Problem Solving in Ophthalmology

Surgeons tend to encounter unique constraints in ophthalmology-whether due to limitations with technology or the availability of certain treatments. Sean Ianchulev, MD, MPH, joins Gary Wörtz, MD, to share insights into the ophthalmic problem solving he has tackled throughout his career. Listen as Dr. Ianchulev explains how he approaches solutions to the problems that physicians face in the field.

Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid. An honest look at controversial topics in the field. I’m Gary Wörtz.

Ophthalmology is no stranger to innovation. In past episodes, we’ve heard from Drs. Malik Kahook, John Berdahl, and Damien Goldberg about their experience turning novel ideas into realities. Another physician who joins the ranks of these inspired individuals is Dr. Sean Ianchulev.

In this episode, Sean takes us along his journey in medicine, starting with his arrival in the United States at 18 years old. From there, he walks us through pivotal moments in his career and his pursuit to find solutions to myriad problems in ophthalmology and beyond. We’ll talk virtual perimetry, intraoperative aberrometry, MIGS, and more. Here’s Sean.

Speaker 1: Ophthalmology off the Grid is an independent podcast, supported with advertising by Alcon.

Gary: Today on Ophthalmology off the Grid, I'm very excited to be talking to a recently new friend of mine, Sean Ianchulev. Sean and I met, actually, earlier this year. Sean has just had an amazing life, an amazing career, and he's still young. It's really impressive to me to meet someone who's done so much in the years since residency and still has such a long track runway to go.

Sean, I hope that doesn't embarrass you, but we would really love to hear about your experiences on the ophthalmic side, both in clinic and in industry, and hear a little bit about your story. What has led you to take some big steps, some bold steps in innovation? Maybe we'll just kind of kick it off there. How did you get started in ophthalmology, and when did you start knowing that maybe innovation was particularly something you'd be interested in pursuing?

Sean Ianchulev, MD: Yeah. Wow. That's a big question, Gary, and I hope we don't have to go way, way back, but probably in terms of contacts ... Again, I just wanted to say first thank you for really making me part of this, and thank you for the interview. I think these series are great.

I think, probably, I would start way back, when I look in retrospect in my life, it's kind of all started about when I was 18, when I came to this country. I think I put that in the context of being young and immigrating from a country like Bulgaria, after living for 18 years in communism. Once you take the step and you come to a completely different country all by yourself when you're 18, I think that probably one is less worried about making missteps or taking risks.

As you said, I think many of the things that we do are a matter of calculated risk. We all make a decision one way or another. What I realized early on, as part of my training, is that I was really drawn to coming up with solutions and optimizing the process, optimizing technology. It was something that, ultimately, I think the pull is so great that we all tend to ultimately do or default to where we have the natural tendency to gravitate towards.

When I came here, I went to college at the University of Rochester. Then I went to Boston at Harvard for my medical training, where also I did a MPH in health policy management and finance. Frankly, this, to me, was an interesting part of my life, too.

When you go out of the purely medical domain, where we treat patients one-on-one, and when we look at out of physiology and pure science and you go to the public health side, which, to me, appeared ultimately very disconnected, like two separate parallel tracks where people exist in one world and the doctors in the other world. We do patient care, which I never really understood. When I did a Master of Public Health program, it really opened up my eyes to all the things we can do in a way that can scale very quickly. The delivery of care is really scalable, and also technology is really scalable. One can do so much by seeing five or 10 or 20 or 50 patients a day.

Actually, recently, when I was talking to the folks at Alcon who took over the Intraoperative Aberrometry technology, I think last year we reached about 500,000 patients who were touched by that technology and technologies like Lucentis, when I worked about 50 years ago, we had hundreds and hundreds of thousands of patients. That's scale, I think as you have also realized, is really achievable when you innovate and when you get involved in technology and you come out of the comfort domain of just direct patient care. That requires a very different skill set.

Gary: That's very interesting, Sean. It sounds like this MPH that you did actually set you up to start really analyzing problems from a global standpoint or trying to find solutions to big problems that could reach populations rather than maybe niche or orphan products that maybe could only apply to a few subsets of patients. In looking at your track record, that really makes sense. The things you've innovated have had that ability to scale pretty quickly and have touched lots of lives, as you mentioned.

You were in training in Harvard. After med school, at some point you got interested in ophthalmology. Talk to me a little bit about that.

