Seeing Things Differently

George Waring IV, MD, joins Gary Wörtz, MD, to talk about his recent career shift from academics to private practice. Dr. Waring walks through his thought process for making this major change and shares additional insights into Snellen acuity, in vivo IOL modification, and more.

Gary Wörtz, MD: Open, outspoken. This is Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz.

Gary: One of the most valuable aspects of ophthalmology is the perpetual opportunity to gain new perspectives—on practice, on surgery, on technology, on scientific theories, and so on. For this reason, most of us in this field enjoy being lifelong learners.

One such person who never ceases to seek and share new perspectives is Dr. George Waring IV. In this episode of Ophthalmology off the Grid, George shares with us his recent experience changing his own vantage point, in a move from academics to private practice. He also describes his views on the importance of thinking beyond Snellen acuity and his outlook on in vivo IOL modification.

Here’s George.

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

Gary Wörtz, MD: This is Dr. Gary Wörtz with another episode of Ophthalmology off the Grid, and I'm happy to welcome back to the program Dr. George Waring. So, George, thank you so much for being willing to come and share a little bit more of your story and give us some more of your opinions.

George Waring, MD: Thanks, Gary. It's always great to be here.

Gary: So, George, I just want to know a little bit about the big news in your life. I recently heard that you had a change in your practice situation, which is always exciting, and fun, and stressful, and sometimes terrifying. And so, just walk us through that a little bit. Tell us about your new practice and maybe a little bit about what went into your decision-making process of saying, "Hey, I think I want to do something different."

George: Gary, we've recently founded a private practice, which we're just absolutely thrilled about. So, we just finished our first month, and things are going really well. We're very thankful. We have transitioned out of an academic setting, where we've been over the last 6 years, and this is something that ... it's really been a healthy transition, very positive, and mutually supportive, which is, I think, so important when you do have an opportunity for a transition of this sort. And so, we still work with the university in that my wife still runs the division of cornea and refractive surgery there.

Gary: Okay.

George: And so, that is ... It's just a real wonderful way to actually expand the breadth and depth of what we do. So, we had two opportunities that really went into this decision-making. Number one, my father, when he passed a few years ago: It was an impetus for me to do something, in a way, to honor him and myself, because this is something that he had always encouraged me to do. And we had hoped to do it together at some point in our lives. So, that was the first real "aha" moment for this.

Gary: Right.

George: The second was our center. We had an opportunity where the center became available. And it was one of these things where it was always a dream, but trying to make a dream like this a reality is not always easy, until you have the vision and the "aha" moments coincide. And that's when you know to move forwards. And that's exactly what we did. So, we did all of our due diligence, really leaned on our friends and colleagues, of which I'm just forever indebted to, to understand what it takes to start a private practice. And the journey has been wonderful, it's been remarkable, and we definitely could not have done it without our friends’ and colleagues' support.

Gary: So, it sounds like it was sort of fulfilling a vision, a dream, a legacy perhaps, but it was also right place, right time. So, trying to capture the momentum of the right opportunity, is that fair?

George: Yeah, that's exactly it. And these things, there's real risk involved, they're real undertakings, there's a lot of change. But, the mantra is, "Sometimes the harder the task seems, the more rewarding it's gonna be." I think a lot of our heroes and mentors ... like, Geoff Tabin is really sort of a perfect example of that. The crazier the mountain that you can climb, the more rewarding it's going to be when you get to the top. And so, this absolutely applies, in terms of a challenge that has just been so fulfilling and rewarding, even in a short period of time. It's wonderful to see these things actually become a reality when it's been a dream for so long.

Gary: That's right. You know, I think about this ... maybe it's a little too philosophical, but I think about ... we're built for adventure, I feel like. We're built to take risks, calculated risks, and life is most exciting, sometimes, when you're doing that, when you're engaged; you're fully engaged. The middle of the road is always going to be there. If this doesn't work out, or another adventure doesn't work out, the safe path will always represent itself as long as you're taking appropriate precautions with what you're doing.

But, I really want to say, great job for being willing to step outside of your comfort zone, being willing to fulfill something that's been a vision and a dream for you, and I wish you nothing but full success, and anything I can do to help, and others; we're just cheering for you to make this a fantastic practice, and we know you're going to be successful.

George: Thank you.

