Great Conversation With Dr. Steven Feldon

Great Conversations Section Editors: Meagan D. Seay, DO Rachel Calix, MD Great Conversation With Dr. Steven Feldon Rachel A. Calix, MD, Meagan D. Seay, DO, Kathleen B. Digre, MD M eagan Seay (MS): Today we have the pleasure of speaking with Dr. Steven Feldon, who was NANOS president from 1994 to 1996. He is going to share a little about his life and career. I’d like to start out by asking, what was your background prior to going to medical school? Steven Feldon (SF): I was born in Los Angeles and graduated from Beverly Hills High School, before attending University of California, Los Angeles (UCLA). I really went to UCLA because, well, it was one of the places my parents allowed me to go. It was also $84 a semester for tuition, so that was helpful. I was a philosophy major, and I actually was planning to be a rabbi. Over a period of time, I went from philosophy into psychology; I flirted a little bit with maybe going into psychiatry which brought me into medicine. And here I am. MS: What was it that got you interested in medicine? SF: As an undergraduate, I had the rare opportunity to do original research with 2 fantastic mentors. One of them, Larry Kruger, was doing neurophysiology. We were studying the cat superior colliculus. The postdoc student left in the middle of his appointment term. I continued all the experiments and got my first publication in vision research as an undergraduate. So, I had already been exposed to vision and vision research and found that very exciting. My other mentoring experience was somewhat different. It was in computer programming and computer modeling, which I also found useful in vision research. I really wasn’t sure whether I wanted to specialize in neurology or ophthalmology until well into medical school. MS: Tell us about where you went to medical school. SF: I went to Albert Einstein College of Medicine in New York. I was not a great undergraduate student initially. I was too busy doing research, engaging in campus activities, and attending fraternity parties to really study hard. But because of my research and because, when I did decide I wanted to be a doctor, I was able to ace pre-med subjects like organic chemistry. For me, getting good grades was purely a matter of motivation and commitment. Departments of Ophthalmology and Neurology (RC), Ochsner Medical Center, New Orleans, LA; and Departments of Ophthalmology and Neurology, University of Utah Moran Eye Center, Salt Lake City, UT (MDS, KBD). The authors report no conflicts of interest. Address correspondence to Rachel Calix, MD, Ochsner Health, Departments of Ophthalmology and Neurology, 1514 Jefferson Highway, Jefferson, LA 70121; E-mail: [e-mail] 402 SF: I had completed all my education through college in Los Angeles and wanted to experience something different. I was really encouraged by the core curriculum that Einstein had introduced. After 18 months you started your clinical rotations and, of course, my first clinical rotation was in neurology. At that time, there were very few treatments available to patients with neurological diseases, and I felt that it was important for me to have more therapeutic impact than what I was experiencing, but I was also fascinated by the cognitive and the diagnostic challenges of neurology. SF: We would spend 10 minutes going on neurology rounds, and then we would sit down for 2 hours and talk about localization and about function. This is before computed tomography (CT) scans and before MRIs. We really had to use our neurologic expertise and the physical exam to determine where the lesions were and who needed to go to neurosurgery, and so on. So, I found it really fascinating. But as a career, I just didn’t find neurology fulfilling enough on the therapeutic side. While on neurology, I was explaining my dilemma of should I be an ophthalmologist or a neurologist to the chief resident who said, “Well, why don’t you become a neuro-ophthalmologist?” I said, “What’s that? I’ve never heard of it.” He replied, “Well, there’s this young guy. He just came out with his book. His name’s William Hoyt, and it defines everything that is the purview of neuro-ophthalmology. There were really only a few other prominent neuro-ophthalmologists in the country, Lawton Smith at Bascom-Palmer, Frank Walsh at Wilmer, and David Cogan at Mass Eye & Ear. Dr. Hoyt is out in San Francisco, and you ought to write to him.” So, I did. SF: I said, in effect, “Dear Dr. Hoyt, I’m a second-year medical student at Albert Einstein and I want to be a neuroophthalmologist when I grow up, and I’d like to apply for your residency program.” He did write me back, which was a surprise in itself. He sent me a very nice long letter about how to choose between neurology and