Jan G.F. Worst: early innovator of IOL design

Jan Worst, MD, says his anterior chamber IOL design wasn’t wrong — it was “right too early.”

With the blood of craftsmen and watchmakers in his veins, a young Jan Worst had the innate ability to chisel chess pieces out of wood scraps, allowing his cellmates to play games lasting into the wee hours of the morning.

The time was 1942, during the German occupation of Holland. The young Mr. Worst was imprisoned for 6 months after he set fire to a Nazi meeting center in a Dutch building.

“During World War II, we had a common feeling that we had to defend ourselves, our homeland,” the now 74-year-old Jan G.F. Worst, MD, reflected recently.

Within the walls of the Nazi-controlled prison, the 14-year-old Worst passed his time developing the handcrafting skills he would later use in his ophthalmic career.

The path he chose led him from his rebellious youth to a life as an innovator and inventor of ophthalmic tools, a pioneer in the physiology of the vitreous humor and an active proponent of blindness control in developing nations. During his lifetime, his contributions to ophthalmology would be at first scorned and later heralded worldwide.

Following footsteps

A teacher by nature, Dr. Worst continues to teach his simplified cataract surgery techniques throughout developing nations as well as those rich in resources. He encourages other ophthalmologists to offer their services to those less fortunate, toward the greater good.

Dr. Worst’s path was directed in part by a combination of his perseverance, a keen interest in medicine, his mechanical aptitude and a little help from his father.

“I had an early start because my father made ophthalmic instruments for a famous Dutch ophthalmologist,” Dr. Worst said in an interview with Ocular Surgery News. “I watched him, saw the instruments, and became very interested.”

In the early 1950s, Jan Worst’s interest in the internal structure of the body led him to study at the Medical College of Utrecht. He began researching anatomy and biology.

“I was doing a lot of biological experimentation when I was asked to do some research in the university clinic of ophthalmology,” he said. His research in the clinic fed his interest in ophthalmology. By the end of the decade, he was studying at the University Eye Hospital Groningen, training to become an ophthalmologist.

During this time, he was influenced by IOL pioneer Cornelius Binkhorst, MD.

“He was my teacher, a man who followed Ridley in the practical sense,” Dr. Worst said. Sir Harold Ridley, the inventor of the IOL, had begun a frenzy of controversy in Europe and America with the idea of adding an artificial implant to an aphakic eye to improve vision.

“Many said it couldn’t be done well, but I was immediately convinced that this was a great breakthrough in ophthalmic surgery,” Dr. Worst said. His adventurous and rebellious spirit latched onto IOL technology in its infancy, and his path was set.

In his early practice, Dr. Worst implanted the Binkhorst iris-clip lens, which was fixated in the pupil of a person who had previously had a cataract removed. But as his client base grew and increasingly demanded the new IOLs, the manufacturer of the iris-clip lens missed months’ worth of shipments. He decided the only thing to do was to develop his own lens.

Creating the iris-claw lens

“I designed a new lens called the iris medallion lens. It was very similar to the Binkhorst lens,” Dr. Worst said. The iris medallion lens was fixated to the peripheral iris, in the iris stroma. It provided firmer support than the Binkhorst lens, which was fixated in the pupil and often became displaced.

Dr. Worst examining a patient of Dr. Binkhorst who received one of the first IOLs at the end of the 1960s. The patient is in the traditional costume of Zeeland, a province of the Netherlands (left). Dr. Cornelius Binkhorst and Dr. Jan Worst with their surgical assistants, as guest surgeons in Avelino, Italy (bottom).

In its first design, Dr. Worst secured the iris medallion lens with a stitch, but he later included a clasp in the IOL design. This lens became the iris-claw lens, today known as the Artisan lens manufactured by Ophtec.

In 1970, the Worst iris-claw lens for aphakia was introduced to the world at an ophthalmic meeting in Paris. At first, this lens was met with skepticism and incredulity.

