Episode 3

Meet a Corneal Surgeon and Contact Lens Specialist

Dr. Melissa Barnett and Dr. Tom Arnold talk with guest César Lipener, MD, from São Paulo, Brazil, about his journey of becoming a corneal surgeon and a contact lens specialist. Dr. Lipener shares advice and provides insights on fitting scleral lenses and the potential risks involved.

Dr. Tom Arnold (00:03):

Hello everyone and welcome to this edition of GlobalEyes with your hosts, Melissa Barnett and Tom Arnold.

Dr. Melissa Barnett (00:28):

GlobalEyes is a podcast which provides a nexus for eye care practitioners all over the world. Each month, a different specialist will be featured for a lively discussion of the status of the eye care profession in their country. We will explore the educational systems, techniques and methods, patient demographics, and what they see as not only the biggest obstacles, but also the greatest opportunities.

Dr. Melissa Barnett (00:55):

Along the way, we'll learn a little bit about their personal lives, hobbies, and interests. A relaxed, loosely structured, and fun atmosphere will be encouraged. Join us as we travel the globe. Our guest today is a world renowned corneal surgeon and contact lens specialist from Sao Paulo, Brazil. Not only is he a prominent international speaker and author, he has been the past president of many organizations; including SOBLEC, a Contact Lens Cornea and Refractometry Brazilian Society.

Dr. Melissa Barnett (01:31):

He is currently an ophthalmologist at the Contact Lens and Refraction Section at the Federal University of San Paulo and the current vice chief of the Contact Lens Section of the State of Sao Paulo and Sao Paulo City. Both Tom and I had the wonderful pleasure of exploring the Salt Cathedral and caves outside of Bogota, Columbia, a few years ago with our special guest. Welcome to GlobalEyes, César Lipener.

Dr. César Lipener (01:59):

It's a pleasure for me to be with you and I appreciate this invitation and I hope we can share some information about all these issues. It's a pleasure. Thank you very much.

Dr. Tom Arnold (02:14):

We do appreciate you coming. It's great to chat with you César. I would like to begin by asking, you've had a pretty good career, you still have years to practice, but what's the one thing you wish you had known when you began your career that you know now?

Dr. César Lipener (02:34):

The first thing that I wish to know or to have when I was beginning was to have a little better financial conditions because when I finished my residence, I started to make some fellows in part of my time. In the other part of the time, I was not able to get an office to start to work, so I started to work as a clinician.

Dr. César Lipener (03:13):

I worked as a clinician during three years and part of the time I was doing some fellows; including contact lenses. So maybe if I had a little better condition at this time, maybe I could have started before. As you know, our entire life…

Dr. César Lipener (03:41):

If you have the youth of that time and the experience of the actual time, probably I will choose some different things. But in general, I think that probably I will make the same choice that I made in the first time of my career.

Dr. Tom Arnold (04:06):

Yeah, that's good thoughts and good advice. What advice would you give someone wanting to pursue a career similar to yours?

Dr. César Lipener (04:16):

At the beginning, we have to use our time to study, to make more fellows, more surgeries, and try to feel which is the area of, in our case, in ophthalmology, that you'll feel better. So you'll have to do something that you are involved with, that you feel that it's very interesting for you because in our career, we have to do many things that are not the things that we most like.

Dr. César Lipener (05:01):

But if you choose an area that you feel good, you feel well, probably it may be easier for you. So you have to think into your future, you have to think in make money, but you have to think to be happy and you can be happy and make money at the same time if you choose correctly the area that you feel more comfortable, that you feel more enthusiastic with, and probably you will be more happy working if you choose like that.

Dr. Tom Arnold (05:45):

I totally agree. I tell students to know their personality, know their likes and dislikes, and try to choose a field that aligns with that. I think that's very, very true and very good advice.

Dr. Melissa Barnett (06:00):

I agree and think it speaks to your passion, whatever you're passionate about and love to do, then it doesn't even feel like work. It's just like fun.

Dr. César Lipener (06:08):

Yeah exactly.

Dr. Melissa Barnett (06:10):

You have a really unique story that you're both a corneal surgeon and a contact lens specialist. How did you decide to become a contact lens specialist and how did this change your career?

Dr. César Lipener (06:22):

When I was in the beginning, I finished my residence. So I started to make a fellow in cornea and external disease and at the same time, in contact lenses. So I stayed during a time doing both, but at that point, I feel more comfortable with contact lenses. Probably because in my University, it was a section with not much politics involved, so it was more comfortable to me.

Dr. Melissa Barnett (06:58):

There were politics everywhere.

Dr. César Lipener (06:59):

Yeah. But it was a section with my boss at this time, a very good person that no interferes with the politics. I was on the second floor, the politics stayed on the first floor, and I felt more comfortable.

