Ramon Castroviejo 1904–1987

Frank M. Polack, M.D.

“The many completely studied successful cases . . . justify thepermanent position of keratoplasty in ocular surgery.”—Ramon Castroviejo

EARLY LIFE AND EDUCATION

Ramon Castroviejo’s biography is intricately entwined with hisclinical practice as well as his clinical and laboratory research.Perhaps more than any other individual, Castroviejo’s contributionto the development of modern corneal transplantation began theshift of clinical and scientific leadership from Northern Europe tothe North American continent. His energetic and sometimes mer-curial personality established him as the clinical leader in the prac-tice and investigation of corneal transplantation as medical art andclinical science.

Ramon Castroviejo Briones (Fig. 1) was born in 1904 inLogrono,1 the capital of La Rioja, a beautiful area in northernSpain not far from Bilbao. Growing up in a countryside of vastvineyards and snow-capped mountains, Castroviejo was an out-standing athlete during his school years and frequently rode hisbicycle to Bilbao to visit relatives.2 His father, Ramon CastroviejoNovajas, was an ophthalmologist, and from early childhoodthrough his college years, young Ramon observed his father per-forming eye examinations and surgeries. After completing univer-sity studies, like his physician father and grandfather, he enrolledin the faculty of medicine of the University of Madrid, obtainingthe degree of physician and surgeon in 1928 at the age of 23. Oneyear later, he began specializing in the clinical practice of oph-thalmology.

MOVE TO THE UNITED STATES

In 1929, he met a visiting American physician from Chicagowho attracted him to the United States with a position as assistantin the Chicago Eye and Ear Hospital. If he had any plans ofreturning to Spain in a year or two, the eruption of the SpanishCivil War, coupled with the opportunities in the United States,cemented his important career in North America for the next 47years.

In the half-century preceding Castroviejo’s move to Chicago,the replacement of an opaque cornea with clear corneal tissue hadbeen a major interest in many European eye clinics. World War I,however, had paralyzed research efforts. In the early 1920’s, nu-merous papers appeared in European eye journals reporting new

surgical techniques for corneal transplantation as well a few clini-cally successful grafts. The work of Anton Elschnig and his schoolcentered at Prague dominated Europe. Then Vladimir Filatov ofOdessa reported his ground-breaking research in keratoplasty andcorneal preservation. It was at the time that Filatov reported hiswork that Castroviejo moved to the United States. European in-terest in keratoplasty diffused to the U.S., where authors likeWoods, Wiener, Key, and Thomas began reporting their resultswith a variety of techniques.

Keratoplasty became one of the primary foci of research inAmerican ophthalmology, with a particular focus on techniques ofcutting the donor tissue and securing the graft to the recipientcornea. At that time, the function of the endothelium was still

The text and graphics for this biography were reproduced from CornealTransplantation: A History in Profiles by Mark J. Mannis and Avi A.Mannis, Chapter 15 “Ramon Castroviejo” by Frank M. Polack, by permis-sion from J.-P. Wayenborgh Press, Postbus 96, B-8400 Oostende 3, Bel-gium. www.history-ophthalmology.com

FIG. 1. Ramon Castroviejo, M.D. c. 1950.

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unknown, and it was believed that the transparency of the corneadepended entirely on the stromal tissue. Accordingly, the results oftransplantation in the United States were not very satisfactory andwere certainly no better than in Europe and Great Britain. More-over, there was considerable confusion engendered by the medicalliterature due to the rapidly proliferating variety of ideas and sur-gical techniques.