Gary: So, let's move onto a couple of topics that I know you're really passionate about, and I share some passion in these areas. The first one is really how we talk about vision. And, George, we've talked about this at a number of meetings, and we've talked about Snellen acuity being so outdated, especially when we are using so many advanced tools to express astigmatism, not only anterior, but posterior, high order aberrations, wavefront, etc, using all these amazing tools, and yet, we're still expressing vision in terms of Snellen acuity.

Walk me through what you think we need to do, if there is a way, or a vision that you have; what are we missing with Snellen acuity, and how can we tell that story a little bit better to patients, so we can tell them, "Here is what you're seeing. Not at just 20 feet, or at infinity, but here are the ways that you see in various conditions; near, far, intermediate, light, dark, et cetera." What are we missing right now, in terms of the way we express vision?

George: Well, Gary, you said it well. Snellen acuity has served an important purpose in what we do. And it sounds so obvious, we take it for granted that it's been around since the mid-1800s.

Gary: Right.

George: And, when you think about how advanced we are optically, with everything that we do; why wouldn't that translate directly into how we measure vision? And we all know that there's more to vision than arc seconds. It's really about quality. And, historically, contrast sensitivity actually really has been the best measure of quality of vision. And some of us would argue that that's more important, in a way, than Snellen acuity.

Gary: Right.

George: But, it's not, sometimes, easy to perform things like contrast. And even contrast is fraught with issues. And so, we have access to advanced diagnostics, which truly tell us what the patient is seeing on the retinal plane. For example, a double pass wavefront device by Visiometrics, the HD Analyzer, is a wonderful example of something like this, where it actually subtracts the light scatter from a wavefront, and can show it on the retina. So, not only can you see what the patient's seeing, you can show the patient what they're seeing, in terms of quality of vision.

Gary: Right.

George: And, over the years, we've looked into this carefully, and we've amassed a library of just about every visual condition we can imagine, and we've developed a system where we can now recognize patterns; just based on the light that falls on the retina, we can make the diagnosis.

Gary: Wow.

George: Much like topography recognition.

Gary: Interesting.

George: And so, we now have a series of papers in review, in the peer-review literature, that now are showing these different disease states, and how it can correlate, and understand these. Most recently, we just had published a grading correlation in keratoconus and the light that falls on the retina, and it turns out that it actually correlates well with the traditional severity scales. We have currently in review what we feel will be an important contribution to literature, in terms of the dysfunctional lens syndrome, and a prospective analysis, understanding how we can improve image quality with dysfunctional lens replacement, or refractive lens exchange, in ways that we cannot do in patients that present for LASIK, for example.

And this has helped us now understand how to stage the dysfunctional lens syndrome to not only make appropriate surgical decisions but also to educate our patients better. And that's just really important. And, yeah, I just really would encourage all the listeners to start thinking beyond Snellen and really start paying attention to image quality, because what we're finding is, with early intervention, with things like YAG capsulotomy, for example, we can really improve image quality. And we have a paper just currently submitted showing that, even with early YAG capsulotomy, that we can prove image quality in a statistically significant manner in a prospective study.

Gary: Now, quick question; was that with monofocal patients?

George: Yes.

Gary: Multifocal patients? Or both?

George: We've looked at both.

Gary: Okay.

George: And the device does have some limitations with the older refractive optics, but it's really interesting because, with some of the newer generation lens designs, it actually really does give you very valuable information. So, we've looked at most of these lens styles in these analysis, but the monofocal implants tend to give you the most pure information, in a way.

Gary: Right. Measurable…

George: But, we show improvement with both.

Gary: That's incredible. So, one thing I'm sort of thinking about is, when I'm counseling patients about refractive options for cataract surgery, for example, that patient ... we're sort of saying, "Do you want to see at distance? Do you want to see up close? Do you want to see intermediate?" And it very quickly becomes this quagmire of a conversation, where we're really not showing the patient ... we're talking in terms that they don't really understand, and I really feel like we need a visual, a graphic that's much easier to say, "All right, when you're 20 years old, this is the quantity of vision that you have," and showing them, you can accommodate, for example, up to a couple inches away from your eye, and all the way out to infinity, showing up to 20/12.5, and you sort of have this area under the curve, for example. And then, by the time you reach 45 or 50, you're presbyopic. In some ways, you've lost half of your vision. Now, we don't think about presbyopia that way, but in reality, you have lost, in terms of area under the curve, from 0 centimeters to infinity, you are losing about half of what you had.