ophthalmology, and that was the first thing I really needed to do. And he invited me out to spend time as a medical student. Between my third and fourth years of medical school, I spent probably a total of 6 months in San Francisco with Bill Hoyt and also with my other mentor, Larry Stark, who introduced me to eye movement research. RC: You ended up doing residency elsewhere, though. How did that happen? SF: Residency was another story. I happened to be with Bill Hoyt at the time that I was applying, and this was before the match existed. Basically, you applied to all these Calix et al: J Neuro-Ophthalmol 2022; 42: 402-408 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations departments, and then they would call you and say, “Okay, you have an interview tomorrow, at 6:00 PM.” So, you’d drop everything, you’d run out there. You do your interview and then they’d say, “Well, you have 24 hours to tell us whether you’re coming with us or not.” Then what you had to do is to call all of the programs that you’d prefer to go to and say that you haven’t had your interview with them yet, but, “I need to know whether you’re going to take me, because otherwise I’m going to take this other program.” And it was very anxiety provoking. SF: I was offered a position at a middling program. I went to Dr. Hoyt with this and said, “What should I do? Should I accept this program?” He said, “Well, it’s quite clear. You need to go to Wilmer.” And I said, “Well, that’s great, but I didn’t apply to Wilmer.” And that was automatically 10 demerits (chuckle); I shouldn’t ever have said that. He said, “Well, where did you apply?” I told him places I applied. And he pooh-poohed them all. He said, “But Mass Eye and Ear should be okay. There’s this guy David Cogan there; he knows a little bit about neuro-ophthalmology.” And I said, “Well, Dr. Hoyt, it’s not so easy. You know, they have to interview you and accept you.” He said, “Well, just do it.” So, I did. I called up Mass Eye and Ear and I said, “I really need to know whether you’re going to accept me into the program.” And I called back the next day and they said, “What’s your name?” I told them what my name was. And they said, “Oh, well, we actually thought your name was something different, and so we sent somebody else through and we turned them down.” I said, “Well, could you now re-ask and see if maybe they’ll take me?” And so, in fact, they admitted me. I was very relieved because I knew that I never could have lived down the humiliation of not going to a training program acceptable in the eyes of the great Dr. Hoyt. RC: Well, that worked out perfectly. SF: It did. RC: What was your residency experience like? SF: Mass Eye and Ear was interesting because I liken it to (at that time; it’s different now) having free access to a library. You had the most brilliant researchers and amazing clinicians, but nobody taught you anything. You had the opportunity to learn and, fortunately, that really suited my personality and how I liked the learn. And I had a wonderful time, made great friends and liked living in Boston. I really felt very comfortable there. RC: Do you think the decision, then, to go back to study with Bill Hoyt, was kind of a given all along, or did you consider other options? SF: I did consider other options because when I was a medical student with Dr. Hoyt, the level of discussion was so elevated that I felt that I may not be able to meet his standards. Ultimately, I really wanted to go back and be with Dr. Hoyt. I had a very, very interesting year. MS: Can you tell us more about your fellowship year with Dr. Hoyt? Calix et al: J Neuro-Ophthalmol 2022; 42: 402-408 SF: Well, it was an interesting time for Dr. Hoyt, because he had just decided not to write the fourth edition of Walsh and Hoyt, and this was something that really just wore him down. He realized he didn’t have the enthusiasm to go through and really re-write another 3 or 4 volume textbook. He was somewhat depressed when I got there and a lot of the energy, that was there when I was a medical student, was missing. I was doing most of the day-to-day work, and then there were people who came in from all over the world to be with him, and they would occupy a lot of his time. SF: I would wake up at 4:30 in the morning to be able to get to UCSF and make sure the patients are ready by 7 o’clock for rounds. We finished the outpatients at 5 or 6 o’clock, then began going through all the inpatients, trying to find the ones that he might be interested in seeing, going to the library to scour the Index Medicus (at that time there was no MEDLINE) until you could find relevant journal articles which were on point, but hopefully new to Dr. Hoyt. I’d spend hours and hours in the library, get home at midnight, and then