“It was an anathema,” Dr. Worst re called. “Everyone said, ‘You can’t do that; you cannot put a foreign body inside the eye.’”

Nevertheless, he persevered, bearing in mind a quote from Louis Paufique: “One is always wrong by being right too early.”

“I thought, ‘I’m wrong by being right too early.’ I kept my will,” Dr. Worst said.

He enlisted the help of his wife, Anneke Worst-van Dam. Mrs. Worst began working on the promotion and manufacturing of the iris-claw lens with her husband.

“She was the brains behind the whole commercial aspect of the lens. She propelled it into the next century,” he said.

Within a few years of Dr. Worst’s design of the iris-claw lens, interest began to grow.

“We had held fast, stuck to our guns, and revealed ourselves when the whole concept of lens implantation really began to boom,” Dr. Worst said. In 1976, he received the Binkhorst Award for his revolutionary work on the iris-claw lens from the American Intraocular Implant Society, now the American Society of Cataract and Refractive Surgery.

In 1983, Mrs. Worst established Ophtec BV, an ophthalmic instrument company dedicated to design innovation and research. Today, the couple’s son, Erik-Jan Worst, is president and chief executive officer of Ophtec BV. There is also an American division, Ophtec USA, based in Florida.

The iris-claw lens for the correction of aphakia after cataract extraction was developed in 1978 and is still used today. More than 250,000 have been implanted worldwide, many of those in India by Dr. Daljit Singh. In 1986, the myopia iris-claw lens was developed for use in phakic eyes for refractive correction. Interest in this lens is rapidly growing, and has expanded with the development of lenses for hyperopia and astigmatism.

Food and Drug Administration approval in the United States is pending completion of clinical trials. Allergan recently signed a deal with Ophtec to distribute the Artisan refractive lens in many parts of the world.

Through it all, Dr. Worst has remained faithful to the ideas and theories initially propounded by his predecessors in IOL innovation — extra- capsular or intracapsular cataract ex traction followed by IOL implantation. In his lifetime, Dr. Worst has performed phacoemulsification only once.

Grass-roots ophthalmology

Mrs. Worst and Dr. Worst at an ESCRS Congress in Lisbon.

Restless with the desire to show the world the benefits artificial lenses could offer, Dr. Worst began an aggressive — and independent — campaign to help relieve the backlog of blindness in developing countries. With the help of his wife, he formed the Jan Worst Research Group, a team of investigators and inventors who created and developed simple tools for cataract surgery — tools so simple and small, in fact, that they fit in a handy toolbox Dr. Worst carried from country to country.

“Over 30 years, we developed strong relations with doctors and communities in Nepal, Pakistan and India,” Dr. Worst said. He paid yearly visits, teaching local ophthalmologists and providing free surgical services to those debilitated by cataract in small rural villages.

Dr. Worst was also often called upon to perform guest surgeries and lecture in developed countries including Italy, France, Russia and the United States. In his personal time, he studied languages to better be able to communicate with his colleagues. Today he speaks several languages including Italian, Spanish, English, French, German and Dutch, his native language.

Through another foundation of his, the Focus Foundation for Aid to the Curable Blind, he helped develop programs to instruct local physicians on how to remove cataracts, implant IOLs and prevent vision deterioration.

“It’s all grass-roots ophthalmology,” Dr. Worst said. “I believe if you try too hard to introduce too many high-tech components, your work will be a failure. Simple techniques and instruments work effectively and better than anything I’ve tried in the high-tech world.”

A teacher by nature, Dr. Worst continues to teach his simplified cataract surgery techniques throughout developing nations as well as those rich in resources. He encourages other ophthalmologists to offer their services to those less fortunate, toward the greater good.

“The experience will make you very humble,” he said.

Unraveling the vitreous

Dr. Worst’s curiosity also led him to explore the uncharted territory behind the capsule.

A royal honor, given to Dr. Worst by the Queen of the Netherlands in 1994, can be seen on his jacket. Dr. Worst celebrates after the ceremony with his oldest grandson, Bruno.

