Standing Up to Complications

In this episode, Gary Wörtz, MD, sits down with Ashvin Agarwal, MD, to discuss his experience practicing what he calls complication care management. Dr. Agarwal shares why he spends his days tackling some of the toughest cases a cataract surgeon could ever see and describes what it was like growing up in a family of ophthalmologist, starting with his first cataract case at age 16.

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

Most ophthalmologists strive to avoid complications. We pull out all the stops to ensure that our cases run smoothly and our days efficiently. Of course, the occasional complication is inevitable, but it makes for one tough day in the OR. But what if that was every day? For Dr. Ashvin Agarwal, it is. Practicing what he calls complications care management, Ashvin dives head-first into the type of cases the rest of us try desperately to avoid. At the AECOS Winter Symposium in Aspen, I sat down with Ashvin to hear about what it was like growing up as a fourth-generation ophthalmologist.

From his first cataract at age 16, Ash takes us along his journey growing up in ophthalmology and shares how practices differ between India and the United States. He also discusses why he really chooses to spend his days tackling some of the toughest cases a cataract surgeon could ever see. All in this episode of Ophthalmology off the Grid.

Speaker 2: Ophthalmology Off the Grid is an independent podcast supported with advertising by Alcon.

Gary: This is Dr. Gary Wörtz on another episode of Ophthalmology off the Grid, and today I am so excited to interview someone who's become a friend, someone I've long considered a mentor, Ashvin Agarwal from Chennai, India. Ashvin, I'm just so looking forward to hearing a little bit more about your story. We're all just amazed at the things that you're able to do with glued IOLs and all the crazy things that give me heart palpitations when I watch you doing them. With that being said, thank you for coming on the show today.

Ashvin Agarwal, MD: Thank you Gary, for having me here. What do you want to know? Let's go from there.

Gary: Okay, excellent. Well, let's dive right in. It's got to be a little bit difficult, and as I think about myself, if I were in your shoes, growing up with such a famous father who is a giant in ophthalmology and there obviously are probably some advantages, but also it's probably a little bit hard to step out of that shadow. Because he casts such a large shadow, and it seems like you have made that transition so seamless. Where in many ways, I think, some people now recognize you and what you're doing perhaps without even recognizing that there is a connection with your father, and you've made your own name so seamlessly. That, I think, is really interesting. I'd like to unpack that a little bit but tell me a little bit about what it was like growing up with a father who is a famous ophthalmologist doing great things. What was that like?

Ashvin: Well you see, back home, back in the day when we were young and we were 10, 11, and you starting to just understand yourself and you're trying to understand which way you want to go, what you want to do in life. It's not about life more than just what you want to do with it. You're at that point made to put blinders to ... and not in a bad way, but blinders to see the part. The part could be ophthalmology at that point, but the whole family actually chipped in. It was not just one person, it was my grandfather, the grandmother, everybody chipped in in their own little way of not brainwashing, rather than you know, "Come, let's go see a surgery."

Gary: Right.

Ashvin: Or "Let's go watch a patient being treated in the clinic," or "Let's go do a procedure, an investigative procedure," new machine comes in, "Let's go see what it is." It was a very seamless method, more than forcing the kids or things like that, that didn't actually happen. We didn't actually have any of these memories. When I say "we," we were four brothers at that point and all of us were in the mix of getting to know ophthalmology at a very very young age. At the age of 11 was when I entered the operation theater for the first time. Not surgery, but entered the operation theater. At the age of 16 was the first case, so it was first year of medicine and most countries, this would be illegal, but we anyways start it very young.

That was how it was growing up, but most important I think was the passion of the field of ophthalmology that came out. That kind of draws inspiration from the grandparents, the ancestral ... I'm the fourth generation in the family who's a ophthalmologist, so it's been awhile that the passion just drew and drew. At the same time, if your company doesn't do well, so you don't actually ... You're not motivated to go behind that same field. The company started doing really well at that point and that gave you the impetus to go one more step, let's do this. Let's go one more step. That was how it was growing up.

