In the Windy City

Live from the 2018 AAO meeting in Chicago, host Gary Wörtz, MD, catches up with John Hovanesian, MD, and David Goldman, MD. Drs. Hovanesian and Goldman comment on the new IOL technologies changing the cataract space, the importance of creating a positive practice environment, the potential impact of private equity, and more.

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

For this episode, I'm coming to you live from the American Academy of Ophthalmology Meeting in Chicago. Listen as I sit down with a few experts to discuss the latest issues in the field. I'll talk to Dr. David Goldman and John Hovanesian about the innovations in IOL designs and hot topics in ophthalmology. From MIGS to practice management to private equity, we've got it all covered. So with that, let's hear from our guests.

Speaker 2: Ophthalmology off the Grid is an independent podcast produced by Bryn Mawr Communications and supported by advertising from Alcon. For a full list of podcasts for eye care professionals, go to eyetube.net/podcasts. That's eyetube.net.

Gary: This is Dr. Gary Wörtz with another episode of Ophthalmology off the Grid. Today we have Dr. John Hovanesian. John and I have known each other for quite a while. We've gotten to know each other more recently through some meetings and some other opportunities. As it turns out, I met John when I was still a Chief Resident at UK at my very first academy meeting many, many years ago. I've really enjoyed all of my interactions with him since that time. So, with that opening statement, John, thanks for coming on and sharing some of your time here at Academy with us.

John Hovanesian, MD: Thank you. And look at you now with your own podcast. I'm a listener and terrifically fond of it.

Gary: Well, I really appreciate that. I always joke that my only job is finding interesting people to say interesting things. So, here you are, and I've got so many things I want to ask you. But first off, tell us just a little bit about your practice, where you're at, what you're doing, and kind of the flavor of your practice.

John: I'm really fortunate to be part of a terrific practice of about 15 doctors now in Southern California. We're specifically in Orange County, very near the epicenter of the Silicon Valley of eye care.

Gary: Right.

John: We're in Laguna Hills, which is near Irvine, and we have pretty much all the subspecialties in ophthalmology covered—three offices with expansion plans. We're looking to add to those and certainly add to the number of doctors. It's a really exciting time in ophthalmology, and I could not be with a group of better people. Of course, that makes all the difference, doesn't it?

Gary: Absolutely. We actually just realized that we're both Michigan guys.

John: Yeah.

Gary: So, we both grew up in Michigan, and you attended University of Michigan.

John: Go Blue.

Gary: Go Blue. We're hoping for our first victory over that team down south soon in football.

John: Right.

Gary: So, how did a guy from Michigan make his way out to Southern California? What's the story?

John: I had trained in Michigan. I was in residency at Henry Ford after med school at Michigan. I then did a fellowship at UCLA at Jules Stein back in '97 to '99. Of course, as too often happens, I met my wife during that time of my life, and she's more in Southern California. Somebody once told me that if you want to know where you're going to live when you "grow up," it'll be very similar to where your wife was born or where she grew up, right? So, that's the case. We now live in Orange County, which is similar to LA, and have three kids and a life—a very busy one.

Gary: Right. Well, you know, it's probably not too hard to convince someone from Michigan to reside in California after you've spent a number of years slugging it out …

John: With winters, really.

Gary: With winters, yeah, absolutely. And your statement is absolutely right. My wife is from Kentucky, and I am now from Kentucky. That's fantastic.

John: You don't have the accent yet, though.

Gary: Yeah, it hasn't really rubbed off totally. But one thing I really am curious and have been really looking forward to talking to you about is MDbackline. I know a little bit about it, probably just enough to be dangerous and misrepresent. So, I don't want to get into what I think it is and having you here, I'd really love for you to give us a little bit of an idea of what MDbackline is, but also unpack the unmet need. How did you come up with this idea, and how did you develop it? I always find those stories to be really interesting.

John: So MDbackline is an online system that automates conversations with patients for doctors so that we can learn how patients are doing. We can also share educational material that's very specific to their needs. It was kind of born out of a need that I saw as a doctor 10 years ago but is even more a problem today that we just don't have enough time for each patient.

We treat conditions like our cataract surgery patients. We treat conditions like dry eye, like glaucoma, where if you think about it, how much better could our patient do if we had unlimited time to talk with them about all the nuances to their care? Well, we don't have that time, but it doesn't take too much to put together a system that can have a logical conversation with a patient, and I don't mean like a chat bot, but structured conversation with branching logic that asks patients some simple questions that's sort of condition-specific and then gives them in real-time feedback and information about them.

