Remembering the pioneering work and life of George O. Waring III

by Dan Z. Reinstein, MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO

George Oral Waring III, MD, FACS, FRCOphth, pioneering refractive surgeon and life enthusiast, died in January 2015 at the age of 73. His contribution to ophthalmology and particularly refractive surgery was only paralleled by his dedication to scientific publication and the relentless mentoring of successive generations of academic clinicians; Waring made a tremendous impact on ophthalmology worldwide. His vivacious spirit and genuine delight in the achievements of others left a mark on all who met him.

George Oral Waring III

George was born in Buffalo, New York, in 1941, son of G. Oral Waring Jr. and Mary Jane Fitzpatrick Waring. In 1959, he graduated from White Station High School in Memphis, Tennessee, and proceeded to obtain a liberal arts degree from Wheaton College in Illinois. His calling to become a doctor came later, and he gained a place at Baylor Medical College in Houston. Waring completed his ophthalmology residency at Wills Eye Hospital in Philadelphia and in 1973 proceeded to a corneal fellowship with Peter Laibson, MD. He developed a broad interest in corneal surgery and external disease, publishing in diverse areas including keratoplasty in children and corneal dystrophies.

Waring’s first academic position was as an assistant professor at the University of California, Davis. During his 5 years at UC Davis, Waring established the first eye bank of Northern California, the Sacramento Valley Lions Eye Bank.

When Dwight Cavanagh, MD, took the chair at the Department of Ophthalmology at Emory University School of Medicine in Atlanta, he headhunted and convinced Waring to leave Southern California and take up a position as associate professor in his department, where Cavanagh encouraged him to apply for an NIH grant to prospectively study the safety and efficacy of radial keratotomy (RK) — a procedure that had begun to spread to the American continent from Russia through a group of disciples of Fyodorov, despite strong objection and condemnation by the American Academy of Ophthalmology. As principal investigator of the NEI-funded Prospective Evaluation of Radial Keratotomy (PERK) study, Waring led probably the world’s first rigorous, large-scale, multicenter clinical trial in refractive surgery, which to this day continues to be recognized as one of the best organized, thorough and rigorously executed prospective long-term studies ever performed in this field. The PERK study produced a total of 29 papers and provided the definitive conclusion that RK produced a biphasic corneal biomechanical response: the initial intended instantaneous corneal flattening effect targeted to emmetropia but also an unexpected second biomechanically induced slow phase of long-term hyperopic progression. The study was also the first to chart the issues of diurnal refractive fluctuation as well as night vision problems. As well as running the trial, Waring simultaneously produced the definitive 545-page textbook on RK, albeit consigning this text to be obsolete almost on publication having demonstrated the drawbacks of RK, which gradually resulted in the demise of the popularity of RK. Waring served as tenured professor of ophthalmology and director of refractive surgery until 2004 and as adjunct professor emeritus until his passing.

During the 1980s, Waring was also involved in the early application of excimer lasers for corneal refractive surgery. His interest in excimer laser refractive surgery applications led to international temporary emigration, escaping the FDA restraints to rapid development, and in 1992, he received a National Institutes of Health Fogarty International Scholars Award to perform research in laser corneal surgery at Hotel-Dieu Hospital, Paris. From 1993 to 1995, he served as chairman of the Department of Ophthalmology and director of research at the Al-Magrabi Eye Hospital in Jeddah, Saudi Arabia, where he helped develop surgical techniques and protocols for LASIK. On his return to Atlanta, he applied for and was awarded the first ever physician-sponsored investigational device exemption from the FDA to study LASIK at Emory.

