Retina Times | Fall 2016 Issue

Below is a continuation of a three-part interview series in the American Society of Retina Specialists publication Retina Times. For part 2, Dr. Charles discussed how being a do-er, an engineer, and a problem-solver coincide with being a retina ophthalmologist. 

PART 2 IN A SERIES / Steve Charles, MD: Portrait of a Private-Practice Innovator

Fall 2016

Many discoveries in retina have come from physicians in private practice. In the Annual Meeting Retina Times, part 1 of this series featured interview with 2 innovative private-practice retina specialists — ASRS Past President Paul Tornambe, MD, and Robert Wendel, MD.

In part 2 of this 3-part series, we’ve spoken with another pioneer in vitreoretinal surgery, Steve Charles, MD, who can talk faster than we can think.

How did you get interested in the engineering aspects of medicine?

One of my grandfathers was a surgeon, and the other was a mechanical engineer. The surgeon grandfather died before I was born. My dad’s oldest brother, my godfather, was a general surgeon. I didn’t think about being a doctor until halfway into engineering school. I loved design from day one. I’ve never wanted to be known as an entrepreneur or a gadgeteer or an inventor—I hate those terms. I don’t like what I call aspirational innovation. It isn’t about, “Oh, I want to be innovative,” or “I want to start a company.” It’s about problem solving. So I kept asking myself, “What can I do in engineering that will help people?” I wasn’t going to design a heavymetal guitar, or a gambling machine, or a new thing to serve wine—all of which have screwed up our society. I wanted to do something with meaning. I hate Hollywood. I hate Las Vegas. I hate gambling, drinking, partying —entertainment in general.

I found meaning. When I was a junior in engineering school, I decided to go to med school and continue engineering. I did engineering all the way through 4 years of University of Miami Medical School. I virtually lived at Bascom Palmer Eye Institute, building ERG machines, ultrasound machines, a lot of instruments—all from scratch.

You’re a big aviation guy. Why didn’t you go into jet propulsion? There are a lot of other things that involve engineering.

Well, I wanted to be a doctor and help people. With aviation, you’re in a cubicle in a room full of hundreds of engineers, and you never even see the final product. You don’t fly in it. You don’t talk to pilots. They give you a part, and you sit there and design a part and do finite element analysis. That’s not me. I don’t know if I have people skills, but I wanted to be around actual humans, not just staring at a screen all day with a mouse in my hand.

But here is the core difference: There’s a philosophical piece I’ve thought a lot about because of my age, and that is, when somebody asks me, “Didn’t you used to be an engineer?” I say, “No, I am an engineer.” I have done engineering every day of my 41-year career in vitreoretinal surgery.

I’ve driven $5 billion in sales. I have 100-plus patents. It’s not about innovation. It’s not about entrepreneurship. It’s not about business. Again, It’s about problem solving. And so it’s constantly an overlap of what I call the 3 Ts: technique, technology, and teaching. If you don’t do a ton of surgery, you’re not valid in the design space. If you don’t keep current in engineering and push the envelope—teach yourself mechatronix, modern control theory, and fieldprogrammable gate arrays (FPGAs)—like I’ve done—then you’re not valid.

I built a conceptual design of the Constellation with 1200 parts in the proposed parts list before Alcon did one hour of work on it. I didn’t sketch stuff on a napkin. I built a big computer-aided design (CAD) model with what the electronics should be, and the Constellation is built very much along those lines. Numerous technologies and patents on the Constellation come from me—same with the Accurus, and before that, the Ocutome 8000.

My late friend, Conor O’Malley, developed the Berkeley Bioengineering Ocutome 800, but I invented the 8000 with Carl Wang for CooperVision; that was the first machine with linear suction. I built the first real-time gray-scale B-scan with Xenotec, Inc. I built MID Labs with Carl Wang, invented the disposable cutter and high-speed fluidics. MID Labs got acquired by Alcon. Then I started InnoVision. The InnoVision ocular connection machine (OCM) is the forerunner of the Accurus and the Constellation and had every feature that’s on the Constellation. InnoVision was acquired by Alcon in 1991.

