“If I have seen further, it is by standing on the shoulders of giants.” Most commonly attributed to Sir Isaac Newton, this quote communicates a concept that is likely familiar 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, a key element are the giants, those who stood tall and blazed the trails before us and who contributed their wisdom so we too could grow wise. One such giant is Richard L. Lindstrom, MD. I recently 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.
—Gary Wörtz, MD
Gary Wörtz, MD: Dick, I appreciate you taking some time to talk about where your career has taken you over the years, where you see ophthalmology today, and how the field has changed. I would love to pick your brain and get some words of wisdom from you.
Richard L. Lindstrom, MD: Thank you, Gary. I got into medicine and ophthalmology indirectly, in a sense. My family owns an insurance restoration construction company, and I was being groomed to join that business. While attending the University of Minnesota College of Liberal Arts, I randomly got the dean of the medical school as my advisor. Things don’t always happen through planning; sometimes they happen through serendipity. I have learned, when an opportunity presents, to be willing to take a risk and say yes to it, so I said yes to medicine.
When I was in medical school, a young cornea professor, Don Doughman, MD, came to our department after his fellowship with Claes Dohlman, MD. He picked me to work in his laboratory with him on corneal preservation. That got me started in ophthalmology and, specifically, cornea. But, again, I wasn’t necessarily pursuing ophthalmology; in a sense, ophthalmology found me. I had either the wisdom or luck to say yes to the opportunity.
Dr. Wörtz: How did it go when you told your family you were taking a different path?
Dr. Lindstrom: I’m probably one of the few sons whose fathers disowned them after expressing interest in medical school. I’d been following my father to work since I was 12 years old, and I grew up in the construction business, so naturally he had in mind that I would join him. It’s funny how things work out. Thirty years later, when he was ready to retire, I was his exit strategy and ended up acquiring the business from him. So, I guess one thing a lot of people don’t know about me is that I’m the chairman and CEO of a construction company.
Dr. Wörtz: From the time you started until now, what are some areas in which you feel like ophthalmology maybe outperformed your wildest dreams? What are we doing now that you never dreamed we might do in your career?
Dr. Lindstrom: We are doing many things I never dreamed we would do when I started in ophthalmology. I think cataract surgery is probably the poster boy for that.
During residency, I was trained to do intracapsular cataract extraction (ICCE) in the main operating room at the University of Minnesota. A full day of surgery, which was 8 hours, included four cases. We did one cataract surgery every 2 hours. Our cataract patients were admitted to the hospital’s inpatient unit, where they stayed for 7 days. We were doing ICCE and fitting the patients with aphakic spectacles. A typical patient would be 20/70 or 20/80 in the better eye and 20/200 in the worse eye when we would consider surgery. The outcomes were not great. The complication rate was significantly higher, as was morbidity.
Today, if you were to spend 2 hours doing surgery in the main OR of a large community or university hospital and then admit the patient for a week’s stay, it would probably cost around $40,000 to $50,000 per cataract procedure. Now, we perform an operation that enables people to see well the next day without glasses in 10 to 20 minutes and with a couple of postoperative visits and achieve a much higher success rate. Advances in ophthalmology have been extraordinary. We are blessed to be in a field that still supports innovation and in which we have good opportunity to apply those innovations to our patients.
Dr. Wörtz: It seems like we now have a lot of people in private practice leading the charge of innovation. Is that something you witnessed starting out, or has that tide turned in your career?
Dr. Lindstrom: I think it has turned in the past 50 years. I spent 10 years in academics full-time, serving as a professor, head of the cornea service, and the Harold G. Scheie Research Chair at the University of Minnesota. While a significant amount of research and innovation occurs in university medical centers, there is also now a great deal of research, particularly applied research and translational research, occurring in private practice.
I tell my fellows that an academic mindset is not based on location but on individual initiation. You can do great research and make huge contributions to ophthalmology out of private practice. We’ve had extraordinary examples of that in cataract and refractive surgery.
Dr. Wörtz: What was it like transitioning from ICCE to phaco?
Dr. Lindstrom: In 1977, I went down to Dallas to work with Bill Harris, MD, who was involved early on in phacoemulsification and posterior chamber IOLs. I went from residency, where we were doing four ICCEs a day at a major university hospital, to a setting where they were doing a cataract procedure every 30 minutes in an ambulatory surgery center. Instead of three cases per day, they did 16 to 20. I couldn’t believe it. It was like I had traveled to a different planet from the one I had trained on. I did a fellowship with the group and worked in a small ambulatory surgery center called Mary Shields Hospital. There, I went straight from ICCE to phaco and later became skilled in extracapsular surgery, too. That was an extraordinary jump.
At that time, Dr. Steve Shearing was innovating his posterior chamber IOL; Drs. Bob Sinskey, Charlie Kelman, and Dick Kratz were teaching phaco courses; Dr. John Sheets was a busy Dallas surgeon; and the American Society of Cataract and Refractive Surgery was being founded by a young ophthalmologist named Dr. Kenny Hoffer. That brings us to this year, the 50th anniversary of the invention of phacoemulsification. These characters were all one-percenters, and I think, to some extent, this was the beginning of innovation in private practice.
One major difference from today is the way in which these innovations came about. I invented my first posterior chamber lens in 1978. I sat down with a few of my older colleagues and said, “I’d like to angulate a little bit, I’d like it to have PMMA loops rather than polypropylene loops, and I’d like to color the loops.” Believe it or not, the company I was working with at the time had a prototype available for me in a week. Another week later, my invention was being implanted into patients. I made a few modifications, and then 2 months later the lens was available for purchase.
Dr. Wörtz: Are you kidding me?
Dr. Lindstrom: It was a different world than the one you’re dealing with today. Maybe that was too avant garde and we should have had more regulation, but we were using proven methods. And you know what? We didn’t hurt people. We were as responsible then as we are today. It turns out that we doctors are not going to do anything that is not in our patients’ best interest.
Today it would probably be hard for phacoemulsification to ever get approval. I don’t know if the early posterior chamber IOLs would have made it either in the current regulatory environment. The barriers might have been too great.
Dr. Wörtz: As you look at ophthalmology today, where do you think our field has the greatest opportunity to advance in the next 20 to 50 years?
Dr. Lindstrom: There is still unlimited opportunity for advancement. In the United States, we perform about 4,000,000 cataract operations a year. For younger surgeons, that rate is growing at about 3% to 4% per year, which means that, in 20 to 25 years, we will be doing about 8,000,000 cataract operations a year in America. We will also have a smaller number of surgeons to do it; about 50 to 100 more ophthalmologists retire than are trained. Young ophthalmologists coming out of training today are going to have to become very efficient and effective.
On a positive note, I have been training fellows for 40 years now. I can sincerely say that the fellows I train today are brighter, more talented, and better educated than they have ever been. I’m not worried about the next generation; I’m extraordinarily impressed with the next generation. These fellows also, in my opinion, have strong work ethics. They are a little more balanced than we were in that they aren’t going to dedicate 100% of their time to ophthalmology. I also see younger doctors who are continuing to innovate and invent. I’m optimistic.
Dr. Wörtz: I agree, 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 on the list of the giants who have helped drive our profession forward. Thank you for committing yourself to making this field what it is today and for working every day to make it better for the future.