One on One with Peter Choyce

In the second part of our series on IOL history, Mr. Choyce tells how he pursued anterior chamber lens development despite Duke-Elder's strenuous opposition.

Ocular Surgery News: You mentioned that Harold Ridley had a very influential opponent to his IOL work, Sir Stewart Duke-Elder. I understand that Duke-Elder also blocked your career because of your association with Ridley.

---Peter Choyce

D. Peter Choyce: Well, I will tell you about Duke-Elder. I think it is very important that this be told.

Duke-Elder was very interested in ophthalmic research. He used to wander in and out of the department of physiology at the University of London because he had ideas about the causation of glaucoma, which he thought was due to swelling of the vitreous, and he had various experiments going on in the department in 1948. I used to go to the department of physiology to do work on cornea. I was doing transplants using bits of rabbit cornea and putting them into cats’ eyes and that sort of thing, seeing if it worked or not. Some of them did and some of them didn’t, as you would expect. Anyway, Duke-Elder and I became quite friendly there.

The Institute of Ophthalmology was set up in November 1948. It replaced the Central London Eye Hospital [CLEH] in Judd Street when the CLEH, the Westminster Eye Hospital and Moorfields Eye Hospital were merged under one board of management. Duke-Elder was located in the Institute of Ophthalmology, which was entirely devoted to research — his responsibility — and teaching — the dean’s responsibility. No patients were seen there and no surgery was performed.

I took the diploma in ophthalmic medicine and surgery at the Institute in the summer of 1949, and on the first of July, I moved up from being an outpatient officer with Ridley to becoming a resident at Moorfields, a 2-year appointment.

I continued the work I was doing on the cornea at the Institute, which of course was subject to the approval of Duke-Elder, who was the director of research. He was quite pleased that I should be doing this and we were really quite friendly. Indeed, there were those who accused me of being too friendly with Duke-Elder, of cultivating him.

Once the Institute had been set up, all the consultants became honorary lecturers. Duke-Elder’s grumble with Ridley was that as an honorary lecturer to the Institute of Ophthalmology, of which Duke-Elder was director of research, Ridley should have told him what he was doing with his lens work. They had a major row about that, in which Ridley virtually told Duke-Elder that he saw no reason why he had to tell him what he was doing, either now or in the future.

Duke-Elder did not take kindly to that. He did everything that he could to get Ridley to stop doing his work. When he failed, he stirred up as much trouble as he could. It’s a great sadness to me that Duke-Elder, who was such a brilliant man, such a wonderful writer, had this intellectual blind spot where lens implantation was concerned. He allowed his personal dislike of Ridley to block out that part of his brain. Such a pity.

I remember Duke-Elder kept on asking me about Ridley. He stopped me on the stairs once at the Institute of Ophthalmology in 1951 and said, “What do you think of Ridley’s work?” I told him I thought that we hadn’t quite got there yet but that this is the way things are going to be in the future. “I disagree, I disagree,” he said, and off he went.

A few weeks later another conversation took place. “Are you still convinced that Ridley is on the right track?” he asked. “Yes, I think so,” I said. “Well, Peter,” he said, “I think you are making a great mistake. I have always thought very highly of you and it pains me to see a young man, for whom I have such high hopes, chasing at windmills. I think you should find something else to concentrate on.”

The third and last conversation that took place was, “Did you think about what I said to you the other day?” I told him I still felt that in the fullness of time implants are the way it is going to be and that I wanted to be a part of that process. He said, “I’m sorry to hear you say that. I’m sorry to tell you, furthermore, that if that is your final opinion, I can no longer help you with your career.”

Which meant that he was going to oppose it. And he did.

In 1952, the year I wanted to become a consultant to my teaching hospital, University College Hospital, I didn’t get that job. And I discovered afterward that he had intervened behind the scenes. The same thing happened over at Guys’ Hospital and at Edinburgh, and by that time I got the message. I was not going to get a teaching hospital appointment. I did get the Hospital for Tropical Diseases, which was rather different. I didn’t have undergraduate students to teach there, only postgraduate ones in tropical ophthalmology, which I enjoyed.

In 1962, I had written a thesis for the degree of Master of Surgery at the University of London, which is the highest degree in surgery that the University has to offer. My highest degree at that time, the FRCS, was in general surgery. I did not have a higher degree in ophthalmology — at that time there was no FRCS in ophthalmology, that came about in 1950 — and people used to tease me about it, not always kindly. So I thought, I’ll show them, I’ll get the MS.