This is particularly valuable for us in premium lenses because we know that, across the country, 80% of patients who go through cataract surgery, if they understood what premium lens options are, they would be interested. But, as it turns out, across the country only 12%, far less than 80%, actually choose premium lenses. We think part of the reason for that is that we as doctors don't have enough time to properly educate patients. So we're now reaching out to patients before they come in for their cataract consult to share some general information about cataract options when they go through surgery so that when they get to the office, it's not a frightening conversation about, "Oh my goodness. I need surgery and so I have to learn all about that, plus there's this added cost option."

Patients are better prepared. They ask better questions at their consults. And we did a study of five physicians over a 10-month period, looking at premium lens adoption, and those five docs went from about 22% adoption rate of premium lenses to 36%—so more than a 50% increase in their adoption over a 10-month period, which is really meaningful for those patients. They're getting better technology, better vision than they might have otherwise. The doctors are doing more advanced surgery and have a little better income stream.

Gary: Actually, and less chair time I assume because, right? I think that's fantastic. Yesterday, I was giving a talk to OIS, and one of the things I was saying is patients have a really hard time connecting their visual needs to a lens choice.

John: Yeah.

Gary: And when we talk about distance vision, if someone is near-sighted naturally they think, "Well, fantastic. I'd love to have distance vision," not really understanding that, that means they're giving up their near vision if they choose a monofocal lens. Earlier in my years, as I was still learning some of these lessons the hard way, I had a patient I still remember and she was 20/20 uncorrected. I look at the chart, I walk in ready for the hero treatment. I'm ready to get a big hug. She's got her arms folded, legs crossed, and looking at me. I'm kind of taken aback by this, and she's like, "I can't see. What happened? I can't see."

What she did when she said that was she took her hand to her reading distance and said, "I can't see,” like an exclamation point. I tried to still get that hero treatment. I said, "No, no, no. You're 20/20. You can see distance. Isn't this great?" And she said, "Yeah, that's fine. I don't care about that, but I can't see."

John: Yeah, you told me about that. You didn't tell me you'd take something away, right?

Gary: Right. There is such a gap in communication, partly because of the time issue, and that's exactly what you've identified. But there's also this issue of when you forgot what it was like not to understand optics. It's really hard to have a conversation with someone who doesn't have optics because you are so far. It's called the Curse of Knowledge. There's some books written on this, but once you have the knowledge, you forget what it's like not to. So we can speak in jargon. We can speak in terms that patients don't understand.

Then, when we're trying to have a conversation, it's going to dramatically impact the quality of their vision, the quality of the rest of their life, we're just speaking two different languages so many times. And it sounds like this is an opportunity for physicians and patients to get on the same page.

John: You're exactly right. We have to remember that if you want everyone to understand something, if it's written word or even spoken word, you have to think about fifth grade vocabulary because otherwise you're going to lose some people. We have to dismiss technical terms and help people understand it from the paradigm that they're used to. You gave a perfect example of a myopic patient who assumes that she will forever have reading vision without glasses, and, matter of fact, putting on makeup and so many different activities that you are really meaningfully affecting their life. So that's one of the things that we absolutely do is begin with what is the patient used to, what's important to them, and then kind of tailor a solution to them. It's really not about selling. We've learned with premium lens implants that people don't want to be sold to, but they do want to buy.

Gary: That's right.

John: They want to know what the opportunities are, what the costs are. They want to know a little bit about what other patients have to say. We have built in, almost like Amazon reviews, actually—comments from hundreds of other patients who've chosen these lenses and exactly what they think so that they can see with their own eyes what the opportunity is, and then patients are prepared to make a great decision for their future.

Gary: How can physicians, if they're interested in this, get more information? I assume this is something they can find online.

John: MDbackline.com is the website address, and there's a contact us link there to get in touch. We certainly are always looking to help more practices to do better.

Gary: Well, that sounds fantastic. We're talking cataract refractive outcomes, patient expectations, these are always themes that seem to sort of recycle. They're always top of mind. We're always trying to figure out is it the conversation? Do we need to change the conversation? Do we need to change the technology? Do we need to change our lens calculations? And it sort of seems to be this rotating wheel that we're always trying to figure out, where are we missing and how can we do better?

