Challenging Conventional Thinking with the Laws of Physics

OIS Podcast 231 web

Podcast Episode 230

How does a chance experience scuba diving lead to a treatment for aggressive/progressive glaucoma? John Berdahl, MD, CEO and Founder of Equinox talks about his humble beginnings in a small town and how mentors along the way pushed him to be better than he thought he could be. Joined by his colleague Matt Larson, Equinox President and COO, they share pages directly from the Equinox playbook to talk about how they went from concept to company and their future commercialization plans. Keep a pen handy for some of the most insightful advice and quotes that will inspire you to climb the mountain of entrepreneurship.

Full transcript below.

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OIS Podcast Transcript:

Intro:
Next up on the OIS podcast, Dr. John Berdahl and Matthew Larson from Equinox take a pragmatic yet innovative approach to treating glaucoma. Let’s listen in.

Dr. Ehsan Sadri:
Good morning. This is Dr. Ehsan Sadri, board certified ophthalmologist here in lovely Southern Cal. I have my two friends, brothers here. We’re totally delighted to have them come on the OIS podcast this morning. Dr John Berdahl, who’s a good friend and he’s a very, very strong entrepreneur and just a wonderful human being. Delighted to have you on John. How are you doing?

Dr. John Berdahl:
I’m feeling great and thank you for saying such kind words.

Dr. Ehsan Sadri:
It’s a pleasure. Our other guest here Matt Larson, President and COO of Equinox another good friend, local and just a wonderful guy. How are you doing Matt?

Matthew Larson:
Doing well, Ehsan. Yourself?

Dr. Ehsan Sadri:
Good, Good. We’re in the middle of this COVID thing, and we were all talking about having kids doing Zoom meetings. How you guys doing with this corona crisis?

Matthew Larson:
Well, we’re adapting right? I mean that’s what we have to do, and it’s happening to everyone, so we just gotta make sure we think differently and solve problems differently than we would have if we were all together in the same place.

Dr. Ehsan Sadri:
How are you John? How are you guys doing at home and with the company?

Dr. John Berdahl:
You know, it’s the best of times and it’s the worst of times because you know you, there’s, ah, we focus on what is critical and what’s essential. You know, things that maybe got in our way like HIPAA laws are gone. Maybe we get to spend more time with our family, but we don’t get to put our hands and to work like we used to on people’s eyes. And you know, that craft that so beloved to us isn’t there every day, but ultimately, philosophically, I think of this is you know, our generation’s moment to own this crisis, and it’s our responsibility and this should be about humans helping humans be better humans. And, you know, every day we try to wake up and do that.

Dr. Ehsan Sadri:
That’s terrific. There was a quote I was reading. You know, I am a big fan of stoic philosophy not to digress, but to your exact point, and basically that the notion is love your fate or amor fati which is a Roman of sort of a stoic philosophy, which this is our fate not just tolerated, but love it and you’re nailing it on. And I think that allows us to then pivot and do things that we’re doing now with telehealth and telemedicine as you’re involved with. So, you know, for those people that are not really familiar with both of you, I’d like to start with you, John. You know, you’re well known in the community, your absolute thought leader, a good friend, brother brother in arms, and I’m actually delighted to have you here. I know how busy you are, personally involved with so many different things. And for those of you don’t know him, he’s at Vance Thompson surgical centers. And he’s just a wonderful, wonderful human being and just amazing savant. Um, tell us a little about yourself. Tell us what people should know, John,

Dr. John Berdahl:
You know, I’m a small town kid. I grew up in a town of 500 people and my family moved into the Dakotas 150 years ago when they were giving away land for free and my family doesn’t see opportunity that well, so I’m still in the Dakotas 150 years later. But, you know, I grew up a small town and went to a small college, came back, taught high school math for a year, coach girls’ basketball on boys’ baseball and then went to medical school. I was actually gonna be an optometrist, and my family optometry suggested that I pursue a path in ophthalmology. I think he was trying to protect the noble profession of optometry from me, and it was kind of like a hand in a glove. Once I started doing ophthalmology, I had mentors like Terry Kim and Rand Allingham, Dick Lindstrom, Dave Harden and Tom Samuelson and my senior partner, Vance who just poured so much into me and gave me the confidence and pushed me to be, you know, more than I ever thought that I could be. And so really, it’s been like so many things, a lot of good people helping you be better than you thought you could be on your own. But and so, we’ve taken some swings on some entrepreneurial ideas, and so far that’s gone really well. But I know in my core I’m a doctor in an ophthalmologist and what drives me more than anything else is delivering on the trust that patients and our team members put in us when they when they entrust us with something, a special is their vision.