Sean: Yeah. I was initially interested in ... That is always something that is a matter of jest between me and my friends, but I was initially heading towards obstetrics and gynecology until, in my last year, when I went through the rotations, I realized through my interaction with mentors and people in the medical school that I was kind of suddenly drawn to ophthalmology, which I didn't consider before.

After medical school, I went to Doheny Eye Institute at the USC at the time, which was a wonderful program and actually quite a shock as well, coming out of the ivory tower of very controlled environment into the LA County General Hospital, which had a very busy surgical program and some of the highest trauma level centers in the US. It was really enjoyable, just the pathway of understanding ophthalmology, treating patients, and honing your surgical skills. Even there, we were facing problems.

For example, one of the first things that we winded up innovating at the time with a colleague of mine, Peter Pham, who's an ophthalmologist in Texas now. We realized that, very often in the county system, patients would take about a month or two to get a visual field test at the time. We would send patients for a visual field test for glaucoma, and they'll come three months later when actually they got the visual field test. We decided to come up with a solution.

At the time, which was probably 18 years now or 15 years, you can imagine this is the time when most people didn't quite know what we can do on the Internet. There were no transactions on the Internet. We came up with a system for virtual perimetry. We virtualized the perimetry test, and we came up with one of the first cloud-based virtual perimetry, where we can do a, in the Internet browser, we can do a contrast sensitivity map and a full 24-2 perimetry.

That was the beginning of, actually, one of the very first products, called Peristat, that now I donated to the Keep Your Sight Foundation, which now does online screening for glaucoma by taking a three-minute perimetry test, which is an emulation of the office-based perimetry and something that we tested out at, actually, UCSF and at Stanford. We showed that, for moderate and severe glaucoma, which is 80% of the bread-and-butter undiagnosed glaucoma, it has a 90% sensitivity and specificity to pick up the defects.

It really started out with a problem. Despite a very busy residency program, we wanted to try to solve it. Again, it also illustrated that, even though this was something that, really, I had passion for and I wanted to solve, even at that time, it required collaboration and partnership with somebody else, at the time with Peter, for us to come up with the system, engage programmers, and in fact, in a very basic way, at the time, create one of the first virtualized perimetry devices which is cloud based.

I think just last year we probably screened 20,000 people with online perimetry. We've diagnosed people with brain tumors that didn't know they had them, and it's really because of something very, very interesting to see the power of telemedicine and internet and to be able to follow that through over the last 15 years, even with that very original device that we created many years ago.

Gary: Sean, real quick, where can people find that? If they want to link that on their website, is that possible, or drive patients to that? How can they find that?

Sean: Yeah. This is online. It's been there for many years now, four or five years. The name of the foundation is Keep Your Sight Foundation, and the website is www.keepyoursight.org. Interestingly, very different from the other technology, the intraoperative aberrometry, online screening took a different path.

Again, it was still innovation. We still developed something new, but I think ultimately I realized that this was not something that should be in the private domain. I realized that this is not something that should be a commercial enterprise, because screening and public health is inherently public. It's really hard to charge for it, and really, the benefit in the public domain and the public health domain was so much greater than keeping it as a private enterprise, doing screening and charging or flashing commercials. That's why, early on, we decided to donate the technology and put it into a bona fide foundation. I've been supporting that.

Again, it's something that we talk about digital health now a lot but something we created 15 years ago. It's interesting to see how telemedicine really evolves and devices in ophthalmology like perimetry are perfect for this, because you can really plug them and virtualize them and deliver them online in a very scalable way.

Gary: That's really interesting, Sean. I think a lot of times, in the American culture, we think about innovating as a mechanism to gain wealth or prestige. A lot times, we think about it in terms of gaining wealth. I think, a lot of times, the people I've met in my life who have had the greatest impact on their field, that is always something that, if it happens and you end up making a profit off of your work, you're happy about that. I think most people who end up being successful don't go into an enterprise with that being the main goal.

Obviously, we all need to be able to fund our projects and exits are great ways to keep that momentum going forward for future projects, but I think this is a really nice story about something that you felt like just needed to be done. You did the work because you saw an unmet need, and when you realized that it would be more beneficial to just be out there for the public to use, that didn't stop you or dissuade you from moving forward. You said, "This will just be a great contribution."