Gary: So it sounds like they never ... you never felt the external pressure, it was more that you saw a great opportunity to have a career and do something with your life that you saw that was very impactful. You probably saw how much your father and your other family members enjoyed it and you saw their passion. That's like a magnet.

Ashvin: I would probably answer this in two ways. One is I'll fill up that gap where ... how do you fill up the shoe of a person or how do you cast a ... how do you unshadow the shadow of a superstar in ophthalmology of sorts. I think the way I looked at it was I didn't look at it. Simple. I had to do what I had to do and what I had to believe in. If I didn't believe in something I would even go back and tell him the same.

Gary: How does he respond to that, when you have those conversations?

Ashvin: That way, I think he's been a very, very patient listener. At the same time, he's a very practical ophthalmologist. He would not put ego in the mix of this. If the procedure is good, he'll just say it's good. "Great, let's go for it." If the procedure is not or if he has hiccups in the procedure or in the investigation or in the idea or even in a technological idea which we have, he would squeeze a little bit and would try and give you those hints that no, this is not going to work. You would still do it and you would still go ahead with it and he would allow you and that is what actually helps. Because you have to understand yourself whether it works or doesn't work.

Gary: Right, so he gave you enough leash to find your own path and knowing sometimes you may agree to disagree on certain procedures but that the truth would eventually sort of find itself.

Ashvin: I think that's so important when it comes to innovation. When you want to innovate, you really need ... Nobody's going to back you, you just got to go for it, you got to try it out, and the disclaimer is you never know at the end how it's going to be.

Gary: That's right, that's right. What were the things in your career ... I know you as a guy who takes care of the worst of the worst cataracts and makes it look easy. You're someone who I really want to continue to learn from and I'm looking forward to learning more from you throughout our careers as they continue to track along. But at what point did you get interested in doing these crazy cataracts? Was it just that no one else was willing to do them and you said, "All right, I raise my hand, I'll go and take care of these things"? Or was it just that there was a need and you had to figure it out?

Ashvin: Okay, this is a long one, but I started my career as I told you, 16 when I started my first cataract. Then I moved on to refractive surgery when I finished my residency, post which I started feeling this need. When I moved into refractive, I said there's a vacuum, there's something left. I'm not able to complete this in my career. I started moving into cataract back again, but this time around I made a difference. I said I'm not going to do the run of the mill, I'm going to take complications of my own and other people who ... and do it in a way that probably has not been done before.

The reason why I did that was I was seeing ophthalmology move in a very different direction. People were moving towards compartmentalizing the eye. The eye is a camera, you can't treat the lens and not the film. You can't treat the film and not the lens. It's one apparatus, the whole apparatus has got to work in a constant together, like a clock. You can't have the seconds arm and not the minutes. It's got to work together. That's where I started understanding I was having complications and that was one of the main reasons. I was having ... I had nucleus drops, I had IOL drops, I had corneal decompensation, I had all kinds of problems.

So I started moving into complication care management and this is a niche segment which I personally like to call it. I don't think it's even existing in most of the setups, but this is something that I personally try to address. So I started doing transplants, I started doing nucleus drops, IOL drops, sulcus placement of lenses, PCR management, endothelial transplantation, DALKs, and anything that works, except for maybe retinal, pure retinal like RD or macular hole surgery. I would refrain from that because I think that needs its own kind of respect and training. But anything else, I think I wanted to achieve that for myself. It was not about, there was nobody there, it was my own intention to go and achieve that for myself, that was why.

Gary: And Ash, I think that's so admirable. A lot of times, as ophthalmologists, we just want to take the easy cases and pat ourselves on the back for a very low complication rate. But maybe we never challenge ourselves and we referred out all the cases that had some sort of challenge. But you saw an unmet need, you saw maybe a deficit in the skillset, either personally or in colleagues and you said, "No one's doing this, no one's doing enough about this," and instead of just continuing to complain about that, you just said, "No, I'm going to do it. I'm going to figure this out." That's really tough.

It's really tough when there's an easier path. The easier path is just to continue to do 20 or 30 cataracts every day and just push those other patients off to the side. But I think that it speaks a lot to your character that you realize that those people, their vision matters just as much as the other patients and if you don't take care of the least of these then no one else is going to. You're just leaving a hole and I just really appreciate not only that you stepped up, but now through your unique experience, you're teaching the rest of the world really how to take care of these patients in an amazing way.

