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Cover Focus | Mar/Apr '18

Nominated by CRST | Iqbal Ike K. Ahmed, MD, FRCSC, and Stephen G. Slade, MD, FACS

Dr. Ahmed is well known as an innovator in anterior segment surgery, particularly in the area of microinvasive glaucoma surgery (MIGS)—a term that he coined—and he has contributed to the development of numerous devices for cataract and glaucoma surgery. In this interview, Dr. Ahmed talks about the advantages of looking from the outside in, finding the courage to challenge the system, and the importance of developing a mindset that is open to innovation.

Interviewed by Laura Straub, Editor-in-Chief, CRST/CRST Europe

BMC: Who or what drew you to ophthalmology?

Iqbal Ike K. Ahmed, MD, FRCSC: I always wanted to a be a surgeon, even before medical school. My career was heading toward trauma or orthopedic surgery, but I happened to apply for a scholarship with Steve A. Arshinoff, MD, FRCSC, and he was my first glimpse into ophthalmology. He convinced me to look at ophthalmology seriously, instead of going into orthopedic surgery. Once I did that, I fell in love with the technical side of ophthalmology—the fine art of microsurgery. I thought, “Wow, this is like taking surgery to the next level."

BMC: Early in your career, who else were your big influences?

Ahmed: My dad is a physician, so I grew up in a household where medicine was part of the family. I think that drew me toward the field. I would also say, being a brown immigrant kid, medicine was one of those noble professions that parents always tried to push their kids toward. That’s probably why you see a lot of brown doctors these days. That may also have been part of my upbringing, valuing medicine in general.

BMC: What kind of physician is your father?

Ahmed: He’s a psychiatrist, which is a very different area of medicine. But I think he was also always interested in ophthalmology. I remember him talking about it when I was a kid.

BMC: You mentioned being an immigrant kid and seeing medicine as a noble profession. I have also read that you saw yourself as different in some ways, growing up. How has that influenced your creativity and your ability to innovate?

Ahmed: That was a really strong influence, being in what I would consider a foreign environment. I was born and raised in Northern Canada, having a name and appearance different from others around me. To me, it was obvious—even if some people didn’t highlight the difference, in that environment, unfortunately, you see some discrimination. The way people look at you and treat you was always in the back of my mind.

I hated that awareness of being different as a kid—you know, the teacher and your classmates couldn’t pronounce your name. No one, whether intentionally or unintentionally, wants to be in a situation where they’re worried about being different.

At first I resented it, and then as I got older, I turned it into an ability to look at things differently. Where everyone else might be part of a peer group and do things together, I was often not part of that group. I played hockey on the neighborhood teams, but I was the last guy who got picked. Maybe it was because of skill, but I think it was also just because I was different.

By looking from the outside in, I saw things others didn’t see. You could say they were blinded by or immersed in their own environment, but I saw things differently. It was a gift in some ways because I always had to be thinking differently, to find my own way to do things, because I didn’t have the usual common bond.

In my college years, I was a bit of a rebel. I had a chip on my shoulder, very vocally antiestablishment, anti the man. I identified with those who were disenfranchised, those with social challenges, whether because of race, religion, sexual orientation, social status, financial status. I was able to channel that into saying: “How are we going to pull things up? How can we look at something and radically change the way of thinking about it? How do we do things that we didn’t think we could because they challenge the norm?”

I’ve had some success in my life, and I am grateful for that, but even now I still feel like an outsider. I still feel like someone who’s antiestablishment and who looks at things differently. You see something, but I see something else, whether in medicine, or in life.

I think all of that made me think radically differently, including when it came to medicine and ophthalmology.

I was also lucky that I wasn’t part of a big institution, where you might have to conform to fit in. In the Greater Toronto area, at Trillium Health Partners where I started working, I felt a part of the community, and I had more openness to try things. So I have challenged a few things, and I hope these challenges have been respectful. I always felt that it’s okay to challenge things, but if you’re disrespectful to your fellow human beings you defeat the purpose of trying to improve things.

BMC: What do you consider to be your greatest professional achievement so far?

Ahmed: I would hope that my greatest achievement has been giving my colleagues the courage to challenge the system. In medicine in general, and certainly in ophthalmology, there’s a feeling of reserve when it comes to challenging norms. When I do things that challenge the norms, hopefully in a respectful way, and people see what I do, I hope it gives them the impetus to say, “Hey, I can be who I am and be successful at it, and I don’t have to feel as though I must be a conformer.”