EARLY TECHNIQUES IN KERATOPLASTY

Castroviejo continued working as an assistant ophthalmologistin Chicago for one year. In 1930 he became a research fellow inthe Department of Ophthalmology at the Mayo Clinic in Roches-ter, Minnesota under the direction of Dr. W. Benedict; there hestudied experimental corneal transplantation. During the year offellowship, Castroviejo traveled to Europe to study the advances inkeratoplasty at several eye clinics. He was particularly impressedwith Elschnig’s technique of partial circular keratoplasty.8 After hereturned to the United States, Castroviejo tried numerous tech-niques in rabbits and dogs and designed several instruments tofacilitate the procedure. Repeated failures using the Elschnig cir-cular trephine and problems with the fixation of the graft led himto employ the double-bladed knife and square graft that became histrademark and which he used until the early 1950’s. (Fig. 2) Theinstrument employed razor blade knives which he had seen beingused in Spain by Dr. Bustamante as fine surgical knives.3 There

was, in fact, significant rationale for the square corneal graft. Itmust be remembered that, for the most part, the corneal surgeonsof the time used overlay sutures rather than direct appositionalsutures. This was, in no small part, due to the absence of finesuture material. Grafts were, therefore, plagued with wound leaksand the frequent formation of peripheral anterior synechiae. One ofthe main advantages of the Castroviejo technique was the fact thatonly the corners of the graft encroached on the periphery of therecipient cornea, thereby lessening the frequency of synechia for-mation and its attendant problems. It is, nonetheless, remarkablethat clear grafts were obtained in both his experiments as well ashis clinical series at a time when the function of the corneal en-dothelium was unknown and when techniques and instrumentsdeveloped simultaneously by several corneal surgeons ignored andeven badly damaged this crucial and delicate corneal layer.

At the annual staff meeting of the Mayo Clinic in November1931, Castroviejo reported the results of his experimental work inrabbits, among which were several clear grafts performed with hisdouble knife.6 The grafts were rectangular, 13 mm × 4 mm in sizeand secured in position with an overlapping flap of conjunctivaltissue and two or three silk sutures (either 6-0 or 7-0 silk). Thesame year, he was invited to move to the Eye Institute of ColumbiaUniversity in New York as Research Fellow under the direction ofMaynard Wheeler M.D. and Ludwig Von Sallmann M.D. Here hewould eventually become a member of the faculty and ClinicalProfessor of Ophthalmology, and would begin his remarkably pro-lific clinical career.

NEW YORK CITY

It was at the research laboratories of the P & S Medical Schoolof Columbia University and at the Eye Institute of the PresbyterianHospital that Castroviejo conducted his most significant experi-mental and clinical work culminating in the development of land-mark keratoplasty techniques and a relatively high number of clearcorneal grafts. The challenges of how to cut the host and donortissue precisely and how to fixate the donor tissue to the recipientwere further addressed in his work.

THE SURGICAL PROCEDURE

After considerable examination of previous techniques and in-strumentation, he arrived at the square graft technique. In a land-mark paper of 1941, Castroviejo described the rationale for and thedetails of his surgical technique.5 First reviewing the techniquesemployed by Zirm, Elschnig, Filatov, and Thomas, he abstractedfrom their approaches and summarized the principles on whichcontemporary keratoplasty had been based. He then argued therationale for the square graft technique that will be described be-low. He based his recommendations on experience with 400 kera-toplasties in animals and 200 keratoplasties in humans. He outlinedhis standard procedure as follows:

“A routine preparation of the eye is made, about 15 minutesbefore the operation, with repeated instillations of 4-percentsolution of cocaine and a solution of adrenalin, 1:1000; im-mediately before the operation, a 20-percent solution of ar-

FIG. 2. A: The double-bladed Castroviejo knife for fashioning asquare graft (courtesy of Joel Sugar, M.D.). B: The signature squaregraft.