I want to switch gears just a little bit. I think while we have you ... There's so many questions I want to ask, but in the interest of time, one thing I always love to ask is about an international perspective. We have our US perspective and as I've been learning from more international colleagues, I realize there's just so many more opportunities to do different lenses, for example. Different corneal refractive procedures. Other things that are maybe coming down the pipeline. Tell me a little bit about your practice in Chennai, the landscape there, and maybe how you see things being different. And then the second part, and I'll ask this maybe a little bit differently, but what products are you most excited about?

Ashvin: So I think there's a huge amount of difference in the regulatory and the legal aspects of ophthalmology in the two countries. That actually governs the way ophthalmology is moving in these two countries. If you take FDA in US, it kind of slows the process of innovation in this country and that actually hurts the whole ecosystem. I don't think it's a bad thing, if you ask me FDA is a good thing, I just wish they've speeding up the process. Because what happens is it's been two years since our technology would be available to any other part of the world and then it comes to US. Kind of is the ... those patients are kind of deprived of that technology which has proven itself already in many many, many eyes.

That, I think, is one of the biggest difference because if you ask me talent wise, I really don't see a difference talent wise. I have seen surgeons in the OR in the US equally or even more talented than the surgeons in India. The only difference I feel between the two countries would be that we just get more chances to do those cases rather than not do them. That's the only big difference in terms of the landscape.

Gary: Right. What about patients? We have patients who are ... those refractive patients who sometimes are a little bit higher maintenance and that's not necessarily a bad thing, we want to definitely meet our patients' needs, but there has been a trend that patients have become maybe more picky or more needy as we have advanced our technology. Are you finding the same trend in your market?

Ashvin: I think it's the same trend but the only difference is the minute you go into the rural areas of India, it kind of gets easier because the doctors in the rural areas of India kind of have a demigod status. So whatever the doctor says, they will just, "Sorry, you don't matter. Doctor says is all that matters to me, and he or she is the be all and end all." We even don't even know where they were trained, what they're doing. But at the end of the day, that's the status that the doctor gets.

Gary: I got you. All right, so following up on that earlier part of the question, what products in the pipeline, and you can answer this either way, either things you're using in India that are not quite yet available in the US that you're really, really enjoying or things that are in the pipeline that you're excited about using someday.

Ashvin: Oh, tough one. I'm actually very excited. I was very excited with SMILE when it came in and it's been a year and a half, maybe two since we've been using it and it's been around for a while even before we started using it. I think we were one of the late bloomers in terms of using that technology and it just got approved in US recently. These are things that could have been really ... come out here, they should have just come out faster.

Gary: Right. And so do you see in your practice a dramatic paradigm shift from mostly LASIK to now mostly SMILE?

Ashvin: Oh, definitely. It's gone more than 60%. There's a huge shift. It's not even funny. We actually ending up charging these patients double and they're still moving in.

Gary: Just to dig in on this a little bit, what has been the thing about SMILE that either you enjoy or you know these patients enjoy that makes it a better procedure or that makes you gravitate towards SMILE over LASIK?

Ashvin: Okay, so I'm a surgeon, so as a surgeon, it actually brings back the surgical element of refractive surgery, which I think was missing in LASIK or femto LASIK.

Gary: Right, you just press a button.

Ashvin: Yes. So that surgical element of dissection and finding that anterior lenticule and then the posterior lenticule, then grasping that and pulling it out, that kind of brings in the whole surgical element, that's why I kind of moved into it. But a lot of the other facts would be … one is the marketing is easier because you have a small incision, no subconjunctival hemorrhages, no pain, no dryness. It's one machine that does it all. It's just 23 seconds, it's not 20 seconds here and then 20 seconds there. It's none of that. Ablation is not there, it's one sweep in, sweep out. It kind of makes your whole process easier and you're able to take in more patients because your time is less. We have a high volume setup so it makes it easier for us to move things around.