There are obviously many individual accomplishments that people talk to me about. Two things, one would be glaucoma surgery and MIGS. The second would be tackling the most complicated surgeries I could find. But on a more global level, it would be the mindset I mentioned.

I see myself as advocating for change, for letting voices be heard, no matter who they are, and for having an open dialogue. That’s what I try to teach residents and medical students. I feel that our education system is too tilted toward rote memory and following standard mindless protocols. It doesn’t encourage people to think critically and analytically. Analytical and lateral thinking are lacking because people have not been brought up to think that way. They’re brought up to answer a quiz or an exam, list a bunch of differentials, and list steps 1 to 10 on how to do something. That’s a good way to start, but it doesn’t stop there.

I’m the opposite. I don’t follow instruction very well, I don’t follow rules, and I challenge every step. I think analytically and laterally around different issues, and part of the reason is because of the way I was brought up. So I feel a responsibility to push for that kind of mentality, to allow us to innovate and change the way we do things to help our patients. That’s what drives me and what is important to me.

BMC: What other changes are needed in ophthalmology right now?

Ahmed: Medicine is changing rapidly. Of course we need to think about how to treat disease better, but also, how do we adapt to our changing environment? We need to be mobile, literally and figuratively, and active beyond the traditional hallways of medicine.

Information technology is one of those areas. It’s imperative that we challenge the way we typically look at things, and information technology, artificial intelligence, and deep learning will be part of that. Those technologies are already changing the way that we practice medicine. That will be an important task for the next generation, to keep up with how our system is changing due to the collision of technology with everything we do in life, including medicine.

And that also applies to the way that the practice of medicine and the scope of medicine are changing. The role of government and regulatory systems are evolving. It is important for us to be able to look at challenges as opportunities and try to find solutions that lead to the betterment of humankind. That means adapting to different cultural environments, whether it’s the way the government runs, the way we teach and learn, the way we do research, or, again, the way technology is merging with health care.

So that’s more of a systems-based challenge, looking at problems at a macro level, rather than microscopically. We have unmet needs in glaucoma: medication problems, compliance, adherence, disease progression, surgical risk. How do we move forward? One way is by embracing what I call interventional glaucoma, looking at things actively rather than passively. That is an ongoing cultural change in glaucoma, brought on by the availability of multiple devices for MIGS.

I may have assisted in moving that change forward by helping to develop MIGS, but on a higher level, it involves changing the cultural mindset of how we look at glaucoma. And that’s challenging because many people have a traditional way of looking at it, a very medication-heavy view. And yet, we’re changing that. Technology has helped us to do that, but changing that cultural mindset requires what we were talking about earlier—bucking the system, challenging the way we look at things, and thinking about things from a more systems-based approach, rather than microscopically. Having the technology gives us the ability to do those things that change the paradigms. I love changing paradigms. We’re in the midst of a shift to interventional glaucoma, and I hope it will help change the course of the disease. I hope it will help take glaucoma from being one of the leading causes of blindness and drop it down on the list.

BMC: What keeps you motivated professionally? Is it these things you’ve already described, or do you have other motivators?

Ahmed: For me, it’s internal motivators. To inspire and be inspired. It’s the drive to discover and to always want more. Asking the right questions, trying to answer them, and learning from our failures. I always want to answer questions and, furthermore, to be the first one to do it. Again, critically looking at ourselves and taking it apart. I use the term blowing things up. I like blowing things up.

The process of discovery is amazing. We talked about deep learning, machine learning, and, on a human level, deep learning is accessing our deep thoughts—our deep level of thinking, in our minds, our bodies, and our souls to address some of our clinical challenges.

BMC: Do you have different motivators in your personal life?

Ahmed: Personal life is different. It’s funny how we have certain ways professionally and in person we’re different. I wear different hats in some ways and have different perspectives. I like to be home. I like to be steady and to have the expected in my personal life. Professionally, every day is a surprise. I like those surprises because I like to take them and figure them out.

My family is my personal life. I need that and want that to be steady, solid, and strong, as opposed to constantly changing and evolving. If I applied my professional philosophy, always changing, blowing things up, it would not do well for my family life. I think I’m traditional in that way, when it comes to my family and my faith. My faith is important to me. It’s 2,000 years old, but I can still use that spirituality to stay strong and healthy in mind and soul. Even though that’s old technology, so to speak.

Personally, I’m a pretty private person. I’m much more reserved and don’t share all my personal details with everybody. Professionally, I blurt everything out in public and speak out of turn in meetings!

