Lessons from an Early Adopter

The field of ophthalmology is constantly evolving as new innovations in surgical devices and procedures pave the way to exceptional care for patients. In this episode, P. Dee G. Stephenson, MD, discusses her experience as an early adopter of one such innovation: intraoperative aberrometry. Listen as Dr. Stephenson shares her story of implementing this technology and how she came to build her boutique ophthalmology practice.

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

With innovations abound, it's hard to sit still in ophthalmology. Most surgeons are fueled by a commitment to offer patients the best possible care and thus continually welcome the challenge of implementing a new device or procedure. In doing so, we often have access to clinical trial data, peer-reviewed literature, and our colleagues’ real-world experience to form our own decision and plans. But someone always has to be first.

In this episode of Ophthalmology off the Grid, I speak with Dr. Dee Stephenson about her experience as one of the earliest adopters of intraoperative aberrometry. Dee weighs in on the merits of thinking outside the box, ignoring the naysayers, and learning to exercise patience when using a new technology. Dee also comments on a life-changing event that affected her path to building her now highly successful boutique practice. Here's Dee.

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

Gary: Welcome to Ophthalmology Off the Grid. This is Dr. Gary Wortz and I am just so delighted and honored to be able to talk to a good friend of mine, Dr. Dee Stephenson. Dee is down in Venice, Florida, in a solo practice. Dee, I know we're going to go all over the board and all over the map on topics today, but thank you so much for being willing to share a little bit of your evening with me. You can tell me and actually all who are listening some words of wisdom from your practice and from your life as well. With that being said, thank you so much for coming on tonight.

Dee Stephenson, MD: Well thank you Gary. It's always a pleasure to do anything with you.

Gary: Ah well, some would argue the converse is true, but I'll take it, I'll take it. Dee, I think we could probably start anywhere, but one of my favorite memories is when I think we had just met and I'm not sure who introduced us. It might have been Mitch Jackson or someone else, but I remember we had a really cool conversation on the ASCRS floor right outside of the Lensar booth. We actually took a selfie and sent that to someone we're both very fond of who I'm now working for, Lance Ferguson. Do you remember that?

Dee: Absolutely. Well actually, it was we had met the day before at MillennialEYE.

Gary: That's right. That's right. That's exactly right.

Dee: Bill Wiley introduced us.

Gary: Okay. All right.

Dee: I had known who you were. You have this incredible speaking voice, so it was nice to put the voice with the person. Yes, we were on the floor at Lensar, and we took a selfie and sent it to my pal and your pal, Lance Ferguson. My favorite and fondest memory about that is this. I said to you, "Gary ... " Oh actually, it was not that day but at the MillennialEYE meeting, I said, "Gary, what do you want to do?" You said, "My ideal, my dream is to be Lance Ferguson's partner."

We sent the selfie the next day from the floor of the Lensar floor and wouldn't you know, not but maybe a month later or less…

Gary: Yeah, it wasn't too long. Wasn't too long after that.

Dee: ... You called and said, "Guess what? Guess what?"

Gary: Sometimes you send things out into the universe and things just end up working out. When you work with good people, good things happen.

Dee: Right. My story kind of starts ... Lance Ferguson was one of the most influential ophthalmologists. My cohort if you would say, my contemporary I guess is a better word. I starting practicing in 1988 in Port St. Lucie. I was in practice a year. Joined right up with American College of Eye Surgeons. Got to know Lance and all the rest that are involved with that group over the years.

Then about a year later, I had something happen to me that changed the way I look at things and that was I moved ... I had an opportunity to move to Venice. I was on the west east coast of Florida and my home is the west coast. I was in preparation to move over here to the west coast and I had an incident that happened and I had a tumor in my spine. From that, I have a bilateral foot drop and a neurogenic bladder. I had to learn how to walk again, and I had to straight cath myself for about a year. I had made the choice to come to Venice, and thank goodness I made that choice.

I joined someone here that I eventually bought out in the next few years, but it sure made me look at the world a different way. It also allowed me to know that I was doing the right thing by being in practice by myself. I've been out of practice long enough like Lance that if you wanted things done right you did them yourself.

Gary: Right.