So I wrote this thesis with great pains and great care and I showed it to Ridley, who thought it was excellent. And I showed it to the representative of ophthalmology at the Royal College of Surgeons, who thought it was excellent. So I bounded into the University of London for an interview in which this thesis was to be examined. Whom do you suppose they appointed to examine it?

OSN: Your old friend?

Mr. Choyce: My old friend. I was summoned by Duke-Elder to the Institute of Ophthalmology for the thesis to be examined in the presence of a general surgeon.

The general surgeon, from Middlesex Hospital, said that he had had a good look at it, and although he was not an ophthalmologist, as far as he was concerned it complied with the criteria laid down by the Higher Degrees Committee of the University of London. But he added that he was only a general surgeon.

Then Duke-Elder launched into severe criticism. He never addressed himself to the message of the thesis, which was the development and uses of anterior chamber lens implants in ophthalmic surgery. All he did was to nit-pick and complain about lower case letters when I should have used upper case capitals and things like that.

At one point he got so impassioned that the thesis was knocked over and fell off his desk into the wastepaper basket, which I thought was symbolic.

I was absolutely furious and couldn’t believe it. Armed with Ridley’s report that the thesis had satisfied him, and with a report from Mr. Keith Lyle, who was the Dean at the Institute of Ophthalmology at the time, that it satisfied his requirements, I went off to see the academic registrar at the University of London. I complained bitterly about how Duke-Elder had acted, that I didn’t think the interview was properly conducted, that we never discussed the subject of the thesis, and I was very unhappy indeed.

He told me he was not surprised that I came to see him because he had a report from the other examiner who had been present throughout Duke-Elder’s tirade, and he had expressed reservations about the way Duke-Elder had spoken to me. The registrar took the matter up with the Higher Degrees Committee and I got a letter saying that I could resubmit the thesis in 1 year’s time provided it contained some new material.

So I did that, and the new material covered the use of anterior chamber implants with tinted opaque haptics to fill in gaps in the iris, to treat albinos and so on. It also referred to the correction of unilateral and binocular myopia, the use of implants as the proximal component of a Galilean telescope system for improving central vision in cases of localized macular degeneration, and the use of an anterior chamber implant preliminary to the treatment of aphakic retinal detachment. Many of these innovations have been reinvented since, which amuses me. Very rarely does anyone refer to my getting there first. But never mind.

I submitted the thesis and two specialist examiners were appointed, one the Dean of the Institute of Ophthalmology, who had looked at it in the first place, and the other the senior surgeon in Edinburgh, whom I didn’t know at all. They both passed it, but to make doubly sure, they sent the thesis along with their reports to Duke-Elder. He sent it back without comment, and I was duly given the degree of Master of Surgery at the University of London.

A chap who lived down my way who had heard of my work — most people had at Southend by then — was a director at H.K. Lewis medical book publishers. He suggested turning that thesis into a book, which was duly published in 1964. [Editor’s note: See below for information on obtaining a copy of this book, which has been out of print until recently.]

OSN: Your thesis was based on the anterior chamber lens concepts inspired by your visit with Strampelli. I don’t think he was very well known or is remembered very well today outside of Italy. What was he like?

Mr. Choyce: Well, he was a very attractive man, tall, impressive looking. A flamboyant Italian. He had a very, very charming wife. Senora Strampelli’s hobby was skiing. I’m sorry to say that somewhere around the time he should have become president of the International Intraocular Implant Club (IIIC) in 1972, his wife was off skiing and she fell down a crevasse and was never found again. That really upset him because he was very devoted to her. He had two daughters who looked after him very carefully. He lived until he was about 85.

When I went to see him, he was very hospitable. I remember that as the operating session proceeded, he got more and more excited. When we finished at about midday, we went into his office and he snapped his fingers and they produced a bottle of spumante from out of the fridge. The spumante was opened, the biscuits and cheese were produced and we polished that off. It was a great occasion.

The problem was communicating with him because he really didn’t speak any English and I didn’t speak Italian to any noticeable extent. But we managed to communicate in O-level French. So we managed.

He retreated from his original tripod, noncompressible, fixed length implant and started doing external fixation implants in which the optic was suspended by a couple of Supramid loops that he brought out through the sclera. So external fixation implants are nothing new. He invented those in 1960. I went back to see him a second time and then I saw one of them being put in. Remember, he was only treating monocular aphakes as a secondary procedure. Very wise.