BMC: Have you found a good work-life balance, and, if so, can you share some of your success in achieving it?

Ahmed: The word balance is not in my vocabulary; we’re constantly evolving ideas and places, and my mind is constantly changing. But I think I’ve prioritized what’s important in life. I value being home in the evenings and for the weekend whenever I can. I travel a lot. But I literally will be in Hong Kong for 1 day or in the Middle East for 2 days and then come back home. I think that priority, being here for my family, is an extremely high priority for me.

Being organized is important, and having great people around me who keep me organized is a big secret to my success. I would be not nearly as close to balancing my life and my work without the help of Daisy, my long-time assistant.

My wife—you know what? I got lucky. I have an amazing wife who understands me, who basically is the CEO of my family. She is an awesome wife and mother, and she is the glue that keeps my personal and family story stable. That allows me to be more open-minded about everything else I do and to be able to challenge things professionally.

I am very blessed, honestly. I have parents who are supportive, I found the right person to be with for the rest of my life, and I have great kids, great in-laws, great assistants, and great people to work with. I really, genuinely love these people. The people you’re with are more important than what you’re doing or where you go. Doing things as a team, as a group, the successes we have as a group, as a family, is the ultimate satisfaction.

I definitely am far from perfect, and I have a lot of things I need to improve on in all aspects of life. I never feel like I’m the best surgeon, the best dad, the best husband, the best brother, the best son, the best neighbor—I am far from it. That also drives me to try to pay attention to those things as best I can. I don’t give a magical solution to work-life balance, but I think that it’s helped to keep me afloat.

I did want to mention one thing, and that’s a little three-letter word: ego. Ego gets in the way of so many successes in life, in terms of relationships and people. I try my best to check my ego at the door, maintain humility, and realize that I don’t know everything, that I have shortcomings, and that people around me, no matter who they are, have many great ideas. Whether it’s a student or someone who’s about to retire, I look at each person I interact with and say, “Wow, they’re a font of knowledge. They know more about certain things than I do, and I’m going to learn from them.” And I genuinely feel that. That sends me back to my childhood because I couldn’t develop an ego being the black sheep in class. It’s hard to have an ego when you’re the outsider.

But I’m happy being on the outside. I feel sorry for people who are on the inside!

BMC: What are some passions you have outside of the office?

Ahmed: Honestly, my hobby is my family. Any free time I have is spent doing things with them. After this conversation, I’m going to pick up my 4-year-old from school because that’s what I want to do. Outside of medicine, my waking hours are spent with my family.

Working out is one thing I do on my own. I follow some sports as well, NFL and NHL, because I played hockey and football growing up. My boys are bigger now, so I can play sports with them, which is fun. But otherwise, it’s work—which I totally love and never feel it’s work, it’s all play.

BMC: If you had to nominate one creative mind in ophthalmology, whom would it be and why?

Ahmed: There are too many to pick from! I truly think every single mind in ophthalmology has the potential to be creative, and all it takes is for us to have the courage and conviction to tap into that. So I nominate all my peers, colleagues, and friends in ophthalmology.

Iqbal Ike K. Ahmed, MD, FRCSC
  • Assistant Professor and Director of the Glaucoma and Advanced Anterior Surgical Fellowship, University of Toronto, Canada
  • Chief Medical Editor, Glaucoma Today
  • ike.ahmed@utoronto.ca
  • Financial disclosure: None

Dr. Slade is an anterior segment surgeon in private practice at Slade & Baker Vision in Houston. He is well known as an innovator in refractive and cataract surgery, having performed both the first LASIK procedure and the first laser cataract surgery procedure in the United States. In this interview, he shares insights on working with industry, picking winners, and raising daughters.

Interviewed by Laura Straub, Editor-in-Chief, CRST/CRST Europe

BMC: Who or what drew you to ophthalmology?

Stephen G. Slade, MD, FACS: Dumb luck. No, I’m serious. I got out of medical school really not knowing what I wanted to do. I went through all the specialties and learned what I didn’t want to do. I thought I might want to go into orthopedic surgery or neurosurgery—I was interested in hand surgery and plastic surgery. I knew I wanted to do some kind of delicate surgery, but I really didn’t know what type specifically. During my internship, I looked around at the people in my class who I thought were intelligent, and several of them went into ophthalmology. So that’s where I went.

BMC: What do you consider to be your greatest professional achievement?