Let's put the patient conversation aside right now. It sounds like MDbackline has a great solution. There are, I think, some other technologies that are sort of approaching that. Let's talk a little bit about either biometry or lenses. Where do you feel we're at right now? What is exciting you in your practice about what you're able to offer? And 10 years from now, where are you hoping we're going to get to, where this conversation maybe changes a bit down the road?

John: You know, if you look at the big-picture goals we should have as an industry, I think one of them that we have to get serious about is much more precision in refractive cataract surgery. When you think about it, what's the difference between a patient in your practice who is -0.25, -0.50 axis, whatever, who has what we call maybe a negligible or a small amount of refractive error versus one who is plano sphere and has a healthy eye? I mean, you get the hero treatment for that patient who is plano sphere. There is a dramatically higher level of satisfaction among those patients when you really nail it. For most of us, we do pretty well. If we're lucky, we have 90% of patients who are within 0.50 D, if we're really paying attention to details. But still that's within 0.50 D.

Gary: Right.

John: That's a lot of defocus, +/- 0.50 D, and astigmatism just adds to it. The solutions like RxSight and Perfect Lens, and of course, the technologies that allow us to change optics of lens implants to swap them out like your design are really promising because we can then hope to deliver a whole different level of satisfaction to patients. To me, that should be one of our goals.

Gary: Right. Matt Jensen who is at Advanced Thompson Vision in South Dakota, a great thinker, one concept he brought up as we were having a conversation was that the past was all about mass production. Big Michigan guys, we know all about mass production with automobiles, etc. So, we got to see that first hand. But his thought in looking at the market and where things are going and millennials and what the generations are looking for now is really this idea of mass customization.

So, for example, in the past, if you wanted to have a custom tailored suit or shirt, you had to go get measured. You had to have a tailor actually create that. Now we can actually take a photo of ourselves and send that photo to some shop through an app and get that shirt mailed to you that is custom-fit to you. So it's this idea of mass customization, and everything is about you, and it's getting things really specified to your design and what you want.

I think that's kind of where things are going with refractive. You look at iDesign and topo-guided LASIK and these other things that are happening in the LASIK world that are really more personalized. And then with the IOL side, exactly what you said—RxSight and Perfect Lens and some of the other options, they're still providing a product to the masses, but it's able to fine-tune and customize in a way that was unthinkable 5 or 10 years ago.

John: I agree with you. And surely, it's not going to appeal to every practice, at least not initially. But the kind of results that you're talking about there are even better than LASIK-like. We talked about LASIK as being so highly precise and cataract surgery as at a level below, and that's why we don't have quite the adoption with premium technology. Well, this kind of premium technology is very hard to ignore, and I think will be adoptable by almost every practice, whether you're high-volume and sort of low-touch or the opposite. So it's surely going to come. It's already approved, and even better versions of it will evolve, taking into account higher-order aberrations and multifocality and all sorts of things that we just don't think about because they're not available to us right now.

Gary: Right. What other things do you feel like are coming down the pike, either with practice management or other refractive technologies? I'm not sure if you're dabbling in MIGS at all. Where do you feel like the refractive cataract surgeon is heading in the next 5 to 10 years?

John: I'd like to see us really get rid of eye drops as another very big-picture goal, and we're taking big steps in that direction. Just this year, we had the approval of Dexycu, which, of course, is an injectable dexamethasone depot that goes in the ciliary sulcus and then dissolves slowly.

Gary: And the data on that looks fantastic.

John: Yeah, it's terrific data. The rates of pressure spikes, the rates of issues with non-controlled inflammation ... just not an issue. And Ocular Therapeutix with Dextenza has very similar results, really no greater pressure spikes with their device than typical patients who are treated with steroid. In the case of Ocular Therapeutix, it's a punctal depot. It goes in the lower punctum, kind of like a dissolvable plug does, and so we basically eliminated steroid drops right there.

Gary: Right. I was part of that trial as well, and it was really amazing to see the patients with that. Not only did I feel like the inflammation was so well controlled, but having a punctal plug, their ocular surface ... you're not giving as many drops with preservatives. That plug is nice because it's actually creating a little more aqueous, so dry eye post cataract surgery ... those patients were actually some of my happiest patients.

