Standing on the Shoulders of Ophthalmology's Giants
Gary Wörtz, MD: Open. Outspoken. It's Ophthalmology off the grid—an honest look at controversial topics in the field. I'm Gary Wörtz.
“If I have seen further, it is by standing on the shoulders of giants.” Although most commonly attributed to Sir Isaac Newton, this quote communicates a concept that is very relatable to me and probably to most ophthalmologists. As we move forward through our own personal victories and the successes we enjoy as a field, we recognize that progress is a collective effort. Although many play a part, there are always those giants, those who stood tall and blazed the trails before us and who contributed their wisdom so we too could grow wise.
One such a giant is Dr. Dick Lindstrom. In this episode of Ophthalmology off the Grid, I sat down with Dr. Lindstrom to discuss his immeasurable contributions to the field, the evolution of eye care throughout his career, and his predictions for the future generations of ophthalmologists.
Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.
Gary: Today I'm very, very just honored and thrilled to have a hero of mine, a colleague and a mentor, someone we all look up to, Dr. Dick Lindstrom. Dick, I just have to say, I really appreciate you taking some time to talk to us about where your career has taken you over the past number of years, where you see ophthalmology now, maybe how it's changed. We'd just love to pick your brain and get some words of wisdom from you. With that said, thanks so much for coming on today.
Richard Lindstrom, MD: Thank you, Gary. I kind of got into ophthalmology indirectly in a sense and the same for medicine. I was on my way to join the family business, and most people know I've had a business interest. We have a family business in insurance restoration construction and I was being groomed to do that. I just happened to be in the honors division at the University of Minnesota College of Liberal Arts and randomly got the dean of the medical school as my advisor.
One thing is some things don't always happen through planning, sometimes they happen through serendipity. One of the other things is, when an opportunity presents to be willing to take the rest and say yes to it so I said yes to medicine. Then when I was in medical school, a young professor Don Doughman who first came from Harvard to our department right after his fellowship with Claes Dohlman in cornea, picked me out to work in his laboratory on corneal preservation. That got me started into ophthalmology and even into corneas.
Again, I wasn't necessarily pursuing ophthalmology. In a sense, ophthalmology found me. Again, I either had the wisdom or the good luck to say yes to the opportunity. I would say for some of the younger ophthalmologists, that's something just to think about. I would say sometimes the slogan is "Just say no," but I would say, "Just say yes" as opportunities present, even though they may occasionally be a little bit scary or intimidating or something that you haven't thought through that you might be wanting to do or not do, say yes to the opportunity.
Gary, I think you're an example of that when you said yes to the opportunity to develop a new product, and it's been, as it always is, an adventure and a learning experience, I'm sure as you've gone along.
Gary: Yeah, yeah. Absolutely. You're exactly right. It's just sort of like putting yourself into the Brownian motion of the universe. If you're around good people and you're working hard and trying to keep your nose clean, sometimes opportunities just sort of present themselves.
How did that conversation go with your family when you said, "You know, I know we've got this tremendous opportunity, but I'm going to go a different path"? How did that go?
Dick: It was bad at first. I'm probably one of those few sons whose father disowned them when I told him I was going to go to medical school. I'd been following him around to work since I was 12 years old and grew up in the construction business and he had in mind for me to join him, but it's funny how the way things work out. 30 years later when he was ready to retire, as it often is, it's difficult to transition a family business and I ended up actually acquiring the business from him, so I was his exit strategy and sort of secured his retirement.
As an aside, one thing a lot of people don't know I guess, is I'm the chairman and CEO of a construction company.
Gary: What? In addition to all the other things you're doing?
Dick: We own an insurance restoration business where if you have fire, water or wind damage to your home, you call your insurance company and we fix it. It's a business my father started right after the war. I grew up in it and I've now been the chairman and CEO of that business for 20 years and my president chief operating officer is my son who went off and got a degree in construction management and my brother and my sister's son have also worked in the business. That's been a nice side light.
As I said, it ended up working out that exactly the outcome that my father wanted ended up happening indirectly. I ended up owning the business and being the chairman and CEO and along the way he got to have his younger son work with him side by side and then later sell the business to his older son.
Gary: That's great.
Dick: Again, things have a way of working out sometimes in an unexpected but amazing positive fashion.
Gary: Yeah, wow. That's very interesting Dick. I had no idea and I don't know where you find time to do all the stuff you do in ophthalmology let alone run a construction company, but that being said, I'm sure you do a great job at that as well.
It's interesting for me, I didn't really choose ophthalmology starting off in medicine. I thought I was going to be a trauma surgeon. Ophthalmology kind of presented itself to me and I just have been so enamored with it ever since I first found ophthalmology.