Dr. Tom Arnold (07:33):

Keep them down.

Dr. César Lipener (07:33):

Yeah. So during that time, I was doing some keratoplasties and the other side, the contact lens refraction. So I feel more comfortable with the contact lens and probably because the ambient, it was more soft and more easy to work. I started to stay just in this area.

Dr. Melissa Barnett (08:02):

When you see a patient in your clinic, how do you decide between corneal surgery and a scleral lens? What factors go into the decision making process?

Dr. César Lipener (08:13):

Well, normally nowadays with the last year's progress in contact lenses, it's very difficult for us to not get a good feeling in contact lenses. So my first option in every patient is to try any way to fit a contact lens. I only choose for corneal procedure when there is no way to use a contact lens.

Dr. César Lipener (08:49):

It's not frequent, it's rare, but maybe we can get some situations that the procedure is a better option. Normally, nowadays, it's very difficult with the many lenses that we have to not get a good fitting in the patients. So normally the first step is to try a contact lens, just go to a procedure when we can get a good fitting.

Dr. Melissa Barnett (09:22):

That sounds very reasonable and all of the recent studies coming out definitely agree with that.

Dr. César Lipener (09:30):

My colleagues that are more dedicated to corneal surgery, they don't like when I say these things in public, because they want to make surgeries. But I say to them that nowadays it's very difficult to not get a contact lens fitting. When the scleral became more popular, it's very, very difficult to not fit a patient with that.

Dr. Tom Arnold (10:06):

Speaking of that then, do you have a scleral lens design preference, César, or a certain philosophy that guides your decision-making? Do you prefer larger lenses, small lenses, and maybe do you have profilometry in Brazil where you can map the sclera? Any particular thing that guides your decision-making process?

Dr. César Lipener (10:34):

Normally, here in Brazil, we don't have a lot of brands of scleral lenses. When I started, I started maybe... I have a study that was published in 2004. We tried to fit some scleral lenses with a small manufacturer, so we sent them some data, some images. He tried to do something probably that fit these patients, so he sent the lenses, we see at the slit lamp, make it over refraction sent again to him, and we are trying to make changes. It was very, very handmade lenses at this time.

Dr. César Lipener (11:36):

I almost got help from Ken Pullen, because a friend of ours was at the multitudes to bring us a trial set, but because of bureaucratic problems, it was not possible. So we started to do it like that, but it was very difficult because we didn’'t have a trial set. There is no pattern to make these lenses, so we stopped it. Maybe 10 years later, I started with a manufacturer that makes very good RGP lenses in general. We started with 18 millimeters, then to 15 millimeters, and then sometime after we received here the maxi lens that was beginning to be made here in Brazil by one manufacturer.

Dr. César Lipener (12:37):

One year later, we got the Zenlens. We now have just two big brands, one is small. I have more experience now with the Zenlens and in some patients when it's possible, I prefer to use the Zenlens RC. They are smaller and thinner, and when it's possible, mainly in patients with keratoplasty or other corneal pathologies, when it's possible to get a good fit with these lenses, I prefer to use it. But normally, I use the Zenlens. Now, we also get the sclera SG. They are originally from maxi lenses, and maybe at this year or big 2021, probably we will get also the one fit from blanchard.

Dr. César Lipener (13:48):

So we don't have a lot of options, but I prefer normally smaller lenses when possible because less material, I suppose that may be better for most patients. We don't have so far the profilometry, we have Pentacam in our University, but the software that makes the sclera measures is not compatible with the model of Pentacam that we have. So we are thinking of finding a way because we are a public University and we don't have many resources, but I'm trying to find a way to get something because since the beginning, I realized that the most important thing is to measure the sclera. So maybe in the future, we can get something to do these measures.

Dr. Tom Arnold (14:59):

Yeah, good luck with that. That's a trend that we see gathering momentum in the United States and very passionate about that, so that's good. Are you pretty much self-taught, César? Where did you actually learn to fit the lens? Was it just trial and error, or did you have a particular resource that helped you learn to fit them?

Dr. César Lipener (15:22):

Yeah, as I said, I listened about it. I read about it in the early 2000 years. We started to work in a very, very simple way. At this time, I organized a contact lens meeting here in our University. We invited a physician from London, I suppose it was Asher Butley, we listened about him to talk about scleral lenses.

Dr. César Lipener (16:13):

I exchanged some information with Ken Pullen, and then when the maxi lens came to Brazil, the manufacturer called some of us to start to fit these lenses. And so, here we are. We learned with our experience and reading and listening, but with no one in particular. Maybe me and others, we are some pioneers here with this kind of lens.

