The Smith-Kettlewell Eye Research Institute

The Smith-Kettlewell Eye Research Institute is a non-profit, independent research institute, affiliated with the Ophthalmology Department of California Pacific Medical Center. Since its beginnings in 1959, it has grown from a small part of the research group at Stanford University’s original San Francisco medical facility into a fully independent research institute, world-renowned for the quality of its research on vision, eye diseases, and sensory rehabilitation engineering.

When the Stanford Medical School moved to Palo Alto, some members elected to remain in San Francisco and form their own research groups. Dr. Arthur Jampolsky helped form the Eye Research Institute simply by the declaration of its existence. He quickly established one of the first ocular electromyographic laboratories in this country. Soon the Institute was joined by other ophthalmologists and visual scientists interested in research, including the first co-director, Dr. Alan B. Scott.

The Eye Research Institute soon needed more space and Dr. Jampolsky worked hard to get funding. Among his patients and contacts, he was able to raise tens of millions of dollars over the years for the Institute. In 1963, the Eye Research Institute became known as San Francisco Eye Research Foundation (later The Smith-Kettlewell Eye Research Institute). Three grateful patients composed the charter group, plus the following major contributors to the Foundation: Clement J. (Jack) Smith, William A. (Bill) and Catherine D. (Kitty) Kettlewell. After the deaths of Jack Smith and Bill Kettlewell, Kitty Kettlewell continued with generous support.

Smith Kettlewell’s mission is to create a unique environment for research on human vision — basic scientific research to increase the understanding of normal vision in support of vision disorders, clinical research to develop new diagnostic procedures and treatments for visual and other sensory disorders, and engineering research to produce better techniques for aid and rehabilitation of the blind and partially sighted.

Smith-Kettlewell has a long and mutually beneficial relationship with CPMC, its Ophthalmology Department, and the Pacific Vision Foundation which supports the Ophthalmology Residency program. Smith-Kettlewell clinical scientists such as Drs Arthur Jampolsky, Alan Scott, William Good, Otis Paul, August Colenbrander, Donald Fletcher, and Arvind Chandna have had their practices at the CPMC campus and/or been involved in training the residents and fellows, who in turn have a close relationship with the clinical, basic and rehabilitation scientists at Smith-Kettlewell, partnering with many on important research projects and publications.

Early research at Smith-Kettlewell included pioneering applications of EMG technology to eye muscles and the diagnosis and treatment of childhood and adult binocular vision disorders. In this realm the talents of Dr. Carter Collins were added to those of Drs. Jampolsky and Scott to develop length-tension measurements on eye muscles, convenient portable EMG systems, and other surgical aids and techniques now in common use.

Meanwhile, Drs. Carter Collins and Paul Bach-y-Rita developed a novel system to substitute for lost vision. The TVSS (Tactile Vision Substitution System) consisted of a camera worn in a spectacle frame, transmitting visual images to an array of 1,000 electrodes sewn into an elastic garment that fit over the abdomen. This was the direct ancestor of the now commercially available “BrainPort” system.

In 1980, Dr. Alan Scott pioneered the therapeutic usage of Botox, or botulinum toxin, as a treatment for crossed eyes (strabismus).  Injected toxin causes a muscle to relax enough to correct eye alignment without surgery. The benefits of Botox  have since far surpassed this original application in ophthalmology and demonstrate the type of counter-intuitive approaches to research that are a hallmark of many Smith-Kettlewell projects, some examples of which are given below.

During the 1980’s, Smith-Kettlewell physicist Dr. Erich Sutter developed a Brain Response Interface that enabled individuals with no motor control except for their eyes.   to control a wheelchair and to generate speech and word-processing functions. This research led to the development and commercialization by Dr. Sutter of the Multifocal ERG, using brainwaves to objectively and simultaneously measure responses at hundreds of points on the retina, providing a unique clinical tool for objective visual field measurements.

Smith-Kettlewell research on electrophysiology and visual disorders in infants and young children led to the “Sweep VEP” system (developed and refined by Drs. Christopher Tyler and Anthony Norcia) which provides a unique objective measure of visual capabilities of pre-verbal children whose vision is otherwise very difficult to assess. This has revolutionized our knowledge of normal and abnormal visual development in infants and young children and provided much better assessment.  Dr. William Good led the nationwide Early Treatment of Retinopathy of Prematurity (ETROP) trial, and current work on VEPs as a tool for assessing the impact of bilirubin on the nervous system in babies with jaundice.

Similarly in the field of low vision, better assessment tools were needed, for the problems faced by elders and the visually impaired under conditions of low contrast, poor lighting, glare, etc. Dr. Jampolsky stimulated research in this area, subsequently carried on by others such as Drs. Gunilla Haegerstrom-Portnoy, Marilyn Schneck, Lori Lott, and John Brabyn, leading to new tests for screening and prediction of vision loss. Other research in low vision has included the application of the Scanning Laser Ophthalmoscope for assessment by Drs. Donald Fletcher and Manfred Mackeben, and the development of widely accepted charts and standards by Dr. August Colenbrander.

To assist people with no usable vision at all, the early TVSS research was followed by a continuous stream of developments, often led by researchers who were blind themselves such as William Gerrey, Thomas Fowle, and Drs Lawrence Scadden, Joshua Miele and Brandon Biggs, increased the likelihood of practical results. Examples included many tools and instruments for use by blind individuals in the workplace, such as an auditory oscilloscope, meters and gauges of all kinds with auditory or tactile readouts. A pioneering navigation system for blind travelers, “Talking Signs,” was developed by William Loughborough and installed in numerous locations around the world. Audio-tactile educational games were developed and commercialized by Dr. Deborah Gilden, providing blind children with enhanced learning tools.

Recent projects involve increasingly sophisticated technology, such as computer vision techniques developed by Dr. James Coughlan to aid blind individuals in numerous tasks; video description technology and automated tactile map production (“TMAP”) by Dr. Miele; and audio maps (“Audiom”) by Brandon Biggs.  Dr. Lora Likova has pioneered a new rehabilitation tool for blind people using training in drawing from memory of tactile images.  fMRI studies confirm the resulting rapid neural plasticity in the visual cortex, improving spatio-motor skills in a wide range of tasks.

Due to the importance of audition to people who are blind, the Institute has long incorporated relevant hearing research, such as exploration of auditory localization (Dr. Helen Simon) and Echolocation (Dr. Santani Teng).

Laboratory studies of the visual system and its deficits in disease conditions have included Dr. Suzanne McKee’s pioneering studies of amblyopia, Dr. Tyler’s invention of the auto-stereogram and study of numerous conditions including mild traumatic brain injury (mTBI). Dr. Preeti Verghese has pioneered studies of binocular vision in age-related macular disease, and Dr. Natela Shanidze has studied the relationships between the visual and vestibular systems, as well as eye movement strategies in people with macular disease. Dr. Stephen Heinen has led the investigation of smooth pursuit eye movements, and currently collaborates with Dr. Arvind Chandna in research challenging the accepted wisdom on binocular vision mechanisms and disorders. Dr. Chandna has also developed practical vision screening tools for parents and teachers of children with cerebral visual impairment (CVI).

Over the years Smith-Kettlewell has hosted and published many international symposia addressing topical vision problems in an effort to stimulate more research. Recent examples include a 2006 Tonus Symposium, a 2011 symposium on the visual impacts of mTBI, a 2012 Strabimus Symposium, a 2013 Workshop on Environmental Sensing, and a 2018 Haptics Symposium. Involvement of scientists and clinicians from around the world in Smith-Kettlewell research is enhanced by provision of its housing for visiting scientists.