start again the next day. It was exhausting. Dr. Hoyt’s office was very interesting. It was just a long conference table. He didn’t have a separate office; he had his manual typewriter, his ashtray, the coffee urn, and about 12 seats around the table. One day, I came in a little late because I was busy brewing the coffee for the day and all the seats were filled. I walked in and said to myself, “There’s no room for me. Maybe I need to find an alternative to hanging around the office.” SF: I spent the next three and a half or four months doing research on pupils and eye movements with Larry Stark, and I would still come and prepare all the patients and do all those clinical duties, but instead of just going between my home on the peninsula and UCSF, I would also make a trip during the day to do experiments with Larry Stark in Berkeley at the School of Optometry there. I certainly learned a lot about eye movements, which was put to good use in the early part of my research career. Instead of spending quite so much time at the library in the evening, I would go over to Dr. Stark’s house, and we would get on the phone modem to the UNIX computer system to do eye movement simulations. Dr. Stark would say, “let’s invent some truth.” I frequently use this same phrase working with my students and mentees. Kathleen Digre (KD): Steve, wow, what an interesting thing. Did Dr. Hoyt mentor you into your faculty position? Tell us a little bit about that. SF: I was set to go back to Mass Eye and Ear Infirmary; I had a Harvard appointment waiting for me there. At that time, and even today, Harvard is one of those places that I would say is not highly collegial. When you’re immersed in that environment, you really don’t think too much about it. You feel like, “I can stand up for myself and I can fight for every square inch of laboratory space, and I can fight for every technician and every graduate student. I’m good, I’m up for it.” But you go away where things are somewhat different and you say, “Well, 403 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 1. Dr. Steven Feldon and Dr. Bill Hoyt. you know, is that really the life I want to live? And is that the way I want to do research?” At the time, there was a young Turk who had just come to Los Angeles and been made the Chief of Ophthalmology at University of Southern California and the Doheny Eye Institute. His name was Steve Ryan. I was from Los Angeles and wanted to return to be with my extended family. I had interviewed there with Steve Ryan as a medical student and again during my fellowship. SF: Jerry Donan, who was another great early neuroophthalmologist, was in private practice and came by once a month to have a clinic, but there was no full-time neuroophthalmologist. The Department of Ophthalmology at USC consisted of 3 clinicians and 2 basic scientists. I wanted to go there to build a brand new neuroophthalmology division including neuro-ophthalmic surgery and research in eye movements. Steve Ryan, of course, knew Bill Hoyt from Wilmer. So, he calls Dr. Hoyt and says, “Who should I have as a neuro-ophthalmologist? What you think of Feldon?” And it just so happened that the year I was a fellow, Steve Ryan had invited Bill Hoyt to be the Doheny lecturer, so he was actually in Los Angeles. And there I was in the Dean’s office with Dr. Hoyt telling Dr. Ryan, “This is really the right decision for you to hire Steve Feldon to be your neuro-ophthalmologist.” So, Bill Hoyt was absolutely critical in getting me the position as the first full-time neuro-ophthalmologist at Doheny, USC (Fig. 1). RC: Were there any other big mentors throughout your training that particularly stick out in your mind? SF: Well, I had spent some time with Bob Hepler, another early name in neuro-ophthalmology, and he had befriended me and took me under his wing as a fledgling neuroophthalmologist. He was very encouraging and supportive. MS: Back when you were in training or your early first job, did you envision yourself being where you are today? 404 FIG. 2. Paradise: (Left to right) Tom Carlow, Steve Feldon, Diane Feldon, and Susan Carlow. SF: Yes and no (chuckle). It’s not an easy question to answer, because one of the things about academic ophthalmology that drove me to academics in the first place is that I like doing lots of different things. Mostly what I like is being creative. I want to make the world a different and hopefully better place. To come to a fledgling Doheny Eye Institute and have had the opportunity to help create what is now one of the top eye institutes in the country gives me a tremendous sense of accomplishment. SF: We haven’t talked too much about NANOS yet, but NANOS was the Rocky Mountain Neuro-Ophthalmology Society (RMNOS). It was both ski club and a fabulous