Dee: We weren't used to used to sharing the burden or the financial burden or the work burden. That's how I was raised. I've never looked back. I've been a solo practitioner now going into my 29th year. It's pretty awesome.

Gary: That is kind of incredible. How long were you into your move to Venice when you had this tumor?

Dee: I had my surgery before ... I moved to Venice then had my surgery and I was out, I was on kind of a sabbatical for about 2.5 months.

Gary: Wow.

Dee: Yeah. Then in September I started practicing with a foot drop and some things that I had to deal with, but I was in a place that was beautiful, a place that I wanted to be. I was just kind of the worker bee for this doctor because he was in the Florida House of Representatives. I really came over here when I was in private practice on the other coast to make some extra money on Thursday and Friday when Congress is in session. It ended up being something that I did full time but I took a few months off to of course, try to recuperate.

Gary: Right, right.

Dee: Venice is a beautiful place not only to live but a pretty place to work. I worked with a doctor for a couple of years then he had a massive heart attack. I hung around to make sure he was stable. He decided to retire from ophthalmology. I bought him out for his pie in the sky, and I moved my office to where it is today. It's a 1926 Italian Renaissance home. Yeah.

Gary: In Venice, that's what you would expect right?

Dee: Exactly. That's where I've been for quite some time. It's a historical register. It's a house, so it's very inspiring to go to and it's very nice for patients and it's where my boutique started.

Gary: Yeah.

Dee: For me, I was just a general ophthalmologist and then about a little more, about 10 years, 10 plus years ago I decided to take the big step. The big step was I ran into a man I know and respect and that was Nick Curtis at the AAO meeting in San Diego, er San Francisco. I bought an ORA or an Orange.

Gary: Right.

Dee: I needed something to change my game. I was kind of bored with cataract surgery. ‘”Bored” is the wrong the word, but not challenged. I did a lot of glaucoma. I did corneal transplants but I really wanted to be a really, a premium cataract surgeon. I was between two really big groups, David Brown, south of me in Fort Myers, and David Shoemaker, Center For Sight, in Venice and then Sarasota. I needed to something that was going to change my game. I was already the only girl in town.

Gary: Right, right.

Dee: That was, I was the commodity. People went to me just because I was a girl. That was kind of cool. I never really felt like being a girl was anything but a plus for me. Of course I love being a girl, but it's also ... I have some really great strong male ophthalmology friends that have never wavered on telling me, "Hey, it's time to go home, you're a girl", and not taking that personally. "Hey, stick around because you really need to hear this." It's always been in my best interest. You know Lance, strong women and bright women are people he likes to hang out with. He married one and gave birth one.

Gary: That's right. That's right.

Dee: My big thing was I stepped off with this Orange thing, this intraoperative aberrometer that a lot of my colleagues and friends kind of poo-pooed. I was so lucky to be able to work with ... I was the first commercial. I bought ... There was, of course, prototypes that were used in research and of course Kerry Assil was the first person to get an orange. I bought the first commercial one and it was installed first. I think shortly thereafter Bill Wiley and Toby Tyson got them, and then the rest is history.

Gary: It was off to the races.

Dee: Right, but I got to work with some really fine people, Dan Durrie, Dick Lindstrom, Vance Thompson, of course Bill Wiley, one of my most favorite guys.

Gary: Yeah. Same here.

Dee: Rob Weinstock. Yeah.

Gary: Let's talk a little, let's dig in to that a little bit.

Dee: Okay.

Gary: Here you are, you're situated in Venice, Florida, beautiful area, very competitive. You mentioned a few names but there is a ton of incredibly competent people within an hour of you.

Dee: Oh, yeah.

Gary: You can have a Mount Rushmore of ophthalmology within an hour's drive of where you're at.

Dee: That's right. That's right.

Gary: Here you are, you're carving out your little fiefdom and you're trying to figure out, how do I make my practice a little bit different? Already have a few little differentiators, but this is a technology I'm going to double down on. You decided to just go from the very beginning. People don't really understand this. It's sort of like when you see on Facebook and it used to be on websites and probably still is, but, “first in,” fill in the blank. “First in Florida,” “first in the US to do X.” Those doctors are really putting themselves on the line a little bit because technology in its first iteration is never the best. We just know that. There are going to be bumps in the road. There are going to be things that you have to work out over time. Take me through ... I think we all the idea that intraoperative aberrometry, or choosing a lens based on that highly privileged aphacic state, that there could be some real advantages to that.