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gyrol is again instilled, followed by anther instillation of co-caine and adrenalin. A retrobulbar injection of 1 cc of 2-per-cent solution of novocaine and adrenalin 1:1000 is given anda few drops of cocaine, 2-percent are injected above andbelow under the bulbar conjunctiva . . . Separation of the eye-lids is maintained with the mosquito lid clamp retractors. Theleucomatous area of the cornea to be removed is outlined witha double-bladed knife without penetrating into the anteriorchamber. Fluorescein, 2 percent, is instilled to make the cor-neal incisions more visible . . . . A continuous corneal sutureis inserted from 1 to 1 1/2 mm. outside the edges of theoutlined square. This suture is destined to hold the transplantin position. Another suture is inserted within the outlinedleucoma to facilitate the removal of this segment. One edge ofthe outlined square is cut though with a keratome kept at anangle of about 20 degrees from the vertical in order to obtainshelving of the inner layers of the cornea. The keratome isplaced so that one side of its blade cuts one corner of theoutlined square. A blade of the scissors is then passed beneaththe cornea into the anterior chamber at this point so as to cutstraight along the adjoining uncut side of the outlinedsquare . . . . The remaining uncut borders are cut in a shelvingmanner with about 20 degrees of beveling, with the aid of aspecial scissors . . . The transplant, equal in size and shape tothe removed leucoma, is obtained in a similar manner, butwithout shelving, from the enucleated eye of a cadaverenucleated shortly after death . . . . The clear transplant re-places the dissected leucoma, and the continuous corneal su-ture is gently made taut without exerting excessive pressure.The knot is tied at one side, away from the graft. Metaphen orany other non-irritating antiseptic ophthalmic ointment isplaced in the conjunctival sac, and a binocular bandage isapplied without pressure.

The patient is placed in bed decubitus supinus, in which positionhe is to remain for about 10 days . . . . Care should be takento keep the head motionless, preventing unnecessary effortswhich might interfere with proper healing of the graft . . . .The first dressing is performed two days after the operation,and atropine is instilled to keep the pupil dilated to preventanterior synechiae if the anterior chamber, once re-formed,should collapse. At the third dressing, six days after the op-eration, the suture is removed under local or general anesthe-sia, depending on the cooperation of the patient. In somespecial cases, such as keratoconus, in which the cornea of thehost surrounding the transplant is very thin and healing takesplace more slowly, the sutures ought to be left in place for atleast eight days . . . . On the tenth day, the other eye may beuncovered, and the patient may be allowed to get out ofbed . . . . The patient is given a fluid diet for the first two days,semifluid for the following four days, and then graduallyresumes a normal diet.”5 (Fig. 3)

Castroviejo maintained that this technique produced a 90% rate ofgraft transparency and functional visual improvement in appropri-ately selected patients.5 A 1989 review of 19 eyes in 12 patients inwhich the Castroviejo square graft had been performed demon-strated that nine of the nineteen grafts remained functionally clear;one of these clear grafts was examined 49 years after the date ofsurgery!4

In the majority of previous experimentation on keratoplasty and

indeed in all of Castroviejo’s early grafts, direct appositional su-tures were not employed. Overlay silk sutures had been used, oftenwith unsatisfactory results. It was not until the mid-1950’s thatBarraquer, Castroviejo, and a few other surgeons started to useinterrupted edge-to-edge silk sutures, when the 8-0 sutures anddelicate Swiss needles first appeared. Until then the finest sutureshad been 6-0 or 7-0 caliber, and the needles were too large foreffective use in delicate corneal tissue.

A PRIVATE HOSPITAL

Despite the outbreak of World War II, research did not stopcompletely. Clinical work progressed at the Eye Institute and thenumber of successful clinical corneal transplants increased. Theend of the war brought many ophthalmologists back to New York;they sought new positions at the hospitals. In 1948 Castroviejodecided to broaden his practice by opening his own eye hospital at9 East 91st Street in New York. An avid speaker and prolificwriter, Castroviejo soon became renowned the world over for hisexpertise in keratoplasty, and his clinic became the center forreferral of all kinds of eye problems in the U.S. and from abroad.In 1952 he was named Chief of Ophthalmology at St. Vincent’sHospital and Professor of Ophthalmology at New York Universityand Bellevue Hospital. He also held appointments as AttendingChief Surgeon at the New York Eye and Ear Infirmary, St. Clair’sHospital, Manhattan Eye and Ear Hospital, Mt. Sinai UniversityHospital, and consultant to many organizations in the UnitedStates.