Dr. Melissa Barnett (16:51):

You're definitely a pioneer and it's wonderful to know the history. I feel like I have a very small part in that since we have ophthalmologists from Brazil who come and train at my institution. Now one topic that we've talked about quite a bit and I'd like your thoughts on this are solutions to use with scleral lenses in Brazil because there have been publications about the risks of scleral lens use coming out of Brazil. So if you can tell us a little bit more about that, that'd be great.

Dr. César Lipener (17:35):

Yeah. We don't have so much solutions. The only multi-purpose solution that we have here is the Boston simplus. We don't have another for RGP lenses. We have some others for soft lenses. Also, we have the clear care with peroxide, but it's not so popular because it's not so convenient for patients because it has to clean and to use another system. For scleral lenses, the case does not fit with the scleral lens diameter. We don't have…

Dr. César Lipener (18:30):

Probably you have in the United States, a special case. I know that Boston does it, but here we don't have it. So when you need to use the clear care with a scleral lens, you have to make some changes in the case to fit the lenses. Normally, we don't have any other option with our multi-purpose solutions, just for Boston simplus. Probably the main problem is patients' education and we use normally disposable saline solution for most of the patients, but we know that most patients do not have the education and the commitment with the care as we wish.

Dr. César Lipener (19:33):

Some months ago, I asked on the Facebook page about it and most of you do not have... Note an increasing number of infections in scleral lenses, but we have in Brazil more markets that we suppose that it's reasonable, but I suppose that the most common problem is patients' education and we have to try to improve this when we fit to these patients.

Dr. Melissa Barnett (20:10):

Do you find that patients are using a preservative-free solution more than one time?

Dr. César Lipener (20:14):

Normally, this saline solutions are from 10 milliliters. It's probably difficult to use more than once, but we know that we are in the last three or four years in a very bad economic situation, and maybe some patients try to use more than we desire that they use. But normally, this volume is very short to maintain more than one day, but probably some patients try to use more than one or two days. There's a possibility. Yes.

Dr. Melissa Barnett (21:08):

In my experience, just clinical experience, I've seen the cases of corneal infiltrates with patients who were reusing their application solutions, and there's a study coming up that's going to be fascinating in the US looking at the rates of microbial keratitis in scleral lens wear. So I think that we're going to know a lot more about this topic in maybe a few years.

Dr. César Lipener (21:32):

They are using the small saline solution more than one day, is it the same solution? Is it?

Dr. Melissa Barnett (21:41):

Well, I don't recommend that. However, some patients, yes, they will be using the solution for more than one time, even in the same day, but there of course are risks involved with that.

Dr. César Lipener (21:55):

Yeah, because we have to educate the patients and educate the physicians here. We have to give something written to the patient and we have to check every appointment how the patient's doing to maintain his lenses because normally, even if you give them something written explaining everything, they forget. They don't do what you recommend, or maybe they go to a drugstore and some people recommend another product or another way to maintain the lenses. It's a very hard job that we have to do.

Dr. Melissa Barnett (22:41):

It's exactly the same.

Dr. Tom Arnold (22:42):

I was going to say we have the same issue. I even had one patient, César, that was filling her bowl of her lens with multipurpose solution and conditioning them overnight in the saline, so she just had it reversed. It happens.

Dr. César Lipener (23:00):

My first patient this year... First patient, January 4th, I suppose. I can't remember, but he put his scleral lenses in the profilometry. The patient did very well in the last few years with a bacterial ulcer. She's doing well, but she has a suture, a circular suture, and we will have to remove part of the suture because after the ulcer, it becomes more superficial. So it was the first patient of the year.

Dr. Melissa Barnett (23:41):

Yeah. Happy 2020, right?

Dr. Tom Arnold (23:46):

Downhill from there, César.

Dr. Melissa Barnett (23:47):

César, tell us a little bit more about your typical day and the patient demographics in Brazil. Do you see some conditions more commonly than others?

Dr. César Lipener (24:01):

Well, normally, I had one or two days in our University. In our University, we have the opposite. Probably you do have the same when you do the same job. We have the opposite of the market. We have in our University, maybe 90% of RGP or special lenses, and 5% to 10% in the other lenses. In my office, I do general ophthalmology, obviously a concentration in contact lenses. When someone refers a patient to me…

Dr. César Lipener (24:50):

It's normally for contact lenses and maybe a special contact lens and in the worst cases, the patients that come to you and say, "No, this is my last option. If you don't fit me, I have to go through surgery." I do general ophthalmology, but undoubtedly in the last years, the number of patients with keratoconus is increasing a lot here. Probably in other places also. Despite we can do more diagnostics before we have more conditions to do more diagnostics, we feel that the number of patients is increasing.

