Richard P. Kratz, MD: defender, teacher of modern cataract surgery
Dr. Kratz helped change phacoemulsification and IOL implantation from pioneer procedures to the standard of care in cataract surgery.
Ophthalmologists entering the field today may not remember a time when phacoemulsification and IOL implantation were considered fringe procedures, possibly malpractice. Richard P. Kratz, MD, remembers. He was there when ophthalmology wanted to oust phacoemulsification and when the Food and Drug Administration wanted to stop IOL implantation. He fought, along with others, to prevent those things from happening.
In the course of defending the emerging technologies he believed in, Dr. Kratz, of Los Angeles, became a teacher of phacoemulsification and of IOL implantation, helping them to become standards of care in cataract surgery. Throughout his career, he has been a supporter and developer of many procedures and instruments in common use today.
Dr. Kratz came from a medical family. His mother was a physician, the only woman student at Stanford Medical School when she graduated. He says he remembers wanting to be an ophthalmologist before the age of 5. When asked what he wanted to be when he grew up, he replied without hesitation; he wanted to be able to heal the “sick eyes” he saw in his mother’s textbook, May’s Ophthalmology, which was the only book in their home that had color prints.
His early years in medicine continued his direction toward ophthalmology. Before he completed his residency, the U.S. Army assigned him to the Eye, Ear, Nose and Throat Service of their largest hospital in the Far East. He was an ophthalmologist not by training but because the Army said he was, Dr. Kratz said. He became chief of EENT at the U.S. Army General Hospital in Tokyo.
When he returned from the Far East in 1948 he continued his training in basic sciences at Moorfields Eye Hospital in London and completed a residency in ophthalmology at Duke University in 1951.
Early IOL exposure
Dr. Kratz was one of the early ophthalmologists to learn about IOL implantation. He had been a classmate of Peter Choyce at Moorfields and was taught by Sir Harold Ridley shortly before Sir Harold implanted the first IOL in 1950. Mr. Choyce went on to be an influential figure in the development and acceptance of IOLs.
Dr. Kratz remembers when cataract surgery involved a 180° section across the cornea.
“We got a lot of experience in treating wound leaks, flat anterior chambers and iris prolapses in those days. The anterior capsule was torn with a toothed instrument which was pushed into the flat anterior chamber, and the nucleus was squeezed from the eye by a squint hook scraped across the cornea. We had no concept of the delicate nature of the endothelium,” he said.
Modern cataract surgery began, Dr. Kratz said, when Charles Kelman, MD, taught his first classes in phacoemulsification in 1971. IOL implantation was rare before 1974. Few had adopted these procedures by the mid-1970s. Generally there was little training in either procedure, and neither was recognized by mainstream ophthalmology, Dr. Kratz said.
Phaco was dismissed by most in the early 1970s. The learning curve was said to be too great. Despite this, the procedure was gaining popularity because it could be done on an outpatient basis, rather than requiring a hospital stay of 5 days.
“Some of the academic ophthalmologists wanted to get rid of phaco. So did those who were starting to lose patients to the ophthalmologists who were doing phaco. They falsely reported that there was a lot of damage, and that vision would lost in an ophthalmologist’s first 50 phaco cases. They warned of all sorts of horrible complications that really weren’t true,” Dr. Kratz said.
The naysayers had enough clout to stop others from practicing phaco. In 1973, phaco was declared experimental and therefore not payable by Medicare. Since most candidates for phaco were covered by Medicare, this effectively shut down the procedure, Dr. Kratz said.
On the eve of the American Academy of Ophthalmology meeting that year, a group of 12 ophthalmologists met in support of phaco for what they called the “midnight breakfast,” Dr. Kratz said.
“Many people wanted to get rid of Kelman’s procedure and cited all kinds of complications. We met to discuss what could be done about phaco,” he said.
We decided to keep performing phaco but to convert to an intracapsular extraction at the end of the procedure by removing the capsule using the enzyme alpha-chymotrypsin. When placed into the anterior chamber, the enzyme loosened the zonules attached to the capsule and allowed the surgeon to remove the bag, he said. This changed the phaco into a reimbursable ICCE procedure, though it was done through a 3-mm incision instead of the standard 18-mm incision.
The AAO subsequently formed a committee to examine the validity of phaco. They found that results with phaco were statistically equal to results using intracapsular extraction, and shortly phaco was reinstated as a payable procedure by Medicare, Dr. Kratz said.
“However, the hostility to phaco did not cease, particularly as newspaper articles hailed the new advances, and some prominent cataract surgeons discovered that they were losing patients to phaco surgeons. This brought on a revival of planned extracapsular surgery, only modernizing it by copying all of the features of phaco except not using ultrasound,” Dr. Kratz said.