But he was badly treated by his profession. Very badly treated.

OSN: Other than Strampelli, who else did you know of in the late 1950s who was doing IOL work?

Mr. Choyce: Well, Cornelius Binkhorst came to Rayner around 1957 and asked them to make his iris clip lenses. For various reasons they made the great mistake of turning him down. They didn’t consult me, or Ridley either, so far as I know. So he went back to Holland and spoke to various opticians. Morcher — the sort of German equivalent of Rayner if you like, a high-class firm with high standards of precision optical engineering — agreed to make these lenses for him. Eventually, when the iris clip lens appeared to have quite a following, Rayner did make iris clip lenses so that those in the United Kingdom who wanted them were able to get them. I never used them myself.

I had gone to Terneuzen and watched Binkhorst operate. Beautiful surgeon. And I saw a number of his postoperative cases. Beautiful. But I didn’t like the iridodonesis that went on.

If you did an intracapsular operation, and the ones I saw were all intracapsulars, there was this four-loop lens being supported by the iris, and when the patient looked around, the whole thing would vibrate. I thought, no, over a period of years this isn’t going to be stable. I don’t like this form of fixation.

So I stayed with my anterior chamber implants and was glad that I did. Binkhorst himself came to realize that iris fixation had no long-term future, and after about 10 years, he moved backward and became an extracapsular surgeon. He put his lenses with their little loops into the capsular bag.

OSN: So you were continuing with the anterior chamber approach you started after visiting Strampelli.

Mr. Choyce: Yes. As I said, the original Strampelli tripod lens was too thick, too steeply curved. Although it’s easy enough to put in, and I got some very good results if the anterior chamber was really deep, I did have, after a few years, some incipient cases of pseudophakic bullous keratopathy, or PBK. Taking out the lens was easy enough, but it didn’t stop the PBK. In fact, probably the best thing to do with a PBK was to do a penetrating corneal graft. Then you bought some time.

But that wasn’t the solution. The solution had to be modifying the implant so that you didn’t get corneal touch or implant rotation.

So, eventually, with the help of Rayner, we got a good design. Of course, whenever I went to them asking if we could make a modification, they started off by saying, “No, it isn’t possible.” But then they’d ring up a fortnight later and say, “Why don’t you meet us for dinner? We think we have this licked.”

We brought down the thickness of the haptic from 1 mm to 0.5 mm to 0.25 mm. Then I said I wanted 2 mm of the footplate to be flat. “It can’t be done.” A fortnight later, “Come and have dinner.” And then I said, “What about a four foot-plate lens?” They said they would have to rejig all the machinery and it would be very expensive. I said they could charge more for the implants. They only charged three guineas, about $10, for the original implants. So they made the change, and I was convinced we got it right that time.

And now we come to a big disappointment. I knew we had a winner, and I said I thought we should protect this design by patenting it. “Oh, no,” they said. “This is for the benefit of humanity.” I said that sooner or later other people, probably the Americans, are going to get hold of this idea. If it is not protected by patent law, they are going to cut all sorts of corners and make implants that are not a proper copy. Which is precisely what happened.

Iolab made a lens using a different type of PMMA and a process of injection molding, not compression molding, they didn’t take proper care over the edge finishing and so on. Introduced into the eye, it caused the uveitis-glaucoma-hyphema or UGH syndrome. This has all been suitably documented. It really turned a lot of people off of a perfectly good implant.

OSN: But there was a variation on your design that became very popular in the United States?

Mr. Choyce: Yes, the Tennant lens. Although Dr. Jerald Tennant took my design, made a minuscule change in it — he provided a planoconvex optic instead of a biconvex optic — and patented it, I don’t object to the Tennant lens because it was a perfectly good lens. I think several hundred thousand were put in, and the surgeons who used it had no complaints about it. Probably half a million or more Tennant lenses were implanted, and about half a million Choyce Mark VIIIs were put in around the same time, some of them manufactured by Rayner and a great many more manufactured by our licensee in America, Coburn.

I did patent, in 1977, the Mark IX. I knew I had to modify the Mark VIII a little bit because the only problem was the tendency of the iris to bulge. Even if you had done a peripheral iridectomy, if there were any sort of goniosynechiae present, there was a tendency of the iris to bulge.