I don't want that message to be lost on other people, who may be thinking about innovation as a mechanism to gain wealth. I think innovation, and I think this is probably how you feel as well, innovation should be done for its own sake and to promote our field. Whether that means an economic good outcome or not, I think those who are passionate about it do it because they're passionate about it. What do you think about that?

Sean: Yeah. I think you're absolutely right. In fact, I would just add to this, as an extension to your thoughts, which I completely echo, is that innovation and innovating is a really, really, really hard way to make money. There's better ways. If somebody wants to just go for the economic part and is really interested in the pure financial profit, there's so many better ways to do that. In fact, we can argue that medicine, even, is a very hard way or a very circuitous way to go about making money.

Again, this is something I talk to my kids as well. If that is a driver, that's great. There are many ways one can approach that in a productive way, but going through medicine and going through innovation for the sake of enriching themselves, it's nice when it's a byproduct, for sure. It's nice to get paid, but I think if you talk to most people who actually innovate or try to solve problems and have been successful, at least the people that I interact with, almost everybody that I know would say, "It's great that you make money and it's great that you add to your bottom line and you can pay for your kids' education and so forth, but this is really not the driver." It becomes really frustrating if that's the driver as well. You end up missing some of the fine points and some of the intricasies which you have to follow. If you follow the money, it's not that easy to innovate.

Gary: Right. That's right. I think that's very, very well said.

Talk to us about maybe your second project. I think that was maybe the idea for intraoperative aberrometry. Tell me a little bit about that.

Sean: Yeah. I mean, again, this starts in residency. I'm on the faculty at the UCSF, and I often interact with residents. Whenever I interact with them, I think most of them are very surprised, like, how can you really start something in residency, because residency's a lot of scut work. You're learning, and frankly, you're really trying to make by and learn. There's so many things on your plate. For me, it did start and actually proved the point that you could start something that can turn into more than a ARVO project. We started that, I think, it was in my second or third year of residency.

It started out, again, with a problem, Gary, as you mentioned. We were starting to have some patients that were coming to cataract surgery that had had, at the time, they had had RK or PRK, which was more popular back then, and even some LASIK. It was just so frustrating to figure out, even in those days, we didn't have good formulas, but it was really frustrating to figure out what IOL power to use. Even if you do, you go through the end, and you find out you're wrong.

It really occurred to me, at the time, that if you take out the lens before you put the IOL, you have this very privileged state of the eye, which is the transiently aphakic state. Right off the table, we have the eye where we've eliminated the confounding effect of the lens. We have the pure optical system from the cornea all the way to the macula. We can take almost like an optical biopsy of the eye to figure out the total optical deficit. That was just an idea, and I wasn't really sure how to approach it until it occurred to me, at the time, because we didn't have the ORA device and we didn't ... That was way later in terms of development, but how can you go out and very quickly prove that out?

In fact, the way we did it was I took the Nikon Retinomax, which is a portable autorefractor. In some of my cataract case, I think there was 15 or 20 cases ... Actually, the case series we published, that was the first time in a publication for intraoperative refractive biometry at the time. We did 20 cases or 25 cases where, right at the time after the cataract extraction, I would stop. We would actually have to make sure sterility was maintained, and we will take an optical reading, an autorefraction, and we'll obtain the spherical equivalent, aphakic spherical equivalent.

Very quickly after I did about 15, 20 cases without having a major in biostatistics, I realized there is an actual correlation that becomes apparent very quickly between the aphakic spherical equivalent and the final refractive outcome. Really, I started reading up on that. Obviously, there were aphakic formulas that were done for clinical use, but again, really nobody had taken an automated refractive reading biometry into the OR and do that.

Again, there were a lot of people that were very skeptical. They said, "You'll never be able to get a reading," or, "It will not work," or, "They'll have some sort of distortions on the cornea." Again, like everything else we do, there are a lot of people who are extremely bright and very reasonable. They come up with a lot of good ideas of why something shouldn't work or it wouldn't work. At the time, I also had good friends like Bob Sinskey, who was a good friend of mine, and I also befriended and became close friend of Ken Hoffer, who was really one of the pillars in IOL calculations.

