Gerhard Meyer-Schwickerath: Fiddler on the roof.

Gerhard Meyer-Schwickerath (1920–1992)[1]

“The spread of civilisation may be likened to a fire; first, a feeble spark, next a flickering flame, then a mighty blaze, ever increasing in speed and power.” Nikola Tesla

Gerhard Rudolf Edmund Meyer-Schwickerath was born on September 10, 1920 in Elberfeld in Germany. When he came of age, he went against the family’s tradition of pursuing a career in law.[2] He felt that he would not be doing justice to his profession in the present circumstances for he refused to defend Nazism. He instead chose medicine.[3] During World War II a knee injury kept him from being called to the front line, but he served as a paramedic. After the War, he joined as an assistant physician at the University of Hamburg-Eppendorf’s Eye Clinic. In 1959, along with Paul Mikat and Kurt Biedenkopf, he transformed Essen’s Municipal Hospital into Essen University Hospital. He served as the Director of the University Eye Clinic Essen and later as Professor Emeritus.[23]

In the aftermath of World War II, attention of several scientists was drawn to the devastating consequence of atomic bombings, including blindness caused by retinal burns from the flashes of light.[2] The solar eclipse of July 11, 1945 was nothing special; it was a celestial event that happened as the heavenly bodies made their way across the Universe Highway and solar eclipse blindness had been described since the time of Plato. Among the people who suffered the fate on this day was a medical student who decided to work on his own macular burn as his doctoral thesis. Meyer-Schwickerath’s teacher, Professor Marchesani, assigned him the task to supervise him in his work. At 25 years of age, Gerhard already had plans drawn out in his head of constructing a new machine for the treatment of retinal detachment with diathermy. In this respect, he was conducting experiments to study the resistance of different ocular tissues to high-frequency current. While helping the medical student, he realized that the morphology of the solar retinal burn was similar to that caused by surface diathermy. One night, in the spring of 1926, he lay awake with these thoughts in his head when, all at once, the purpose of managing retinal detachments, the knowledge of the effect of intense solar energy on the retina, and the idea of using light as a power source for therapeutic purpose, all fell into a perfect alignment. Fearing he would forget, he jotted down two words, “light” and “coagulation.” Before dawn, he had already thought of the clinical indications including prophylactic treatment of retinal detachment and treatment of small intraocular tumors.[4]

His initial experiments were carried out in rabbit eyes with a machine that he constructed using a carbon arc from an old episcope and few lenses and mirrors. By 1946, he was able to perform localized coagulation in 1–2 s in rabbit eyes.[4] When he showed the laser marks to Professor Marchesani, he nonchalantly replied, “These are typical diathermy burns and you have mixed up the animals.”[5] It was much harder in human eyes with smaller aperture, and it took more than 10 s to achieve a light burn. Eyes with malignant intraocular tumors prior to enucleation were used for the initial attempts. During the course of his research, he found that the wavelengths between 400 and 900 nm could pass through the retinal layers without losing energy to absorption and scatter through the ocular pigments (melanin, lipofuscin, xanthophyll, hemoglobin, and photoreceptor pigments like rhodopsin). With rising temperatures, the retina would turn white from its usual transparent state and would then start reflecting rather than absorbing light, indicating the end point for coagulation.[26]

He then invented another instrument which would use sun as the light source using a Galilean telescope. To compensate for earth’s movement, he used a heliostat, a moveable mirror which would direct the rays to the optical axis of the instrument.[5]

The description that follows next is more from a futuristic Jules Verne book rather than a medical literature. One of the patients, with dark sunglasses, and the machine were placed on the roof of the clinic. The patient would call the doctor on phone when a relatively longer period of sunshine was in the forecast. The heliostat compensated for the movement of the earth and sun. The accessory mirrors would reflect the light beams through diaphragms, directing them to the operating room. Here, a magnification field glass would enlarge the image of the sun, which would then be directed with a handheld plane mirror in through the patient’s pupil. The doctor moved the mirror to focus it on the desired spot with the patient lying on a stretcher. The intensity of light was varied with a foot pedal–controlled filter in the path of the aiming beam [Figs. 1 and 2].[5] Take a moment to imagine this and soak in the glory of the moment – this was the first therapeutic use of sunlight for eye surgery, the foundation of laser surgeries, and the first non-invasive retinal surgery.

Figure 1

The sunlight photocoagulator[5]

Figure 2

The sunlight photocoagulator in use[5]

The difficulties were not few. He had to achieve the smallest burn which would not only weld the retina in position and prevent detachment, but also try to preserve as much vision as possible. The sun would also not often wait till the men and the machine were ready for inducing the treatment.[24] Understanding the limitations, but recognizing the potential of his ideas, he continued his work with the high-intensity Beck arc. He conducted the first surgery in 1949; his first two cases were a peripheral horseshoe-shaped tear with minimal detachment and a traumatic macular hole in a young boy. In 1952, he directed the light to treat the first case of melanoblastoma, melanoma as it was then called, with light photocoagulation. He was a one-eyed patient, who went on to live his life with full vision.[4] In 1956, the unpredictable sun was replaced by high-pressure xenon lamps in a photocoagulator developed by Zeiss and assembled by Dr. Littmann and Dr. Meyer-Schwickerath. He also made an attachment for the photocoagulator for iris and ocular surface coagulation to successfully treat small iris tumors like hemangiomas, fibromas, melanomas, carcinomas and melanomas of the ocular surface, subconjunctival hemangiomas, and eyelid xanthelasma.[5]

Dr. Meyer-Schwickerath described the indications, efficacy, safety, and outcomes with photographic evidence and long-term follow-up of using photocoagulation for the management of retinal detachment, diabetic retinopathy, intraocular tumors (melanoma and retinoblastoma), Eales disease, Coats disease, and retinal angiomatosis.[4789] He elaborated on the increase in size of the burns over time and the dramatic response in patients with darker uvea. When he came to introduce the Zeiss photocoagulator in India, he was consulted by a patient, who had seclusion of the pupil following a cataract surgery in his only seeing eye. His account is best described in his own words, “After local (retrobulbar) anaesthesia I directed the light beam to the middle of his iris. I underestimated the darkness of his iris and coagulated with too high power. I pushed the button and immediately with an audible noise a central hole of 2 mm occurred. The patient jumped off the table, shook my hand and said, ‘Thank you, professor. I can see you; you look very young’! Unfortunately no photographic documentation of the iris hole and the smiling patient was possible.”[5]

Some attribute the first retinal photocoagulation to Spanish ophthalmologist José Morón. He did not publish his work till 1950. While Schwickerath cited Morón in his papers, Morón reciprocated the acknowledgment graciously, “Meyer-Schwickerath was more lucky or more perseverant than me, getting what I was looking for, and resolving three retinal detachment cases with that technique. I hope to repeat the successful experience of the German surgeon, taking into account that Spanish sunlight is more intense than Hamburg sunlight.”[10]

He was a recipient of the Gonin Medal, the Fellowship of the Order “Pour le Merite for Science and Arts,” and was nominated for the Nobel Prize thrice.[23]

On January 20, 1992, Dr. Meyer-Schwickerath left to take his place among the brightest stars in the night sky, marveling from a distance, the rotations of the celestial orbs bringing about an eclipse and the revolutions in the treatment of diseases of the orbs on the earth. Today, laser photocoagulation has replaced xenon coagulation. The indications and contraindications have changed as have the designs of the machines. As we bask in the warmth of the present, it is often worthwhile to look back at the spark that lit the first beacon.

“We didn’t start the fire, It was always burning, since the world’s been turning.” Billy Joel

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Conflicts of interest

There are no conflicts of interest.