Dr. Ehsan Sadri:
I love it. I’ll go back to that at the end because I really want to dive in on that, cause you’re very unique in the sense that you’re not only very busy, you know, with the practice and doing all the stuff, taking care of patients where you are, but really also, more importantly, you’re really took It took a really, really courageous movements. And said okay, you know what? I’m gonna actually try this. And you went you pushed beyond the fury of failure, which most people are afraid of. So, we’ll come back to you. Don’t worry. Don’t forget about that. So, Matt, I want to talk to you a little bit, really introduce you to everybody a lot of people know you from your old company, I know you and I talked about sort of all your clinical research background also launching Kamra and in Asia specifically when you were living in in Tokyo, Japan. Tell us a little about your passions, your background how you’re here now as president, COO of Equinox.

Matthew Larson:
Yeah, so, I joined my first ophthalmology company about 15 years ago or so. It was Acufocus, as you mentioned. And I started kind of on the bottom of the clinical team when it was a really small team overall. Early on in the project, I moved over to the commercial side when we started to sell the product in Japan and then I actually, as you mentioned, moved to Tokyo and lived there for about eight or nine months while we were launching over there. And moved into other geographies of Asia and as I moved forward in the company I also got a chance to kind of be the project lead for the second product, which was IC-8 IOL and then got to launch that in Europe and Australia and a couple other areas. And so, I kind of fell in love with the startup world, the small company, and having to adapt quickly and solve problems and really get your hands dirty and dig in. And then I had met John about, I don’t know, eight or nine years ago, and when the opportunity came up to join him at Equinox, I jumped at it and it’s been exciting. So far a 2/2.5 year ride working closely with John on the Equinox Project, and we’re making good progress and hopefully changing the face of glaucoma.

Dr. Ehsan Sadri:
That’s wonderful. Next ones doing for John. John again, you know, I really want to touch on how you are a full-time ophthalmologist. But really, how did this idea of Equinox start? I know it’s a very unique story when you were diving, and you were thinking about brainstorming. Then take us through really just the highlights of Okay, I have this idea. I think this is gonna be There’s something there. How did you then formulate the team to put a real company together?

Dr. John Berdahl:
Yeah. So, naivety is a strange asset. It’s an asset because you can ask questions before your mind’s been put in the box by too much knowledge in too much reading. And so this is kind of directed towards all those young residents or medical students or early career folks. Don’t let what is taught to you is dogma, dominate your thoughts. The only way that progress occurs is by challenging conventional thinking. And so, my story went like this. I was a first-year resident at Duke. My wife and I got our one week of vacation and we were in the Caribbean and doing a scuba dive and I was down 30 feet thinking back to my scuba diving lessons that at 30 feet you had one atmosphere pressure to your body and to your eye, and that’s 760 millimeters of mercury when you’re 30 feet underneath. I thought, how is it possible that we could add that much pressure to the eyeball and people don’t go blind? So instead of, um, instead of enjoying my dive or a corona on the beach afterwards, I was kind of like a dog with a bone on this idea, and it came to help me believe that the absolute pressure inside the eye ball probably isn’t what matters, because if you’re in Denver, there’s less atmospheric weight pushing on you, and the absolute pressure in your eyeball is different. Or if you’re scuba diving your absolute pressure is way higher. It’s pressure differentials that matter, because that’s what cause net forces to be generated. And so, the disease of glaucoma happens if the optic nerve head when we lose retinal ganglion cells. What’s the pressurized fluid on the other side of the optic nerve head is cerebral spinal fluid, and we know that cerebral spinal fluid affects the optic nerve because we see it all the time and idiopathic intracranial hypertension and papilledema when the optic nerve goes forward and Glaucoma, you know, perhaps, is just the opposite of that. An elevated intracranial or an elevated intraocular pressure or a low intracranial pressure. And that started to explain so many things like, Why does normal tension Glaucoma exist? Well, the eye pressure is normal, but the cerebral spinal fluid pressures really low. Why do most people that have ocular hypertension, high eye pressure, but no glaucoma, not get it. Well, because they’ve got elevated and protective CSF pressure. And so, I brought those ideas back as a resident and, you know, my attendings were gracious. They said, We think you’re wrong, but you should study it. We studied Mayo Clinic and found out that it turns out that that’s true. And now, you know, 10 years later, there’s 400 different citations, you know, to this paper with, to my knowledge, all but one of them demonstrating that it’s accurate. So I guess when you have an idea, do something about it.