opportunity to learn more about what was happening clinically and scientifically in our sub-specialty. I take great pride in being an early advocate for what would become the North American Neuro-Ophthalmology Society. Early on I was involved in trying to bring together the Walsh Society and the RMNOS. I had the privilege of working with Tom Carlow and with all the early leaders to help create what today is NANOS (Fig. 2). This was just another fantastic creative experience, which I couldn’t have anticipated. Then of course, I had a career as an inventor that I found very rewarding. I invented the Tono-Pen among other devices back in my very early days as a faculty member. Then, 22 years later, I had the opportunity to start my own eye institute here in Rochester (Flaum Eye Institute). What started out as a small clinical program with a faculty of 4 developed into a robust academic department with strengths in research, education, patient care, and population health. There are currently about 40 clinical faculty and 10 basic scientists. Calix et al: J Neuro-Ophthalmol 2022; 42: 402-408 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 3. Steven Feldon (third from left) and family. SF: After stepping aside from chairing Ophthalmology at U of R, I took on a new position as Associate Vice President and Director of the Office of Biomedical Research. My job is to help commercialize intellectual property that other faculty members are interested in developing. I’m bringing to bear my cumulative experience as an inventor, researcher, and academic partner to industry, bringing that all around to help my fellow academics achieve success as inventors. Could I have anticipated this career? No, but was I prepared to take advantage of these opportunities when they came along? Absolutely, I am someone who is always looking forward to the next challenge. KD: One thing I have to bring up is that Steve went and got an MBA. I think you were 1 of the first neuroophthalmologists to get an MBA, and it was really critical in forming and coming up with strategic planning for NANOS. Tell us how you integrated that into your career, because that’s not easy to do when you’re starting up and starting a whole institute in neuro-ophthalmology. SF: I went back for my MBA in 1994 after I had already been on the Doheny/USC faculty since 1979, so this wasn’t an early decision. I had already started 2 companies by the time that I said, “You know, I’ve been fortunate. I’ve been sort of going by gut, by feel, and by knowing people; but, I have no idea what I am really doing.” What I learned in business school was the language of business. Just as when you go to medical school, you learn the language of medicine. In business, the same words mean different things than they do in the medical profession or in the engineering world or in the biological research world. I’ve been able to take my experiences in all these different areas and translate them across disciplines. I really feel that my biggest strength right now is as a communicator. So often, synergistic projects fall apart due to misunderstandings. Bridging communication gaps can make a huge difference. MS: Is there anything you would go back and tell yourself in your early career, if you could? SF: I am not a person who looks back very much. I like looking forward. There is nothing I would tell myself to do Calix et al: J Neuro-Ophthalmol 2022; 42: 402-408 FIG. 4. Dr. Steven Feldon. differently, because I feel that every day I make the best decisions I can make, and to go back and second guess those decisions isn’t fruitful for me. I would much rather expend energy on the next decision. RC: Do you have advice you would give to those early in their training or career? SF: I really think that most academic departments don’t adequately encourage their residents and medical students to go into academics. For me, the idea of going into private practice was absolutely frightening. I thought it would be the most boring, dull thing I could possibly do. Once you’ve done 100 cataracts, does it make any difference if you have done 200 cataracts or 500 cataracts? Well, it is great for the patient; I think the patient gets a lot out of it, but what have I learned and what unique contribution have I made that someone else couldn’t have? I think the important thing that we can do for our young, growing neurology and ophthalmology residents and our medical students is to really sell academic medicine and to tell them that they can have a career that’s secure, that allows them the opportunity to be creative, to explore new things, and to take risks in a very supportive environment. The likelihood is that they would never take those risks if they were in private practice. I think that we under-sell academic medicine. 