Castroviejo married Cynthia Warren Smith and had two chil-dren, a boy and girl. His daughter wrote a memorial after his deathin a Madrid newspaper2 describing the little known facets of hispersonal life, such as his dedication to his children, the affectionand kindness to relatives and friends, and his generous philan-thropy. His sense of humor had been appreciated not only byfamily, but also by friends, fellows and colleagues who frequentlylistened to his short stories and tales. Occasional patients havedescribed Castroviejo as a detached and arrogant person, but mostof them rationalized that as a scientist and clinical genius, thisbehavior could be forgiven. Castroviejo was a dedicated physicianwho took care of indigent patients. With his students, he alwaysmade time to talk about ophthalmology and research. He was astubborn man, although his stubbornness was tempered with hu-mor. He was among the first to establish a corneal fellowshipprogram in 1945, which he generously supported. He also gavegenerously to support special research projects.

In the early fifties, Castroviejo redesigned the circular trephineand corneal scissors, both of which are still used by hundreds ofcorneal surgeons around the world. By this time, he used thedouble-bladed knife only occasionally—in cases of keratoconus—because he felt that that condition required a large graft to preventrecurrence of the disease, while at the same time, he wished todiminish the occurrence of synechia formation.

Castroviejo’s hospital at 9 East 91st St. was one of the earliestclinics to perform a large volume of outpatient surgery in the earlyfifties, with only a few cases under general anesthesia admitted forone or more days. The hospital served as a gathering point forophthalmologists from all over the world, particularly from Spainand Latin America. It was also the site of the fellowship programsponsored by Dr. Castroviejo.

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INTEREST IN THE IMMUNE RESPONSE

Castroviejo taught at the NYU post-graduate program where hewas an animated and enthusiastic lecturer on eye surgery; his talkswere augmented with excellent movies of his techniques in cata-ract surgery and corneal transplantation. Even though the immunecause for tissue rejection had been demonstrated by Medawar6 in1948 and subsequently by several investigators directly interestedin corneal transplantation, the cause of corneal graft rejection or“graft sickness” as it was called, was still debated. Until the early1960’s, Castroviejo was convinced that the main cause of graftopacification in avascular corneas was anterior segment inflam-mation due to sinus infection or dental disease (Fig. 4).8 He sug-gested to the author an experiment to induce chronic sinus infec-tion in rabbits or monkeys to cause intraocular inflammation andgraft opacification. Professor George Smelser at Columbia Uni-versity suggested alternatively inducing intraocular inflammation

with intra-vitreal injections of bovine serum albumen. The inflam-mation caused graft opacification but this process was not a truegraft rejection.9 Despite his theories of the relationship of sinusinfection to graft rejection, Castroviejo eventually accepted theimportance of the immune response as the cause of graft rejectionand the role of endothelial failure as one of the leading causes ofgraft edema. The importance of the endothelium in maintainingcorneal transparency had been established in the mid-1950’s, butin 1960 many corneal surgeons still ignored this important obser-vation, as is shown in the techniques described in some surgicalatlases of the time.

Castroviejo’s excellent Atlas de Queratectomias y Queratoplas-tias, published in 1964 in Spanish (Fig. 5) (published in English in1966 as Atlas of Keratectomy and Keratoplasty), brought togetherall the latest technology of his time.10 Recognizing the importanceof the corneal endothelium, Castroviejo preferred to use fine for-ceps to suture the graft instead of clamps to hold the graft as were

FIG. 3. Diagram of the CastroviejoSquare Graft technique. (Am J Ophthal-mol 1941; 24 (1): 1–20, Figure 6, p.16),Courtesy, The Ophthalmic PublishingCompany.

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used by many at that time (Fig. 6). Some reasons for his goodresults in circular penetrating keratoplasty without the endothelialprotection we use in contemporary keratoplasty, using sutures oflarge size, and without the benefit of corticosteroids, include: thesmall size of his grafts (5 mm), his unusual skill as a surgeon, hisexperience as an investigator, and the elimination of the transplantclamp for the placement of sutures in the graft.

