
Three former fellows have advanced to faculty professorial positions with Dr. Apple in Charleston: Kerry Solomon, MD, now a recognized leader in the field of refractive surgery and Director of the Magill Center for Vision Correction, Qun Peng, MD, and Lilliana Werner, MD, PhD.
Dr. Werner, now an assistant professor, and Suresh K. Pandey, MD, have been with Dr. Apple for 3 years. Both came across his research while working on their theses and sought to work with him. Dr. Pandey’s thesis advisor had worked with Dr. Apple previously.
“Dr. Apple’s research confirmed the importance of secure fixation of the IOL in the capsular bag,” Dr. Pandey said. His own research has dealt with implantation of posterior chamber IOLs in children.
Likewise, Dr. Werner found Dr. Apple’s research to be closely related to her PhD thesis on surface modification of IOL biomaterials, which she performed in France. In addition to her assistant professorship at the Storm Eye Institute, Dr. Werner is now a senior scientist at the Center for Research on Ocular Therapeutics and Biodevices.
“I decided to continue working in this area related to IOLs and other ocular prosthetics and wrote a letter to Dr. Apple, who accepted me to work with him,” Dr. Werner said.
Their most recent projects have dealt with interlenticular opacification between piggyback IOLs, IOL optic calcification and other previously unreported conditions associated with IOLs.
“Descriptions of these conditions have led to modifications in the surgical techniques for multiple ‘piggyback’ intraocular lens implantation and in the manufacturing process of some hydrophilic acrylic lenses. We have also focused our research on both anterior and posterior capsular opacification after implantation of different IOLs,” Dr. Werner said.
Both Drs. Pandey and Werner acknowledge Dr. Apple’s guidance and leadership in the winning of various awards. Three years ago, their videos won second and third prizes at the European Society of Cataract and Refractive Surgeons meeting in Vienna. This was during the time Dr. Apple was under treatment for throat cancer. Last year, Drs. Werner and Pandey won two best-paper-of-session awards, best cataract poster and first video prize at the American Society of Cataract and Refractive Surgery meeting in San Diego.
The other side of the visionary
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Dr. Apple has spent most of his professional efforts working in the field of ocular pathology and eye research, mentoring students and fellows and lecturing. In addition, he has a keen interest in history. He was born in Illinois, the Land of Lincoln, he said, and many of his ancestors were involved in issues of their times, such as the Civil War. Even now, he and his wife participate in historic festivals where they reside in Charleston.
“This is a special old city, with a special history and architecture. I also became interested in the history of the IOL after meeting Sir Harold Ridley, the inventor of the implant, in 1985,” Dr. Apple said.
Sir Harold passed away in 2001, and Dr. Apple is now writing his biography. Initially little importance was attributed to Mr. Ridley’s work and the IOL was viewed with skepticism, even outrage. Mr. Ridley’s contribution was largely overlooked by many for more than 4 decades, until IOL implantation began to become routine practice in the 1980s.
“Since 1985, an important part of my career has been associated with Sir Harold. I had a close personal relationship with him and I am pleased that we helped rediscover him by conferring an honorary degree upon him in Charleston in 1989,” Dr. Apple said.
Mr. Ridley finally received the recognition he deserved when he was belatedly knighted by the queen of England in 2000. He was 93 years old.
“Many people didn’t realize how important the IOL was and how important he was,” Dr. Apple said. “I believe that, partially because of my help, the value of his work became better known; that’s something I’m really proud of.”
Last November Dr. Apple stayed with Dr. Ridley’s son and daughter-in-law, and photographed and copied old documents and memorabilia related to Sir Harold’s career. He plans to interview other family members and colleagues for the book as well.
Looking back
The past 3 years have been especially difficult for Dr. Apple. In July 1999, he was diagnosed with a throat cancer. He said the cancer pain has been very difficult to deal with, but he is now a 3-year survivor. With the help of Drs. Peng, Werner, Pandey, as well as his staff, the laboratory has remained fully operational during his absences for treatment. Dr. Apples’s loyal staff members include Dr. Marcela Escobar-Gomez, Joyce Edmonds, certified histotechnologist, and Ms. Maddie Manuel, his administrative assistant.
“During this period, Dr. Apple’s laboratory remained on the top in terms of productivity and financial support,” Dr. Pandey said.
Dr. Apple would like to see the research laboratory, which now focuses on monitoring refractive surgical techniques as well as cataract/IOL procedures, continue functioning after he retires. He admits that finding a successor might be difficult because the work is highly technical, he said.
Retirement from the laboratory is still in the distant future. He is focusing on completing the Ridley biography and is planning a 6-month part-time sabbatical to work on the book.
Looking back, Dr. Apple cites Dr. Ridley’s post-World War II invention as the beginning of a golden age of ophthalmology.
“It’s been wonderful that I’ve been able to observe and participate in ophthalmology’s advances for almost 25 years,” Dr. Apple said. “That’s been most satisfying.”
For Your Information:
- David J. Apple, MD, Suresh K. Pandey, MD, and Liliana Werner, MD, PhD, can be reached at the Storm Eye Institute, MUSC Department of Ophthalmology, 167 Ashley Ave., Charleston, SC 29425-2236; (843) 792-2760; fax: (843) 792-7920; e-mail: appledj@musc.edu;wernerl@musc.edu; pandeys@musc.edu.