Slade: Trying hard for the patients. Our motto at my clinic is, “Patient first.” No matter what we do, we always try to put the patient first. It sounds Boy Scout-ish, but that’s what we try to do. I’ve stuck to that goal throughout my 28 years of practice.

BMC: What is something you’d like to do that you haven’t yet accomplished?

Slade: There is one patent research idea that we started working on that I would love to see turn out because I think it would be valuable for patients. For the most part, I am satisfied with my accomplishments, the patient care I’ve provided, making great friends, and being involved early on in many technologies.

BMC: You mention getting involved in technologies early on. You and Stephen Brint, MD, were the first two US surgeons to perform LASIK. How did you get to be involved in that? What was it like performing that first procedure?

Slade: I was doing lamellar keratoplasty with a keratome—myopic keratomileusis—which was sort of a precursor to LASIK. Steve Brint was one of the first ophthalmologists to get an excimer laser. We put the two together for something we called excimer laser myopic keratomileusis.

We would take about two-thirds of the cornea off, about 350 µm, with a manual keratome. Then we would take that piece of corneal tissue, walk it over to an excimer laser, modify it with the laser, then bring it back and sew it onto the patient’s eye—needless to say, it was an involved procedure. The laser manufacturer at the time, Summit, started a trial called the Excimer Laser Myopic Keratomileusis Trial, and Steve invited me to be an investigator, so I got a Summit excimer laser.

That was a wild trial. We would take the patient into the OR, slice off that big hunk of cornea, and then literally put on coats and walk the tissue across the street to the building that housed the laser, go up the elevator, treat the tissue, come back down, go back into the OR, rescrub, and sew it back on. One time we got on the elevator to go back up to the OR, and there was the patient’s family. They knew that we were operating on their family member, but there we were, me and Steve, with all of them in the elevator together. It was awkward.

Anyway, in the course of that trial we did the first true LASIK in this country, in that we made a flap and did the ablation on the patient’s eye in situ, rather than moving the tissue to and from the laser.

BMC: How has LASIK evolved over the years? Are you proud of how far the procedure has come, and what is left to be accomplished?

Slade: LASIK has become a wonderfully mature technology, or modern LASIK. We did the first LASIK in the United States here in Houston in 1991. When we first did LASIK, we were making the flaps with manual keratomes. The lasers fired between three and six shots per second, there was no eye tracking, and we used very basic nonaspheric ablation patterns.

Now, of course, we have eye trackers, femtosecond laser keratomes, excimer lasers that fire 500 to 1,000 shots per second, scanning laser patterns, and sophisticated aspheric ablation patterns. We also have customized wavefront- and topography-driven ablations.

I’m proud of how much technology, effort, and innovation has gone into LASIK. It’s become a wonderful technology—so much so that I wish we could go back and treat some people who were previously left behind, those with irregular astigmatism, decentered LASIK, or trauma, because we can now address these issues with complex ablations.

Modern LASIK, the way we do it now, is such a good surgery. It’s the most successful, most accurate surgery in medicine, in my opinion.

BMC: More recently, you were among the first US surgeons to perform laser cataract surgery. How have you kept yourself in position to periodically be one of the first to use new technologies like these?

Slade: You know, I’m not sure. We did have the first laser cataract surgery device in the United States and were the first to do the surgery. We had the first laser flapmaker in the United States, the IntraLase (now Johnson & Johnson Vision). We implanted the first Crystalens (now Bausch + Lomb), and we’ve had few other firsts.

Honestly, this may sound like a copout, but I think a lot of it is just luck—knowing the right people and being in the right place at the right time. My contribution might be that I understand how to work with early-stage companies and technologies. When companies come to you with an idea, you have to realize that you’re sort of the test dummy, if you will. It’s a huge responsibility because you’re using it on your own patients. There’s no one to learn from because you’re the first. You have to innovate as you go along and figure out the best techniques and how best to use it, whatever it may be.

When you work with early-stage technologies, you have to know how to be honest and frank with the company about what works and what doesn’t. You also have to know that you talk to the company, you don’t go out and shout to the world, “This device doesn’t work.” Instead, tell the company, “This is the problem.” You must be part of the team.

Many people don’t realize that it takes 5 to 10 years to iterate a device from the first mock-up to the finished product; you have to work with the FDA, work with engineers, do the clinical trial. The people in the company are making a bet with 10 years of their life—maybe one-third of a 30-year career—that their product is going to work. Sometimes it doesn’t, and sometimes this is the only product they have. If it fails, I’ve still got my day job, but for the people in these companies, the news is considerably worse. They’re working for not a lot of money, maybe with some venture funding, hoping it works.