405 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 5. (Left to right) Diane Feldon, Steven Feldon, Vivian Mismondo, Alfredo Sadun, and Debra Sadun. RC: Do you have advice for those in neuroophthalmology? How would you influence someone to go into neuro-ophthalmology? SF: Well, if I were talking to a medical student, I think my bias is toward being an ophthalmologist, neuro-ophthalmologist. I would also encourage them to have a surgical specialty, whether it be oculoplastics, glaucoma, muscle surgery, or pediatrics. Making neuro-ophthalmology alone attractive for people who started ophthalmology as a surgical subspecialty is a tough sell. Neuro-ophthalmologists that start with neurological training have a great advantage when it comes to understanding the disease processes involved. But they have a substantial disadvantage in separating neurological disease from eye disease. We become kind of the sleuths of ophthalmology, charged with finding out what everybody else missed. That could be refractive error, a bad cornea, macular hole, or any of a myriad of other eye problems. Neurology-trained neuro-ophthalmologists should spend a fair amount of time in an ophthalmology department. You really have to be competent in ophthalmology to be a great neuro-ophthalmologist. MS: Is there anything you would do to influence a neurology resident to pursue neuro-ophthalmology? SF: I think the neurology departments tend to shy away from recommending an ophthalmology rotation for their trainees. I’m not really sure why. Often, the best neuroophthalmologists come from neurology programs where there’s a priority placed on neuro-ophthalmology. RC: Going back to the process of establishing NANOS, I think it would be interesting to hear about any specific challenges or interesting stories during that period. 406 FIG. 6. Steven Feldon and Mark Borchert circa 2007. SF: How many hours do we have? (chuckle). SF: The big problem was that there were actually 2 potential subspecialty societies that arose at the same time. For many years, the Walsh Society wasn’t the Walsh Society. It was the Neuro-Op Path club that had annual meeting with rotating administration, depending on what medical center decided to host that year’s meeting. If you wanted to be in the club, you just signed up to go to the meeting. I went to my first meeting of the Neuro-Op Path club in 1972 when I saw my first brain CT scan. It was held at UCLA, and I was there with Bob Hepler. The furthest thing from anybody’s mind at that time was the idea of a formal organization. SF: Bill Hoyt and David Cogan were often in the front row. Bill would challenge everybody. David Cogan sitting next to him, kind of saying, “Well, that’s an interesting concept, let’s think about that a little bit.” It was an unbelievable experience and there were no holds barred. Just about the time Tom Carlow saw that the Rocky Mountain Neuro-Op club could be more than just a meeting and should be organized in some way, the Neuro-op Path Club changed its name to the Walsh Society. The name change was initiated by Tom Hedges II in a fitting tribute to the memory of Dr. Walsh. SF: Neuro-ophthalmology was too small a group to have 2 competing societies and, initially, neither the Rocky Mountain nor the Walsh was organized in any formal way. Even though there was nearly a perfect overlap between the 2 groups membership, cultures were quite different. The Walsh was always held in medical center auditoriums and everyone was in business attire. The Rocky Mountain Calix et al: J Neuro-Ophthalmol 2022; 42: 402-408 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations attendees sported parkas and after-ski boots and met at the slopes. The “Society” was going to be to the group that organized best and first. I would say, “We’re talking to ourselves. We can continue to have a Walsh meeting; it’s very important that we don’t want to do anything to change the Walsh meeting. We can also have an organization that’s more formally organized around subspecialty education including, but not limited to, clinical–pathological correlations. They’re not mutually exclusive. We can come together.” There were some really difficult conversations. SF: In an ecumenical moment, I suggested to Tom Carlow, Jim Sharpe, and Jack Selhorst that the Presidentelect, after I finished my presidency, should be Neil Miller. Neil, of course, was a Walsh member and a NANOS member. He understood the value that both organizations brought to neuro-ophthalmology. Although Neil was somewhat reluctant to accept the presidency, he was successful in re-uniting us. MS: Would you have ever thought that NANOS would be what it is today? SF: I was on the board of NANOS for, I don’t know, more than a decade. And during that