I've talked to Sean Ianchulev who was the guy who originally wrote the patents on Wavetec for this device.

Dee: Right.

Gary: He was talking about this. We have one chance to change or alter our lens choice, and that's right before we're about to put the lens in the eye.

Dee: Exactly.

Gary: We all saw that opportunity. Take me through the evolution from being one of the first or the first commercial install through their various changes and psychologically, at some points was that a tough transition? Walk me through that.

Dee: What was talked about was not the fact that nobody knew what the heck it was and nobody knew what the end game was going to be, but I had known Nick Curtis a long time and he said, "Dee, this is technology that's going to change the way people do ophthalmology. Trust me." What do you do? I've known him 30 years. What do you do 20 years into a friendship, but you trust somebody that has the ability to pick out technology that's going to last or endure. Needless to say, surround yourself with all of those people that I mentioned, then surround yourself with some of the smartest engineers in the world and the smartest guy I know, and that's Michael Breen. Line yourself up with that.

The first year I was with it, Tom Berryman was the CFO if you will.

Gary: Right.

Dee: We just didn't make a whole lot of progress, but we started to. I did, in that first year, have my a-ha moment. That a-ha moment was, I took a patient to the operating room with about two bucks of astigmatism against the rule. All my preoperative information said it was with the rule. I wasn't too worried about that much astigmatism. I get there, ORA tells me it's against the rule, and what do I do?

Gary: Right.

Dee: I did LRIs at the time, not toric lenses. I did AIs or limbal relaxing incisions at 90. Of course, what did I find the next day, but now I’ve got twice as much astigmatism as I started with.

Gary: Wow.

Dee: I thought, "Oh my god, this is horrible." I had Michael Breen look at the fringe patterns and the testing and he said, "No, ORA looks pretty good."

When I went to do the other, the patient's second eye, everything was the same. Everything said 90 on all my preop. Get to the operating room, ORA said 180. What did I do? I listened to ORA this time, made my cuts at 180, decreases astigmatism to 0.50 D or less. 20/25, a couple of weeks out 20/20 minus a quarter. Life was good.

I went back and titrated his right eye with some other, he looked like he had a 360 degree LRI.

Gary: Right.

Dee: It was more kind of a live-and-learn thing, but that was really my a-ha moment, because I really, if I had listened the first time ... really where I wanted, what I wanted to do is, astigmatism had been something that I had watched over the last, say, 4 years before that. The last 14 years, I've really been looking at astigmatism. I look at patients, and I'm sure Gary, even in your practice, you look at patients that you didn't do any astigmatism. They had no ancillary, fancy ancillary testing, just a straightforward A-scan. I'm always amazed that a person is like minus 125 plus 250 at 90 and they're 20/40 with nothing.

Gary: Or 20/30.

Dee: Yeah. Your spherical equivalent is so good and you're happy.

Gary: Right.

Dee: I think, "God, this patient isn't worrying about astigmatism."

Also, too, I'm in Florida. In spite of the fact that it's an older population, there's still a lot of very young baby boomers here that have all had LASIK. Now, it's a big mixed bag about astigmatism. Preexisting astigmatism, what they're topography looked like, and I was not a cornea guy. I did corneal transplants and they ended up with astigmatism, but they could see.

Gary: Right. Right. It's a different game.

Dee: Yeah. It was all relative at the time. Now, I needed to figure out what I was going to do. Toric lenses, the Staar lens was out. I was really, I had been using plate lenses with Chiron for many, many years. I thought, "I want to do this. I really want to do this." It's my first initiation into toricity, big time toricity with the Staar lens. At the time, unfortunately they don't make them anymore, but you really had four powers because you could put it right side up or upside down.

Gary: Right. That's right. That's right.

Dee: I knew how plate lenses work. I really had, I felt like I was ahead of the game for that. It's just where I started.