As you have the perspective looking back from the time you started til now, what are some areas that you feel like ophthalmology maybe outperformed your wildest dreams when you were just starting? You look back to when you started, what are we doing now that you never dreamed we might be doing in your career?
Dick: We're doing many things that I never would have dreamed we would do when I started in ophthalmology. I think cataract surgery probably is the poster boy of that. I restrict my comments to cataract surgery, but the advances that we've seen retina and glaucoma and certainly creation of a whole new field in refractive surgery which didn't even exist when I started have been amazing.
Just a give a little history for some of the younger ophthalmologists, I was trained during my residency to do intracapsular cataract extraction in the main operating room at the University of Minnesota. A full day of surgery, which was 8 hours, was four cases.
Dick: We did one cataract surgery every 2 hours. Those patients were admitted to the hospital for 7 days. They were in the inpatient hospital unit. Every morning, we would be going to make rounds. Our corneal transplants were in the hospital for 10 days and our cataract patients were in the hospital for 7 days, if you can imagine that for cataract surgery.
Dick: We were doing intracapsular cataract extraction and fitting the patients with aphakic spectacles. A typical patient would be 20/70, 20/80 in the better eye and 20/200 in the worse eye when we might think about doing surgery.
The outcomes were not great. The complication rate was significantly higher and it was a lot of morbidity. If we look at the cost, if you were today to do in the main OR at a large community hospital or a university hospital, spending two hours in the OR and then putting somebody in the hospital for a week, it would probably be about $40,000 to $50,000 for cataract surgery. Meanwhile, we're doing an operation where people are seeing well the next day without glasses in 10 to 20 minutes and a couple of postoperative visits with a much higher success rate.
If there is a poster boy for what the triple aim of what our government says they want, which is they want us to generate high-quality outcomes, they want us to generate highly satisfied patients and they want to do it at progressively reduced costs. I think there's no better example actually than cataract surgery. It's amazing.
As far as refractive surgery, there was no refractive surgery. The only refractive surgery that I did was an intra-incision corneal relaxing incision in my corneal transplants that had a high astigmatism. This was pre-RK and pre-excimer laser, pre-femtosecond laser. Advances in ophthalmology have been extraordinary. We're really blessed to be in a field that is still actually supporting innovation. We have a very good opportunity still to be able to apply those innovations to our patients and many cases, have patients reimburse us directly for it which has allowed our profession to be somewhat independent of some of the more negative changes that have occurred in the practice of medicine.
Gary: Yeah. Absolutely. I was speaking to Manus Kraff the other day, and he mentioned something that I really wasn't aware of and I'd love to get your take on this. He said that back in his earlier days in practice, really to innovate you had to be the chairman of an academic center to really feel like you had the ability to do something that was a little bit different than the mainstream.
It seems like nowadays, we have a lot of people in private practice who are leading the charge of innovation. Is that something that you witnessed or that you saw that tide turn in your career or is that maybe a little bit geographically disparate?
Dick: No. I think it has turned in the last 50 years. Many of you may be aware that I spent 10 years in full-time academics. I was a full professor and ran the cornea service at the University of Minnesota. I had an endowed chair. I was actually the Harold G. Scheie research chair. I pretty much have seen the academic side of the world.
It's still fair to say that a significant amount of good research and innovation occur in the university medical centers but there is also now a great deal of research, particularly applied research and translational research, where we're taking bench research to the clinic and applying it to patients. That's occurring in private practice. I train fellows and I've been training fellows since I was in admission at a university and have continued in private practice. What I tell my fellows is that an academic mindset is not based on location. It's really based on individual initiation.
You can do great research and make huge contributions to ophthalmology out of private practice. We've got extraordinary examples of that even in cataract surgery from Charlie Kelman to others that have designed all the intraocular lenses. Really most of the advances in cataract surgery, the poster boy that I mentioned, they did not come out of academic centers. The academic centers were actually resistant to those changes really in the cataract field and also pretty much in the refractive field. Most of the innovations have come out of private practice.
In glaucoma and retina, there's certainly been a lot of innovation out of universities, but not so much in bread and butter cataract and refractive, and that's probably because most of it is done in a private setting.
Gary: Right, right. You mentioned that you feel like cataract surgery really is the poster boy for exceeding expectations. I think we would all agree with that. How was your transition from intracapsular surgery where you're admitting patients to this paradigm shift of phaco? I understand that in the early days of phaco, it was a rough road to get phaco to where it is now. Do you have any stories of your journey trying to learn phaco and what point did you realize that phaco really is the future for cataract surgery?
