|Year : 2021 | Volume
| Issue : 3 | Page : 365-369
Dr. Charles Kelman: The Saxophone Player In Ophthalmologist's Mask
C Biju John
Department of Ophthalmology, Regional Institute of Ophthalmology, Government Medical College, Thiruvananthapuram, Kerala, India
|Date of Submission||19-Sep-2021|
|Date of Acceptance||20-Sep-2021|
|Date of Web Publication||08-Dec-2021|
Dr. C Biju John
Department of Ophthalmology, Regional Institute of Ophthalmology, Government Medical College, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
John C B. Dr. Charles Kelman: The Saxophone Player In Ophthalmologist's Mask. Kerala J Ophthalmol 2021;33:365-9
Can music attract medicine graduates to pursue a career in ophthalmology? Well, there is a famous American ophthalmologist who will vehemently say yes to that. He would also tell you that it is not because there is anything musical about ophthalmology, but just because it would give him the most flexible hours leaving him lots of free time to pursue his true passion which was music. All he wanted in life was to be a great musician and saxophone player. He just wanted to be that star on the stage playing to the audience and basking in the applause. But fate had other plans for him. As a teenager, he was caught red-handed by his father at 2.00 a. m. in the night with his beloved sax in hand trying to run away from home so as to join Louis Prima's band. Taking the saxophone away from the 16-year-old, his father said: “You can be a singer, you can be a composer, you can be a songwriter, you can play with bands, you can do whatever you want. However, first you will be a doctor.” The boy did exactly that. With his head full of music and sax in hand, he joined medical school with the intention to make it a side story, while he pursued his true passion. However, the affliction of his father with cancer and subsequent death from it spurred him on, and he graduated in time. After graduation when it was time to choose a specialty, he chose ophthalmology for the sole reason already mentioned. It proved to be the right decision for him as he could spend hours and hours writing and rehearsing pop songs. The young doctor struck gold when he approached Chancellor records with a pop song written and sung by him. The studio head liked it so much so that the young man was allowed to record the song himself. Nervous about the reaction from his colleagues, he recorded under a false name, Kerry Adams. Kerry Adams shot to fame as the song (Telephone Numbers) became a box office hit. He was elated. His life's dream had come true, and his career was made. Music and entertainment would be his life with medicine playing the sidekick. However, it was not to be. The musical taste of the world changed, and people embraced the new musical sensation which was “The twist” by Chubby checker. Kerry Adams was soon forgotten and thus suffered a premature death at the hands of Chubby Checker. However, out of the ashes arose the man who gifted ophthalmology, one of its most loved invention, one which was a box office hit as far as ophthalmology was concerned and earned him the title “Ophthalmologist of the Century.”
This is the fascinating story of Charles D Kelman who gave us phacoemulsification.
| The Kelman Cryo Stylet|| |
Charles D. Kelman, MD — Charlie [Figure 1] to all those who knew him was born on May 23, 1930 to Eva and David Kelman in Brooklyn New York. He graduated in medicine from the University of Geneva in Switzerland in 1956 and after that joined Wills Eye Hospital in Philadelphia for residency. It was during the residency that he achieved fleeting fame and glory as Kerry Adams. But when that ended suddenly, the disappointed Charlie turned his attention to Ophthalmology. He started his private practice as an Ophthalmologist in 1960. But Charlie as Kerry Adams had tasted something wonderful and exhilarating-the heady feeling brought in by fame, recognition, and audience applause. He now wanted the same from ophthalmology and began brainstorming with several ideas. In July 1962, an article about Irving S Cooper and his cryoprobe use in brain Surgery appeared in the “Look” magazine, which he was subscribing to. He was hooked on to that. Dr. Kelman knew exactly how he wanted to use the cryoprobe in Ophthalmology. He needed to get into that lab and work on those ideas. Cooper who initially ignored the letters and phone calls from Dr. Kelman finally had to yield to the perseverance of the young ophthalmologist who showed up in his office uninvited and literally begged to be allowed the use of his lab couple of times a week. Working on cat's eyes the innovative Dr. Kelman soon found out that he could use the cryoprobe to extract out the lens easily and atraumatically. The jubilant innovator named his invention the “ Kelman Cryo stylet.” However, before he could take credit for the same, two other ophthalmologists already came out with publications on the method. Worse was to follow when Cooper, sensing potential of the cryoprobe, decided to expand on it and appointed a better-known doctor for the program at the expense of Charles Kelman. Charlie was devastated. It was like Chubby Checker happening again.