Then I realized how quickly, how valuable the iterations became of Orange. Then it became VerifEye. VerifEye kind of changed the game. That's when Wavetec began to be looked at by the big companies, the big three I would call them, Allergan, Alcon and Bausch + Lomb. That's when Alcon got very interested and all these studies were done. I did astigmatism studies. I did all kinds of studies with Wavetec.

I really learned the machine and the gestalt of the machine. I knew where I could ... I knew that I had to follow a recipe. The intraocular pressure was a must, it had to be measured.

Gary: Right.

Dee: Corneal edema from your incisions, you really had to look at your incisions. The first 50 cases that I did, I did a patient that I talk about Bill Wiley, but I did a patient that was post-refractive and I was 2.00 D off.

Gary: Right.

Dee: I called Bill and Bill, bless his little pea-picking heart, sat on the phone with me while I explanted that guy's lens and we did ORA, at the time, yeah, would have been, it was still Orange at that time, but we did Orange on him until we got a great reading. He said, "Let's put this lens in", so we did. The guy, unbelievable ... we just had to really look at some stuff.

Gary: Right.

Dee: At the same time, I was able to the guy's other cataract and then call Billy back on the phone. He said, "Okay, let's look at these readings. Take a picture, send it to me." He talked me through it. I had a very, very happy patient because I had somebody that thought out of the box, way out of the box and was very patient.

The thing I guess I learned most about working with Wavetec and Orange and now VerifEye and VerifEye plus is patience. Patience that you have to have with yourself. You have to look at your outcomes. If you don't put your data in a data bank, you don't know where you've been and you don't know where you're going.

Gary: Right. Right. I really believe in that too.

Dee: I do too. It's like we're so, and I still am amazed Gary, and you know this, I'm still amazed when I ask somebody, "What's your surgically induced astigmatism for your right eyes? What's your surgically induced astigmatism for your left eyes?" They don't even know. It's different for every implant you use. If you use a sub-2, 1.8 incision which I use, and if I'm using a monofocal lens that goes through that, I have nothing. My surgically induced astigmatism is 0.1, if any.

Gary: Right.

Dee: If I enlarge to 2.8 or 2.4, you've got to know what those are even though they've become nominal for some people. It's still a learning process. I'm also an old-fashioned surgeon. I still do, my primary incision is at 90 degrees. I was taught that way. It's the furthest away from the central cornea. It causes the least amount of astigmatism when you make a near clear or clear cornea. Maybe not a scleral pocket like your partner did way back when ...

Gary: Right, right.

Dee: ... But, near clear or clear cornea at 90. I induce very little astigmatism. I'm really, even though it seems to be old-fashioned, everybody is learning temporal, I really, all my data and my results are based on a 90 degree incision. I really feel like being farthest away from the cornea, I really am not doing the patient really much of an injustice at all, which is why I can look at patients almost 30 years ago and they don't really have much astigmatism that I've induced. It's still pretty close to what it was postoperatively before, of course phaco not extracap.

Gary: Right. Right. I think you've brought up some very interesting things about trusting the technology. That's, as I've talked to some people who have really invested themselves in ORA, they can almost all point to a case at which the pendulum swung and now they trust the ORA data more than they trust their preop biometry.

Dee: Right. You know Gary, it has to be ... We work for that holy grail. The holy grail is as you know, that all your preoperative measurements match your intraoperative measurements.

Gary: Right. Right.

Dee: If the world was perfect, perfect all the time, you and I would not be challenged, you would not be inventing things.

Gary: Right.

Dee: I would not be talking with you. You know what I mean?

Gary: Right.

Dee: It is. It is one of those trustful things. I work with some other companies. I've worked with Cassini, I'm a KOL for Cassini. I started out with them as a KOL and we've come a long way. We still have a long way to go because the reason I got involved with Cassini and it's total corneal astigmatism, it's measuring the posterior cornea as well as the anterior cornea was because I was in kind of a place where I wasn't a real big Alcon user of any kind. What was going to happen when Alcon bought Wavetec and where would that leave me if they choose to not take care of the users but base it on the implants that you use. I was really kind of looking for something else that was going to help me or what if the ORA wouldn't work one day.

Gary: Right.