The Mark IX is much narrower and has a couple of holes in the haptic portion that allow the circulation of aqueous during the immediate postoperative phase. So this bulging was pretty well eliminated. I don’t think I ever had any cases of it — maybe one.

I think, in round figures, I inserted 2,000 or 3,000 Mark VIII lenses and a similar number of Mark IX, say 5,000 all together. And I inserted 500 secondary anterior chamber implants before I ever did any primaries.

A great many Mark IX lenses were sold until they stopped making them around 1992 or 1993. I did get paid some royalties for the Mark IX. Well, a very, very modest amount compared with what other people have made.

OSN: Tell me about the founding of the IIIC in 1966.

Mr. Choyce: It took about a year for me to convince Ridley that we must have our own scientific society. He said that we must have a club and not a society. He also insisted that it was not enough to invite people along for anecdotal reasons; we had to invite people who had published work.

The IIIC was eventually formed on the lines of the Gonin Club, which was set up in the 1930s to bring together people with an interest in retinal detachment. You see, what Ridley did with his cataract treatment in the 1950s mirrored what Jules Gonin did in the 1920s with retinal detachment.

OSN: How so?

Mr. Choyce: Well, before Jules Gonin, there was no real treatment for detachment of the retina. The only treatment consisted of sending them to bed for about 6 weeks with their head positioned in a certain way in the hope that the retinal tear would adhere to the choroid underneath.

But Jules Gonin thought, well, this won’t do. In the 1920s, he decided that the two things you needed to do were to create a cautery burn on the outside of the eye overlying the tear and at the same time plunge a hot needle through the middle of the cautery to drain out the subretinal fluid. Then the retina would go back on the heated, cauterized area and become stuck. That was his basic treatment, subject to numerous modifications.

Jules Gonin was hotly attacked by the rest of the profession until eventually he successfully treated some member of one of Europe’s royal families for retinal detachment. That did the trick. Then like-minded people founded the Gonin Club.

OSN: Who were the founding members, and what work were they doing that led to their invitation?

Mr. Choyce: Well, obviously there was Strampelli. I also was reading the literature and I knew all about Binkhorst’s work. Although, as I said, I had visited him and I personally doubted the long-term capabilities of the iris clip lens, I knew it was a perfectly valid way to go and he had written some very thoughtful papers. We also knew that Binkhorst had gotten on the wrong side of the very conservative Dutch ophthalmic establishment. We had Edward Epstein in South Africa, another thoroughly unpopular member of the profession. He was expelled from his teaching hospital in Johannesburg, but still a very good surgeon, getting very good results and writing good papers.

There was Michael Roper-Hall in Birmingham and Neil Dallas in Bristol. They were both using iris clip lenses. Sandy Brown also was at the Bristol Eye Hospital, but I think he used Choyce lenses. There was Leonard Lurie in London and Alexander Rubinstein in Birmingham who used mine. And that was about it from this country. I was very much in the hands of Harold over which Americans were to be invited. He said, “Oh, we must have Warren Reese.” In 1952, Ridley had gone to America and the first group he addressed was the Chicago Ophthalmological Society. This was about 6 months before Ridley went back to Chicago and spoke at the American Academy of Ophthalmology. He took 10 of his lenses with him and gave them to Warren Reese, who went home and started implanting them. Anyway, I phoned Warren Reese and he said he would come.

Jörn Boberg-Ans was another very fine and thoughtful surgeon in Denmark. He had published papers and Rayner had made lenses for him, so I invited him. He made several modifications to anterior chamber implants that were illustrated in my book. Boberg-Ans was very personable but very unpopular with the Danish ophthalmic establishment because he was so outspoken — a Danish Fyodorov or a Danish Epstein, if you like!

The story of Svyatoslav Fyodorov is an interesting one. There was a publication called Ophthalmic Literature, in which ophthalmic literature from all around the world was reviewed by people who spoke the appropriate language. In those days, if you took out a subscription to the British Journal of Ophthalmology, which was edited by Duke-Elder in those days, you automatically got Ophthalmic Literature.

I read a lot of abstracts of papers published by Fyodorov in which he talked about his version of the iris clip lens. He called it the Sputnik because it had these prongs to help improve its fixation.

Fyodorov was in Archangel, a remote outpost of the Soviet empire. I knew a chap in the Soviet Embassy there, and he made some inquiries of the Russian ophthalmic establishment. Fyodorov was a typical implant pioneer in that he was a rebel, a maverick and an outcast, if you like.

