Lewis reflects on an ophthalmic career
OSN Glaucoma Board Member Richard A. Lewis, MD, recently announced his retirement from private practice.
In addition to clinical practice and research endeavors, Lewis is past president of the American Society of Cataract and Refractive Surgery (2014-2015) and past president of the American Glaucoma Society 2000-2002. He is currently chief medical officer at Aerie Pharmaceuticals.
Q: What accomplishment are you most proud of in your career?
A: There are a couple of answers to that. I am most proud of creating this practice, Sacramento Eye Consultants, which is the referral base for anterior segment disease in Sacramento, California. I am proud of the surgery center that we created early on which helped facilitate some of the surgical innovations along the way. I have been involved in a lot of clinical research that changed some of the approaches to glaucoma, both medically and surgically. Lastly, I am proud to have been honored to be president of ASCRS and AGS. I think I have loved every minute of my career.
Q: What would you say is the most important or impactful innovation or invention that you have been associated with in your career?
A: I have had a few innovations that were impactful in ophthalmology. In my fellowship, I was involved in the development of topical carbonic anhydrase inhibitors, and that was acquired by Alcon and became a mainstay in glaucoma therapy. Later in my career, surgical innovation has always been important to me as the surgery for glaucoma has historically been very slow to change. My close friend and colleague Reay Brown has been the undisputed leader in this area. Perhaps, my work in developing and promoting canaloplasty was one I was proud of and became the intermediary step from traditional trabeculectomy to MIGS. On the pharma side, I became involved with different pharma companies regarding both non-preserved glaucoma therapies and then more recently with Aerie on being part of the ROCK inhibitor team. We had gone 22 years without any innovation medically in glaucoma until Rhopressa (netarsudil ophthalmic solution 0.02%) and Rocklatan (netarsudil 0.02%/latanoprost 0.005% ophthalmic solution) were approved. I was involved with Aerie from 2009, ultimately helping to oversee the clinical trials in terms of medical side effects and then participating in the FDA hearings, both as an adviser and then chief medical officer for Aerie. I think that ultimately, the ROCK inhibitors will be a game changer for managing lowering IOP. I think we still have a way to go with the ROCK inhibitors, but it has been good, and I feel proud of that.
Q: Who would you say had the most impact on your education and your career as a surgeon or a researcher?
A: That is a tough one. How much time do we have? You come out of fellowship, and you are turning one way. Then over the course of my career, we went from intracapsular cataract surgery to extracapsular cataract surgery to phaco, and it is easy to change when you are in residency or in fellowship, but it is hard to change when you are out of it. As phaco clearly became the predominant way to do cataract surgery, I wanted to quickly adapt.
I took all the courses, but Alan Crandall, whom I have always had tremendous respect for, is the guy I think who was probably the most instrumental in getting me in the modern era back in the ’90s. Actually, he was not only doing phaco, but he was doing a clear corneal topical, and I thought that was the right way to do it.
In the ’90s, I flew to Salt Lake City and worked with Alan. My first case was a young 12-year-old girl with cerebral palsy, and I don’t think any surgeon I ever knew would have done that case under a topical anesthetic. They would have all done it under general because of her age and her cerebral palsy. But he showed me in that one case how you do it. Alan has always been one of my true heroes.
But there are a lot of people. I think when I got engaged with the executive committee of ASCRS, David Chang, Ed Holland and Tom Samuelson all were instrumental in molding my approach to surgery. I feel fortunate because combining all the anterior segment things we did from glaucoma with the way modern cataract surgery was going was a great marriage. A lot of glaucoma surgeons did not adapt. They were reluctant to make that change, and I went with it and continaued to innovate, and I feel fortunate that I was around such unique people.
I should add one more name to that. It has got to be Dick Lindstrom. I became friends with Dick, and listening to him talk in meetings as well as watching him in surgery were so valuable as far as the “right” way to do things.
Q: What advice would you give to an ophthalmologist who is just starting practice now?
A: That is a good question. I think that the advancing technology is remarkable and offers patients a means to get off drops as well as excellent vision. There is really no limit to what we can achieve.
In the past glaucoma fellowships underemphasized anterior segment surgery. The focus was on teaching traditional glaucoma surgery, ie, trabs, tubes, and goniotomy/trabeculotomy for congenital glaucoma. The game has changed and patients expect more than that. For example, we just hired a new glaucoma associate who trained at one of the very best fellowships. The first thing I said to him was, “What you learned in fellowship is the bedrock of current glaucoma surgery but not what you’ll be doing in the future. You really need to learn beyond glaucoma, beyond cataract, and get into the entire anterior segment. Be able to be comfortable with phaco, angle surgery, iris repair, lens exchanges and with vitreous surgery. Ideally, get comfortable with the evolving approaches of the anterior segment.” As our practice has grown to three corneal surgeons and now three glaucoma surgeons, each addition has pushed the group further down this path. The talent of the newer ophthalmologists is remarkable. With observing live surgeries on YouTube and the like, achieving such surgical proficiency is achievable.
Q: If there is anything you could change about your career, what would it have been?
A: I wish that someone had told me that advice. I had a great fellowship at the University of Iowa. It was very glaucoma centric. I wish that I had gone on to do an anterior segment fellowship, like what Alan Crandall offered or what the Minnesota Eye group ended up offering. I think I would have been a better surgeon knowing how to do IOL exchanges for our pseudoexfoliation patients and iris implants for traumatic injuries and so many things that come up in glaucoma that I was not trained in. I suppose everyone in ophthalmology might say that as the advances over the last 20 years make you wish you could start over.
Q: What brought on your decision to retire from practice, and what are your plans moving forward?
A: It has been almost 40 years in medicine. It has been a great career but a number of events (ie, grandkids, COVID, consulting opportunities, etc.) over the past year got me thinking about retiring.
I am still involved with Aerie as chief medical officer. I am also consulting on the surgical side for a bunch of companies. I think glaucoma continues to be an exciting spot. I think there is tremendous opportunity for innovation.
I look forward to a period when we are going to get beyond device-only type of mixed procedures, and it will be drug-device combinations. We will be able to not just lower pressure, but to begin to influence the impact of glaucoma on the nerve fiber layer and optic nerve. I hope we can ultimately impact visual function and restore damaged ganglion cells and that this occurs in my lifetime.
I think that we are blessed by living in a world that allows us to have such a tremendous impact on patients. I think that that opportunity to continue to influence our patients and their visual needs is profound, and feel we are fortunate we practice ophthalmology at this time.