| The Idea|| |
Dr. Kelman was not somebody who would accept defeat easily. He became more determined. The incident however made him paranoid about people trying to steal his research and probably resulted in him being too secretive about all his further research. He decided to apply for a grant from the John A. Hartford Foundation for further studies in cryo, specifically on the effects of freezing on the ciliary body, retina, and the choroid. Having filled the application he went to bed unhappy and dissatisfied as he thought that the study aims were not enough to interest the foundation. In the middle of the night, Charlie woke up and almost as in a trance filled out some more lines, which changed his life as well as the ophthalmology landscape for ever. They were as follows. “In addition to the freezing studies, this investigator will develop a method for removing a cataract through an incision small enough so that no hospitalization will be required.” It was the hardships of the elderly due to the extreme immobilization needed after cataract surgery which he had witnessed in the Will's eye hospital that probably led him to add those lines. He knew that the immobilization was necessitated by the giant incision needed to take out the lens, and the answer was to devise a method to take it out through a small incision. However, he did not have any idea how to do it. However, the chairman of the Hartford foundation thought otherwise, and a 3-year grant was approved.
He convinced the authorities to give him some space in the research floor of the Manhattan Eye, Ear, and Throat hospital and set up his lab there. Charlie and his assistants moved into this space on the 10th floor of the building with cages of cats. Charlie was very secretive about the whole thing. Cheryll Jalbert, his favorite assistant, later remarked in an interview. “We were always conscious of somebody coming up the stairs, and the doors were always kept locked”. For 2 years and 8 months, he toiled hard. He tried innumerable devices such as small drills, vibrators, manual disintegrators, rotating brushes, and small balloon-shaped bags for sucking in the lens to facilitate disintegration. He tried miniaturized meat cleavers and corkscrews. All that would happen was the lens spinning furiously damaging the corneal endothelium and iris. Nothing worked the way Charlie wanted. By 1966, both the funds and time allotted to him had been exhausted and Charlie had nothing to show for it other than hair which had grown to his shoulders, teeth which had developed scales and black circles under his eyes. He had been so obsessed with his research that he had neglected himself. It was time to stop, tidy up and report his progress to the foundation and try to get some more funds. Charlie had a haircut, and then he went to visit his dentist.
Dr. Larry Kuhn, the dentist used a newly acquired tool to remove the scales. It was the Cavitron dental cleaner which vibrated at ultrasonic frequencies flicking off the tartar of the teeth without damaging the teeth itself. The vibrating tip was being cooled by a stream of water. Dr. Kelman listened spellbound as the dentist explained its working to him. It was the Eureka moment for Kelman. He had the answer he was looking for. He became so excited that he ran out of the dentist's office shouting “I have got it! I have got it!” It was almost like Archimedes running shouting Eureka with one striking difference-clothes. While Archimedes did not have any, Dr. Kelman had in addition to his own, the dental bib around his neck too. The surprised dentist and his staff who did not have any idea what was it that he got or what had got into him was in for more surprise when Dr. Kelman returned an hour later with a freshly extracted cataractous lens in hand. He tried out the instrument on the lens and watched with delight as the vibrating ultrasonic tip engraved deep lines on the lens surface without the cataract itself jumping off from his hand. There it was! The Aha! moment. Charlie had found the answer he was looking for. He realized that he could use a suitably modified version of this instrument for disintegrating the cataract inside the anterior chamber without the lens spinning about.,
| Idea to Invention|| |
Without wasting any time, Charlie and his engineers with the help of Cavitron (later acquired by Alcon) designed a similar ultrasound probe [Figure 2] for the eye, but which incorporated both irrigation and aspiration rather than irrigation alone as in the dental probe. It was working effectively in animal eyes, but still left the cornea opaque and white until he began using physiological saline imported from the Barraquer Institute. After several months of painstaking work and experimentation, in 1967, Charlie was ready for his first human subject, a man with a painful blind eye due to glaucoma already scheduled for enucleation. The patient agreed to the experiment. The procedure was done in utmost secrecy. Charlie's paranoia had rubbed on to his assistants also. The large machine [Figure 3] was wheeled into the OT on the previous day by Charlie's favorite assistant and confidant Cheryl Jalbert who locked it in the nurse's locker room and slept there with the machine by her side. Dr. Kelman and his assistants started the surgery in the early morning to escape the attention of the head of the department of surgery, who was not very supportive.
