Ambition, Aberrations, and Amor

Karolinne Rocha, MD, PhD, recounts her ophthalmology journey to Gary Wörtz, MD, and shares her experience training in Brazil and then retraining in the United States. Listen in as Dr. Rocha discusses her insights into spherical aberrations, premium lenses, and the importance of efficiency in being a successful practitioner, partner, and parent.

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

We all have moments in our training and in our careers that test our dedication—these stressful events try us in ways that often require us to, in a sense, recommit to our commitment to ophthalmology. It’s not to say we don’t love what we do; it’s just that sometimes, the going gets really tough.

When I first heard about the journey Dr. Karolinne Rocha took get to where she is today, there was one word resounding in my mind: ambition. Karolinne has an amazing list of credentials, contributes extensively to our understanding of optics, serves as an active mentor, and, above all, is a dedicated wife and new mother.

In this episode of Ophthalmology off the Grid, Karolinne takes us on her journey from Brazil to the US, recounting the challenges she faced along the way and the mentors who helped in her pursuit. She also sheds light on spherical aberrations, premium lenses, and the importance of efficiency in being a successful practitioner and parent. Up next, Karolinne.

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

Gary: Today I have the pleasure of speaking with Dr. Karolinne Rocha, and Karolinne is one of those people that when you meet, you instantly gravitate towards, you want to hear more about how she takes care of her patients, takes care of her family. And as I got to learn more about her story, I realized that as much respect as I had for her on the surface, there is so much more beneath the surface of how she got to where she is today, and so I thought it would be a fantastic idea to have Karolinne come on and talk about her journey and sort of what's exciting her about ophthalmology today. So, Karolinne, thank you so much for coming on and being willing to talk with us today.

Karolinne Rocha, MD: Hi Gary. Thank you so much for having me. I'm excited to be here and to talk about my story.

Gary: Yeah. So, let's just start out about maybe when you decided living in Brazil, that you were interested in ophthalmology. I know that you got your PhD and your MD, so just give us a little bit of a back story of your early interest in ophthalmology. Maybe we can just kind of start there.

Karolinne: Yeah, so during med school, I knew I wanted to do something surgical subspecialty, and I had an opportunity, I had a rotation in ophthalmology, and I was just in love with how you can just you know, look at the eye and make the diagnosis. Like this patient has diabetes, or it's a hypertensive patient or toxoplasmosis, the lesions are so typical you can just make the diagnosis and treat the patient. So, yes I was fascinated with cataract surgery and transplants. I might think that's why I decided to proceed and to go into ophthalmology.

Gary: So, did you have your PhD ... when did the PhD start, was that during residency, was it before residency? When did you do your PhD? I guess I don't even know that story.

Karolinne: Yes, so in Brazil, it's a little bit different. I know here, some programs you can do your MD in PhD program. In Brazil, you can do actually after your residency.

Gary: Okay.

Karolinne: Yes, but it's nice because you can focus; for me, for example, my thesis was on wavefront and IOLs, so, it was really perfect because it's something that I'm passionate about. It's something I'd been studying for a couple years.

Gary: Yeah, what a great opportunity to really dive deep into something that's going to affect your patients and your career for the rest of your life. So, you had the opportunity to go to med school, figure out that you were passionate about ophthalmology and optics, and you did your PhD after residency? Is that correct? You did your residency, and then you did your PhD.

Karolinne: Yes, so I did my training in Brazil in Sao Paolo at UNIFESP/EPM, one of the best programs in Brazil. Great training, and then actually, after my residency I started a PhD program. It's really nice because you kind of do a fellowship and your PhD at the same time in Sao Paolo.

Gary: Oh good, okay. And then you did ... how many fellowships have you done? I've heard, but I want to confirm the number. How many fellowships did you actually complete?

Karolinne: Okay, so I finished my training in 2005 in San Paolo, and actually during that first year, I did glaucoma, so I did glaucoma. Very old school, lots of trabs and tube shunts, and then after that when I was planning to apply for the PhD program, I started doing some research on IOLs and wavefront, and, during my PhD, I was working in the cornea and refractive surgery divisions in Brazil.

Gary: So, you sort of did a cornea refractive fellowship during your PhD, it sounds like?

Karolinne: Yes.

Gary: Okay, and then at some point, you decided it was time to come to the United States to get some either additional training or ... walk me through your decision to come to the US.

Karolinne: So, in Brazil, we have an opportunity to apply for a grant for your post-doc, during the PhD training. I said you know, it would be a really great opportunity to come to the US for one year.

Gary: One year only.

Karolinne: One year only, and then I was planning to go back to Brazil. So this was back in, I would say end of 2007/2008, and then I applied for this grant and I got the grant and I was very excited, so that's why I then moved to Cleveland, to the Cleveland Clinic.

