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Cover Focus | Sep 2016

My Smartest Investments

CRST Europe asked its editorial board members to describe their most rewarding investments in their practices and for themselves personally.

No Longer a Lone Wolf

Detlev R.H. Breyer, MD

In my practice. I started performing small incision lenticule extraction (SMILE) 5 years ago, pioneering this revolutionary third-generation of laser vision correction (LVC) with great enthusiasm. In my opinion, this was a magnificent step forward in LVC regarding safety and having the right method to offer people with discomfort due to contact lens overwear and dry eyes. I never liked flap-associated surgery because of the early and late complications the surgeon cannot avoid, even when doing his or her best job. I always felt uncomfortable performing LASIK in otherwise healthy eyes. Now I feel much more safety for my patients and myself.

With pain-free SMILE, patients can take a shower the same day and engage in any sport they like the next day without wearing an eye shield at night. The only drawback of this method is that it is not so easy to learn as LASIK.

In my personal life. Perhaps this is not an investment, per se, but a divestment. When the volume at my private practice clinic exceeded 3,500 surgical cases, with me performing every one of the surgeries—from LVC to cataract to vitreoretinal surgery—I had to make a change. I sold one-third of the practice to Karsten Klabe, MD, a surgical genius, and one-third to Hakan Kaymak, MD, a fantastic scientist and controller. It is much more fun and more creative to work in a team with those two than to be a lonesome wolf responsible for everything. I could never have focused so intensively on LVC and refractive cataract surgery without their support, help, humor, and understanding. I must not to forget to thank Gerd U. Auffarth, MD, PhD, who asked us to become founding members of his IVCRC.net research network, and Florian T. Kretz, MD, PhD, for being the scientific coordinator. Thanks to all of you guys. You are great!

Family Trumps Any Financial Investment

Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth), FRCS(Edin)

In my practice. My smartest investment in my practice has been investment in great technology for laser refractive surgery. This still forms the bulk of my practice today, and, in terms of revenue, this is even more so. Cataract and refractive lens exchange numbers are still increasing strongly, but, given the downward pressure on reimbursed fees, their contribution to the bottom line will remain relatively static. Having a great laser platform provides excellent results, with few patients unhappy due to surgical complications.

Another excellent investment has been outcomes analysis software to help continually refine nomograms and provide ever better refractive outcomes. I would go as far to say that I would have difficultly referring to a refractive surgeon who was not following his or her outcomes this closely.

The final important practice investment has been investing in great staff. This has led to a team environment with a spirit that not only is tangible but also is commented on by most visitors and patients who attend our clinic. It is undoubtedly the most important part of why the clinic enjoys the reputation that it does. Smart people enjoying their work and looking out for each other and for our patients create a wonderful work environment that makes this my best investment in the practice to date.

In my personal life. As far as personal investment, the answer is easy: Investing time in my family when they were young and needed parental guidance on a daily basis has paid off more than any financial investment that I have ever made. I have had some financial successes, but they pale to insignificance compared with the results of time well invested into my own family. Running a private practice is a huge commitment, and individuals can become engrossed in it at the expense of all else. My best piece of advice would be to work as hard and as diligently at your practice and at building your brand as you can—but not to the neglect of your family.

Versatility and Increased Access Via an Ambulatory Surgery Center

Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth

In my practice. The best investment I ever made in my practice was establishing an ambulatory surgery center. This facility has provided considerable versatility and increased access for both patients and doctors. There have been other benefits, such as ease of adoption of new technologies and close collaboration with industry.

After a huge capital outlay, the first 5 years were definitely tricky in terms of managing cash flow; however, we are now in a much better place. I might add that we probably are not obtaining the level of return on investment that we should, but, nonetheless, the facility is profitable.

In my personal life. An investment I made personally that has been of considerable benefit was enrollment at the Cranfield Business School’s Business Growth Program in 2006. The course was like a mini–masters in business administration that provided me with a different perspective on business and gave me the confidence and courage to develop a much larger business.

Investment does not need to be just about technology. Investing in oneself is far more important, and I would urge colleagues to consider business courses such as the Physician CEO program, developed by SurgiVision Consultants and offered by the Kellogg School of Management at Northwestern University in Chicago. I understand from friends who are recent alumni that the program was extremely worthwhile, taking them to the next level in terms of business and leadership.

Invest Regularly to Keep Your Competitive Edge

Detlef Holland, MD

In my practice. In recent years, it has become important to invest regularly in both the clinic and practice to be able to compete in the changing medical marketplace and to ensure that we are offering the best medical diagnostics and treatments to patients. For our practice, the best recent investment was adoption of the laser-assisted cataract surgery (LACS) technique in 2012. I introduced the Lensar Laser System (Lensar) in our clinic after having tried the laser in Lima, Peru, in spring of that year.

Both from a medical and a financial standpoint, it was quickly apparently that this is the best investment for me and my patients. Ours was the first clinic in Europe to incorporate the Lensar system specifically and among the first adopters of femtosecond laser technology overall. We were lucky to enjoy all the advantages of this smart technology from the start.

In the beginning, in 2012, we performed only capsulotomy and lens fragmentation with the laser. Even at that early point, the performance of the laser and postoperative results were impressive, and patients started to demand this new technology. In 2013, we began performing corneal incisions, and arcuate incisions for astigmatic correction followed in 2014.