We thought the afternoon of July 14, 1966 was about right. It was the end of the Oxford Congress, you see, which ended at lunchtime on that particular day. So we knew these people would be in the United Kingdom anyway.

So I wrote off to these various people, including Fyodorov — not at all expecting that he would turn up, but he did. He was flanked by a couple of KGB minders, who drank themselves silly in the Royal Society of Medicine bar while our meeting was going on upstairs. He didn’t speak any English at that time, but he presented a paper after a fashion. We all presented papers on what we were doing and then we went and had a buffet supper.

OSN: Looking back, what stands out most in your mind about those early days of IOL development?

Mr. Choyce: I think that I was extremely lucky to be in the right place at the right time with the right qualifications to appreciate the importance of what Ridley was doing in 1949 and 1950. I knew just enough about ophthalmology at that time to see the scientific logic and the humanitarian logic of what he was doing, but I hadn’t been in ophthalmology long enough to realize the dangers of what he was doing.

If I had been further advanced and had done a lot of cataract surgery myself, which was not the case, I would very possibly have aligned myself with those who were opposed to him. But because I worked so closely with him and saw his own results, I thought this has got to be right in the long term. So I backed him every inch of the way.

Of course, the science and art of public relations were virtually nonexistent then. If ever an initiative needed a competent PR person, this had to be it. Unfortunately, it wasn’t available.

Next time: An intraocular lens movement blossoms in America and the Choyce Mark IX becomes the first FDA-approved IOL.

First IOL book available again The book that Peter Choyce wrote based on his earliest IOL work, Intra-Ocular Lenses and Implants, is now available again after being out of print for several years. First published in 1964, this book includes many color photographs of early intraocular lens implants and implant surgery. It documents the work done on IOLs in the 1950s and early 1960s and also includes chapters on Mr. Choyce’s groundbreaking work on Galilean telescope systems, opaque implants for aniridia and external fixation of lens implants. The book is being made available through Rayner Intraocular Lenses, the British company that made the first IOLs used by Harold Ridley and Peter Choyce. Interested parties can call 011-44-1273-205401 or fax 011-044-1273-324623 to inquire about price and shipment.

The Intra-Ocular Implant Club (now the International Intraocular Implant Club, or IIIC) first met on July 14, 1966. Although the group portrait taken that day is reprinted often, it is usually without a detailed description of the people shown. Positioned front and center, straight-backed and dominant, is Harold Ridley. Appropriately seated at his right hand is Peter Choyce, Ridley’s protégé from Moorfields. Flanking them are (to Choyce’s right) Cornelius Binkhorst, who was to become the godfather of an IOL renaissance in America just a year after this photo was taken; Benedetto Strampelli (to Ridley’s left), whose colleagues in Italy opposed him so violently that a planned IIIC meeting in Italy as late as 1970 would have to be canceled; and Edward Epstein (next to Strampelli), who was already writing letters to Dow Corning asking if a soft IOL could not be made from Silastic. At either end of the first row sit Jörn Boberg-Ans and his wife, remembered for the way she charmed some of the Club members who wondered aloud what she was doing there. In the back row are the statuesque Neil Dallas (directly behind Ridley) and C.A. Brown (to Dallas’ left) with their fellow Englishman Alexander Rubenstein (next to Brown). Continuing down the row we come to the only American member of the Club, the bow-tied Warren Reese of Wills Eye Hospital, who was the first American to report on IOL implantation. Next to him at the end of the row is Leonard Lurie, just about the only other London ophthalmologist who was using IOLs at the time. The young man with the brush-cut hair (standing just over Choyce’s shoulder) is Svyatoslav Fyodorov, who spoke no English at the time but soon learned. Next to him is Michael Roper-Hall, another English surgeon who challenged the conventional wisdom and followed Ridley’s lead. Beside Roper-Hall is Reese’s friend Robert Murto, not a member of the Club but a guest at this first meeting. And at the far left, looking a bit self-conscious, is John Pike. He was not an ophthalmologist but the optical scientist at Rayner who collaborated with Ridley on many of his projects. Long-time Rayner employees remember that despite the obvious warmth between the two men who had survived so many battles together, they remained “Mr. Pike” and “Mr. Ridley” to each other in every conversation. — Joseph Hoffman, Editor in Chief