Dick: I did it kind of in a learn how to swim by being thrown into the lake or ocean. I finished my residency at Minnesota and then I did a year fellowship in cornea. They wanted me to come back on the faculty and basically run the cornea service which I ended up doing. I really had gotten a little bit of an introduction to the fact that there were other ways to do cataract surgery than what I had been trained in.
I went down to Dallas, Texas. A lot of stories that I could tell starting from that but I get a couple of them to the group. I went down to Dallas, Texas, and worked with a gentleman who's name was Bill Harris who was early into phacoemulsification and poster chamber lenses. Right across the hall was Charlie Keats. I left that university where we did four intracaps a day in a major university hospital and basically went to a setting where they were doing a cataract every 30 minutes in an ambulatory surgery center. Instead of doing three in a day, they were doing 16 to 20 in a day. They were doing phacoemulsification. They were putting in posterior chamber lens implants. This was 1977, so very early. I just was like, I couldn't believe it. It's like I'd gone to a different planet from a planet that I had trained on.
That was just an amazing immersion. I went in a fellowship training session, I did a fellowship with the group, worked a little ambulatory surgery center called Mary Shields Hospital in Dallas, and learned how to do phaco. I went straight from intracap to phaco. Later got to be talented, if you will, in extracapsular surgery too. That was just an extraordinary jump if you will.
Dick: At that time, that was when Steve Shearing was innovating his posterior chamber lens and Bob Sinskey and Charlie Kelman and Dick Kratz were teaching phaco courses, and John Sheets was a busy Dallas Texan surgeon and Jim Little. These guys were all kind of one percenters. They were a small number of people. It was actually that year that the American Society of Cataract and Refractive Surgery was founded by a young ophthalmologist out on the west coast, Kenny Hoffer. That whole story is now bringing us to this year, which is the 50th anniversary of the invention of phacoemulsification.
These people were characters, and we've seen similar characters as innovators in other settings, but this was kind of, I think to some extent, the beginning of innovation in private practice because all of these innovations occurred in private practice. There was minimal regulatory barrier.
A total difference from today is that we would sit down, and we would say, "This would be an interesting way to make a posterior chamber lens." I actually invented my first posterior chamber lens in 1978. I was sitting down with a few of my older colleagues, and I said, "I'd like to angulate a little bit and I'd like it to have PMMA loops rather than polypropylene loops and I'd like to color the loops." Actually, believe it or not, the company I was working with at the time, one was Surgidev and one was Iolab, they had a prototype for me in a week.
Gary: Oh my word.
Dick: One week later, my invention was being implanted into patients, then I made a few little modifications and then 2 months later they made it available for other people to buy if they wanted it.
Gary: Are you kidding me?
Dick: It's a little different world than the one you're dealing with today.
Dick: Maybe that was too avant garde, and we should have a little bit more regulation than that, although we were using proven methods and the like, but it was just a whole different environment.
You know what? We didn't hurt people. We were as responsible as probably we are today. It turns out that we doctors are not going to do anything that is not in our patients’ best interest. You know what, our colleagues are not going to adopt anything that's not in the best interests of their patients. I don't think we really did much worse than we do today with all the cost and regulatory barriers. I think today it would probably be hard for phacoemulsification to ever get approval. I don't know if the early posterior chamber lenses would have ever made it either in the current regulatory environment. The barriers might have just been too great.
Gary: Right, right. That's interesting. It's sort of a right place, right time, right people, and now we benefit from the challenges that were overcome in that environment. Part of this interview is really telling the story so that younger ophthalmologists, like myself, who weren't maybe around for all those fights or weren't around for that period of time can appreciate the work that some of the guys like you and others have done that have delivered ophthalmology to us, and now in the next few decades it's going to be up to a newer generation of ophthalmologists to further advance the ball down the field. It's always important to look back and see and respect the battles that were fought for you on your behalf maybe even before you realized it.
With that in mind, where do you see ... We're talking about unmet needs and innovation and advancing the profession. As you look at ophthalmology today, where do you see the biggest unmet needs or where would you predict that our field has the greatest opportunity to advance maybe the next 20 to 50 years?
Dick: There's still unlimited opportunity for advancement. I'll stick with cataract surgery a little bit because it still is the most common operation that we all do. We do about 4,000,000 cataract operations a year today in America. For those of you who are younger surgeons, it's growing at about 3% to 4% a year, which means that in about 20 to 25 years we'll be doing about 8,000,000 cataract operations a year in America.
We'll have slightly smaller number of surgeons to do it. As I do the numbers every year, about 50 to 100 more ophthalmologists retire than are trained. Every year, there's less of us. I would say that the young ophthalmologist coming out of training today is going to be doing, just in cataract, twice as many as they are today and they'll be less of them. They're going to again, have to become very efficient and very effective.