John: I agree. One of the commonest things we've learned from MDbackline, the patients complain about, when you ask them what did you like about your surgery, what did you not like, is the eye drops, is that you have to take so many eye drops for such a long time. It's a very confusing prospect for people. And let's remember, the average patient is 70 years old, 69 years old, and so they've got a lot of other health issues that they're dealing with, in many cases. Not everybody has perfect memory, and it's difficult. I don't think I could take drops consistently four times a day.

Gary: I totally agree. I think just the compliance, the confusion. If we can take that conversation out of the patient's hands, and we can really take care of it at the time of their surgery, there are so many improvements. We will probably see a dramatic overall reduction in CME, because personally, I think most CME is probably ... I'm not trying to blame the patients all the time, because sometimes we get some inflammation that's real, but I think it may, a lot of times, be either a dose that is when you don't shake up the bottle and you've got pred acetate, or dosing can be all over the place or they're not taking it or taking it intermittently. I think there's a lot that we can do for patients if we just take care of it at the time of surgery.

John: You're right. It's impossible to know exactly what amount of that is being caused by drops until we substitute something that doesn't depend upon the patient.

Gary: Right, exactly.

John: We'll soon learn what the real rate of CME is, and of course, nonsteroidals play a role, too, where we're moving toward having nonsteroidals that can be delivered by drug. I'm very excited about, on the antibiotic side, that the ASCRS is now undertaking a study to kind of propel the effort to get an FDA-approved antibiotic that's intracameral approved, so that we can make that part of the practice without using a compounded product.

Gary: Right.

John: About half of US eye surgeons report that they are concerned about using any compounded product for their patient. That's reasonable. I worry myself about that. But I think there's some really responsible and highly effective compounding pharmacies. Imprimis comes to mind as doing a great job.

Gary: Ocular Science also doing a great job.

John: Absolutely. Very well-respected and a great track record, but you know, ultimately, the physician take responsibility. If there's any side effect or complication and you're challenged with the fact that you used a non-FDA approved version of a drug, it's pretty hard to defend yourself. So a lot of us would love to see an FDA-approved antibiotic that we can inject, so that, to me, makes the ASCRS study very exciting. I think we're just really a couple of years away from being able to approach truly dropless cataract surgery using on-label, FDA-approved products.

Gary: I think that's something that we all need to make all of our sincerest efforts to make happen. So, John, any parting words, any final thoughts on what you're looking forward to at this Academy?

John: Well, it's always fun to see friends. The Academy is just such a great meeting because everybody's here, from industry and from all subspecialties.

Gary: It's one big family reunion.

John: It is like summer camp. Once a year, you get together with all the friends you don't often see.

Gary: That's right.

John: Hope you enjoy it. I'm really honored to be part of your podcast, and thank you for inviting me.

Gary: Thanks to Dr. Hovanesian for providing us with his insights on the latest technology in ophthalmology. Next, we'll talk to Dr. Goldman about a range of topics, and I can't wait for you to hear that conversation.

Gary: It's my distinct pleasure to welcome the one and only hilarious David Goldman. David and I have known each other for a number of years. We actually met during Durezol speaker training. You may or may not remember this.

David Goldman, MD: I do.

Gary: We have had probably more laughs than is legally allowed since that time. So, Dave, thank you so much for coming back. You're a repeat guest of Off the Grid. I'm so excited to get some of your perspectives on where you're at in your practice, new IOL technology, and we're just going to see where the conversation takes us.

David: Sure, sounds great.

Gary: Let's start from the beginning. In the not too distant past, you started a private practice and have been able to grow that to a pretty impressive volume. As we were talking over the past couple of days, I realized you are just about to add a new partner. I think it's a really great benchmark when you think about not only going out on your own to make a nice successful practice for yourself, but you actually have recently gone through that growth process of, "Hey, is it time to add a new partner?" I really want to know what went into that thought process of, "Man, it's time for me to add capacity. I don't think I can maybe do it all on my own at this point."

David: Sure. I know, last time, we talked about what I thought some of the secrets were to practice success, and I've seen this over and over again when I've visited other practices that were successful, is that those practices that take really good care of their staff and have a very family-style environment tend to be the ones that grow. The patients feel that feel-good energy, and if you're getting good, ethical care, the word-of-mouth more than any other form of advertisement is going to be what really grows the practice. And I think that's been behind the growth of the practice that I started once I left academics.