“I was always thirsty for knowledge,” he said. “I wanted to uncover the inner workings of things, so I delved onto the physiology of the vitreous.”

Dr. Worst said anatomists have until recently seen the vitreous as a “a glob of gel,” or a simple congregation of tissue. He believed there was more to it. After hours of study, Dr. Worst mapped out an anatomical structure of the vitreous that had never been observed before.

“I went searching for a needle in a haystack and came out with the farmer’s daughter,” he joked.

Dr. Worst credits serendipity for leading him to describe the bursa premacularis, a hollow space in front of the macula that he says is responsible for the health of the macula. Without an adequately nourished bursa premacularis, neovascularization of the choroid may develop as a secondary cause of age-related macular degeneration, he said.

Research has shown that cystoid macular edema can occur if the posterior capsule is ruptured in cataract surgery, and this is related to his observations of vitreous structure, he said.

“These pathologies are coming from forward backward, instead of from backward forward,” he said.

Dr. Worst said the anterior and posterior chambers may appear to be two separate structures, but his studies suggest that they are two complex and interrelated components of a single entity.

Dr. Worst has published a comprehensive textbook outlining his observations on the vitreous, entitled Cisternal Anatomy of the Vitreous (Kugler Publications), as well as a handbook on the vitreous with three-dimensional illustrations, published by the Jan Worst Research Group in 1995.

Dr. Worst has been recognized by his native land, the Netherlands, as an influential force in advancing the science of ophthalmology. He was appointed Officer of the Order of Oranje Nassau by the Queen of the Netherlands in April 1994.

Interests still growing

In his later years, it might seem that Dr. Worst would seek well-deserved rest, but that is not the case. At an age when others are cherishing their retirement, he continues his research and development to further advance ophthalmology. While teaching and performing refractive and cataract surgery with the lens now dubbed the Artisan, he continues his research on the physiology of the vitreous. He still performs a wide range of surgical procedures in his private practice.

“It’s amazing how little success we have had in stopping the regeneration of the epithelial cells of the lens that are left behind after cataract surgery,” he said. According to Dr. Worst, posterior capsular opacification is the most significant postoperative complication after cataract removal.

And Dr. Worst is still studying. He is working with the University of Amsterdam on a theory about accommodation, and hopes to complete in his lifetime a theory on the mechanism of action of accommodation and the reason for the onset of presbyopia.

His latest technical challenge has been the development of a foldable version of the Artisan lens, called the Artiflex.

“The Artiflex lens is inserted through an incision of 3.7 mm. It unfolds itself,” he said.

Dr. Worst and Ophtec BV have designed the new lens to fuse modern technology with the trademark design incorporating iris fixation. He hopes to launch the updated lens into the new century.

Echoing the words of a lifelong friend, Dr. Worst said, “If you want to make your mark in the world, do one thing and do it right.” By following the guidance and example of his father, his predecessors, and his heart, Jan Worst has left his mark by paving a pathway for future ophthalmologists.

For Your Information:

• Jan G.F. Worst, MD, can be reached at the Jan Worst Research Group, Julianalaan 11, 9751 BM Haren, Holland; (31) 50-534-8320; fax: (31) 50-534-9877. Dr. Worst has a direct financial interest in the products mentioned in this article. He is not a paid consultant for any companies mentioned.

• Ophtec BV, manufacturer of the Artisan lens, can be reached at Schweitzerlaan 15, 9728 NR Groningen, Holland; (31) 50-5251-944; (31) 50-5254-386; Web site: www.ophtec.com. Ophtec USA Inc. can be reached at 6421 Congress Ave., Boca Raton, FL 33487; (561) 989-8767; (561) 989-9744.
• Allergan, distributor of the Artisan refractive lens, can be reached at 2525 Dupont Drive, Irvine, CA 92612; (800) 433-8871; fax: (714) 246-5913; Web site: www.allergan.com.