A Teacher, a Surgeon, a Researcher: Ramón Castroviejo Briones – A Peek Behind the Curtain

The American Society of Cataract and Refractive Surgery recognised Ramón Castroviejo Briones as one of the 10 most influential people of the 20th century. His contributions to ophthalmology, especially corneal transplantation, were essential milestones that put keratoplasty on the path it is today. He was passionate and sure-headed and believed in going after what he wanted.1 'Almost all advances in Science in a specific field are due to persons with an obsessive dedication both in and out of their work'. R. Castroviejo Early life and education Ramón Castroviejo Briones was born in 1904 in Longrono, Spain. He was the eldest of four children born to the well-renowned ophthalmologist Ramón Castroviejo Novajas. His grandfather was a physician as well. Gaining inspiration from his father's surgical practice, he aspired to become an eye surgeon. He received his medical education at the University of Madrid, graduating in 1927. Following this, in 1929, he received a fellowship from Dr. Fisher to work as an assistant in the Ear, Nose and Throat Hospital and College of Chicago. After passing the American Board Examination in 1930, he returned to Europe to visit the centres in Madrid, Prague, Paris, Berlin and Vienna, where keratoplasty was practised. This helped him formulate and implement a plan on his return to the USA.2,3 William L. Benedict had offered him a research fellowship at the Mayo Clinic in Rochester, Minnesota and in 1932, Dr. Maynard C. Wheeler granted Castroviejo a research fellowship at the new Eye Institute of the College of Physicians and Surgeons of Columbia University. He moved to New York, where he continued his animal research at the Eye Institute of the Columbia Presbyterian Medical Center and was an early developer of techniques for transplanting the corneal tissue.1-4 THE TRAIL BLAZER OF KERATOPLASTY While not being the first to graft a human cornea successfully, he improved the operation technique in the 1930s and 1940s, prompting the worldwide adoption of corneal transplantation as a standard way to deal with severe corneal pathology. His keratoplasty technique, creating a rectangular rather than circular 'window' in the cornea, was the secret to his successful transplants and remained standard until more efficient suture materials became available. During his description of this technique in 1937 to the American College of Surgeons, he contended that rectangular windows gave better results than the circular ones that had been tried earlier, since their edges could be fitted better to merge with and become a living part of the rest of the eye.4,5 Castroviejo's sight-saving corneal tissue transplant techniques were initially slow to gain recognition in the medical community, but he was eventually lauded for his successes. He continued to refine and teach these techniques for many years and promoted the donation of corneal tissue in the USA. PERSONAL LIFE AND SUCCESS Both his practice and personal life flourished in Manhattan. He married Cynthia Warren Smith in 1945. They had two children: a son, Christopher Ramón, and a daughter, Cynthia Alix. Nevertheless, he was often plagued by sleepless nights, but even this time was not wasted. He utilised this period to imagine new instruments and techniques. He was fiery, dynamic and hard working. He often joked, 'When I die, the epitaph on my tomb should be "Wake me at 8 a.m."'. Apart from his scientific pursuits, he also dedicated time to art and literature in his life. His favourite hobbies included photography, tennis, swimming and boating. Castroviejo and his wife Cynthia frequently hosted esteemed guests with diverse interests in medicine, arts, politics, philanthropy, literature and finance. The Castroviejos were among the founding members of an organisation that brought Spanish culture and performing artists to New York. They often held concerts in the ballroom of their Manhattan residence. Castroviejo frequently brought his guests and corneal transplantation fellows home during the evenings or to his summer residence on Centre Island on weekends. He passed away at the age of 82 after living a fulfilling and fruitful life.1-5 His motto for life was never to take no for an answer. One such example was the meeting of the American Academy of Ophthalmology in Chicago in 1950. During a keratoplasty symposium, statements by some of the organisers and panellists cast doubts about the reliability and accuracy of the purported results of keratoplasties. This rumour created such a ripple that the conclusion derived was the condemnation of keratoplasty due to its high rate of failure and complications and the suspicion that the results achieved in animal studies did not apply to humans. When Castroviejo caught wind of this threat, he did something entirely in character: he asked many of his patients who had undergone penetrating keratoplasty to go to Chicago to help him prove this point. He hired a rail coach from New York to Chicago, and he arranged for the approximately 100 patients who agreed to travel to meet in the ballroom next to the auditorium where the symposium was conducted. When the time came to back up his findings, they filed into the meeting, each with their own penlight, so that members of the Academy and doctors could observe the results of the keratoplasties firsthand. That incident was a pivotal turning point for the acceptance of keratoplasty procedure in the USA.1,3 HIS HERITAGE Every day, in the operating rooms worldwide, surgeons ask for a fine-swaged suture loaded on a 'Castro' needle holder, be it cardiac, plasty, dental or ocular. The skilled surgeon firmly grips an ingeniously crafted instrument that has retained its original design since it was patented in 1953. Surprisingly, only a handful of surgeons are familiar with the individual who designed it or are knowledgeable about his numerous other advancements in the field of surgery.4,6,7 He designed this needle holder with the idea to hold and manoeuvre finer and finer sutures which were being developed for corneal surgery and gave an eloquent brief of the same and about the locking and release mechanism, which was simple in design but a wonder in execution. The needle holder featured a unique single ratchet system positioned between the folded arms, which served to simplify the intricate ratchet mechanism typically found in conventional needle holders. This innovation was particularly advantageous in the delicate and precise environment of the operative field, where fine motor skills are essential. The needle could be securely locked in place with a gentle application of pressure on the arms and similarly released with the same controlled movement. Moreover, the design of the needle holder emphasised the importance of achieving a harmonious balance between functionality and usability.8 Dr. Ramón Castroviejo was an ophthalmologist, a teacher and inventor of the needle holder and several other precision instruments that bear his name, including callipers, corneal scissors, eye speculum, cyclodialysis spatula and tissue forceps. He also made it a point to not patent most of his inventions, so that everyone could have access and benefit from them. His son also recollects that 40% of surgeries performed by him throughout his lifetime was pro bono. His belief was that his knowledge and skill should benefit everyone, irrespective of their economic status.4 He pioneered successful human corneal transplantation and was instrumental in developing 'atraumatic' swaged sutures to facilitate corneal grafting and other delicate ophthalmological procedures.9 He has published 247 papers and a famous book Atlas de Queratectomı'as y Queratoplastias. Launched in 1987, the Castroviejo Lecture takes place during the symposia cosponsored by the Cornea Society at the Academy's annual meeting.10 He was appointed as the director of ophthalmology at St. Vincent's Hospital (1952–1969). Following this, he opened his own hospital after buying the Hammond House in New York. After closing his private hospital, he retired as a clinical professor at the University of New York and moved permanently to Madrid, where he founded the Instituto Castroviejo at the Complutense University of Madrid and organised the Spanish Eye Bank, maintaining extensive clinical activity whenever his health permitted. Ramón Castroviejo died in 1987 at the age of 82. Even beyond death, he donated his cornea, which was successfully transplanted to a patient with previous corneal rejection. The operation was performed by none other than one of his very own trainees, Juan Murube del Castillo.1 Dr. Ramón Castroviejo's enduring legacy serves as a constant source of motivation not only propelling us in our academic endeavors, but also inspiring us to excel in various facets of life. His influence encourages us to strive for fulfilment and balance, fostering a holistic and purpose-driven approach to living. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.