In terms of adding another partner, it was really serendipity. I'd already had an optometrist when things started to get a little bit busy. But bringing on another ophthalmologist, people would say is like a marriage. Or even more than a marriage, because you sometimes spend more time with your partner at work than you do actually with your spouse or significant other. So, for me, it was a really hard decision. I knew, at some point, I had to pull the trigger but wasn't sure when. And I had just been happening to have a conversation with, in this case, it was Dr. Mark Milner who's a good friend of mine, a very strong mutual respect developed over many years of working together on several projects.

Gary: He's fantastic. I mean, absolutely.

David: He was asking me about some potential job opportunities because he was thinking about moving, and then I just sort of offhandedly mentioned how I might be looking to hire someone in the next couple of years, and he said, "Oh, well, you know, certainly would love to work with you." And I kind of paused and said, "Well, let me look at the numbers and see if it makes sense to bring another person in now." And in those next few days, I was inundated with so many patients that I was actually a little bit miserable, and I thought, "You know what, I think I'm ready now."

And I've seen different scenarios where, especially practice consultants will come in to a practice, and this happened to me, actually, very early on in my career, when I was finishing my training, where I looked at a practice that was interested in hiring me, brought in a very well-known practice consultant who spoke to the practice and said, "You know what, you guys aren't ready to hire another person. Don't hire this guy." And I think that's completely the wrong way to go. Even if you're not super busy, and this is all relative, but if there's an opportunity to hire someone who is an all-star, in this case, I think Dr. Milner is absolutely an all-star, very well-recognized in dry eye and cornea and external disease, and even if I wasn't at capacity yet, I know that if I bring him into my practice, he, irrespective of what I'm doing, is going to build an incredibly busy practice.

I think there are other factors that you have to look into, but again, it's someone who I think is going to match with everyone in the practice. It's someone who's going to keep that same philosophy about giving good care, taking good care of the patients, taking good care of the staff. I've seen very different models where physicians will bonus their staff based on hitting certain productivity measurements. This is another big thing that consultants will discuss is compensating them for more conversions to multifocal lenses, for example. But I think that creates this environment where technicians will cherry-pick the healthier patients because they want to convert the patients to multifocals, and then there's animosity between technicians.

So, in my practice, there's basically a pot of money at the end of the year, and we divide that amongst the staff. They know that. So everyone is working together toward the same philosophy. It's not just my surgical counselor who may discuss the benefits of a toric lens, but when the patient's checking out, they may ask the front-desk person a question, and they'll reiterate that they think correction with astigmatism is helpful. And they're knowledgeable about ocular diseases, as the billers are and everybody else. It helps to create this kind of universal happy environment, with everyone focused on a common goal.

Gary: The last thing you said is something I was going to reiterate. It's really about establishing alignment in your practice, not only from the front-office staff to your back-office staff, technicians, etc., but also bringing someone into your practice who's going to be aligned with your goals. And I 100% agree with what you were saying. When it's time, when you can finally convince yourself that it's time to add another person, or a consultant will tell you it's time to add another person, it's probably too late. You really should be looking probably a little bit ahead of your actual need, because it's not just about plug and play. Ophthalmologists, optometrists—it's not like cogs in a wheel. It's a very delicate balance, and it is like a marriage. You need to find someone who you're going to jive with, not just from a practice standpoint but personality-wise.

Also, like you mentioned, a Mark Milner doesn't just come in off the street every day. So, when you have an opportunity to get an all-star into your practice, not only probably in a practice that's flourishing ... you probably have the capacity, but think about what they're going to bring to the practice, not just what you're going to be giving up.

David: Absolutely.

Gary: I think that this is a really unique scenario, but I've heard this time and time again from other folks, as I've interviewed people throughout time. Good surgeons usually can find a job somewhere because someone will recognize their talent and are willing to roll the dice on them, so I think that's absolutely fantastic.

Switching gears a little bit, just from practice management over to the technology side, one thing we're focusing a little bit on this episode is new IOL technology. And that may seem like I've got a dog in this fight, and I do, a little bit. But I'm just curious, as you are looking at the landscape of all the technologies that are coming … we've been talking for years about accommodating lenses, and we've had various iterations that have sort of come into the market, perhaps, or almost come to market. We've got electroaccommodative lenses, we've got multicomponent lenses, we have light-adjustable and laser-adjustable lenses.