Castroviejo’s reports of success in keratoplasty were not uni-formly believed, particularly by colleagues who had tried the op-eration unsuccessfully. In 1950 he was invited to participate in aSymposium on Keratoplasty held at the annual meeting of theAmerican Academy of Ophthalmology in Chicago. Castroviejohad learned prior to the Symposium that the outcome had beenpredetermined and that the conclusion would be that keratoplastyshould not be recommended due to the high rate of failure andassociated complications. Determined to disprove this erroneousconclusion and to demonstrate the success of his keratoplasty pro-cedure, Castroviejo hired a rail coach in New York to transport 100post-operative keratoplasty patients to Chicago. He collected 200patients, many with bilateral transplants, and brought them to aballroom next to the auditorium. Each patient held a penlight, sothat all members of the Academy could see the surgical results firsthand.11,12

INTERNATIONAL MEETINGS

Castroviejo attended most of the international congresses, andhe particularly enjoyed the meetings of the Pan American Asso-ciation of Ophthalmology. While at the III Pan American meetingin Lima, Peru in 1963, the photograph later used for the covetedCastroviejo medal was taken (Fig. 7). In 1971, he attended the VIIPan American meeting in Bogota Colombia (Fig. 8), where hedemonstrated his sparkling sense of humor, appearing at the open-ing of the bull fight plaza in Guatavita in the garb of “matador”together with several of the society’s directors.

FIG. 4. Reproduction of a letter fromCastroviejo expressing his belief in thelow incidence of graft rejection (Graftsickness) in avascular corneas and graftfailure due to inflammation.

FIG. 5. Frontispiece of Castroviejo’s Atlas of Keratectomy and Kera-toplasty. Ed. Salvat, Madrid, 1964.

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INSTRUMENT DEVELOPMENT

Castroviejo’s greatest contribution to keratoplasty was, perhaps,his innovation in technique and in the advancement of cornealsurgical instrumentation. Throughout all the years of his practice,Castroviejo performed surgery with loupes. His instruments werelarge and well-balanced, a design that suited the surgical tech-niques of the day. However, he saw the emergence of microsur-gery and, recognizing that keratoplasty would be revolutionized bythe advent of the operating microscope, he began to miniaturize hisinstruments. He had been working with Ethicon, Inc. (a suturemanufacturer) toward the development of fine, atraumatic cornealsutures. In addition, he designed a variety of instruments for an-terior segment surgery and for corneal surgery in particular, suchas the microsurgical keratotomy knife (Fig. 9), and the electricmicrokeratome (Fig. 10).

The operating microscope was introduced in the United States inthe late 1950’s. Despite his prescient understanding that instru-mentation would have to change with the arrival of the operatingmicroscope, Castroviejo found this instrument too constraining forhim and, in his own practice, saw no need for it. Until 1971, he wasstill using loupes and silk sutures for keratoplasty, removing thesesutures six to seven weeks after surgery. However, when 10-0monofilament nylon sutures became available, the use of the mi-croscope became a necessity. He attempted to design a suspendedmicroscope that could be moved with the head from one side of theoperating table to the other, as he used to do with his loupes; thisinstrument unfortunately did not work well for him. The develop-ment of microsurgery, micro-surgical nylon sutures, and the in-vention of phacoemulsification, which he refused to accept as aviable surgical technique, contributed to frustration during the lastperiod of his professional life. His frustration with changing sur-gical techniques was aggravated by the frequent strikes of unionpersonnel and by continuing problems with the municipal govern-ment of New York City, which was increasingly strict in its regu-lation of small hospitals.

In his later years, Castroviejo’s main interest was the organiza-tion of a corneal research unit at the Fundacion Mediterranea and

the Universidad Autonoma de Madrid. In New York, he dedicateda significant amount of time to clinical research on a cornealprosthesis, which he developed in cooperation with Hernando Car-dona M.D. and Arthur G. DeVoe MD.

FIG. 7. A: Castroviejo MD photographed in Lima, Peru in 1963 (Pho-tograph by Frank Polack). B: The Castroviejo Medal.

FIG. 6. Two types of corneal graft clamps used to place sutures andtwo methods using forceps to place end to end graft sutures.Castroviejo R., Atlas of Keratectomy and Keratoplasty, Ed. Salvat,Barcelona, 1964.

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RETURN TO SPAIN

In 1973, Castroviejo closed his private hospital in New Yorkand retired to Madrid “to work for some time among his col-leagues.” He was Professor at the University of Madrid and Di-rector of the Eye Department of the Mediterranean Foundation. In1973 and 1974, he became ill, requiring several major surgeriesthat contributed to the deterioration of his health; there were timeswhen death seemed imminent.

