Disclosures: Melles reports no relevant financial disclosures.
March 18, 2020
4 min read

Disruptive innovator ultimately rewarded after deviating from path of mainstream thinking

Game-changing concepts and techniques are often met initially with fierce opposition.

Disclosures: Melles reports no relevant financial disclosures.
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Innovation takes more than creativity — it takes courage: the courage to take risks and face antagonism.

“If everyone says, ‘I think that’s a good idea,’ it basically tells you that other people have been thinking in the same direction and that there is no real invention or innovation since the thought is out there already. So, the opposite might be true: If a project lacks antagonism, you’d better stop it,” Gerrit Melles, MD, PhD, of the Netherlands Institute for Innovative Ocular Surgery (NIIOS), told Ocular Surgery News.

When Melles first described his endothelial keratoplasty technique in 2006, he thought it would soon gain consensus because of the documented better results and fewer complications compared with full-graft surgery.

Gerrit Melles, MD, PhD
Gerrit Melles

“Better outcomes while most complications are eliminated, that sounds like a ‘win-win’ for everyone. But it does not work like that, not at all. In fact, quite the opposite. You trigger an incredible antagonism,” he said.

Not only was he struck by “a tidal wave of emotionally driven personal attacks, the ‘ophthalmic establishment’ wrote a letter to our Ministry of Health suggesting that endothelial keratoplasty techniques were ‘unethical.’ As a result, the health care inspectors knocked at our door, and I was invited to stop being a troublemaker and to discontinue ‘destructive creativity.’ Looking back, it may sound hilarious, but at the time it felt like my license as an eye doctor might be revoked,” Melles said.

After this experience and to avoid further political conflicts, Melles decided to review all ongoing NIIOS projects, about 80 at the time, with the intention to put the most controversial projects on hold.

“Surprisingly, the review brought something far more interesting to light than any of the individual surgical techniques even all put together. After scoring all these projects for various parameters, among which the risk of professional antagonism and scientific merit, one thing clearly stood out: All potentially ‘breakthrough projects’ triggered the most opposition. In other words, there seemed to be a strong correlation between scientific merit and antagonism. It may actually feed into a paradox, for the more an idea deviates from mainstream thinking, the more it will be ridiculed and rejected,” he said.

Mainstream thinking less risky

Time after time, history shows that any true deviation from mainstream thinking may later be perceived as a game changer, most often at great personal expense, Melles said.

“Around 1840, Semmelweis suggested for doctors to wash their hands before deliveries to reduce the incidence of puerperal fever, now transcended into the use of sterile gloves. But at the time, he was crucified for even bringing it up, ending up in a mental asylum where he was beaten up by his guards. So much for having a good idea,” he said.


Melles said that the system pushes toward mainstream thinking, often with the complicity of academic institutions. For example, grant applications for research that sounds universally plausible have a greater chance to be funded and published.

“Taking risks does not align with most university policies, and uncontrolled thinkers are prone to embarrassment,” he said.

Thinking in a tissue-directive manner

NIIOS is an independent organization that furthers innovation in ophthalmic surgery.

“We review how ophthalmic surgeries are conducted and then try to come up with new surgical concepts,” Melles said.

His research internship years with Perry Binder, MD, in San Diego, working in depth with pathology specimens obtained before and after surgery, taught him the importance of looking for surgical approaches in a tissue-directive manner.

“When designing a surgical technique, what I am always trying to understand is what direction the body, or in our field the eye, has taken: Where do the tissues want to go? Too often as surgeons, we force our will onto the human body, almost as if we wanted to teach nature how it is done, like we know better,” Melles said.

The idea is to align with nature rather than fight it because nature “simply has her own, quite often unintelligible agenda, and we probably do not grasp but a tiny fraction of what is really going on at various levels,” Melles said. Consequently, surgery should interfere with nature as little as possible and not do more damage than necessary.

“The less damage you do, the better. If you can give the eye the impression that ‘nothing happened,’ so that it barely notices that a surgery was done, then you may avoid a lot of problems,” he said.

Redesigning corneal transplantation

The tissue-directive design concept was the driver of Melles’ Descemet’s membrane endothelial keratoplasty technique, as well as Bowman layer transplantation, hemi-DMEK and quarter-DMEK, and still drives the research into possibly more advanced approaches at NIIOS.

“There are several layers in the cornea, and most often only one layer is affected. Furthermore, each layer has its own tissue characteristics and wound healing properties, so if you respect that and selectively replace the diseased layer only, then the surgery may be a bit more challenging, but you steer the process in the right direction while doing much less collateral damage. And the graft quietly sits where it belongs,” Melles said.

This approach and the surgical techniques that it inspired have redesigned the field of corneal transplantation and gained traction with ophthalmologists all over the world.

“In a nutshell, abandoning mainstream logic has been NIIOS’ strategy since our start, and it seems to have paid off,” Melles said. – by Michela Cimberle

Disclosure: Melles reports no relevant financial disclosures.