And so, I feel like there must be tools and ways for us to show patients, wherever they are on that scale, to show them, "This is where a perfect eye would be at age 18 or 20. This is where you are. And then, here are these lens options." And show them the amount of vision the quantity and quality, even under different lighting conditions, that these lenses would provide for them. So, they can kind of compare a normal, young eye to what these lenses would restore, potentially, and that, I feel like, might be a better way to have a conversation than just saying, "Well, do you want the standard lens, or do you want to see near and distance?" I mean, what are your thoughts on that?

George: Well, Gary, you and I have had these very thoughtful discussions in the past. I just really love the way that you think about these, and you've had some just really fabulous ideas about how we can put together, really, a true vision score. And the importance of this is that of capturing what we're calling "functional vision."

Gary: Right.

George: It's functional vision, which Snellen really doesn't tell you anything about. And so, when we look at this as a univariate manner, that's probably the right way to do it. So, I really think you're onto something with this, and we look forward to, hopefully, working with you to develop some project where we can actually take these models, simplify them, make them kind of a universal language, easy to apply, and establish some real value on where we can help people understand what their opportunities are and really what their limitations are on things that we've always taken for granted, like loss of accommodation, which, as an .05 dysfunctional lens patient myself, meaning I'm an incipient presbyope, and it stinks. There's real quality of life issues that I'm dealing with, and it's not until you start dealing with it…

Gary: It becomes a problem.

George: You realize this is a real thing.

Gary: Right, right.

George: And so, anyways, I applaud your vision and your efforts to do this, and I do think it's something that we should continue to forge ahead on.

Gary: Yeah. I think you're right, and we need, sort of, I think, a head of steam, or some momentum from either societies ... it's too big of a project for a couple people to probably do on their own. This would probably require societies to get together and talk about new, common ways of expressing vision. But, I do think it's time that we put it out there, and say, "Let's start the conversation of making a new language for expressing vision."

George: Well, it can always start with an editorial in the peer-review literature. And, furthermore, it can always start with a thoughtful analysis and proposal that can also be submitted to the peer review literature as well. A great example is Dan Reinstein's contribution to the literature on how we standardize reporting in the peer-review literature, on intraocular lens implants, and outcomes. The same contribution was made a number of years ago by my father and others on understanding how we should be reporting corneal refractive outcomes and in standardized reporting. So, I could foresee an opportunity where we do this for understanding and proper reporting for visual outcomes, and just in terms of ... not so much necessarily from interventional standpoint, but more in terms of clinical use in everyday conversation.

Gary: Yeah. So, let's move the conversation from that conversation with patients before surgery, to dealing with patients after surgery who may not have achieved the outcome that they want. This happens probably more often than we even realize, but it happens enough that we know it's a problem. We would love to eliminate that, but, at this point, we don't have the magic wand. We have laser refractive surgery, we have exchanges, piggyback IOLs. We're all looking for that solution that's the easy button, where Mrs. Jones comes in, and she's +1.00, and has maybe 1.00 D of cyl as well, and you're trying to figure out what to do, and you can basically modify her outcome in a noninvasive way. And I know you've been working with Perfect Lens on what seems to me to be a very compelling new technology. And I'd love for you to unpack that a little bit, and talk to us about why you are investing your time and energy at making this idea sort of come to fruition.

George: Perfect Lens is really a disruptive technology that is one of the most exciting things that we've worked on in our career, that we've had an opportunity to work on, and we consider ourselves very fortunate to be involved. This is a concept ... it's been around for a number of years, and through a few iterations, in terms of the core concept of refractive index shape changing. And this really uses the idea of a femtosecond laser, and a concept called "phase wrapping," which allows ... phase wrapping allows you to take a lot of information and put it into a small space. And this is based on Fresnel optics.

So, we can effectively create large, refractive changes within a very small, physical, three-dimensional space. Well, an intraocular lens implant turns out to be a wonderful space to do that in. And you can apply a femtosecond laser to an acrylic lens, and actually, with a very high degree of reproducibility, essentially, customize or affect just about any optical circumstance that we can think of. And so, for example, this is something that we can do in vivo, and you can do it again, and you can do it again.

And you can create changes, you can undo changes, you can modify and customize different circumstances for just about any optical circumstance we can think of, whether this is defocus change, sphere, cylinder, toricity; whether this is adding multifocality, diffractive optics, refractive optics; whether it's removing multifocality; whether it's changing asphericity; whether it's creating a hyperprolate or extended depth of focus profile. You can pretty much do it all. And the neat thing is, you can do it simultaneous, and you can undo it if you don't like it, or customize it.