THE CASTROVIEJO SOCIETY

Reports of his failing health prompted some of his friends andstudents to form the Castroviejo Cornea Society in May of 1975 at

FIG. 8. Bullfighters opening the plaza in Guatavita, Colombia in1971. In the first row Drs. Castroviejo and Palomino followed by Drs.Boyd, Puig, and Arce.

FIG. 9. Microkeratome knife and double spatula for corneal grafts.From Atlas of Keratectomies and Keratoplasties, Ed. Salvat, Madrid,1964.

FIG. 10. Electric microkeratome for thin buccal mucosal grafts andlamellar keratoplasties. From Atlas of Keratectomies and Kerato-plasties, Ed. Salvat, Madrid, 1984.

FIG. 11. Richard Troutman MD presenting a diploma to Dr.Castroviejo. Atlanta 1979.

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the Pan American Congress of Ophthalmology in San Juan, PuertoRico. Although Castroviejo recovered from his physical ailments,he fell into a severe depression. In November 1975, the author,along with Dr. Alfredo Dominguez, visited Castroviejo in Madridwhere he was recovering from depression. They notified him thata society bearing his name had been formed in the United States,and presented him with a special medal of the Castroviejo Society.He refused to accept this honor and rejected repeated letters on thesubject from colleagues and new society members. His responsewas even more negative to the plan to organize a society meetingin Madrid in 1976. Happily, he recovered from his depression inthe latter part of 1976 and graciously accepted the idea of thesociety bearing his name. In 1979, he accepted an invitation toattend the annual meeting of the Castroviejo Society held duringthe meeting of the American Academy of Ophthalmology, wherehe gave a lecture and accepted a diploma (Fig. 11).

LATER LIFE

In 1980 and 1981, Castroviejo was busy organizing the EyeBank of Madrid and the research department of the Mediterranean

FIG. 12. Castroviejo (standing, third row,middle) surrounded by his corneal fel-lows, Madrid, 1985.

FIG. 13. Discussion between Claes Dohlman and RamonCastroviejo on the subject of keratoprosthesis development. (An-dover, 1962).

FIG. 14. Ramon Castroviejo, investigator and clinician. A caricatureby one of his friends portraying Castroviejo as many saw him. Evenin his private practice, his mind was not far from his experimentalwork.

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Foundation. He personally tried to recruit investigators from theUnited States for this purpose, but funding for the project did notmaterialize. He dedicated significant time to foster the Fellowshipprogram of the Castroviejo Foundation (Fig. 12). Again in 1981,Castroviejo attended the Atlanta meeting of the Castroviejo Soci-ety. Claes Dohlman, MD delivered the Castroviejo Lecture (Fig.13) and graciously commented on Castroviejo’s work on the de-velopment of a keratoprosthesis. The interest of these two impor-tant leaders in the subject of keratoprosthesis development hadbeen long-standing, and a few of their colleagues remember afriendly but heated discussion about keratoprosthesis design be-tween Dohlman and Castroviejo during the 1962 Cornea ResearchMeeting in Andover (Fig. 13).

CASTROVIEJO’S LEGACY

For the next several years, Castroviejo continued working inMadrid, although his health continued to deteriorate. He died onJanuary 1, 1987 in Madrid at the age of 83. Interestingly, his deathwent virtually unnoticed in the United States. In Spain, however,newspapers, journals, and magazines published articles about hislife and work for months after his passing. His curriculum vitaeincludes 247 publications, his important surgical atlas, and numer-ous scientific and honorary Awards from universities and scientificorganizations in North America, Europe, Latin America and Asia.

The achievements of Ramon Castroviejo extend over half acentury In his clinical practice, which was the “clinical laboratory”for his many technical innovations, Castroviejo performed over3000 grafts during his long and creative career. His contributionwas largely in the design of new instrumentation, the advancementof surgical technique, and new experimental work (Fig. 14). It isimportant to point out that Castroviejo also contributed to areas ofocular surgery besides keratoplasty and to the development of eyebanking. He was a man of strong convictions—some would sayopinionated. Nonetheless, he remained open to many new conceptsand techniques, as exemplified by the evolution of his thinkingabout corneal immunology and surgical technique over time.Through the years, at meetings and conferences, he zealously de-fended and promoted the surgical techniques he had developed,especially those relative to keratoplasty.