It was interesting, because even people like Ken, who were part of the establishment who drove the knowledge where and that were the experts of IOL calculation with preoperative methodology, he understood the potential here that we can go in a completely different level and move the curve. If you imagine all of the formulas of preoperative biometry we've been using, they come back from Fyoderov, from the '60s and '70s. They're about 50 years old. We're using old Russian technology that has been perfected, obviously, with different formulas, but the bottom line is the biometry that uses the keratometry and the axial length through preoperative measurements is something that's been around since the '70s.

Again, I think we realize quickly that just because we have that privileged state of the eye when it's aphakic, transiently aphakic and we can do that reading, we can capture something new, and then we can correlate it and derive a very powerful IOL estimation method. It turned out exactly as we thought. We found out it is extremely useful and predictable for naïve virgin eyes that haven't had any refractive surgery, and also we found out that it really helps nail down the IOL prediction in eyes that have had prior refractive surgery.

Again, we just published, I think, not long ago one of the seminal papers with intraoperative aberrometry in post-refractive eyes, where we're coming exactly ... In the old days, about maybe 30 to 40% of the eyes were within .75 or 1.00 diopter if they had prior refractive surgery. We're coming back on 90% and plus. We've been able with this technology to solve one of the most challenging, I think, problems, because those millions of patients who have received LASIK, as you can imagine, are now marching towards the cataract age.

We really need the tools to give them the vision they expect, because as you know, they already paid for their LASIK. They hope that that didn't really, in some way, jeopardize their cataract surgery 10 or 15 years down the road, because really that wasn't a risk that anybody ever told them about when they got their LASIK. It was really central that we, as ophthalmologists solved that problem. I think right now we have the tools, and intraoperative aberrometry is one of it.

Again, the technology took its different course. It ended up not being in the public domain. As a holder of all the patents for aphakic autorefraction, which really covered the whole spectrum, which I wrote as a resident at the time with very little legal help, those were developed by and I licensed them to WaveTec. WaveTec did a brilliant job, really, the engineers there and the team, with a lot of hard work to develop the ultimate device that we know had several lives. It illustrates that ultimately, even if you have a great idea and you can quickly validate it and get a read, which we did about 15 years ago, it took another 15 years and probably close to $70 million of venture funding to get it to where it really became introduced in our lives and in service to patients and physicians.

Again, I think one realization or another take-home point, Gary, as you know with your company as well, as you're doing this, that ultimately it's really hard to do things in the garage and then take them out. In the old days, people would do their own instrument. I keep laughing with Bob at the time, like, "The Sinskey Hook was really successful. It's everywhere and everybody knows it.” These days, technology and innovation is way more complex and requires a lot of validation. It requires a lot of quality processes, and it requires a team. Unfortunately, it requires capital.

I think we as innovators, and I've been on both sides, on the venture capital side funding companies and on the innovator side where you realize always you felt like you probably deserved more than the venture capitalist will give you ... Ultimately, that path is, again, with the WaveTec you can see, it took about a decade and millions of dollars and ultimately no guarantees until you're finally there. It was good to see the technology come through, but definitely as being one of the pioneers and the original founders of that technology, I wouldn't want to take the credit for it because there's been a lot of work by many, many people.

Actually, there is a lot of work now that is going to go into perfecting it and even making it better. One thing I realized that what we built at the time and with the ORA device, it's probably one of the very first, if not the first, intraoperative biometry device or biometric device that is an extension to the scope. What we're going to see in the next five or 10 years, we're going to see that the microscope and the surgical suite, it will turn into a cockpit where is going to be a lot more biometric devices or refractive devices and so forth. When we started, there was nothing. It was really a challenge to figure out how to get it on the scope, how to make it integrated with the system. It's not perfect, but it was first or one of the very first devices that kind of started, I think, the whole diagnostic imaging and automated biometric integration in the surgical suite intraoperatively.

Gary: Sure. One question I have from that story is: You were a resident. You wrote the patents. You did a little validation project with a Nikon autorefractor, and you got the patents. You said at some point you licensed that technology to WaveTec. How does that occur, or how did that occur? Give me some sort of a roadmap for someone maybe who's a resident right now and has an idea for a new technology. They may be doing the same kind of thing, trying to write a provisional patent or a utility patent. Maybe they've even done a poster project at ARVO, and they've proven that there's something to this concept. How would you coach someone through trying to find a good partner to help take your technology and shepherd it through the approval process?

