The Smith-Kettlewell Eye Research Institute is a non-profit, 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 in 1959, some members elected to remain in San Francisco and form their own medical center and research groups. Dr. Arthur Jampolsky informally established an eye research group including one of the first ocular electromyographic laboratories in this country. In 1963 it was officially incorporated as the San Francisco Eye Research Institute. The new Institute was soon joined by other ophthalmologists and visual scientists interested in research, including the first co-director, Dr. Alan B. Scott.
Patients of Dr Jampolsky, William and Catherine Kettlewell, and Jack Smith, provided important early funding and the name was changed to the Smith-Kettlewell Eye Research Foundation (later Institute). The mission was 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, accessibility, and rehabilitation of blind and partially sighted people. Space was secured at the medical center campus, to facilitate clinical research collaborations with the Ophthalmology Department of California Pacific Medical Center (now Sutter Health).
Smith-Kettlewell’s success at the forefront of translational research is largely due to a mutually supportive environment where scientists, clinicians, and engineers work closely with the blind and visually impaired community. The Institute has a rich history of using rigorous basic science to develop tools to better understand visual impairment, such as multi-focal ERG to evaluate functional vision across the retina (Sutter, 1991), the sweep Visual Evoked Potential to obtain cortical measures of visual sensitivity (Norcia & Tyler, 1985), and techniques to improve the treatment of strabismus such as the use of adjustable sutures (Jampolsky, 1979) and botulinum toxin (Botox) to weaken extraocular muscles (Scott, 2004). SK has made equally impressive contributions on improving accessibility for the blind, such as the first sensory substitution device (Bach y Rita et al, 1969), Cognitive-Kinesthetic training demonstrating brain plasticity (Likova, 2012), Talking Signs (Loughborough, 1979), Tactile Maps Automated Production (Miele et al., 2006) and accessibility research (computer vision applications, Coughlan et al., 2020), accessible instruments and appliances, crowd-sourced audio descriptions of video (Packer et al., 2015).
The tradition continues with a strong series of new and innovative translational research studies aimed at better understanding and impacting the problems of vision and blindness. A timeline of selected research highlights can be found here.
HISTORICAL TIMELINE: SELECTED RESEARCH HIGHLIGHTS
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.
Dr. Jampolsky popularized techniques for using adjustable sutures in strabismus surgery, allowing surgeons to make corrections to the eye muscles during the patient’s recovery. 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.
Drs Tony Adams, Gunilla Haegerstrom-Portnoy and Brian Brown and conducted important studies for the US Army on the effects of atropine (used as an antidote to tear gas) and other drugs on human visual function. They also developed a novel instrument for testing glare recovery.
Dr. Ken Nakayama joined Smith-Kettlewell and began a long series of contributions to visual psychophysics and electrophysiology, binocularity, depth perception, and motion perception.
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.
Dr. Christopher Tyler invented the random-dot autostereogram, making it possible for a person to see 3-dimensional shapes from a single 2-dimensional image without the aid of a stereoscope.
Dr. Suzanne McKee joined Smith-Kettlewell and soon became one of the foremost experts in the world on stereopsis and motion detection. This in turn led to a huge landmark study on amblyopia for which she is best known, resulting in one of the most-cited papers ever on that subject.
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 of the Multifocal ERG, using brainwaves to objectively and simultaneously measure responses at hundreds of points on the retina, providing a unique clinical tool, widely used and imitated, for objective visual field measurements.
The “Sweep VEP” system was developed by Dr. Christopher Tyler and subsequently refined by Dr. Anthony Norcia to provide 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.
A pioneering navigation system for blind travelers, “Talking Signs,” was developed by William Loughborough. Over the next 25 years the project was taken up by Dr. William Crandall and installed in numerous locations around the world. It served as a model for other navigation systems using various types of beacons.
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 Drs. Gunilla Haegerstrom-Portnoy, Marilyn Schneck, Lori Lott, and John Brabyn, leading to the “SKI Study” of aging and vision impairment, and new tests for screening and prediction of vision loss.
Drs Donald Fletcher and Manfred Mackeben pioneered the application of the Scanning Laser Ophthalmoscope for understanding and assessment of visual impairment due to macular disease. Dr. August Colenbrander developed a series of widely accepted charts and standards for low vision.
Dr. Gunilla Haegerstrom-Portnoy is nominated as a member of the National Advisory Eye Council, National Eye Institute.