Gary: Okay, so you did a year there and something happened that made you want to stay.

Karolinne: I know, here comes trouble.

Gary: So, at some point, something happened that made you want to stay and probably could talk to George about that at another occasion, George Waring IV. So, you decided to stay, and then you must have had to do the calculation that I'm going to have to go through this all again.

Karolinne: Yes, so I actually, I had a great opportunity at the Cleveland Clinic. My mentor, Ronald Krueger, I had an opportunity to work with B.J. Dupps, and Dr. Steve Wilson, just really great, great mentors. I'm very thankful. Then I had initially a grant from Brazil, right, to stay one year, but with the Cleveland Clinic, they offered me to stay one more year. It was really nice; I was doing some projects, working with adaptive optics technology. At that time, Dr. Krueger was finishing the wavefront-guided trial, so it was really great. But then, yes, that's true, that was when I met George, and everything changed because I was supposed to go back to Brazil.

Gary: Right, right. So, you said, okay, at some point you said, so I'm going to stay and I'm going to re-train, and that had to be a pretty big decision?

Karolinne: Yes.

Gary: To be willing to re-train.

Karolinne: That's true, and then George was finishing his training in Kansas City with Dan Durrie, and he was planning to move back to Atlanta, and then I had an opportunity to do actually another fellowship in cornea refractive at Emory University with Dr. Brad Randleman and Dr. Stulting. Again, great, great mentors. Then when I was deciding, should I go ahead and re-do my training? So, it was really hard to take all the USMLE, right? Step one, step two, step ... the CKCS, and then step three.

Gary: Right, oh my gosh. And then you had to repeat your intern year as well, correct?

Karolinne: Yes, yes and then I was extremely, extremely happy I matched with the Cleveland Clinic, and then I did one year of internship as well. It was really, really hard.

Gary: Yeah, oh my gosh. So that's why you know, it's really interesting, you can hear people talk and realize there's sort of different layers to what they're talking about, and I picked that up pretty quickly when we had had conversations about things and knowing all of this back story is, I think, very, very interesting. I'd be interested to get your take on the differences in training in Brazil versus the US, and we had a conversation about this a few months ago and you really had some great stories about both training there and also you helped train residents for a while down there, is that correct?

Karolinne: Yes, yes, yes.

Gary: So talk to me about the differences. What did you like about one system versus the other? I'm sure there were disadvantages or advantages of either, so ...

Karolinne: Sure, that's a great question. I think in Brazil, same as what we see in India, we have a really, really high volume of surgeries. The surgeons are fantastic and very creative just because all the really hard cases that we see in Brazil and I would say in India. I think a third-year resident is really, you've seen a lot of complications and how to do deal with complications. I would say maybe this is number one. In the US, the technology that is available and how you really, really need to study hard, like genetics, neurophthalmology, pathology. I think it's a really great combination, and I think I've learned so much during my second residency in the US, for sure.

Gary: Right, so maybe some strengths and didactics and some of the standards, but also some strengths in Brazil on the experience side of things, where you really are expected to be able to handle all sorts of crazy situations?

Karolinne: Yes, and then there's a funny story. I remember we had this huge room with ten beds and everybody doing cataract surgery at the same time, and we had our retina guys doing vitrectomy in the corner.

Gary: And what did you tell me, the retina guys are sort of really like excited when they got a chance to jump in and do a vitrectomy and when things didn't necessarily go perfectly, it kind of gave them an opportunity to have a chance to operate?

Karolinne: That's true, the retina fellows that usually just walk around and say, "Do you have anything for me there?" They were just waiting for a dropped lens, and they were ready to go and we'd just move the bed from one side to the dark side of the room.

Gary: The dark side, that's exactly right. Well, Karolinne, you've done so much research. I want to get in a little bit deeper. I love hearing your story, and it's really inspiring, all the work you've gone through to get here and it makes me appreciate ... I thought my road was tough. It's nothing compared to what you've gone through, but talk to me a little bit about what is exciting to you in ophthalmology. What keeps you engaged? Maybe talk a little bit about your research. I know you've done a lot of work in pseudoaccommodation? So, talk to me about what you're still excited about and what really motivates you right now in ophthalmology?

Karolinne: Yes, I think my research actually started in Brazil. My mentor, Wallace Chamon had this idea to measure patients with aspherical lenses and, at that time, we were never just launching the aspheric IOLs ... at the same time, I had the opportunity to work with adaptive optics technology that you can measure wavefront aberrations, and then correct the aberrations, and then simulate what happens if you give a little bit of spherical aberration or a little bit of coma, can you expand the depth of focus? We published lots of studies, and I continued to work on this area, but I think my goal is, especially when I'm seeing patients now, what is the best technology for that patient?