Sean: Yeah. I mean, I can tell you that I personally have advised so many people, whether they're residents or not, but in general, colleagues who have ideas. I think that it's really not a cookie cutter process. I wish I would say it is. The best and the most important thing, I would say, is manage expectations because I think that's where it breaks down the whole deal. It breaks down innovation. If you manage expectations, I think, and you realize that you as an inventor or whoever comes up with the idea is not the beginning and end of that, I think it's much easier.

I think probably for many of them who are inventing and innovating, if they kind of look at the history of some companies and technologies and read about them, maybe that would be the best thing that they can do to realize what goes into bringing those things to life and how many things actually fail. That would certainly help people understand the other side, because there is another side where investors and companies lose a lot of money. The statistics are maybe 80% of projects or venture-funded companies don't succeed. That is the other side of the coin.

I think that there are a lot of law firms, obviously, once you get to the point of having an expressed interest from a company. I think one should always engage a law firm and not sign, obviously, anything until you have legal counsel, because those documents are complex. Obviously, the companies have a lot of legal advice.

Manage expectations, number one, very, very important, and that's more of a holistic-type answer for everybody. Then the second is when there is something on the table and an understanding that, yes, I would like to work with this company, do get the advice of a legal counsel, a IP counsel. Of course, they're not cheap, but I think they're well worth it when you get to that point. The way you sign or the way you have the contract will determine, really, the fate of that technology and also the fate of your economics.

Probably the third thing I think that's very important is really to look at the company and not only focus on the money factor. Maybe some companies will throw you more money upfront or a higher rate. Just really assess the ability of the company to deliver and the team behind the company, because there is a lot of times when people license technology and it doesn't see the light of day because the companies couldn't develop it or they couldn't execute and so forth. That is sometimes even more important, because getting a few percentage points lower on your economics is okay when this thing is successful versus having all of it when it doesn't go anywhere and there is no economics whatsoever.

Gary: Right. Yeah. Having 100% of nothing is not a great deal, is it?

Sean: Absolutely, absolutely.

Gary: Sean, I'd love to hear a little bit more about your journey with Transcend and the CyPass. That's a device that I think, as cataract surgeons, we're all really excited to learn more about because of its recent approval. It's launching right now. Here again, it's another technology that you've helped develop that solves another big unmet need. I'd love to just hear a little bit about where that idea maybe came from and, again, a little bit of how you walked through that development process.

Sean: Yeah. I mean, again, I think many of the technologies I've been involved in different capacities, some of them as innovator, other as inventor, and others as developer, and really whatever it takes to really spearhead and get the technology to fruition. Ultimately, I really don't feel that the fact that a technology is yours is what matters. One can get on the bandwagon and drive innovation in many, many ways. As you know, Gary, you're a pioneer using cutting-edge technology that may be developed by somebody else, but you help make it better. That has a significant value.

Before even Transcend, I actually went to Genentech and I was there for about six or seven years, which was a really great experience, too. When I went there, Lucentis and Genentech were really a product and company that weren't heard in ophthalmology. It was still in the research and development days. We launched Lucentis, and to me, that was actually another great innovation, which was in the retinal space. Again, I've been able to go from one place to another in terms of innovation. Innovation could be in glaucoma, but it could be in retina and it could be in cataract surgery today or tomorrow or in something else. Through the venture of business, I've been exposed to and been interacting with people doing innovation outside ophthalmology.

Again, Lucentis was an interesting product. I headed a group there towards the end when I left in 2009, and what was very interesting is I was kind of coming to terms. We've already launched Lucentis. I was helpful in engineering the programs for diabetic macular edema, retinal vein occlusion, and so forth. I said, "That's a maturing product. I want to be back somewhere looking 10 years out, because I really enjoy that part." Once something already becomes commercial and mainstream, I realized this is not the part that I really love. I was looking for the next stage coming out of biotech and of a extremely successful product as Lucentis.

Again, one of my friends and family friends and mentor, Gene de Juan, who had started working on Transcend and very early work with the CyPass micro-stent said, "Sean, I would really need some help. This is a company where we're at the point of coming out and we need a very efficient team and expert team to develop it." That was really at the stages when a company's just in technologies really coming out of the garage and had been fostered by the ForSight incubator.