To assist people with no usable vision at all, there was a continuous stream of developments since the early days of the TVSS, often led by researchers who were blind themselves such as William Gerrey, Thomas Fowle, Drs Lawrence Scadden and Joshua Miele. 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. Audio-tactile educational games were developed and commercialized by Dr. Deborah Gilden, providing blind children with enhanced learning tools.
Dr. Helen Simon joined the Institute to pursue studies of binaural hearing and localization. Due to the importance of hearing in blind rehabilitation, this expertise was invaluable as an addition to the toolbox available to understand spatial perception and navigation problems and solutions in this population.
In 2000 Smith-Kettlewell moved out of its mainly rented space at the Medical Center and into its own building on Fillmore Street.
Dr. William Good led the nationwide Early Treatment of Retinopathy of Prematurity (ETROP) trial, which changed the way in which ROP is managed. Drs Alan Scott and Joel Miller introduced injection of bupivacaine into extraocular muscles to shorten them in the treatment of strabismus without surgery.
Dr. James Coughlan pioneered the application of computer vision techniques to aid blind individuals in numerous tasks including finding crosswalks, finding and reading street signs, and navigating indoors.
Dr. Joshua Miele developed a novel crowd-sourced method for generating audio descriptions of videos to make them accessible to blind viewers. He also invented a unique method of automated tactile map production (“TMAP”) audio maps
Dr. Christopher Tyler led a series of studies of the visual consequences of mild traumatic brain injury (mTBI), using fMRI techniques.
Dr. Lora Likova 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.
Dr. Preeti Verghese pioneered studies of binocular vision in age-related macular disease, including the development of training methods to improve performance of tasks involving depth perception.
Dr. Stephen Heinen conducted investigations of smooth pursuit eye movements. Dr. Arvind Chandna joined Smith-Kettlewell and initiated research in accommodation and vergence, in collaboration with Dr Heinen, challenging much of the accepted wisdom on binocular vision mechanisms and disorders.
Dr. Chuan Hou conducted new studies of amblyopia, including the application of dichoptic attention tasks in promising treatment strategies.
Dr. Suzanne McKee is awarded the Tillyer Award from the Optical Society “for contributions to fundamental understanding of visual motion and of normal and abnormal human stereo vision, revealing the limits and character of brain mechanisms responsible for the perception of depth”.
Dr. Lori Lott, in collaboration with Drs Gunilla Haegerstrom-Portnoy and Marilyn Schneck, conducted a new longitudinal study showing that simple low contrast vision test charts could be used to predict which patients with early macular disease would progress to advanced disease and significant vision loss.
Dr. Natela Shanidze joins Smith-Kettlewell and sets up a specially equipped laboratory to study the relationships between the visual and vestibular systems, as well as eye movement strategies in people with macular disease.
Dr. Don Fletcher founds the Low Vision Rehabilitation Study Group - a no-strings-attached roundtable event of all the best minds in low vision rehabilitation care and research: ophthalmologists/optometrists, clinicians/therapists, and researchers within the low vision field
The long series of international symposia hosted and published by Smith-Kettlewell was extended by a 2011 symposium on the visual impacts of mTBI, a 2012 Strabimus Symposium, a 2013 Workshop on Environmental Sensing, a 2018 Haptics Symposium, and two “State of the Science” symposia on blindness and low vision. These were aimed at engaging researchers, clinicians and consumers in identifying emerging problems in each field and stimulating new research.
In spite of the disruptions of COVID, innovative research activities continued, with investigators developing novel methods to pursue studies remotely when required. For example, Dr. Chandna undertook the development of a practical screening and diagnostic questionnaire, suitable for remote administration, for parents and teachers of children with cerebral visual impairment (CVI).
Dr. James Coughlan and his team's paper “Towards Accessible Audio Labeling of 3D Objects” wins the Dr. Arthur I. Karshmer Award for Assistive Technology Research. This honor is awarded for best submission to the Science/Research Journal Track of the CSUN Assistive Technology Conference.
Dr. Tyler begins a study of the mechanisms of elevated light sensitivity (photophobia), including the discovery of abnormal EEG results in people with this condition.
Dr. William Good applied the Visual Evoked Potentials (VEP) to detect neural deficits in babies with even mildly elevated bilirubin levels (jaundice) previously thought to be harmless – potentially impacting future clinical management.
Dr. Santani Teng, who had recently joined Smith-Kettlewell, established a new laboratory for studying the mechanisms and uses of echolocation in blind individuals.
Brandon Biggs, another recent addition to Smith-Kettlewell, wins First Place in the Innovative Designs for Accessibility (IDeA) competition for his accessible map reading system called “Audiom” that enables blind users to explore digital maps using auditory cues.