Dee: I wanted my preop data to be really good and we're getting there. We're not there yet, but we're getting there with Cassini.

Gary: Right, but just to be clear though, I feel like Alcon has done a really nice job with continuing.

Dee: Oh, they've done an ... now, I'm just more prepared.

Gary: Right. Right.

Dee: Yeah. Alcon has done a fabulous job. In fact, I've done, I've been very fortunate the last ... I've done two of the Access meetings. I'm getting ready to do one at the academy, I mean one at ESCRS and then one in Houston a couple weeks after ESCRS. I'll tell you, they have some, again, some great people. Tina Williams, Michael Breen, Tom Paddock, all the engineers that started with all of that.

Gary: Right.

Dee: I'm so lucky that Alcon has really, really come to plate for me and really helped me continue to be a better surgeon. Of course I have VerifEye+. The difference between VerifEye and VerifEye+ is there's some new software, but also you can look in your ocular and see the measurements and the targets ...

Gary: It's like an overlay, right?

Dee: Yeah. It is like an overlay. It's really nice because you don't have to look up and look at the monitor, however, there are some docs that do TruVision and they do like the heads up. Also too, the cart gives me a lot of information on the fringe pattern, making sure the cornea is not moist and that the images are clear, et cetera, et cetera.

Gary: Right.

Dee: They both give you a good idea, but their new iteration coming out, I'm not at liberty to speak to everything about it, but it's going to be even better, so I'm excited for that. I'm excited.

I watched, having papers approved and presented at ESCRS back in Milan, Milano and then again in Amsterdam and then in London. London was the last year that Wavetec was an entity on its own. It was bought out by Alcon after that. I've not been to ESCRS since then, but I've been ... Mark Packer and I still work together quite often about ORA, and I've got a paper I'm writing right now about Trulign in ORA.

There's so much information in that little box and effective lens position, as you know, is a big proponent of how well we do.

Gary: Right. Right. It's a critical factor.

Dee: Yeah. That's one of the little things that they're working on and they have some great information about, but then with my world being, 25% to 30% of my patients are post refractive and I'm getting community calls. The cornea specialist up in Sarasota refers me patients that have had post refractive surgery, because he said, "Dr. Stephenson and I may be able to do the same amount of, both do good cataract surgery, but she's going to give you a better chance because she's got ORA."

Gary: Right.

Dee: I had people from South Florida sending them my way as well. It's been a great ride for me, and there's so much valuable information. When I look back and I think, "I don't want my patients to have any astigmatism." I've been doing this thing now with using iTrace after your placement of your toric lenses, and it tells you if you turn it 5 degrees you'll get this much more astigmatism correction.

Gary: Right. Correction.

Dee: It's been wild because I've got 50, 60 patients that says one degree whatever. I'm so right on and it's such a great feeling.

Gary: Right. You know you're spot on.

Dee: It's such a great feeling for me as the physician but for my patients. Then you learn more things, like you flip the axis and give them with-the-rule astigmatism, so you're going to overcorrect their astigmatism against the rule, give them a 0.50 D with the rule. Now they've got to increase depth to field so now they ... In a monofocal toric lens, they're two Jaeger three. I've done them just as good a job as if I was to have put a multifocal toric lens in.

Gary: Right.

Dee: You can play with all that knowledge once you understand it. That's what's so fabulous about this. That's what's so exciting when you start to treat astigmatism. Don't get me wrong, Gary, because you know me, I'm always the first one to say, "I'm not sure I believe that" or "Hey, I really believe that."

Gary: You call BS on some things sometimes. That's true.

Dee: Yeah, yeah. Exactly. Not every patient is 100%.

Gary: Right. Right.

Dee: Not every patient is 100%, but I'll tell you, my outcomes, I've got about 98, in ORA data bank, I've got 98% within 0.50, 86% within 0.25, so I'm loving life. I've worked really hard. That's my last 182 toric patients.

Gary: Wow.

Dee: I'm loving life and I've worked really hard to get there. Like you, we're on a learning ... It's an adventure. Every day in ophthalmology is an adventure. We get involved personally and our families are so important. The time we spend away from our families is important, but the time that I've spent away from family with about and with ORA has made my life so much better and my outcomes for my patients so much better.