And we've learned a lot about optics through this project. Sounds a little obvious, but there are things that a lot of us have taken for granted; those of us that enjoy the optics as surgeons, like yourself, that we didn't appreciate before we started working on this project. There's all the obvious things about how this really could be a game-changing technology, but when you start to dig into the opportunities to customize multifocality, for example, at least myself, I always just thought of this in terms of add power.

Gary: Right.

George: We started with the high adds, and then, the trend has been to go to lower and lowers adds. Well, it turns out that, independent of the add power, there's also the light, the far, near differential of the lights bit. And that's independent of the add power.

Gary: Interesting.

George: And traditionally ... And this information is available on the boxes, we just never really paid attention to it. So, not only has the trend been to go away from high add, to moderate add, to low adds, but it's actually been to give more and more light towards distance, believe it or not, and less towards near.

Gary: Light distance…

George: Right, it's a differential.

Gary: Okay.

George: And with this technology, you can actually do both. So, you can just leave the add power the same, and then customize just the light, near differential for how much light you've distributed for distance, and near, or intermediate.

So, all of the sudden, you're taking a minimally invasive procedure, what appears to be ... So, the animal studies have been done at Moran with very favorable outcomes. And we're now looking at first and man studies, and working on our protocols, actually, that we're helping with as we speak. So, this is something that we really want to be paying attention to. It really represents a whole new generation of treatments that is in vivo customization. But, this particular technology, if it works like we all hope it's going to work—and we all keep being surprised because it keeps working—that we can now do this multiple times to get it just right.

Gary: I mean, this seems like pretty close to the holy grail, in terms of refractive tool that we would use for our cataract patients. And, correct me if I'm wrong, but the way I've understood phase wrapping is, basically, you're changing the relative hydrophilicity of a hydrophobic lens, for example. And so, some people have asked me the question ... when I've tried to explain phase wrapping and this technology, they've said, "Well, how does a lens change shape inside of an eye? How can you change a lens? Where does it go? Or, what happens to it? That doesn't make sense."

But, it does make sense if you realize that all acrylics have a certain relative hydrophilicity, or hydrophobicity. And if you're able to alter the refractive index by altering the amount of water, for example, that is absorbed by an acrylic, you can do whatever you want. And if you can increase and, or decrease those parameters and use that in a really smart way, this could be a really, really exciting technology. And very disruptive, I might add, to the IOL space, because it really could disrupt the way we make lenses in the future. I mean, every lens may be a monofocal, and every procedure may be standard, and all the customization happens after surgery. Really kind of game-changing in terms of the way we even think about refractive cataract surgery.

So, we are all very excited to follow the progress, and this is something that I've been aware of back when ... I think it was Aaren Scientific. When they first were starting this, I went to the little meeting, and I was like, "If this is real, this is really amazing." So, I'm glad that you're working on this, because we need a lot of smart minds to help this project along. But, this is something we're all really watching with great interest.

George: Well, again, we totally agree with you. And we remember those really discussions and thinking about this as a great science project, but cautiously optimistic, because it was so disruptive. And what we've found is just kind of every milestone, we just keep being surprised, because it keeps working, and it keeps working, and it keeps working. And so, essentially, in a nutshell, you're creating a lens within a lens. You're creating a refractive shape within a lens, so this is not disrupting the boundaries of a lens, it's actually sitting within it. And the phase wrapping process is really more of a modeling shape process that's independent of the refractive index shape changing. It's really an optical modeling process; it allows you to take a large amount of optical information, and then put it into a small, physical, three-dimensional space through optical modeling. But, totally agree with you. Really appreciate your interest in this. And it's going to be fun to watch.

Gary: Yeah. Absolutely. Well, George, I really appreciate you coming on and giving us a little update on what's exciting in your life; the shared passion we have for all things refractive surgery. This is definitely not the last time you'll be on, so we will talk again very soon, my friend.

George: Gary, we always appreciate the opportunity, it's so fun to get to do this with you, and thank you so much.

Gary: Welcoming new perspectives and a willingness to see things from new angles is a challenge that clearly George has embraced. The opportunities afforded by this approach are multiple, and we thank George for his knack for seeing things differently and for coming on to share some of those views with us today.

That’s all for this episode of Ophthalmology off the Grid. If you like what you hear, please be sure to rate, review, and subscribe. Past episodes are available at eyetube-dot-net-slash-podcasts, and, as always, thanks for listening.

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