Demanding the Best

How did you get into ophthalmology?

It’s funny how I got into ophthalmology because I initially wanted to be an orthopedic surgeon – I was a young athlete and in medical school I was very interested in sports medicine. But I also liked research, and one of the researchers in the immunology lab where I worked was a Chinese corneal surgeon who had left his country for political reasons. He taught me to transplant rat corneas and I taught him to drive. I think I got the lion’s share in that exchange!

What is a normal day like?

I see patients four days per week, usually 60–70 a day. Our process is quite meticulous; even if someone just comes for an eyeglass prescription, we still measure everything – refraction, anterior segment tomography, topography with Placido and multi-color LED, OCT mapping of the epithelium and cornea, OCT imaging of the macula, and scatter measurements with the HD analyzer. We try to do that for every patient.

Doesn’t that slow down your workflow?

Yes, but it’s worth it. You’d be surprised how much we pick up. About one in fifty of our apparently “normal” patients will have a compelling eye irregularity or epithelial findings that are crucial (in my opinion) to the diagnosis and the management course I will recommend. Many routine patients consider this protocol “too much,” but I think they appreciate our passion to investigate everything and offer the best care possible.

You practice in Greece, New York and also lecture at NYU. How do you manage your time?

The New York practice is quite small. I try and avoid doing much surgery there, as I will not be available for timely follow-ups; I consult mainly on extremely complicated cases that are referred to me from all over the US. At New York University, I work with the residents and try to involve them in some of our ongoing research projects – this is time-consuming, but I enjoy immensely helping these brilliant young doctors “get their feet wet” in clinical research. Even if they end up not following a purely academic path, knowing the “nuts and bolts” of clinical research is quite important in my opinion; it makes clinicians evaluate the ongoing ophthalmic literature in a much more critical way. My personal pride is that our team in Athens (Costas Karabatsas, George Asimellis and I), in conjunction with the New York City office (Gregory Pamel), report numerous clinical studies in the major annual meetings: ESCRS, AAO, ASCRS and ARVO. We collectively teach over twenty didactic courses – a fun and very significant duty that, in my mind, generates an enormous responsibility for my practice and continuing medical education. I am able to manage our Athens practice on top of all these in quite a careful and “hands on” manner, but I have to acknowledge our great team and especially our office administrator. Few people can do this work if they don’t share the compassion for patients and passion for excellence in care as I feel I do for my patients.

Some ophthalmologists may become commercially biased. Do you think you have avoided this?

I consult for many companies, and understand that this can be viewed as a factor contributing commercial bias to my academic work. In reality, I try to remain always objective; I would never use anything but the best option for each patient I treat. Some people may think my research funding comes from industry support (discounted technology etc.), but the reality is quite different. Our practice in Athens conducts over twenty ongoing clinical registration and research projects, which significantly affects our budget. Fifty percent of what our practice nets goes back into research, which is a huge monetary commitment for me as a practitioner. I would not like to change this, though; I consider the state of the art technology we use daily an integral part of the quality of care I can offer. More importantly, this long journey of 1,000 presentations, 100 peer-reviewed publications, dozens of book chapters and hundreds of trade journal articles has, in essence, helped me to become a better clinician. I enjoy the fact that even now, in my twentieth year of practice, I overtly empathize with my patients’ problems. I don’t want to become a “salesman”. I try to give my patients the facts, with ample documentation, and I will always advise them according to what I think is best for them. I think I’m fortunate to be able to practice in this way. I know that economic and quota pressures can take that away, so I consider it a precious luxury.

What’s your management style?

I’m extremely demanding of my associates – I’m sure some would say too demanding, but our patients drive our practice and we’re committed to only the best for them and to excellent care. I don’t do all the day-to-day management, but I’m very involved in the hiring and assessment of associates. We are lucky to have in our group eight talented optometrists – a real testament to how ophthalmology and optometry work together. I think the bottom line is that every aspect of our practice, academic or clinical, blends into providing the best possible care.

What is exciting you in ophthalmology right now?

The direction corneal collagen crosslinking (CXL) is taking. I am personally proud that my team’s ongoing research efforts have brought CXL into an era of higher fluence, combined with LASIK and a partial PRK surface normalization in keratoconus (the Athens Protocol): all procedures practices use globally today. I think in collaboration with significant industry innovation, the WaveLight platform from Alcon, and the KXL I and KXL II generation devices from Avedro, we’re still really opening up new fields – for instance, predictable refractive correction with CXL alone is fascinating as a concept. I think, internationally, we’ve agreed that it works and has established itself as a major player. The key questions for the future are: when should we treat and how early should we screen? That’s where “easy” corneal epithelium imaging has really come into play for us – I’d like to see it in every patient, because it always has significance. The three main areas I’m concentrating on, clinically and academically, are corneal epithelium, keratoconus diagnosis and CXL. I nevertheless enjoy, in my routine practice, cataract surgery, keratoplasty and routine refractive surgery – a great gift to everyday lifestyle.

At what stage do you crosslink?

For me, it depends on the age of the patient and the degree of ectasia. The younger they are, the keener I am to crosslink at first diagnosis – I would recommend it to anybody under 20 years of age. For older patients, it depends on how serious the keratoconus is, how thin the cornea is (which tells me how much leeway I have for future thinning), and how rehabilitated the patient is; if they’re functioning well with RGP lenses, I don’t know if I can reproduce their vision with CXL.

What advice would you give yourself ten years ago?

I’ve thought about this a lot, as I’ve got many friends and respected colleagues whose practices are completely different to mine. It’s always compelling to look back at what you’ve done and ask, “What have I produced?” I think the academic research I’ve done has made me a better clinician, and I wouldn’t change it for anything. If Kanellopoulos Jr has the same drive as me, he has no choice but to become proficient in these areas, because it’s made me happy. I feel extremely blessed to have had significant mentors and great associates who enabled me to “live” my ophthalmology dream to the fullest extent. I also feel blessed to have a wonderful family, my wife and three children to share this joy with.