Why didn’t I do engineering in an academic environment? Because I wanted to see the finished product. I’m on the ARVO Foundation board of governors just to push what I think is translational research. People always use the phrase, “the bench to the bedside,” and say, “It’s translational research.” No, it’s not. It’s about getting a product into widespread clinical use. So on the technique side, I invented fluid-air exchange, internal drainage of subretinal fluid, forceps membrane peeling, endophotocoagulation, scissors segmentation, scissors delamination, linear suction, punch-through retinotomy for subretinal bands, retinectomy instead of Robert Machemer’s relaxing retinotomy, 3-port aspiration lensectomy, and anterior proliferative vitreoretinopathy (PVR) dissection.

Steve, if I can push you a bit … My impression of Machemer is that he was a full-time faculty guy who was tinkering in his garage and then …

Although Anton Banko patented a device similar to the VISC before the VISC was developed, it was never commercialized. Banko was the fluidics engineer for Charles Kelman, and sent a letter to Charles Schepens, Harvey Lincoff, and Edward Norton, saying, “Look what I’ve got. Could you guys use this? Kelman lost vitreous all the time. I invented this because I invented mechanical lensectomy, and it didn’t really work as well as ultrasound. So what do you think?” And Banko’s patent was issued 2 years before Machemer came out with his device.

Machemer created the specialty of vitreoretinal surgery. He trained a bunch of people because he was at an academic institution, and he and Jean-Marie Parel invented endoillumination. That’s a big deal. And Machemer invented membrane peeling with a bent needle. That’s a big deal. He technically didn’t invent the vitrectomy probe because Anton Banko’s patent preceded his work. But it doesn’t matter. What matters is creating the field, and Machemer created the field and trained us.

Conor O’Malley was in private practice too, wasn’t he?

Correct. He trained at UCLA. Conor was in San Jose and he just loved to invent things. He wasn’t an engineer; to use an old-timey term I hate when they apply it to me, he was a tinkerer. But he hooked up with a guy named Ralph Heinz, and that’s where the Ocutome came from; it had a bellows drive so it wasn’t disposable, but it was the first pneumatic cutter and the first axial cutter and first 20-gauge, 3-port system.

So, when you were inventing devices and techniques and presenting at meetings, how did the retina community accept you as an engineer-doctor from Memphis? Do you think it would have been an easier road had you been at the platform of a Wills, Wilmer, or Bascom Palmer?

I’ve thought a lot about that. It’s a great question, and I think it would have been worse for me. I’m not a committee guy. I don’t want to sit in discussions at meetings—I just want to do it. And I don’t want to apply for RO1 grants and walk around trying to hit people up for money. I just hate all that. I want to design and build, so I had to find a company capable of getting it out there.

Why not then say, “Okay, forget this. I’m going to go out and just take my company and do it full-time to take my engineering …”

Because then you’re not valid in the operating room. If you’re not constantly doing more cases than anybody else, you don’t know what you’re talking about. You’ve got to be embedded. Guys who are in aeronautics, have a PhD in aeronautical engineering, and fly jets are the best guys to design airplanes—not guys who do one or the other, but not both. And the technically confident guys who drive race cars, who really understand suspension systems and engine tuning, are better race car drivers. But what don’t I do? I haven’t seen a movie in 30 years. I have zero intent to see a Hollywood movie ever again.

Come on, you would have been to Titanic and shed a little tear, or something.

No, I hate all that. I haven’t been to a concert. I went to one NBA game with my grandkids last November. I live in Memphis; I’ve never seen the Grizzlies play. I’ve never been to an NFL game. I don’t play golf. I don’t hunt. I don’t fish. It’s been 20 years since I’ve been on vacation. I don’t have a house, a bird, a plant, a fish. I work and work out. That’s it.

And fly planes.

So, the only things at my apartment are me and my biome—the bacteria in my gut.

I’m super-tight with my kids and grandkids, but for me, it would be morally wrong to take a vacation, go to a concert, go to a ball game, or to gamble or drink because I have a moral obligation to do what I do. I’m not a religious guy, but religious people where I live would describe what I do as a calling.

I’m super-involved with Alcon and creating the next machine. Plus, I’m the main surgeon for the National Eye Institute’s stem cell project, the iPSC, and that’s coming along. I’m participating in 3 Orbis International fundraiser events, one I’m running here at Memphis at FedEx, and I’m doing the first China trip on the new MD-10.