He was true to his beliefs, even in death, and he made sure thathis corneas were donated. Shortly after his demise, both corneaswere successfully grafted in Madrid.

REFERENCES

1. Losada F-Ramon Castroviejo. In Memoriam. Cornea 6; 44. 1987.2. Castroviejo A. ABC.-Tribuna Abierta,. Madrid, Enero 1, 1987.3. Castroviejo R. Keratoplasty. Am J Ophthalmol 15:905, 1932.4. Aquavella JJ, Smith RS, Ruffini JJ, Locascio JA, Binder PS, Shaw EL,

and Perry HD. The Castroviejo square graft: A retrospective study.Refractive and Corneal Surgery 5:262, 267, 1989.

5. Castroviejo, R. Keratoplasty. Comments on the technique of cornealtransplantation. Source and preservation of donor’s material. Report ofnew instruments. Am J Ophthalmol 24 (1):1–20, 1941.

6. Castroviejo R. Preliminary report of a new method of corneal trans-plantation. Proc. Staff Meet. Mayo Clinic, 6; 669, 1931

7. Medawar PB. Immunity to homologous grafted skin III. The fate ofskin homografts in the brain, in subcutaneous tissue, and in the anteriorchamber of the eye. Brit J Exp Path. 29:58, 1948.

8. Castroviejo R. Cornea and Lens Symposium. Ocular allergy. TransAm Acad Ophthalmol 50: 342. 1952.

9. Polack FM. The effect of inflammation on corneal grafts. Am J Oph-thalmol 259, 1965.

10. Castroviejo R. Atlas de Queratectomias y Queratoplastias. Ed. Salvat.Barcelona, 1964.

11. Castroviejo R. In: Radial Keratotomy. Eds. Schachar R, Levy N,Schachar L. Proc Keratorefractive Soc Meet. Denison, Texas, 1980.

12. Vega Fernandez, LD. Personal communication, 1998.

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study with penetrating keratoplasties and keratectomies. Trans AmOphthalmol Soc. 47: 183–197, 1949.

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Castroviejo R.: Keratoplastie lamellaire; etude comparative des kerato-plasties perforantes et des keratectomies. Ann Oculist (Paris), 183:641–659, 1950.

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Castroviejo R.: A new needle holder. Trans Am Ophthalmol Soc 48: 331,1950.

Castroviejo R.: Suturing forceps for scleral, corneal and cataract work.Trans Am Acad Ophthalmol & Otolaryngol 54: 373, 1950.

Castroviejo R.: Trephines for keratoplasty with micrometric regulation.Trans Am Acad Ophthalmol & Otolaryngol 54: 373, 1950.

Castroviejo R.: Total penetrating keratoplasty: a preliminary report. Am JOphthalmol, 34: 1697–1706, 1951.

Castroviejo R.: Symposium: Ocular allergy. Cornea and lens. Trans AmAcad Ophthalmol & Otolaryngol 56: 242, 1952.

Castroviejo R.: Double purpose instrument for keratoplasty. Trans AmAcad Ophthalmol & Otolaryngol 56: 927, 1952.

Castroviejo R.: New handle for razor blade knives: Manner of preparingthe blades. Trans Am Acad Ophthalmol & Otolaryngol 56: 928, 1952.

Castroviejo R.: Improved needle holders. Trans Am Acad Ophthalmol &Otolaryngol 56: 929, 1952.

Castroviejo R.: New double—bladed knife for keratoplasty and other sur-gical procedures. Trans Am Acad Ophthalmol & Otolaryngol 56: 932,1952.

Castroviejo R.: La betatherapie dans la vascularisation corneene. LannTherap Ophtalmol 4: 289, 1953.

Castroviejo R and Casanovas J: Significacion de las afecciones focales y,especialmente, de las sinusitis en oftalmologıa. Arch Soc OftalmolHispano-Am 13: 237, 1953.