Gary: That's awesome. Anything that you see on the horizon that you haven't had a chance to play with yet but you think could be interesting down the road?

Ashvin: I'm actually excited about the capsule laser we saw in the morning today, in one of the sessions. The capsule laser was kind of interesting because having a perfect capsule with just using your microscope kind of makes sense.

Gary: Right. The interesting thing about that is it's, again, one procedure, it's in the operating room, I think it's very interesting also and it looks like it's a very robust, very strong tensile strength capsulotomy. And I think that is very interesting as well.

I guess one thing I like to ask beyond just what you're excited about, we talked about this, do you have anything that you do on a daily basis, any morning routine that helps you actually get into the zone, so to speak? I know you operate a lot. Do you have anything that particularly you like to do to help you focus or stay focused throughout your day or in the morning that you feel like helps you?

Ashvin: I think I'll answer that with two birds, one arrow. I'm going to also answer the question, and I know you didn't ask me this, but I'm still going to answer it, of the failures. Because that kind of defines who you are. I always felt that whenever I start a case, I have to always think of the worst case that I ever did. I think that gives the process a little bit of sincerity. That could be a lot of things, when you go into surgery in the OR, there's a lot of things in your mind. Your wife screamed at you or your kid is not listening to you or ... so many things that happen at home or happen in the OR or happen even outside in the clinic, which kind of effects your brain during surgery.

Gary: Right.

Ashvin: But when you go into the microscope, it's a completely different world. You just got to think, "Okay, this case could go that way. That is not something that I want." So one of my biggest failures as a surgeon was when I was training, I had one of a mentally retarded patient who suddenly started moving on table. This was a small incision cataract surgery, was going pretty routine, but ended up with a nucleus drop. At that point I was a little more bullish or I would say foolish. So I went in and I was training for ... trying to do these more and more complicated cases. So at that point I started trying to get it from the retina. I closed the eye and I did a vitrectomy and the patient started moving more and more. It was just going a downward spiral which I was not able to control. And I did not have the courage to stop because there were people looking at me and there's now ego and a lot of other aspects which actually are negative at that point of time.

At that point is when my dad comes up to me and he just doesn't say a word, just taps my shoulder and says, looks at me, "What's up?" And boom, eureka, okay, this is ... this means get up, give the case off to someone else, move on. Watch what somebody else would do with a sane mind rather than do it yourself. Because that doesn't actually help and that's the day I started deciding to get up and give the case off if I'm struggling. I mean, you may be a great surgeon and you could go 20 years without a complication but the day you have that complication, something changes in the brain and your hands, your palms are sweaty, everything goes wrong and that's the time you just stop and say, "It's just not my day. Come, take over, I think you'll do a better job than me today."

Gary: Right, and I think that brings in a nice point, one of my [inaudible 00:21:00] told me that he would rather, if he were a patient, have a surgeon with average hands and excellent judgment than a surgeon with excellent hands and poor judgment. When we're training, that's when we're trying to learn when is it time to refer? When is it okay to press forward? That comes with time.

Ashvin: Absolutely.

Gary: I think that the lesson that you learned there is a lesson we all relearn in ways, from time to time. Ash, I think we could continue to talk on for hours and hours, unfortunately we're pressed a little bit for time today. You have a standing invitation, any time you'd like to come back and talk about a new technique, something that's just cool in your life that you'd like to share with other people. I always learn from you, I always become I think a better person when we get together and from bottom of my heart and I'm sure all the patients around the world that you're treating, thank you for being courageous enough to step outside of your comfort zone and figure out how do you take care of the patients who no one else will take care of? So my hat's off to you.

Ashvin: Gary, thank you so much for having me, Gary.

Gary: If you've not yet seen Ashvin's surgical videos, I strongly encourage you to take a look. There's a lot to be learned from watching him navigate these complex cases. We can continue to hope we never encounter them but also rest assured that surgeons like Ash are around us to show us the way, should we find ourselves in need.

This has been Ophthalmology Off the Grid with Dr. Gary Wörtz. For more episodes like this, visit eyetube.net/podcast and please be sure to rate, review, and subscribe. Thanks for listening.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.