Like wine, new and early technology makes the conversation better

At Hawaiian Eye 2006, ophthalmic pioneer Robert M. Sinskey, MD, related his experiences as a vineyard owner and his role in the early days of phaco and modern-day ophthalmology.

WAILEA, Hawaii — I want to take you back before I started phaco and explain how my career coincided with my interest in wine.

Robert M. Sinskey

In 1969, I had just finished a 2-month bout of intractable pain from a duodenal ulcer. As a result, I found that instead of drinking scotch or bourbon or vodka at home in the evening or at a social event, drinking wine made the food taste better, helped the conversation, and was better for you than not drinking anything at all.

In 1972, I took Charlie Kelman’s phacoemulsification course and it changed my life. I was 47. I was performing cataract surgery at a time when you put in five interrupted sutures. The patient had to stay in the hospital 3 to 5 days and even upon hospital release had daily activities restricted for 6 weeks.

Dick Kratz had taken his course about 3 months before I did. I watched him in surgery and I was excited about it. It gave me a real incentive to make life easier for our patients.

After the course, and after I had done some cases, I started a phaco course with Dick Kratz that went on for the next 20 years. About 3,500 doctors, from all over the world, took this course. In between, I was traveling the world teaching.

I was the first surgeon to perform phaco in Russia in 1974. I was asked to see Svyatoslav Fyodorov, who at the time was not the No. 1 ophthalmologist in Russia, Mikhail Leonidovich Krasnov was. It was an experience in itself because it was at the time of the Iron Curtain. I had to teach Fyodorov separately from Krasnov because they did not speak to each other and also teach each of their associates separately. In March, with temperatures at 40 below zero, finding rabbits and cats to perform surgery on was difficult.

In Krasnov’s clinic they had leeches in a jar on each floor. One night, we had a cocktail party and after a couple of vodkas I asked Krasnov why they had leeches. He said, “That’s because we treat glaucoma and iritis using these.” I said, “What do you do with the leech?” He said, “I put it on the temple.”

I asked him to explain the pharmacology of it and he said, “It was good for Hippocrates 2000 years ago, it’s the same now.” So I said, “Let’s have another vodka.”

Intraocular lenses

In 1974, Robert M. Sinskey, MD, traveled to Russia to teach Svyatoslav Fyodorov, MD, pictured here on the left. Images: Sinskey RM

In the early days of IOLs, we were taking out the crystalline lens, but we were not replacing it because of the many problems with IOLs.

In 1974, about 50 of us spent a week with Binkhorst and Worst. I decided, at that point, to start using IOLs after removing the cataract. Previous to this there had been a lot of controversy because of the high rate of complications with various types of lenses. However, Binkhorst and Worst had developed IOLs that had complication rates of less than 10%. I thought it was time to start implanting lenses because some of my patients for whom I had removed the cataract using phaco had returned with a secondary implant, which had been performed by Henry Hirschman.

The lenses available in 1974 were the Binkhorst-type lenses (made by different companies with the same design with longer loops and shorter loops), the Sputnik lens invented by Fyodorov, the Maltese Cross lens, the Krasnov lens, and the Copeland lens, which was invented by Edward Epstein in South Africa but was made by Michael Copeland in New York.

I implanted 50 Binkhorst two-loop iris-supported IOLs before I realized there was a problem. The platinum-rhodium loops were wearing through the iris, causing recurrent hyphemas, and they would eventually dislocate either into the anterior chamber or into the vitreous. When I first started implanting the lens, it was so traumatic that everything kind of stuck down. But as the surgery was less traumatic, the results were worse because the iris would move back and forth over the platinum-rhodium loops, causing all the problems described above.

Sinskey hook

In 1977, the Shearing J-loop posterior chamber lens was introduced in one of my courses. Without the use of viscoelastics, which were not available at the time, the lenses were difficult to put behind the iris in many cases. The lenses had holes in them because IOLab needed the holes to fix the loops into the lens. I made a hook out of an old cystotome using an Arkansas stone in order to enable me to get the loops behind the iris. Unfortunately, Katena who made the first Sinskey hook thought that the diameter should be 0.4 mm, which was the size of the hole, but some of the holes were smaller, and when you put the hook in the hole it got stuck, which caused some problems. So I asked Kate Tiedemann at Katena to make the hook 0.2 mm so that it would fit loosely in various sized holes.