Castroviejo R.: Total penetrating keratoplasty. J Intern Coll Surg 21: 761,1954.

Castroviejo R.: Keratectomies—Retransplants. In: Corneal Grafts: B. W.Rycroft, Ed. Butterworth, London.

Castroviejo R.: New masks to limit the active surface of radiation on betaray applicators. Trans Am Acad Ophthalmol & Otolaryngol 60: 486,1956.

Castroviejo R.: Betatherapie en ophtalmologie. In: Therapeutique Medi-cale Oculaire. Sedan J Paris, Masson, 1957, p. 524.

Castroviejo R.: Contributions to keratoplasty. In: Problemes actuelsd’ophtalmologie. E. B. Streiff and J. Babel, Eds. Karger, Basel. 1957,p. 460.

Castroviejo R.: Indikation zu Keratektomien und Keratoplastiken. In: Au-genheilkunde en Klinik und Praxis. W. Rohrschneider, Ed. Enke,Stuttgart, 1958. p. 122.

Castroviejo R.: Selection of patients for keratoplasty. Survey Ophthalmol3: 1, 1958.

Castroviejo R.: Electrokeratotome for the dissection of lamellar grafts.Trans Am Ophthalmol Soc 56: 402, 1958 and Am J Ophthalmol 47:26, 1959.

Castroviejo R.: Suture marker for keratoplasty. Trans Am Ophthalmol Soc56: 409,1958 and Am J Ophthalmol 48: 255, 1959.

Castroviejo R.: Two new handles for razor blade knives. Trans Am Oph-thalmol Soc 58: 331, 1960.

Castroviejo R.: Symposium: Corneal Surgery. 3. Instrumentation and tech-niques of keratoplasty. Trans Am Acad Ophthalmol & Otolaryngol 64:775, 1960.

Castroviejo R.: Marker for variable size square keratoplasties. Trans AmOphthalmol Soc 58: 329, 1960.

Castroviejo R.: Instrumentation and techniques of keratoplasty. Trans AmAcad. Ophthalmol & Otolaryngol 64: 775–785, 1960.

Castroviejo R. and De Voe, AG: The Cardona keratoprosthesis: First clini-cal evaluation. Acta XIX Int Cong Ophthalmol, 1962.

Castroviejo R.: Recent advances in keratoplasty. Trans Canad OphthalmolSoc 25:98, 1962.

Castroviejo R.: Keratoplasty: Instrumentation, techniques, and results.Trans Ophthalmol Soc Australia 22: 34, 1962.

Castroviejo R.: Three new dissectors for lamellar keratoplasty. Trans AmOphthalmol Soc 60: 363, 1962.

Castroviejo R.: Four spatulated dissectors, for intralamellar surgery of thecornea. Am J Ophthalmol 56: 999, 1963.

Castroviejo R.: Keratome—sclerotome with micrometric calibration. TransAm Ophthalmol Soc 60: 359, 1962 and Am J Ophthalmol 56: 652,1963.

Castroviejo R.: Improved needle holder. Trans Am Ophthalmol Soc 60:357, 1962 and Am J Ophthalmol 56: 144, 1963.

Castroviejo R.: Electrokeratome with sterilizable stainless steel handle.Trans Am Ophthalmol Soc 60: 361, 1962 and Am J Ophthalmol 56:468, 1963.

Castroviejo R.: Latest approaches in keratoplasty. Japanese J Clin Oph-thalmol 18: 673, 1964.

Castroviejo R.: Surgical treatment of anterior synechiae before and afterkeratoplasty. Arch Ophthalmol 72: 245, 1964.

Castroviejo R.: Keratoplasties. Ethicon, Somerville, New Jersey, 1964.Castroviejo R.: Atlas of Keratectomy and Keratoplasty. W. B. Saunders

Company, Philadelphia, 1966 (Original Spanish edition: Atlas deQueratectomias y Queratoplastias, Salvat Editores, S.A., Barcelona,Espana, 1964.

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Cornea, Vol. 19, No. 5, 2000