The procedure took about 4 hours, and the phacoemulsification part alone took 70 min. The vibrating probe was quite heavy and Dr. Kelman struggled to control it. The disappointing experience in Kelman's own words was like this. “During the procedure, I found that the cornea was collapsing on to the probe. Happened about 30–40 times during the procedure. It could have ended there, because the next day, I had to remove the eye which was a bag of pus.”
However, one thing Dr. Kelman would never do was to give up on anything. He spent 2 years away, looking for a solution. Finally, he managed to find a company that had a device which could sense flow through an artery. This was incorporated into the aspiration line by Cavitron along with an air relieved valve. If the speed of the flow in the aspiration line exceeded that of the irrigation, the valve would open to immediately stop the suction. This settled the issue to some extent. Furthermore, several improvements were made to the probe including increasing the tip vibrations from 20000 cycle/s to 40,000 cycles/s and decreasing the total weight. Almost a year later, after innumerable animal experiments, Charlie was ready to make one final attempt on another patient. This was a CRAO case with No PL vision. The surgery was a reasonable success. Although there was severe striate keratitis on the first postoperative day, it subsided by the 6th day. His results improved with the subsequent patients, and by the fourth patient, he was ready to announce his invention to the world. The Cryo episode had left an indelible mark on his mind. Dr. Kelman was not going to let anyone take away the credit of this dream invention. He patented his ideas and entered into a contractual agreement with Cavitron. He named the procedure Phacoemulsification. But Dr. Kelman and his procedure were set to have a tumultuous bumpy ride through an ocean of unprecedented resistance.
| The Ride Through Troubled Waters|| |
Charlie's methods were unconventional and unpalatable to many. Entering into a business relationship with an equipment manufacturer was considered scandalous at that time. There was staunch opposition from the chief surgeon of the hospital itself (Manhattan Eye and Ear Hospital) as a result of which the hospital appointed a committee to oversee the surgeries. To make matters worse Charlie did not do what was considered as accepted scientific practice of introducing new knowledge, which was publishing in peer-reviewed journals. Instead, with the help of Cavitron, he propagated his procedure by conducting meticulously organized weeklong training courses to selected practitioners. The news about the procedure and the course spread mostly by word of mouth. Charlie taught his students himself, painstakingly taking them through special tasks to improve hand-to-eye coordination and dexterity, familiarising them with the instrument as well with the operating microscope. His students were treated to a few of his shows also in the evenings, a mix of music and stand-up comedy. Charlie's actions irked the academicia and the major institutes. Phaco was described as malpractice and was declared experimental by even the National Eye Institute resulting in insurance companies declaring it nonreimbursable. In 1973, at the annual Welsh Cataract Symposium, the procedure was literally crucified by surgeon after surgeon sharing bad experiences and patients with poor results giving testimonials. As David Paton M. D, would put it “the conference became the crucible in which phacoemulsification was thrust where upon it was left there to roast and boil.” In 1974 a committee constituted by the American Academy of Ophthalmology (AAO) concluded that Kelman's procedure did not have any additional benefits over Intracapsular Cataract Extraction (ICCE) and may not be suitable in many situations. The committee however accepted that the results were comparable to that of ICCE.