Along with Waring’s nearly unparalleled career in the field of refractive surgery, in 1989 he became editor-in-chief of the Journal of Refractive Surgery, a position that he occupied for 21 years until changes to the laws in the United States meant that a journal editor was required to have no financial conflict of interests. At the time, I wrote an article published in the JRS that discussed how this law, based on paranoia of bias, had denied the Journal his exceptional, dedicated service and his unbiased, balanced approach. Indeed, through his position as editor, he touched an innumerable body of new authors. He had an insatiable appetite for editing and perfecting manuscripts, going to extraordinary lengths in order to take manuscripts up to the best possible level scientifically — and grammatically. He had a natural ability to engage with authors in a polite and reasonable manner even when conveying strong criticism. This ability allowed him to turn bad papers into good ones and develop and maintain excellent relationships with the vast majority of people he dealt with. His perfectionism was demonstrated by the fact that he did not rely only on reviewers to spot problems with submitted papers. Before being published, he reviewed every single manuscript personally, which gave him an ever-widening range and depth of knowledge into all areas of refractive surgery. He also went out of his way to help authors whose first language was not English to revise their manuscripts, so that the Journal could reflect the best of international refractive surgery. This is demonstrated by the numbers: During his tenure, between 1990 and 2010, only 30% of papers were from American authors and a total of 62 different countries were represented. Waring’s efforts also helped many first-time authors achieve their goal of publishing a paper. Again, the numbers back this up, as the ratio of unique first authors to the total number of papers published was 0.62, indicating that only 38% of papers were authored by previous authors. It is uncanny the number of people who would say that they considered him to be their primary mentor, people from all over the globe. As he wrote in his parting editorial in 2010, editing the Journal was a labor of love: “Seeing authors improve their submissions to become more accurate, sophisticated and relevant, laboring with the editorial board and publishing staff, and gauging the annual improvement in the Journal’s quality all make each issue a joy for me.”

Similarly, he built excellent relationships with many editors and associate editors on the editorial boards of ophthalmology journals, demonstrated by his spearheading of the use of the standard graphs for reporting refractive surgery, which is now a required standard for all publications in the Journal of Refractive Surgery, the Journal of Cataract and Refractive Surgery and Cornea.

His skills as a communicator were exemplified in his back catalog of editorials, which often tackled controversial subjects and cut to the heart of the matter with fine prose and exquisite insight. He remains one of the paramount influencing minds in our field.

In total during his career, Waring published 259 peer-reviewed papers, as well as two textbooks on corneal refractive surgery, over a period of 40 years. On top of the subjects mentioned above, his papers ranged in topic from ocular findings in leprosy (1973), to the use of sulfur hexafluoride gas in the repair of intractable Descemet’s membrane detachment (1987) and preventing posterior capsule opacification (2011). He lectured and taught internationally, speaking at more than 600 ophthalmic meetings in more than 60 countries on six continents. He trained more than 60 fellows and received dozens of international awards in recognition of his excellence in ophthalmology, including two Lifetime Achievement Awards. The Waring Medal is awarded annually by the Journal of Refractive Surgery to a published author for editorial excellence; it is worth noting that this award was introduced while he was still alive, a rare accolade and confirmation of his standing in our field.

But there was so much more to him than his scientific record. To borrow from Robert Maloney’s eulogy at Waring’s memorial service:

“These accomplishments, though amazing, are not the reason his passing received so much attention. Many of the tributes recalled how unique George was. He was the only person we knew who would kayak to his wedding in a waterproof tuxedo. Who else would make a first ascent of a peak in Nepal, but only after he had his secretary hire a Sherpa to deliver his favorite granola to base camp? Better than anyone, he could explain the most complex topic simply. He had a Dictaphone surgically implanted in his left wrist. He could cram 18 hours of work and 12 hours of play into a single day. He offended people by speaking the truth about bad ideas. His eyes would twinkle when he said something provocative, inviting us to react. He slept in a sleeping bag in his office for days at a time so he could get more work done. He reached out with encouraging words for young investigators wherever he went in the world. He had glowing warmth for us, his friends. His infectious enthusiasm made ophthalmology the most exciting thing in the world when we came into his orbit. He drew us into that orbit with his radiant light.”

His life was not only ophthalmology. He was a passionate traveler, explorer and art collector. He pioneered the sport of whitewater kayaking, taking up the fringe sport in its infancy. He kayaked a multitude of rivers on several continents including the Sun Kosi in Nepal, but the apex of his descents was the Zambezi River in Zimbabwe, Africa. He played squash weekly and was an avid snow skier, taking annual heli-skiing trips in the Bugaboo Mountains of British Columbia. As a mountaineer, he completed the first ascent of the Kang Yaja (20,000 ft.) in the Nepalese Himalaya. He climbed the tallest peaks in South America and Africa, as well as several mountains in the European Alps. He became a Divemaster with the Professional Association of Dive Instructors. He also went on multiple African safaris by land, on rivers, in hot air balloons and on horseback. In 2001, Waring was inducted into the prestigious Explorers Club.

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