Eventually, people asked for more holes of various sizes to be put in lenses by different companies. It was then that we realized that the holes were the source of glare problems. I then developed the Sinskey II hook that went over the anterior curvature of the lens and was placed in the crotch of the lens where the loop and the lens came together. I am probably better known throughout the world for the hook than anything else. (I have no financial interest in the Sinskey II hook.)

Modified J-loop

At meetings in 1978 and 1979, it was apparent that ophthalmologists were having trouble with getting the upper loop behind the iris. The IOL was a rigid design, and viscoelastics were not available.

In 1980, I took the J-loop design and modified the loops so that the loops curved toward the lens as it left the lens, making it more flexible. This IOL was eventually called the Sinskey lens or modified J-loop lens. It became an immediate success and from 1980 to 1990 was the most popular lens in the world.

Laser capsulotomy

In 1980, at the American Society of Cataract and Refractive Surgery meeting Daniele Aron-Rosa presented the first laser capsulotomy technique. I sat down beside her and said, “Daniele, I’ve got to get that machine.” Daniele said, “Well, you teach me phaco and I’ll teach you about the machine.”

So I went to Paris and had a fascinating experience. The original laser was very large and bulky, but it worked beautifully. I told her I would write a check that day for it, but I wound up with a third machine in North America, but it was a lemon. It was so bad that you could hit an anterior chamber lens and open up the posterior capsule with one shot.

The lenses available in 1974 included the Binkhorst-type lenses, the Sputnik lens invented by Fyodorov, the Maltese Cross lens, the Krasnov lens and the Copeland lens.

The platimum-rhodium loops of the Binkhorst two-loop iris-supported IOL would often dislocate either into the anterior chamber or into the vitreous, causing trauma.

Wine

Also in 1980, I became a partner in the Acacia winery and began to buy land around it in Napa Valley. In 1984, the president of Acacia was caught in an embezzlement situation, and Acacia had to sell out to Chalone. In lieu of payment for the money I had loaned Acacia, I was given 11 acres on the Silverado Trail, which they had planned to expand to. I decided to do my own thing at that time without a multitude of partners.

I had my first vintage in Forest Springs in 1986 and built my own winery in 1988. I continued to buy more land. The vineyard, which started with only 11 acres, then had 200 acres and would eventually produce nine varieties of wine.

We made some mistakes. In 1988, my son Rob came on board as the marketing person because I was more interested in the production than in the sales. I was still traveling all over the world teaching. It turned out he had a palette that was better than the winemaker at that time. We got rid of that winemaker and hired a new winemaker who is still with us.

We now have 200 acres of vineyard in seven Carneros locations and a winery with an estate vineyard in the Stags Leap District of Napa Valley. We are certified organic. Our organic vineyard’s goal is to create a balanced farm environment by employing an ecologically sound, self-supporting farm system.

We have caves and put on dinner parties and other events because winemaking is closely associated with entertainment. Fortunately, my son loves this aspect of the business. He works 7 days a week. I never thought that I would beg my son to take a weekend off and relax once in awhile.

Present and future

So what do I do now? This is a tender age. The problem now is energy.

But I have an old project that I got involved with and started with about 47 years ago. Basically, there is not any good treatment for nystagmus.

I discussed with an orthopedic surgeon the treatment protocol for spastic, which is basically a similar condition to nystagmus, both of which are uncontrolled muscle movement. He told me that they remove the offending muscle. So that is what I did. I started with monkeys first and then humans. I removed the muscle and threw it away. That’s the problem. Critics worried that patients wouldn’t be able to move their eyes, but people have a neck, you know.

The hardest part is to convince pediatric ophthalmologists who specialize in muscle work to do this because they say, “What happens if it doesn’t work? You can’t put the muscle back.” I say, “But it works.” I have performed four of these procedures on patients with success and three other ophthalmologists have performed a few cases with success. More on this will be heard of in the future.

For Your Information:

• Robert M. Sinskey, MD, is a clinical professor at the Jules Stein Institute. He can be reached at 351 23rd St., Santa Monica, CA 90402; 310-393-0206; fax: 310-393-3426; e-mail: rsinsk@robertsinskey.com