However, in the words of Charlie's wife Ann Kelman, instead of getting depressed as a normal person would have by this time, Charlie went in to the “It is not going to happen. I will show you” kind of mood. He went to the public. He was a man of the stage and knew how to play to the audience. He organized a teaching course on Phaco at the Mt Sinai hospital and at the end had his not so receptive audience laughing by suddenly shifting to an entertaining musical show with his dancing girls suddenly making an appearance on the stage and dancing to his jazz rhythms. On February 21, 1975, Charlie shocked the ophthalmic community by appearing on the Tonight Show, Starring Johnny Carson, the most prestigious talk show on US television at that time. Dressed flamboyantly like a media personality Charlie joked with Carson on air chatted freely about phacoemulsification and even played his saxophone. He became sort of a celebrity overnight. His practice boomed, and he also became the darling of talk shows. However, phacoemulsification still remained in the back burner, practiced by Charlie and few of his good students. However, the advent of the foldable Intraocular lens (IOL) (Mazzocco taco) in the early 1980s changed all that. The tide slowly turned and Phaco began getting the acceptance it deserved. While watching his invention slowly becoming the norm in cataract surgery, his innovative mind was wandering over other horizons. He designed his own IOL and described the principles on which IOL design have to be based on. In the 1989 American Society of Cataract and Refractive Surgery (ASCRS) Binkhorst Lecture he touched upon some of his futuristic ideas, which included innovative use of electromagnets to break up the cataract in the eye, filling the empty capsular bag after cataract removal, with a clear gel made from the patient's own collagen thus restoring accommodation, etc.
| Recognition Finally|| |
It started with the Innovators award Lecture by the ASCRS in 1985 and he had his audience laughing with his opening statement- “I am deeply touched by this recognition which for most innovators is reserved for their funeral.” This lecture was subsequently (in 2003) named after Dr. Kelman himself. Five years later in 1989, the society awarded its second prestigious award also to Dr. Kelman which was the Binkhorst Lecture. In 1999, Dr. Kelman was selected as one of the ten most influential ophthalmologists of the 20th century by the ASCRS and became president of the society. The AAO after cold-shouldering Dr. Kelman for so long finally recognized his genius in 1991 when it gave a special recognition award to him and in November 2003 bestowed its highest honor, the laureate award on him.
The country recognized him by giving him the National Medal of technology in 1992. In February 2004, he was inducted into the National Inventors Hall of Fame in Akron, Ohio. Posthumously he was awarded the Lasker award, the nation's highest honor for Medical Science.
| The Restless Kelman|| |
Charlie famously said during the Binkhorst Lecture “I have always been a Saxophone player wearing the mask of an ophthalmologist. If it was not for my parent's intervention, I would have carried on with my own dream, which is to be a musician.” There were two sides to Dr. Kelman. The Innovator and the Show man. The two sides were sometimes competing for space and time and many a time complementing each other also. However, there was no doubt that, Dr. Kelman was at home most on the stage and that is why Ophthalmology has to thank Chubby Checker for kicking him off the stage at least for some time, time enough for his other side to take over and give us the fantastic gift of Phacoemulsification. However, even after fulfilling his father's dream, even after achieving success as an inventor, even after getting so many honours, Charlie's restless mind never felt fulfilled. To some extent, his love of performing music had been met by the performances he delivered at the end of his teaching courses in New York. But that was not enough. He took voice lessons and set up his own show at the Atlantis Casino in Atlantis City, New Jersey, where he performed regularly. He also performed on television as well as in the Carnegie Hall in New York, alongside several notable jazz musicians and entertainers. In 1985 He published an autobiographical masterpiece book “Through my Eyes.” The book with the subtitle “The story of a surgeon who dared to take on the medical world.” Is a must read for all physicians and young innovators., He learned to fly and subsequently purchased a helicopter to commute from his office in Manhattan to his house on Long Island. He also took up golf, hiring a professional for several months to improve his technique as rapidly as possible.
| Epilogue|| |
Dr. Charles Kelman is fondly remembered as the father of Phacoemulsification. But in the words of his long-term colleague Dr. Jack Doddick, he is also the grandfather of small incision surgery in the entire human body as he was the first in any speciality to take out unwanted human tissue through a small incision. He passed away on June 1, 2004 after battling metastatic Lung Cancer for 6 years. As the technique that he gifted to the world reign supreme as the gold standard of Cataract Surgery, Dr. Kelman's own words (in his book “Through My Eyes”) speak to us across the ages, sharing the secret of his success.
“I admit that I may have certain talents as an inventor, musician, and surgeon, but they are nothing compared to my ability to persevere, to keep going in the face of discouragement, to take the blows and stand up again.”
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Packard RM. From music to medicine – A tribute to Charles D. Kelman, MD, the inventor of phacoemulsification. Cataract and Refractive Surgery Today-Europe 2013.
[Figure 1], [Figure 2], [Figure 3]