Where do you think we're going to be 10 years from now? You're having conversations with patients all day long right now about the options that are there. I'm sure we both have opinions about where technology could be improved, but I guess I'll ask a two-part question: What excites you now? You know, current technology or technology that's very close to coming to market. And look at the crystal ball. Where are we at in 10 years or 15 years from now? What do you think we'll be doing?

David: Of the current IOLs that are on the market now, I'm most excited about the ReStor ActiveFocus lens. This has been a real game-changer in my practice because it's working for the patients that want multifocal lenses, which is typically the post-LASIK or younger cataracts surgery patients that want to function without glasses and their needs are iPads and iPhones and computers. They're not reading The Wall Street Journal. They need that intermediate range better, and the fact that I can put this lens in and not have to worry so much about glare and halo complaints has been a complete game-changer. The patients come in, and, as long as they have realistic expectations, we can almost guarantee those expectations get hit every single time.

As far as future technology, one of the questions patients always ask me is, “Hey, doc. I had cataract surgery 10 years ago. Any chance I can swap out my lens and get a new one put in?” We tell them, unless you develop macular degeneration and need an implantable telescope, that's probably not a great idea. But, in all seriousness, I think, for example, your invention will be a great addendum to what we have out there, so we can say, "Yes, actually, we can exchange it." I think, obviously, the PanOptix lens that's coming out soon is also going to be excellent to offer trifocal vision. Going forward into 20 years, I think we will have a true, full range of vision lens out there.

In the meantime, the most exciting technology coming forward is probably the Light Adjustable Lens from RxSight. I think it takes all the extra elements out. So, for example, you no longer need femtosecond laser. You no longer need ORA. You no longer need to be on the most accurate optical biometry device anymore because, if you miss the mark a little, hyperopia a little, myopia a little, astigmatism, or even a little spherical aberration that you want to titrate one way or another, you can do it all with that lens, and you can effectively guarantee a 20/20 or better outcome every single time. And the fact that it's a premium lens also makes it a very financially viable option for all practices. That's probably the most near-future technology coming that I'm excited about.

Gary: Yeah, when I look at the landscape, and I gave a talk at OIS yesterday and went through a little bit of this, there essentially is a different risk category and reward category for different lenses. So, you have the low risk, low reward, so I would say monofocal lenses would be low risk, low reward. We’re going to make most people happy, but could they be happier? We'll never know because we set a pretty low bar for ourselves, and we know most patients do find we give them glasses, and that's okay. It takes a lot of pressure off the surgeon to deliver on that. And then you jump up into the multifocal area of high risk, high reward, so there are going to be some patients who really, really love their vision with multifocal lenses because they can adapt to the changes, so they get good distance vision, good near vision, and their brain can sort of tune out the other aberrations.

But the new category that I'm really even more excited about, and it fits into the ReStor or the ActiveFocus and Symfony EDOF lenses, maybe even the IC-8 lens that's being developed by AcuFocus, and even some of the laser technologies or Light Adjustable Lens. It's this new category, which is high reward, low risk. So, you can easily implant this technology, and the chance the patient is going to be unhappy is very low. The chance that you're going to be able to make them thrilled and they're going to be really happy with their range of vision or quality of vision really goes up. I really see the market consolidating around the idea, not only of adjustable and exchangeable lenses, but really giving surgeons and patients options where the risk profile has decreased and the opportunity for increased range or clarity has really gone up.

So, another type that we've been recently been talking about is MIGS, and I think that it's been interesting to see over the past couple of years, I guess maybe I was just naïve. I didn't have my eye on the ball as much, but MIGS, to me, just seems like it has exploded, and the opportunity that we have to have a simple conversation with a patient who has a concomitant disease process along with cataracts, you know, glaucoma, that is a potential game-changer, and I'm just very interested. Where do you see the future of MIGS going, and tell me a little bit about MIGS in your practice.

David: So, as an ophthalmologist, it's hard to say if I was really an early adopter or late adopter, because I know for years colleagues like Jai Parekh and others, would come to me and say, "You're missing the boat." I think the real change was when I was told, "You're doing your patients with glaucoma a disservice by not offering them this because it's such an easy thing to do at the time of surgery and gives them so much benefit.” Fast forward, now I think my happiest patients are those patients that I've performed cataract surgery on that postoperatively, forget about their vision, that they no longer need glaucoma drops any more, and they don't need the burden either financial or just quality of life of having to deal with these drops all the time, so that's been terrific, and obviously there's multiple MIGS devices out. It's definitely the hot topic here at the Academy.