Dr. César Lipener (25:45):

I see a lot of patients with keratoconus. I have many patients with RK, but I do general ophthalmology. So I have some patients for refractive surgery, not so much how I was in the past. Cataract surgery, glaucoma. So we have a mix, but normally the most patients that I receive are for contact lenses, mainly special contact lenses.

Dr. Melissa Barnett (26:21):

Do you enjoy the diversity of having general ophthalmology patients and specialty contact lens patients in addition to surgery?

Dr. César Lipener (26:33):

Unfortunately, I cannot choose to do just a contact lens, for example. So it's interesting to vary it should you see the different things. The surgical issues are interesting also because we have patients that become very happy. I also do crosslinking that I think that in the future, we will be a very, very important source of control.

Dr. César Lipener (27:02):

These patients probably if the surgeons are not so happy with the contact lens, maybe in the future we can do more crosslinking, they will be more sad than today because most patients will stop to progress and it's very easy to fit contact lens and less patients to make surgeries, but it's interesting to see different things. I prefer the contact lens.

Dr. Melissa Barnett (27:38):

Excellent comments. I can tell you're definitely passionate about contact lenses. Who are three people who have been most influential in your career?

Dr. César Lipener (27:49):

There are some, but I can start with my father because my father was a physician, but an old-fashioned physician with general clinics, general surgery, a gynecologist, and it was because of him probably that I decided to be a physician. The second one was a relative that was an anatomy teacher in our University. During the graduation, he called me and said that he normally gives the atomic and anatomic curse to the people from our topics.

Dr. César Lipener (28:49):

So he was going to have to do a period in Boston and he called me to start to give to this student the part of eye anatomy. So I started to talk to the students about the eye anatomy, and then I decided to remain an ophthalmologist. I made some contacts with some teachers during my graduation, and I started my residence, and then I started to make the fellow with my first teacher in contact lens.

Dr. César Lipener (29:38):

He was very important to open to me many areas for work and to succeed him as a chief of the section to be involved in. So maybe these three are the most important, but there are more, but probably if I start to remember them, the main three are the main important.

Dr. Melissa Barnett (30:10):

That's a wonderful story of your mentors who helped you each way in your career. I happen to know that you have some favorite hobbies and that you have attended the World Cup. So please share with us a few of your favorite hobbies.

Dr. César Lipener (30:27):

Well, a lot. I play soccer weekly, obviously now we stop it with the pandemic, and it became more interesting because I have two sons at 25 and 21 years. Each one, they started to go with me as little boys to follow me and to see me play, and now it's very pleasant because they play with me. Weekly, we are together playing soccer.

Dr. César Lipener (31:11):

I normally run twice per week. I'm not a professional like you, Melissa, but I'm trying to maintain this running habit. I made four half marathons last year in Buenos Aires and normally is a thing that is very pleasant for me. I like to cook. I like to do some barbecues, some caipirinhas. Maybe in the future you can try a caipirinha.

Dr. César Lipener (31:58):

That's a typical Brazilian drink with cachaca and many different fruits. When possible to travel, it's difficult now to travel without a meeting, but when possible we do both or but to travel, it's a thing that I like very much, and mostly when I can go with my family.

Dr. Tom Arnold (32:29):

Well, we certainly want to welcome you to the ICSE meeting of which you were scheduled to be a keynote this year. Of course, because of the pandemic, we had to reschedule, but we still have you on the program, César. We're going to look forward to seeing you in Florida 2021.

Dr. César Lipener (32:48):

Yeah. I was planning to attend, but most of the meetings are postponed, but we will get there.

Dr. Melissa Barnett (32:59):


Dr. Tom Arnold (33:00):

I will hold you to that caipirinha because I've had caipirinhas and I really enjoy them. That's a great drink. I'd like your special touch.

Dr. César Lipener (33:11):

Have you tasted it before?

Dr. Tom Arnold (33:13):

I have, yes. I've been skiing in Chile several times. Of course, that's from Brazil, but Chileans do a decent job of it.

Dr. César Lipener (33:23):

It's good to try.

Dr. Tom Arnold (33:27):

Well, César, we so appreciate you joining us and you are truly what we'd call a Renaissance man. You have the total eyecare package of surgeon, contact lens practitioner, educator, and mentor I'm sure to a lot of your students at the University. You've had a wonderful career. I know you still have work to do. Melissa and I sure have enjoyed getting to know you and look forward to the next time that we can all be together.

Dr. Melissa Barnett (33:59):

Yes. Thank you so much.

Dr. César Lipener (34:01):

No, it was a pleasure to share with you some points of my activity and I hope that it can be useful and interesting for other people. It was a pleasure. It was a pleasure to meet you before in London and then in Colombia and Argentina, it was a pleasure. I hope that we can enjoy many opportunities together for fun and for work. I hope that we can do many things together.

11/17/2020 | 36:22