So that’s what I need to be doing. It isn’t about getting awards. It isn’t about being an officer in any of these organizations. I’m so fortunate that people like Julia Haller do such an awesome job of making the ASRS and the Retina Society and the Macula Society happen. I’m just privileged to participate and learn and interact.

Look at Sandy Brucker; he singlehandedly built the journal, Retina. That’s hard work, and it’s an enormous contribution to our field, just like Julia’s leadership and George Williams’ leadership and people like that—so I get that people play different roles.

I don’t have the skill set of Julia, or Sandy, or Lee Jampol. My skill set is engineering, teaching, and operating, and they all overlap, so that’s what it’s about for me.

What would you suggest to fellows who are interested in doing new things?

Number one is to stay current. For example, last Monday night, I spoke to a Memphis startup. They asked, “Would you give a lecture on this subject from 6:00 to 7:00 PM, followed by Q & A?” I said, “Sure.” So, when did the Q & A finish? At 10:30 PM. A bunch of young engineers are studying there, and I said, “Guys, if you get an MBA because you want to start an engineering-based company, what will follow most of the time is engineering incompetence.”

I said, “Engineering and technology are exploding; you have to study every day to keep up. Because you once studied engineering, that is just a language to study going forward, and if you don’t continue studying, you’re not going to make a contribution.”

It’s mind boggling to me how guys say, “Well, I’m going to start a company.”

I ask, “All right, what technology are you good in?”

“Oh, I want to start a company.”

I ask, “Do you have a product in mind?” “Well, I want to be innovative.”

As I said, I call this aspirational innovation. It doesn’t work. So, if someone says, “I want to be like Steve Charles,” I say, “Okay, throw away your golf clubs. Don’t go to a wine tasting. Don’t go to a movie theater. Don’t tell me about Spotify and Pandora. Don’t tell me about Hulu or Netflix. You’ve got to put all that stuff aside.”

Now, I didn’t put aside being a daddy. I got the 15-year attendance award at my kids’ elementary school. But none of that other stuff, zero, ever. That’s the way I could have a career that encompasses engineering and surgery. I have no interest in being a CEO. I’ve been chairman of the board several times—I hated it. I hate finance. I hate negotiations. I don’t like financial types. It’s not me. I don’t want to be that. I’m not a wheelerdealer, venture capitalist, negotiator, businessman, Donald Trump.

I’m an engineer, and engineers who design products read 40, maybe more, engineering trade journals a month. They are throwaways like we have in retina. But I read. I say, “Oh, that company keeps cropping up. They have got a new sensor or incremental encoder. I see that company all over the place; they seem to be the best at linear amplifiers.” So that’s how I study.

Dyson Hickingbotham at Duke invented cannulas. Vitrectomy was described in Japan by Tsugio Dodo, and as I mentioned, Anton Banko patented VISC. Gholam Peyman had an early machine called the vitreophage. Dyson Hickingbotham is an engineer and a lovely guy, and he never gets proper credit. He was at Duke; then he went to Grieshaber, and later to Alcon. Now he has a one-man independent instrument development company in Wake Forest, North Carolina. He’s just a spectacular guy—no ego at all, no greed, just does his work incredibly well—and he built the first cannulas.

How would you advise would-be inventors in retina?

My best advice is, don’t get an MBA; don’t go to entrepreneurship or innovation conferences. Learn some technology, keep current, push it, and mingle with the best and the brightest—whether it’s biotech or med-tech.

There’s an endless list of things that bright people have launched that have been failures. It’s just plain complicated, hard, expensive and time-consuming work, and if you don’t enmesh yourself in the technology and meet with numerous technologists, nothing is going to happen, so that’s a big problem.

Sometimes people worry, “Oh, I don’t want anybody to find out my ideas.” Well, your ideas won’t ever get out if you don’t interact. You’ve got to try things, develop them, push them, and find out what the limits are.

ASRS Mission Statement 

The mission of the ASRS is to provide a collegial open forum for education, to advance the understanding and treatment of vitreoretinal diseases, and to enhance the ability of its members to provide the highest quality of patient care.

Retina Times is published five times a year by the ASRS as a service to its membership.