I see the future of that much like the future of these premium IOLs where we're going to get more and more impressive drops in IOP with a lower risk profile, and I do think as they continue to develop, we're going to see glaucoma become much more of a surgical disease rather than using pharmaceutical drops.

Gary: Well, and that's been the old paradigm, and paradigms die hard, but I think that we are in the beginning of seeing a revolution where optometrists and ophthalmologists are looking at mild to moderate glaucoma or even moderate plus. You know, when we get to this severe disease, I think it's pretty easy to say, "Hey, let's send you to a glaucoma specialist for a filtering surgery. You know, I think that severe has always been surgical, and mild to moderate has always been pharmaceutical, and SLT gets, I think, way underutilized. I'm a huge believer in SLT. But what I think that MIGS is really doing is shifting the conversation of glaucoma from a pharmaceutically managed disease to a MIGS-managed disease.

You know, if I were a patient, to be honest, from what I've seen, I would want to have a MIGS procedure at the time of cataract surgery. Or, if I was pseudophakic. There's some really interesting technology coming out from Sight Sciences, the OMNI procedure, and Kahook Dual Blade. There's some other technologies that are out there. You know, this is not just smoke and mirrors. We're really seeing some great efficacy from these devices and these procedures, and, you know, I would hate to have to take drops all the time. It's nothing against the drops. These medicines, and we actually have some new medicines coming out that are a new categories and ROCK inhibitors, etc., but I would much rather have a surgical treatment. Just solve the problem. You know, as cataract surgeons, we're all about let's just solve the problem and move on with life. And I really feel like we're getting there with glaucoma. Don't you think so?

David: I agree, and you look at the future, the reality is there is going to be so much glaucoma in the future from an epidemiologic perspective. We're not going to be able to handle it all if we keep going at the path we're doing. Glaucoma surgeons are already overburdened. In my area, to get in with a glaucoma surgeon for a trab or tube is a lengthy process, and a trab or tube, in its own right, can have all sorts of complications, and, you know, it's associated with maybe a little drop in vision or at the very least, some discomfort from the surgery, etc. Now, we're in a situation where I think the glaucoma surgeons are still going to be more than busy, but your comprehensive ophthalmologist, even your cornea refractive docs, can do something to mitigate how many patients have to get referred out and reduce the burden on those glaucoma specialists so they can take care of those patients that have more severe disease. Otherwise, we're going to be in a situation where there's just not enough supply of physicians to meet the demand.

Gary: Absolutely. You know, I think the analogy I've heard is the general ophthalmologists are going to be turning down the faucet so that less percentage of patients have to go see the glaucoma specialist. Maybe the same number of patients end up going to see a glaucoma specialist, but relatively speaking, it may be a lower percentage. And hopefully that is the case. We can maybe do a better job of assisting them so we don't get as many patients into severe disease.

So, Dave, one other thing we share is a common love for exercise and that sort of thing. Tell me a little bit about what your thoughts are on ergonomics in the OR, ways that you are trying to keep yourself healthy. I think it's recently become a hot topic, as we have seen a lot of our colleagues who are a couple of decades older than us either suffering from neck injuries or having to slow down or having cervical disc issues, etc. What do you do and how do you approach keeping yourself healthy enough to have a long and productive career?

Dave: That's a great question. Fortunately, I think, in general, when you look at the statistics, ophthalmologists are actually some of the healthiest of all subspecialists in medicine. I think there are a lot of factors behind that, you know, that we have not as drastic calls. We have better hours, but the personalities that go into ophthalmology in general—even when we come to this meeting. My wife is an OB/GYN, and she goes to an OB/GYN equivalent meeting of the Academy that we're here today, and the physicians are dressed down. They're wearing Birkenstocks. Here, everyone is in suits, so it's a different mentality.

As far as exercise and ergonomics and everything else, you know, this is definitely the bane of existence for every practicing ophthalmologist, and it's something that starts right in residency, that you really have to make sure you learn how to properly position at the slit lamp and at the OR scope. If you don't make those changes in the beginning, you're going to be suffering with all sorts of back issues down the road. I go through it every single week when I go into the OR, I go in the room, and I get to the scope, and the bed's not right or the chair's not right. You know you could just whip through the cataract surgery and go to the next room and not think about it, but in my head I'm thinking about the long-term effect, so I take that extra minute, and if they've changed the bed or the seat or whatever it may be to be sure it's back where it should be so that I'm properly positioned.