Full acceptance of phaco by the ophthalmic community took nearly 2 more decades, said William F. Maloney, MD, a former fellow of Dr. Kratz, now a well-known teacher and the Cataract/IOL Section Editor of Ocular Surgery News.
“The resistance remained for many years after I learned it. Though phaco had been with us since 1967, it languished for almost 20 years until 1987. The cause for the explosion at that time I think was the small incision and the foldable lens developed by Thomas Mazzocco, who was Dr. Kratz’ partner in practice. Before that, phaco’s small incision really couldn’t be exploited since it had to be enlarged for the rigid PMMA lenses,” Dr. Maloney explained.
Dr. Kratz said that midnight breakfast committee crossed the first hurdle in modernizing cataract surgery.
At the same time phaco was battling for acceptance, IOLs were also drawing the disfavor of academic ophthalmology and others. Many ophthalmologists believed IOLs were too risky, and complications with the early implants seemed to prove them right. The term “intraocular time bomb” was often applied to IOLs.
The first implants by Sir Harold were large, heavy lenses that frequently became dislocated in the posterior chamber. Those implants often had to be removed and were seldom replaced. Other early IOLs were sometimes poorly designed or manufactured. They at times became dislocated or were associated with other complications.
However, supporters of the technology persevered. Courses taught by Drs. Cornelius D. Binkhorst and Jan Worst in the Netherlands drew interested ophthalmologists from many countries. Among them were Drs. Kratz and Mazzocco.
“We got to see Binkhorst and Worst do surgery, and it became obvious that this was going to be very popular in the U.S.,” he said.
Once again, Dr. Kratz became a leader in adopting and defending this technology.
“What turned it around was that we began seeing U.S. surgeons like Hirschman, Shepherd and Jaffe get good results with IOLs. Since it was something I had always wanted to do, my partner Tom Mazzocco and I started putting in IOLs in 1974,” Dr. Kratz said.
In 1975, the California Food and Drug Administration declared IOLs a drug and thus under their jurisdiction. (Like the U.S. FDA at the time, the state agency had no authority over medical devices.) Again, this made the technology unpaid by Medicare, though only in that state. Implantation of IOLs was also declared experimental and subject to malpractice in California, Dr. Kratz said.
Although California was the only state where IOLs were unpaid by Medicare, it was also the state where most of the world’s IOLs were manufactured, and the ruling affected distribution of IOLs to other states.
“The manufacturers received an opinion from their legal advisers that an IOL was not really an IOL until it was sterilized. They got around the Medicare problem by manufacturing and assembling the lenses in their California facilities and then having them sterilized and distributed from Las Vegas,” Dr. Kratz explained.
But this strategy did not help the California ophthalmologists. Dr. Kratz said they were affected by the ruling for about 6 weeks that year. The American Intraocular Implant Society helped to obtain a court injunction against the ruling, and then IOLs could once again be reimbursed in California.
Nader and Wolfe vs. Welby
Subsequently the U.S. FDA also declared IOLs a drug, and thus under their jurisdiction. Ophthalmologists were required to report all adverse events involving IOLs to the FDA. These adverse event reports were used in another effort to stop the use of IOLs, this time nationally.
In 1980, Sydney Wolfe, MD, an associate of consumer advocate Ralph Nader in the group Public Citizen, testified at an FDA hearing investigating the safety and efficacy of IOLs.
“Dr. Wolfe added up all of the even minor adverse reactions and divided them by the number of cases done, and he incorrectly concluded that the incidence of problems was over 50%. He insisted on a hearing by the FDA,” Dr. Kratz said.
Dr. Kratz was among the surgeons attending the hearing in defense of IOLs. He and other U.S. ophthalmologists brought forth three witnesses to testify about the efficacy of IOLs.
The first witness was a doctor who said that without IOLs he could not have continued practice. A second witness, an airline pilot, testified that he would not be able to fly with the thick glasses that would have been given to him if he did not have IOLs implanted.
But the third witness is the one who gets the credit for changing everything. The testimony given by Robert Young, actor and patient of Dr. Kratz, is said to have saved IOLs from extinction and put them on the road to acceptance by ophthalmology.
The popular actor – best known at the time as TV’s “Marcus Welby, MD,” and before that as the father who knew best on “Father Knows Best” – “was really quite blind before I did bilateral cataract surgery and inserted IOLs in him,” he said.
The actor had sought out Dr. Kratz at his Los Angeles practice in 1976, and had received IOL implants before the Medicare ruling. Mr. Young testified about how poor his vision had been and how it had affected his career.