Gary: Yeah, talk to me about that. What are your working theses on maybe one type of patient that would be better with monovision or one patient that would be better with EDOF or who is better for a multifocal? What are your thoughts on that, if you have some?

Karolinne: Sure, I look at I would say the corneal profile, right? Is it a patient that has a lot of positive spherical aberration? I look at the pupil size or someone that had a myopic ablation or a hyperopic ablation, and then I try to match the best lens. For example, if I see a patient with keratoconus or a lot of coma, I may select just an aberration-free lens.

Gary: Right.

Karolinne: Same for a patient that had a hyperopic ablation, that has a lot of negative spherical aberration to start with. And then I know that negative spherical aberration enhances the depth of focus. These patients, again based on our study, sometimes if you use an aberration-free lens, they can see distance and near. They have a really good extended range of vision.

Gary: Because of that pre-existing negative spherical aberration from their hyperopic LASIK?

Karolinne: Exactly.

Gary: Very interesting.

Karolinne: And then now, we know again, when you're talking about premium lenses and all the newer lenses, Symfony, Active Focus lenses, you still need to look at the topography and try to rule out patients with really high, high-order aberrations, especially coma, you want to make sure that patient is a good candidate for premium IOLs.

Gary: So coma, it sounds like coma is one of those things and I've heard this and we use this as well, but that seems like a thing you're very much keyed into when you're looking at patients, potentially for multifocals, for example?

Karolinne: It's a great point, because we know that general rule you know, if the higher-order aberrations are greater than 0.5 or 0.6 RMS for a 6-mm pupil, you should not do a premium lens. But one thing that I've learned while doing research with adaptive optics is that some aberrations are worse.

Gary: Right, not all aberrations are created equally.

Karolinne: They are not the same. If you look at the Zernike, right, the pyramid. Basically if you are adding a coma versus sphere corroboration or trefoil, we know that all aberrations right in the center of the Zernike…

Gary: Right.

Karolinne: They are worse.

Gary: Right.

Karolinne: So, including defocus. So defocus and spherical aberration, so I remember when we're testing, sometimes if you give trefoil or generating quadrafoil, the patients, they still can see and the same amount of coma, they lose lines of vision.

Gary: That is a really great point that I think we need to keep in our minds, that not just looking at the RMS number, but actually looking at which Zernike polynomial is making up the majority of that. That makes a lot of sense.

Talk to me a little bit about, you're obviously someone who works very hard but you have a family and I'm sure you have other interests, and it's really hard for the best of us, with less going on, to keep life working and trying to figure out this whole balance, the work life balance. How does that work for you? What are your philosophies on perhaps taking on new projects or saying no to things so that you can devote time to other opportunities? You're someone I respect so much, not just professionally but personally. I would just love to learn from you of how do you go through figuring out opportunities to dive into and then also opportunities to say no, I need to have some time for myself?

Karolinne: Yes, we have a little baby, George the Fifth.

Gary: Yes, absolutely. We're all excited to watch him grow up in ophthalmology, so yes.

Karolinne: We're really busy but I've learned to be very efficient. When I'm done my OR days, usually I finish around 2, 3 PM and I go straight home and sometimes you know, when the baby's taking a nap, I'm like finishing up a paper, and I know I have that 1 or 2 hours, I need to get things done. But it's really important. I think family's number one. Some meetings, sometimes I wish I could stay for the whole thing, but several times I just fly in for a talk and I fly back home.

Gary: Right.

Karolinne: So, it's really ... but I think family is number one.

Gary: Yeah, well I totally agree, and it is all about being efficient and realizing you don't have the luxury of being lazy, you know? Sometimes we just want to sort of do a little bit of nothing for a while, but when we're efficient, if we don't have that luxury, it really does drive home that point that being efficient and using your time wisely, that sort of thing, is most important.

So Karolinne, I just want to thank you so much for coming on and sharing a little bit about your story. I think it's something we can all find ways to relate to and also again, when I think of you, I think of someone who I just tremendously respect and I learn from, so thank you for teaching me a little bit and sharing your story today.

Karolinne: Thank you so much, pleasure to be here, and we are always open for you know, students, new residents and open for questions. Even though, sometimes people they call me from Brazil, you can do everything you want to do.

Gary: I love it.

Gary: Karolinne’s dedication is an inspiring reminder of what it means to be committed—to our field, our practice, our patients, and our families. I can’t image training and retraining, but on behalf of everyone in ophthalmology—Karolinne, we’re sure glad you did.

That’s all for this episode of Ophthalmology off the Grid. If you like what you hear, be sure to subscribe. Also, your feedback means more than I can say, so please log on and leave us a review. Thanks for listening, we’ll see you next time.

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