As far as exercise, it's tough. I've got three kids now and now a puppy, so the ability to get out of the house and participate in sports or gym with them is just very limited, so we actually purchased a Peloton. Ours is an indoor spin bike. I use it a ton. My wife uses it a ton, and the nice thing about having some sort of home workout equipment is that you can just do it at any time. So typically, I'll put the kids to bed, and then I'll hop on the bike for a half hour to an hour, and it gives me that stress relief. It gives me that sense of energy back in the morning. It helps me sleep better, and I know you're a fan of the technology as well.

Gary: Absolutely. I recently got a Peloton bike as well, and no financial interest to disclose, actually they take a lot of my money, but I don't mind. I did the investment analysis, and I thought, "You know, if buying this bike adds another week of productivity to my year or cumulative life, I've well paid for the amortized cost," so I'm really looking at investing in my own health and my body and my longevity, those sorts of things. I look at it as an investment of, if I can go for another year or 2 or another 10 years of being active and productive, then the money I'm spending and the time I'm spending right now keeping myself in shape, it will pay off in spades.

Something you said is actually really key. Having something that's in your house, it may be that you're still a member of a gym, and I still belong to a gym and love working out and lifting and that sort of thing, but there's really something about having something in your own home. Because sometimes you have to skip the gym, you've got to get home to pick up the kids, or you've got a project to do, or you've got a phone call, and it just doesn't work out. But having something inside your own home where you can walk down to the basement or somewhere and get a 30-minute workout in, and you feel great and haven't skipped that day, I think it makes a world of difference.

David: Yeah, I actually have mine next to the bed, so even if I want to be lazy, I go to my room, as soon as I sit on my bed, it's staring at me, and I've got no excuse, and so it forces me to do it.

Gary: And I do have to say, Peloton is really the coolest exercise technology. We actually compete back and forth. We get to follow each other.

David: We do.

Gary: And it's a pretty good rivalry, I think, so it's pretty fantastic. Dave, any parting thoughts on where you feel like ophthalmology is right now, things that you're excited about, things that you've learned. I mean, we've talked a little bit about private equity. I know it's another hot topic. Any thoughts on where ophthalmology is heading in that direction?

David: Yeah, I think, in ophthalmology, it’s interesting that you bring up private equity. We are starting to see a lot of acquisitions. It's becoming a bigger thing. I think we're seeing mergers of practices into these larger groups, and I think that's going to continue to happen. I do have fears about that, that ultimately these groups of 10 practices will get sold to become mega-groups of 30 practices and then 200 practices and then 1,000 practices, and then does that group just get sold to Humana or something, and all of a sudden the whole dynamic changes? For me, I've spoken to private equity. I'm still in talks with private equity, but, for the most part, I've never seen a deal with private equity that seems to make sense to me. It always seems like a loan almost in that you're getting a very large sum of money up front, but you're giving up a portion of your practice, you're losing a lot of control of your practice, and you're effectively paying that money back over many years in this group.

The reality is, these investment bankers and private equity groups that are buying these practices, they're in it to make money. So obviously, if they're making money, you may not end up on the right side of the coin in this situation. But, going forward, I think ophthalmology, the field itself, continues to improve. I love doing what I do with cataract surgery. Obviously, we're fixing people's vision, but now between LASIK, cataract, and these glaucoma surgeries, we're really getting better and better at just curing people of whatever the disease may be, and I'm excited about what the future holds.

Gary: Fix it and move on, right. That's where we really want to be. Dave, thank you so much for taking some time. I really appreciate it. And, again, any time you want to come back on, always welcome any time.

Gary: Thank you to all of our guests for taking the time to talk to us here at AAO. Listeners, thank you for checking out another live episode of Ophthalmology off the Grid. I invite all of you to reach out with any other hot topics you've picked up at the meeting. With that, thanks for listening to Off the Grid live. Until next time.

Speaker 2: Ophthalmology off the Grid is an independent podcast produced by Bryn Mawr Communications and supported by advertising from Alcon. For a full list of podcasts for eyecare professionals, go to eyetube.net/podcasts. That's eyetube.net.