time, it was maturing as an organization and the positive direction it was taking was clear. I was there for a good part of that evolution, and even after, I left the board I came back to lead a few strategic planning sessions. I had no doubt about what NANOS could become. I think that Tom Carlow and then Larry Frohman as EVP’s provided wonderful leadership, being very open to innovative change, welcoming new talent, and grooming future leadership. I am pleased with the evolution of NANOS, but I’m not surprised how successful the organization has become. RC: Well, you’ve had such a successful and impactful career. What would you consider your biggest successes? SF: My biggest success is my family (Fig. 3) (chuckle). I have always put my family first and, in turn, they’ve responded. So, 20 years ago, when I spoke to my wife about leaving Los Angeles where all of her friends and family were to come to Rochester where we knew nobody she said, “That’s what we should do. Because that’s what’s best for you.” Now we have 6 wonderful grandsons and a seventh grandson on the way. SF: It’s really hard to identify only one greatest success in a professional career. I think creating the Tono-Pen was special, not only because I was able to invent it, but because I truly believe that, as probably the world’s most popular device for measuring intraocular pressure, there are likely to be thousands and thousands of patients whose glaucoma would have been undetected, except for the ability of the Tono-Pen to be used as a screener to make earlier diagnoses. It has been on the market a long time, so I’m very proud of that. Also, I am very proud of what we were able to do at Doheny, to go from essentially a start-up to be one of the top programs, regularly ranked in the top 10 in the country. I’m very proud of what we’ve done in Rochester taking a Calix et al: J Neuro-Ophthalmol 2022; 42: 402-408 FIG. 7. 2011 Annual Nanos Meeting Fellow Dinner: (left to right) Courtney Francis, Guy Jirawuthiworavong, Khizer Khaderi, Essam Saber, Vivian Rismondo, Vivek Patel, Steven Feldon, Alfredo Sadun, Alice Kim, Filipe Chicani, Peter Quiros, Deb Friedman, and Zoe Williams (behind). bare bones department, and building a highly respected eye institute (Figs. 4–6). RC: In any free time that you have, what do you like to do? Do you have hobbies or other creative outlets? SF: I really like working. As I said, I get bored very quickly, and I like to be productive. Most hobbies, I would say, don’t really have any appeal. However, I’m a wine collector; I love tasting wines, adding to my cellar, and writing notes on my wine tastings. That gives me a lot of pleasure and of course, it’s something to share. Having people over for dinner, serving a nice wine, and having them get a taste of that hobby makes me happy. Snow skiing and water-skiing traditionally have been the kind of recreational activities I do. It’s one of the reasons I enjoy having a son who lives in Utah, so we can go skiing (chuckle). SF: My hobby is looking forward to what I’m going to do for my next career. RC: Do you have any thoughts? SF: I really would like to see a successful commercialization of other people’s ideas. I really like being a mentor, I feel that I get a great deal of satisfaction out of having medical students and young researchers with whom I’m able to share my experiences, not from the standpoint of knowing what’s better, but from the standpoint of them discovering what they can do with some basic tools and with some gentle guidance. MS: Is there anything else you would like to discuss? SF: The community of neuro-ophthalmology; there’s nothing quite like it. I know that I can go to almost any city in the world and have a friend there, and that’s unique and special. MS: Yeah, absolutely. KD: I couldn’t agree with you more on that one. SF: Yes, we’re a community. We’re our own community. I had never, until 2 years ago, missed a NANOS 407 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations meeting ever (Fig. 7). I had been to every single one, and so it broke a chain. Before that, I had been to almost every single Walsh meeting since 1972. The meeting content is always great, but the time with our colleagues between sessions is even greater. RC: Well, I have to say, this has been just such a fascinating Great Conversation and we’re so grateful to you for giving us a window into your career and the history behind NANOS, and we just thank you so much for talking with us today. 408 SF: Thank you for this unique opportunity. ACKNOWLEDGMENTS Drs. Seay and Digre are supported in part by an Unrestricted Grant from Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah. Calix et al: J Neuro-Ophthalmol 2022; 42: 402-408 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.