Even more importantly, it is also a serious deal for the study participants and potential patients for any new technology. I feel an obligation to those patients to do the best I can.

BMC: Working so much with these early-stage companies, have you learned to discern a good opportunity from a bad one? How do you decide that?

Slade: Some people in the industry have told me that I have a good ability to pick winners. I’ve turned down a lot more projects than I’ve gotten involved with; a lot of that is just gut feeling, looking at something and saying, “I like this,” or “I don’t see how this will work.”

There was a lot of doubt when LASIK was introduced, but I knew it was going to work. When I first started showing videos, people would say, “That’s crazy. You’re splitting the cornea open with a keratome? We already have PRK. All we have to do is have the patient lie down and do an ablation, and now you want to slice open their corneas? This is back to RK days. We want to go away from RK.” But I saw it and said, “This is going to work.” A lot of it is instinct.

To someone who is starting out in consulting, I would say to be aware that this is what you’re doing. In your career, you’re going to be presented with different projects. Try to be conscious while you’re making the decision of whether to get involved. Step back, watch yourself, try to learn something, and maybe try to teach something. Whatever it is, be honest in your assessment. I think I have done that, and I think it has helped me to mostly pick winners in technology.

BMC: You’re a Houston native. What’s it like to practice in the place where you grew up?

Slade: I like being here. I was born in Houston, and my family has been in Texas since the 1830s. I have friends from college who are still here. I understand that California is wonderful, and New York is New York, but I like where I am. It offers some advantages, mostly personal. When my mother got an extended illness, I was here and able to help take care of her. It meant a lot to me to be able to do that, and it would have been painful if I was in Vancouver or somewhere else.

BMC: You have children who are approaching the age of entering the workforce. What advice do you have for them?

Slade: We have two daughters, ages 18 and 24. The 24-year-old is out of college, and she has a job in the fashion industry in New York. Our 18-year-old just started at New York University. So they’re both in New York City, which is something we never envisioned. We hope that they will some day come back to Texas; I think they will, but they’ll probably come back to Austin, not Houston. Austin is for Texans who are lost. And people from New York City.

The advice I have for them is almost embarrassing because it’s so stodgy and old-fashioned: Practice self-discipline and take responsibility. Have the self-discipline to make yourself reliable, to do well, to do a little work every day, and to work hard. And take responsibility. When you screw up, just raise your hand and say, “I screwed up here.” Take responsibility for every little thing. Don’t procrastinate. Go ahead and make the decision, and if it doesn’t work out, learn from it.

It is also important to me that they know how to be an honest, kind person. Stick up for friends and be loyal to them. These are the qualities that, if I passed away, I would hope people would say about me. You would think that in this day and age I could come up with something snazzier, but it’s those simple qualities that matter. To me, things get simpler as I get older. I don’t know how else to say it; those are the things that I value now.

Somebody told me this once, and I thought it was amazing advice: “We know right from wrong. We know the right thing to do. Almost all the time, we know what we should do in a given situation. The trick is that it’s so hard to go ahead and do the right thing.” We know what we’re supposed to do—it’s just hard to do it sometimes.

BMC: If you had to nominate one creative mind in ophthalmology, whom would it be and why?

Slade: Creativity is an amazing talent. This is an outside-the-box choice, but I would nominate two people, and they are not ophthalmologists: David Cox and Adam Krafczek, the cofounders and president and vice-president, respectively, of BMC, the publisher of CRST. They are creative, and they have done things to advance the specialty. They helped to create the American-European Congress of Ophthalmic Surgery (AECOS), they publish a range of subspecialty magazines in ophthalmology, and they produce meetings—all of which have valuable content. The team that they have put around them is really creative.

Is there an amazingly creative ophthalmologist I could name instead? Sure. There are many, but their creations tend to be more scientific. The work that Dave and Adam do is creative communication, which is a great value in the information age we live in.

Dave and Adam came into a field where they didn’t have a medical background or similar experience, but they built a creative company that brings value to the field. They are amazing guys with complementary talents and an ability to pick great people to work with them. They truly love the field and our people, and it shows.

Stephen G. Slade, MD, FACS
  • Private practice, Slade and Baker Vision, Houston
  • CRST Editor Emeritus
  • sgs@visiontexas.com
  • Financial disclosure: Consultant (Alcon, Carl Zeiss Meditec)