Again, when I looked at that, and in fact when I talked to some of my glaucoma friends and specialists, colleagues, they all said, "Really, we have trabeculectomy. That's really working well." Many of them were completely puzzled by why would we do something like this and why would we put an implant in the supraciliary or suprachoroidal space at the time, as we thought. Again, the feedback I got from friends and family was, in fact, discouraging in some ways because …

Gary: Really?

Sean: Yeah, because most people really ... I mean, MIGS really didn't exist at the time. There was maybe one other product I had with the Glaukos, but again, this was still the technology was way out of the mainstream. Again, most people simply couldn't quite see the value. It wasn't that apparent until you kind of figure out that, when somebody tells you that we've had something for 70 years and it seems to be working okay, and when I have trabeculectomy patients coming a month after surgery not very happy, I just said, "First, these are statements that didn't reconcile." They didn't compute, because (A) trabeculectomy patients are not okay and (B) after 70 years, maybe it's time for something to change.

Again, I think that I took a risk. There was really nothing to kind of stand on except for the fact that I knew, as a clinician, that cyclodialysis was a really good way to lower IOP. If we can snip it open, it's a really good way to approach IOP lowering. Then if we put an implant there, which will keep it open, that's actually great. That would give us a good purchase on IOP lowering.

Again, you have to trust your gut and intuition. Gary, as you know, with many of these things, it's much easier if you're a clinician and kind of have a sense of what might work and what wouldn't work than if you're, say, somebody that is a finance guy or a commercial guy.

I really started working with Transcend and spearheading the development program, all of the research and development there with the team. We had a phenomenal team, and frankly, it was a lot of fun. It was one of the best and one of the hardest things we've done, because, again, maybe another learning point for this is when you come up with a new technology, always ask yourself, "Is it just a new technology, or is it a new category of treatment?" MIGS, in general, is a new category of treatment. Lucentis and anti-VEGF is a new category of treatment. Intraoperative aberrometry is a new category of treatment. It's not just another antibiotic. It's not just another like anti-VEGF now or just another IOL.

That, to me, really is very important because creating and coming with a new categorical treatment paradigm is extremely difficult and ultimately it's immensely more complicated because you have to figure out everything as you go. There's not that many things that really you can follow. The regulatory path and the development path and the clinical science you have to do. It's a complex development, because doing a PMA with one of the largest clinical trials in surgical glaucoma, that was then with Transcend, is huge. There was definitely no cookbook to that, and again, something that requires high expertise, dedicated people and a lot of capital.

That, actually, turned out very successful. The technology, we just published the results in the Journal of Ophthalmology. Again, I can tell you, you never know how things will turn out. I've been kind of lucky that pretty much most of the technologies I've been involved really turned out fine. I don't know what it is, because I'm sure I'm going to make a mistake next time. I think, ultimately, all of these technologies could have failed in a big way if we didn't have the right people thinking through how to develop them, how to improve them, and how to make the idea turn into a solution and then the solution turn into a product and then the product turn into a business. All of these things are necessary in order to have a great company and a great technology that comes out.

Gary: That's very well said. All those things are true. You can have a great solution that, at the end of the day, doesn't pay for itself. Those are products that aren't good business, very true.

I want to give you a little bit of a chance, here at the end, to talk about your latest invention and company, the MyLoop. This is actually how you and I met. I was invited to take a peek at this technology. It looks really, really interesting to me and really, again, trying to find the niche to solve an unmet need. Tell us a little bit about this, if you don't mind.

Sean: Yeah. I'm just trying to think, as you were asking me, and I probably should have known you were going to ask me about this because I'm not sure how much is in the public domain on that yet. I will actually say one thing, stepping back a little bit. Again, I started with perimetry in glaucoma. Then we went into the cataract refractive with ORA, then Lucentis in retina, then glaucoma with MIGS.

It was interesting that phaco, what we do every day as surgeons, which has been so successful, has been around for 50 years. Actually, Anne Coleman and I were talking the other day in an ESCRS Foundation board. We're kind of getting excited about next year, because next year is going to be 50 years of phaco. That's a huge milestone. If you look at, for example, things like computers and mobile phones and internet and all that, very few things actually last through 50 years. Phaco has been extremely successful, but at the same time, it's kind of like trabeculectomy. We're still pretty much doing cataract surgery the way we've been doing it for 50 years.