Dr. Kratz recalled that when Mr. Young left the hearing room, there was a crowd of reporters waiting to interview him. When asked about his testimony, Mr. Young grabbed a reporter by the tie and said, “Let me tell you, IOLs saved my career, and they should be available to all Americans.”
Dr. Kratz said the evening news coverage of the event most likely convinced Congress of the worth of IOLs.
“Even though the FDA had already made up its mind to ban IOLs, Congress sent a mandate to the FDA to make IOLs available again,” Dr. Kratz said.
Mr. Young’s testimony helped to cross the second hurdle in the making of modern cataract surgery, Dr. Kratz said.
Teacher of modern cataract surgery
In the midst of the controversy over phaco and IOLs, Dr. Kratz became a teacher of both technologies. He had already been teaching at the University of Southern California when he was approached in 1972 by Robert Sinskey, MD, a classmate from Duke who wanted the two of them to teach phaco together.
“The original phaco courses were taught by Kelman beginning in 1971. He taught a class of six once a month, but not every month. It was obvious that phaco would go nowhere because he wasn’t reaching enough people,” Dr. Kratz said.
Drs. Sinskey and Kratz began teaching 25 students a month. Their phaco courses from 1972 to 1980 helped spread the technology to many surgeons, Dr. Kratz said.
Since then, numerous ophthalmologists from around the world have sought out Drs. Sinskey and Kratz for their teaching. Dr. Maloney was one. He persuaded Dr. Kratz to take him on as a fellow.
“I remember trying to contact him for maybe 6 months, and each time he politely said, ‘no,’ probably because he hadn’t been set up to have a fellow. I’m not exactly sure why he changed his mind, but I’m glad he did because it allowed me to get the training necessary to be on the leading edge as all of these changes unfolded,” Dr. Maloney said.
He called Dr. Kratz a major figure in the evolution of modern cataract surgery.
“A lot of impetus and encouragement came from men like him who saw phaco’s potential and where cataract surgery could go and were persistent enough to make sure it happened,” Dr. Maloney said.
Dr. Kratz’s devotion to ophthalmology has also had an influence on his family. He is a father of seven, and two of his sons, Richard and Alan, have become ophthalmologists. His daughter, Katherine Owens, is involved in corneal research. His wife Carmen was his office administrator for 25 years. He has 15 grandchildren.
Still going strong
Although Dr. Kratz has been retired for 12 years, he maintains a presence in ophthalmology and continues to support new technology in which he believes.
He is a medical adviser for rotary vortex emulsification, in development by NeoMedix and Bausch & Lomb, a rotary device that grinds the nucleus through a 1-mm capsular opening. It is hoped the device will enable the surgeon to remove the contents of the capsular bag and refill it with a flexible material to restore accommodation.
He is also a supporter of viscocanalostomy as an alternative to trabeculectomy for lowering intraocular pressure in patients with glaucoma. Viscocanalostomy, developed by Robert Stegmann, MD, of South Africa, is a relatively new surgical procedure that restores the circulation of aqueous from the anterior chamber into Schlemm’s canal.
“Cataract surgeons do a lot of glaucoma surgery and are quite good at taking on new procedures. Working with Dr. Stegmann and Jack Kearney of New York, we set up a teaching program at the American Society of Cataract and Refractive Surgery and presented viscocanalostomy as an alternative to trabeculectomy,” Dr. Kratz said.
Acceptance of viscocanalostomy may allow surgical treatment of glaucoma earlier in the disease process instead of saving surgery as a last resource, he said.
He and Paul Honan, MD, and others have developed an active interest in alternative medicine, and they brought a course on “energy medicine” to ASCRS for the first time this year in Philadelphia.
These are some of the projects that have kept Dr. Kratz from fully retiring. However, he does enjoy his retirement in other ways. Nearly every year he and his wife take a motor home trip to some part of the country. He called his trips “escaping from the phone.” Fishing in Alaska is a favorite pastime, as is bridge.
In the past, he said, he enjoyed hobbies as diverse as scuba diving, sailing, power boating, off-road motorcycling and dune-buggying. At age 82 he has had to lay these more strenuous pastimes aside.
“I haven’t changed, even though I retired, Dr. Kratz said. “My wife says that I haven’t really retired because I’m still working. When I told her that I’m retired because I’m doing what I want, she said in that case you’ve been retired all your life.”
For Your Information:
- Richard P. Kratz, MD, can be reached at 1280 Bison Avenue, Suite B9, Newport Beach, CA 92660-4204; (949) 759-1829; fax: (949) 759-3634; e-mail: email@example.com.
- William F. Maloney, MD, can be reached at 2023 West Vista Way, Suite A, Vista, CA 92083; (760) 941-1400; fax: (760) 941-9643; e-mail: firstname.lastname@example.org.