Refractive Revolutionary

What inspired you to become an ophthalmologist?

I have always wanted to be a doctor and that has never changed, despite being exposed to other opportunities. After completing my medical degree, I was conscripted into the army – as all South African young men were at the time – and ended up working in urology. I enjoyed it so much that I decided to specialize in it. Coincidentally, my best friend had landed up in ophthalmology and having known each other for years, he persuaded me to spend a day with him in the eye clinic. I know it’s a cliché, but the rest is history. One look at the iris through the slit-lamp and I was sold – hook, line and sinker.

Who were your mentors during your formative years as an ophthalmologist?

I trained at the University of Pretoria in South Africa. I was appointed to the residency by the legendary professor Hennie Meyer, the doyen of South African ophthalmology at the time. He retired during my residency and I completed it under Polla Roux. Both men had extraordinary qualities and I like to think that they influenced my life and career in equal measure. The other consultants at the academic hospital played a big role too, with much of my surgical experience in retinal surgery coming from assisting these surgeries privately and after hours. Harold Konig, Jan Talma and Eugene Meyer were especially instrumental in developing my retinal surgery skills.

I learned the fine art of patient interaction from Louis Kruger. He was a master surgeon, but his patient interactions were equally impressive. Michiel Kritzinger, one of the pioneers of LASIK, was also very generous with his time, teaching me both LASIK and ICL. Given how my career turned out, I am eternally grateful to him. Surgical volume was no issue during our training with the typical resident doing close to 2,000 cataract surgeries; we tended to learn an awful lot from our seniors, as well as our more junior residents.

How has ophthalmology changed over the course of your career?

The technological advances are the most obvious. In ophthalmology, and especially refractive surgery, they seem to change at a furious rate. Other changes include more women entering the speciality – a very welcome development – and patient expectations rising dramatically, especially in the elective fields of cataract and refractive surgery. As the technology develops, so do the expectations, so to be a successful cataract and refractive surgeon today, you need to be a bit of a psychologist and an entrepreneur, too.

What are your career highlights so far?

I have had so many positive things happen to me that it’s very difficult to pinpoint any one highlight. I would say that cumulatively, the following chronologically correct events have all had an impact to the point where the more obvious achievements are noted, and one appears to be an “overnight success.”

Making the decision to specialize in refractive surgery and relocate to Ireland to a clinic doing refractive surgery was very likely the start of this journey. Being introduced to WaveLight very early on in their history and developing a lifelong relationship that today is still very dear to me also played a significant role. Meeting Guy Kezirian, who was doing the FDA trial for the WaveLight, and learning from him that trying to achieve a perfect outcome for every LASIK patient was just as admirable as closing a retinal hole. He taught me the concept of performance-based versus disease-based medicine. Guy’s contribution to our specialty is phenomenal and it’s a privilege to call him a friend and mentor. Working with Michael Mrochen, developing a lifelong friendship and, along the way, collaborating on multiple projects has been life-changing for me. Michael taught me never to make assumptions. His brilliant mind is always an inspiration to me. His friendship is cherished.

Being listed on The Ophthalmologist’s Top 100 list in 2018 and the Top 50 list in 2019 was pretty special too, although I am fully aware that there are far more deserving people that are not on the list, simply because the wonderful contributions they make are simply less public. The recent Joseph Colin Award from AECOS Europe was very special to me. To be recognized in this way by such an extremely accomplished group of people was truly humbling, and an experience that I will never forget. It was the emotional highlight of my public professional life.

However, the cherry on the cake has been the appointment to the board of directors of Alcon Inc., as they spun-off from Novartis in April 2019 to become the world’s largest ophthalmology company. The process started in August 2018 and I have still not completely processed the fact that it happened. I am on a learning curve that is very exciting, and I am grateful beyond words to the Alcon leadership for entrusting me to this role. I am determined to help grow the market, to help encourage their innovation quest and bring the benefits of modern ophthalmology to more people.

What are your current projects?

There are a few innovations that I am involved with, either through clinical trials or as a member of a medical advisory board. Vivior, the producers of the Vision Behaviour Monitor (VBM), comes to mind first. This technology is going to revolutionize how we treat our patients, allowing us to make choices based on objective lifestyle data and provide the most appropriate refractive correction by means of presbyopia correcting IOLs or blended vision laser vision correction.

What advice would you give to those at the start of their ophthalmic career?

Be grateful every day that you have chosen ophthalmology, or perhaps, that ophthalmology has chosen you. Be aware of the immense privilege of being in a position to help people on a daily basis in ways that transform and enhance their lives. Take nothing for granted. Treat patients as people, not a diagnosis, there is no “retinal detachment in bed seven.” There are people behind the eyes, with real fears and hopes. Lastly, go for it – see what you can contribute, rather than only “what’s in it for me.” Be a giver rather than a taker.

What do you think will be the next big step in the field of eye surgery?

There are a few exciting technologies either completing clinical trials or just entering clinical trials that are very promising indeed and have the ability to revolutionize current practice. Adjustable IOLs, either light adjustable (already proven technology) or those that still need to be proven clinically. LIRIC (laser-induced refractive index change) may provide refractive power change to the cornea, IOLs or a contact lens – all without shape or thickness changes.

Developments in femtosecond laser technology may see the cataract being removed with irrigation and aspiration after the femtosecond laser, without the need for phaco. There are also some technologies on the horizon that may replace phaco with light-based handpiece solutions altogether. Artificial intelligence is going to become a bigger part of our lives and decision-making will become easier in terms of screening, making therapeutic decisions and selecting IOLs.

How do you see the field of robotic surgery changing in the near and far future?

Any maneuver that requires precision and repeatability (such as capsulorhexis and other aspects of cataract surgery) has the potential to be improved upon using robotic technology. If robotics can help improve outcomes and make procedures safer for patients in a cost-effective manner, we have no option other than to embrace them. Eventually, many of our procedures may be performed by robotic devices – of course, surgeons will be required to operate them and manage any complications. This may improve productivity, as clinicians can perform surgery faster and more effectively. I see robotics playing a role in the diagnostic space, too. Today we have so many diagnostic devices, instead of having patients move from device to device for measurements, we may see more innovative solutions by having the devices move to the patients. Sounds like science fiction? It’s not. Just watch this space.