On a positive note, I've continued to train fellows starting 40 years ago. I would say, and, I mean this sincerely, the fellows that I'm getting to train today are brighter, more talented, better educated than they've ever been. I'm not one of those that is worried about the next generation. I'm extraordinarily impressed with the next generation. Of course, I have two children myself that are 34 and 30, and I am extraordinarily impressed with them and their spouses as well.
The fellows that we're training are better, brighter, more talented than they've ever been. They also, in my opinion, have strong work ethics. I think they're a little more balanced than we were in that they maybe have a greater appreciation that they aren't going to dedicate 100% of their time to ophthalmology which we might have done more than we should have. Hopefully, they'll have even a little more balanced lives as far as family lives go, but we're going to have great doctors.
I'm not worried about my cataract surgery being done. I've got eight partners, all of whom are spectacular that I would be only too happy to have do my cataract surgery. I see younger doctors, and you're a good example, but I can give you a whole bunch of examples that are continuing to innovate and are continuing to invent. I think the fact that it's better and easier to do it in private practice today gives more people the opportunity. I'm optimistic.
Let's just say cataract surgery, what are we going to be doing in the next generation if we will? We're going to be doing office based cataract surgery. It's going to be bilateral same-day sequential cataract surgery, so you're going to do both eyes the same day in an office setting which will reduce the cost somewhat and I think reduce the regulatory barrier.
We, I think, are going to move away from phacoemulsification. I think we're going to have some advanced methods that will allow us to soften a lens so it can simply be aspirated with a simple aspirating device which will be less expensive. The classical 50 year anniversary now of ultrasound, we won't need ultrasound anymore. That will reduce endothelial cell loss and make the surgery safer. Then through a small incision, we're going to put in an intraocular lens that will be adjustable accommodating intraocular lens, so you'll be able to adjust to a plano sphere and probably eliminate any meaningful higher order aberration and that lens implant will accommodate.
When that starts to happen, then people are going to want to have their cataract surgery and quotes done as soon there become meaningfully presbyopic, which will be about age 50. I've seen us go from an average age for cataract surgery of 77 down now into the 66, 67. It's going to move its way down into the early 50s.
It will be this dysfunctional lens syndrome concept. The definition of a cataract has changed extremely during my career but the definition in the future is going to be probably loss of accommodation, a little bit of loss of contrast and you've got a cataract and you might as well get an adjustable accommodating interocular lens that will make you see better than you ever did in your life.
When that happens, it's probably going to be even a larger number than the projected 8,000,000. There might be 10,000,000 cataract operations a year being done by about 7,000 cataract surgeons. The average American cataract surgeon, the average American cataract surgeon, is going to have to do 1,500 cataracts a year, so they're going to have a ton of work to do. They'll be busy and the outcomes will be even better than they are now so it'll be a very rewarding field.
Meanwhile, very similar changes will come along in refractive surgery and in glaucoma and in retina, etc. The future is extraordinary for the ophthalmologists, and we're going to be a scarce resource, so we're going to be in demand. Since these surgeries will be taking place in the 50s, most of them I think will be cash paid.
Gary: Yeah, yeah. I think you're probably exactly right. What a great outlook. It's really incredible just to think about that as being reality where the next boom ... We sort of had that LASIK boom in the late 90s, early 2000s where you had a build up of patients who were waiting and ready for a new procedure to help them. When this new lens technology catches up to the unmet needs, I think you're exactly right, we will have a boom of patients who are waiting, ready, willing and able to have that procedure done. You're right, bilateral I think is coming. Office-based is kind of already here in some ways.
I agree with you. I think the outlook for ophthalmology is incredibly bright but Dick, I'd be remiss if I didn't say that it's only bright because we've been led by some of the nicest, smartest people on the planet. You are definitely on the list of the giants who have helped drive our profession forward. For all the contributions you've made to our field, to me personally and for a lot of folks that are mutual friends, just want to say thank you for committing yourself to making this field what it is and every day trying to make it a little better.
Dick: You are welcome. Proud to be a part of it.
Gary: Awesome. Dick, thanks for spending some time with us today. We will have you on again at any time you'd like, okay?
Dick: All right. Thank you a lot.
Gary: Thanks. Take care.
Particularly, as a young ophthalmologist I have to thank Dick for paving the way and sharing the wisdom and experience he brought today and every day. Fortunately for us, Dick stands in good company with several other giants in the field. We'll hear from them next time on Ophthalmology Off the Grid. Thanks for tuning in and if you like what you hear, be sure to rate, review and subscribe. This has been Dr. Gary Wörtz. See you next time.
Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.