It's one of those once, for me, one of those once in a lifetime things. I didn't think it could get much better than and then I got involved almost 5 years ago with Lensar. Femto and ORA and Cassini, I'm loving life in ophthalmology.

I really am, but it's hard work. Data bank, data bank, data bank, and analyzing stuff, analyzing what did I do wrong, what made this patient ... not only patient satisfaction, but before you get there you've got to give them the vision. You've got to give them the outcome and then you worry about the patient satisfaction.

Gary: Right.

Dee: It's kind of a double-edged sword.

Gary: Dee, I love your passion. I love the fact that every time I'm at a meeting your intellectual curiosity is just, it's palpable. You're always asking the right questions. You're trying to get better and that's really inspiring. Sometimes we can go through our profession and we can sort of hit a plateau. I think that's what you were expressing before you got into ORA or Orange, is that you felt like you were at a plateau, and you were looking to take your professional skills, your outcomes, however you want to say it, to a different level.

Dee: Right.

Wortz, MD: You were willing to go on the journey knowing that there were going to be some ups and downs along the way.

Dee: I'll tell you, it's amazing our field is so technology driven. I can tell you that this is the best step off being first user, that I've ever done. Have I ... I've used other things in the first wave, but not as the first person, but in the first wave.

Gary: Right.

Dee: You learn that, but boy, howdy, what it's allowed me to do is meet people like you, Bill Wiley, people that just ...

Gary: We've got a bunch of characters in our profession. Let's be honest.

Dee: Oh my gosh. Lance Ferguson, every time I'm with him, he teaches me something.

Gary: Right. Right, right.

Dee: Even if it's back to something basic. That's where I think as professionals in ophthalmology that love technology, the one thing we always have to go back to. I think this is my advice to my daughter as a young woman, my advice to you as a young inspiring ophthalmologist, is always reevaluate where you've been so that you know where you're going. Once you get to where you're going, look back on where you've come from because it all builds on something. Good choices and good paths are great but we've all had to get that tar on our shoes and have to walk through the house with it.

Gary: That's right, and live with it. Live with it for a while and look at the stains.

Dee: Live with it. Absolutely.

Gary: Dee, thank you so much for sharing a little bit about what it's like to be first and what it's like to go through that journey and also the joy of the victory on the other side, of seeing those patients who you know, you know you help people. You know you've helped people who otherwise may not have had the best outcome achieve something that you're both proud of.

Honestly, I think that there's, you mentioned engineers, I'll also mention Tom Frinzi. I think he had a huge role.

Dee: Oh my God. That was my other thing. I was with Tom Berryman and then all of the sudden, what took us to the next level was getting Tom Frinzi involved. He is the reason that this company went and has done what its done. Without Tom Frinzi ... what a leader, what a believer, what a leader. He guided all of us. He was the one that said, "I can make this happen. We can make happen." He was always such a, he is today a dear, dear friend and such a great leader and I'm so proud of him and proud to have worked under ...

Gary: Everyone in ophthalmology loves Tom Frinzi. I think that's almost a given. That being said, Dee, you're another one of those people that we all just love to hang out with, learn from, talk to. I think we'll just leave it there. Our next meeting, I guess it's coming up shortly, let's definitely sit down and continue this conversation. How does that sound?

Dee: Sounds great, Gary. Thank you for being my pal. You're awesome.

Gary: Awesome. It's a true honor and joy.

In a specialty as innovative as ophthalmology, we can probably rest assured that new technology and techniques will continue to come our way. We will always want to change the game and in turn will be taxed with determining when something new is worth our time, energy and headspace.

As Dee described, surrounding ourselves with the right people, asking the right questions, analyzing our outcomes and calling our colleagues all become trusted lifelines in this pursuit. Above all that though is that gut check. That visceral confirmation that the end game might just be what you want it to be. In Dee's case, it certainly was.

This has been Ophthalmology off the Grid with Dr. Gary Wörtz. If you like what you hear, please head over to iTunes and rate, review and subscribe. If there's a topic you'd like to delve into or a brain you'd like to pick, your suggestions are welcome. That's all for this episode. Thanks for listening.

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