The ability to perform this refractive procedure with the laser made LACS superior to traditional phacoemulsification, in my opinion. We began a prospective study regarding the safety and efficacy of LACS and arcuate incisions, which made our work much more interesting and focused. This had a positive effect on our surgeries, even for traditional phaco, because we were looking more precisely at our postoperative results.

The next step in 2015 was an update to Streamline, a feature that enabled connection of the Lensar femtosecond laser with our Cassini Corneal Shape Analyzer (i-Optics) topography unit. This was another big advance. Streamline allowed us to transfer preoperative topography data and iris photography to the laser via a wireless network. This eliminated steps and decreased the risk of transcription errors. We can now easily plan our arcuate incisions and offer a 2.5-minute procedure that we have implemented into our workflow without a big loss of time. From the financial point of view, it was soon clear that this investment brought benefit and a return on our investment.

Now in the fourth year after our investment in LACS, we have seen a remarkable effect on our marketing, as patients increasingly demand these new technologies. Videos on our website demonstrate that LACS is safe and reproducible. Overall, this has been our best recent investment in the practice.

Learning How to Breathe

Michael Lawless, MBBS, FRANZCO, FRACS

In my practice. It is impossible to single out the best piece of equipment. Many excimer lasers, SMILE, the LenSx laser (Alcon), and too many anterior segment imaging systems to count: but they have all helped. The best financial decision was to sell our group practice to a publically listed company (Vision Eye Institute) in 2005. I served on the board as an executive director and as the company’s medical director, and that experience educated me in the way of corporate life. We were able to use the good systems that well-run companies employ to make our practice more efficient, profitable, and sustainable.

In my personal life. The smartest life investment I ever made, apart from marrying my wife, Alison, was taking the advice of Richard C. Troutman, MD, my mentor. That advice was to set aside a specific time every week, even from my first week in practice, to think, write, and publish. The best way to learn is to write, as writing forces you to really come to grips with a topic. This habit kept my interest in ophthalmology alive over the years and still does.

One additional thing may sound a little weird, but I have spent a lifetime studying and performing martial arts. Learning how to breathe properly through this practice has enabled me to finish a busy operating list still relaxed. It has enabled me to deal with stressful surgical situations and patient interactions in a way that has kept me sane. So I would have to say my investment of time in this practice has been a worthwhile one over a period of many years.

From Skeptic to Believer

Abhay R. Vasavada, MS, FRCS

In my practice. It is hard to choose only one investment, but, in recent times, the acquisition of femtosecond laser technology for LACS has been one of the best for my practice. This has been useful in differentiating my practice from others, but, more important, it has opened up new dimensions and unexplored applications of this technology in enhancing my outcomes.

Four years ago, I was not a big proponent of this technology, and I looked at it more as a marketing tool for practice enhancement than a medical advance. However, I now am convinced that this technology is here to stay and will only get better with time. The femtosecond laser has helped me to manage even difficult cataracts, such as mature, posterior polar, dense, and even subluxated cataracts better and more confidently. The best part is the ability to create a customized, OCT-guided rhexis and nucleus-division patterns. All of this capability enhances the precision and predictability of surgery and reduces the need for ultrasound energy.

In my personal life. Early in my private practice career, I started teaching and researching. In the part of the world that I live, this was almost unheard of, and I was often ridiculed for being professorial. Yet over the years, the satisfaction of training more than 110 national and international ophthalmologists in the art of phacoemulsification has been unparalleled.

Another passion that still continues to drive me is basic and clinical research. I remember spending time in the zoology department of my university, learning about cellular research and how to set up a research facility. As a result of these efforts, and my hard-earned time and money, I established the Iladevi Cataract & IOL Research Centre. I believe we all should create some legacy to inspire the future generation.

Detlev R.H. Breyer, MD
• Head, Breyer.Kaymak.Klabe Eye Surgery, Düsseldorf, Germany
• Member, CRST Europe Editorial Board
• Financial interest: None acknowledged

Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth), FRCS(Edin)
• Consultant Ophthalmologist, Wellington Eye Clinic and Beacon Hospital, Dublin, Ireland
• Associate Chief Medical Editor, CRST Europe
• Financial disclosure: Consultant (Alcon, WaveLight)

Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth
• Director and Consultant Surgeon, Centre for Sight, East Grinstead, United Kingdom
• Chief Medical Editor, CRST Europe
• Financial disclosure: Consultant (Nidek, Bausch + Lomb)

Detlef Holland, MD
• nordBLICK Augenklinik Bellevue, Kiel, Germany
• Member, CRST Europe Editorial Board
• Financial disclosure: Consultant (Lensar)

Michael Lawless, MBBS, FRANZCO, FRACS
• Vision Eye Institute, Chatswood, New South Wales, Australia
• Clinical Associate Professor, Sydney Medical School, University of Sydney, New South Wales, Australia
• Financial interest: None acknowledged

Abhay R. Vasavada, MS, FRCS
• Director, Raghudeep Eye Clinic, Iladevi Cataract & IOL Research Centre, Gujarat, India
• Financial disclosure: Research support (Alcon)