Again, we are serving the population well and it's great, but I do a lot of missionary work. I can tell you that phaco is really, really challenging. It's not moving the needle when it comes to the hard cataracts or the third world. Also, in the first world, it still introduces a lot of undesirable energy and leads to endothelial cell loss and all kinds of things like that, which we know. Kind of the assumption behind femto has been let's try to use that to reduce phaco energy for all good reasons.

I think where we are with MyLoop and also with the micro-interventional aspects is that, having worked in micro-interventional technology with glaucoma and great engineers who have a lot of experience from the cardiovascular space, one thing we realized, there is a lot of innovation and a lot of things from interventional radiology and cardiovascular medicine, from the micro-interventional aspects, which haven't trickled down to ophthalmology. You can see we're still doing capsulorhexis in many cases with the forceps, as has been done more than 50 years ago. We're still doing phaco with the same way and the same probe as 50 years ago. Yet people are now putting coils and they're putting all kinds of stents all the way to your brain and in your heart.

All I'll say about what we're working on next is that I think we are on the threshold where technology and innovation outside ophthalmology in those fields is becoming really pertinent to cataract. We can probably change the paradigm there too or improve phaco tremendously to make everybody a great phaco surgeon, to make phaco even more adopted globally. Potentially in the future, to go beyond phaco, to be able to reduce or eliminate the energy that we deliver in the eye to take out the cataract.

Again, you kind of pursue innovation where it is. Hopefully, we'll be successful here. We have a great team. I think this is one of the technologies I'm working on. We have another one also called Innovia, which I don't think you and I probably talked before, which does micro-delivery or micronization of therapeutics. It uses Piezo print technology so you can print the drug on the ocular surface by delivering exact micro-doses versus an eyedropper.

That's another thing that, when I look at it fundamentally, we've been giving drops to our eyes and to patients' eyes for 200 years exactly the same way, with a pipette. That's not a good way to do it. We've come up with a technology just like in the ink jet printers that uses Piezo ejection and can literally spray the exact micro-doses of 5 or 8 micro-liters, which is the entire tear lake that's necessary for the ocular surface. You can deliver all these eye drops in the eye before you can blink, beating the blink, in the same way as ink jet printers deliver very precisely print and ink to the paper to really pixelate the picture. I think that those two are kind of the technologies within ophthalmology that I am intimately involved.

I'm excited because, again, these are big areas where, if we're successful, we can, A, change how every drug is delivered. In fact, this technology has smart elements. It syncs with the phone, and we know when the patient gave it. It has a lot of benefits of really 21st century delivery of medication.

The other part is really moving the bar forward and pushing the envelope for cataract surgery, which has really improved, but it's kind of like pre-op biometry. It has improved, but it really goes back 70 years or 50 years. It's about the same thing we're using. The chassis is the same. We're putting a little bit better things, but maybe it's time for a Tesla. Maybe it's time to really get rid of the engine and put something new, because only then you can majorly inflect the curve by really mounting a new technology curve and taking off. We'll see, but it's exciting.

Gary, I really think all the work that you're doing on your IOL and how you're approaching this is really great as well. We hope to see a lot of new technologies on the horizon, because I think now, also, the FDA has become a lot more efficient. I think we have a real opportunity to partner with them and partner with the clinicians to get these technologies out in a expedient way.

Gary: Sean, I really just want to say thank you for giving us a little bit of a peek into your history. I've learned so much. Every time I talk to you, it is a real learning experience. I knew that the people who listen to this podcast would love to hear a little bit about your journey. It sounds like disruptive innovation and early-stage disruptive innovation is really where your sweet spot is. That's where I love to innovate as well, taking risks, making big changes, kind of resetting the deck and then letting other people make incremental improvements through the year.

Sean, you have an open invitation on this program. If you ever have something you'd like to share with us, a new technology, some new ideas, just give me a call. We'll get you right back on the podcast, because disruptive innovation is something that we all need to be cheering on, both as innovators and just fellow clinicians. Thank you so much for coming on the program.

Sean: Thank you, Gary. Let's innovate in 2017 and beyond.

Gary: That sounds good.

For more insights into the minds of ophthalmology’s innovators, check out our previous episodes at eyetube dot net, backslash podcasts.

Thanks for listening to another episode of Ophthalmology off the Grid. If you like what you hear, be sure to rate, review, and subscribe, and let us know if there are any topics you’d like to delve into. This has been Dr. Gary Wörtz. See you next time.