Dr. Ehsan Sadri:
So that was a really good overview, for the new starting entrepreneurs, of John who basically had an idea and kind of worked it and put company together and just kind of didn’t give up and kept asking the right questions. And I think another thing he noted that I think was really significant was you know, when you’re starting out, it’s easy to give up and, you know, talk yourself out of it and I think if you have too much of knowledge it could be call analysis is paralysis. Would you agree with that, John?

Dr. John Berdahl:
Yeah, I think that that’s totally right. And so now we’ve got kind of this fundamental scientific, you know, idea, right? that Glaucoma maybe is a two-pressure or three-pressure disease. A balance between eye pressure, cerebral spinal fluid pressure and maybe ocular perfusion pressure. But then how you turn that into something that actually helps people? So, I go on the fellowship with Tom Samuelson and Dick Lindstrom and I remember this so vividly. I sat down with Dick. Lindstrom as my fellowship director and I’m nervous because I’m presenting to the King and like he does with so many people, he just brings out so much good in every situation. So, I presented this idea about CSF pressure, and eye pressure glaucoma. He said, John, I think you’re right. What are you gonna do about it? And I had had this moment where I thought I don’t know. I guess people are gonna think that I’m smart because we help figure this out. You know, if it turns out to be true and he said, Well, that’s okay, But I like to try and actually use these discoveries to help people. And even if you don’t have an idea now, opportunity will favor the prepared mind. And so fast forward four years. I still hadn’t had a good idea about what to do about this and I was reading an article about how astronauts are losing vision on the international space station because they’re getting papilledema and I thought well that’s because there’s no gravity in space, cerebral spinal fluid and all the fluids in the body go toward the head and now CSF pressure is higher than IOP and maybe that’s pushing the optic nerve forward. And so I reached out to NASA, and that led me to think if we could put a pair of goggles on the eye, pressurize them, raise the eye pressure to balance, the cerebral spinal fluid pressure, maybe we can help these astronauts. Which is then led to say, Well, why couldn’t we do the reverse? If we just lowered the pressure in my goggles, reduced the amount of atmospheric weight on the eye – even though the atmosphere weight is on the rest of the body – we can dial in and lower eye pressure. So, I cobbled together some stuff off Amazon, and we tested this in cadaver eyes and then ultimately in humans and showed that yeah, it’s just basic physics. We can do it and that was enough to get some people to believe enough to put some of their own money into kind of what’s called the friends, family and fools round. They may not understand the science but they believed in me enough to give us some of their hard earned money to chase this dream. And, you know, you take the next step and you set a milestone and you prove it. And then you start to get, you know, real money from professional investors. And that’s when you absolutely have to put a team around you. You know, like Matt and the rest of the Equinox team. And honestly, Ehsan, that’s for me, that’s the most motivating part or the risk of failure part. I don’t wanna lose anybody’s money. That’s really important to me. I don’t wanna look stupid either, but that’s the least important part. The most important part is that Matt Larson, Gary Berman and Paul Yoo and the whole economics team. They’re dedicating years the best years of their life to chasing this idea. And so, we want to pursue it hard and see if we can turn it into something real.

Dr. Ehsan Sadri:
That’s great. Matt, so you met John, and here you are. You saw this opportunity. Tell me when you came in, what was the state of the company and where are you now? And tell us a little bit about the funding state, sort of who’s who is backing you up and the board and all that stuff. Give us a little insight, please.

Matthew Larson:
Yeah, sure. Well, first, I don’t remember when I first talked to John about the idea, but I do remember seeing him present it for one of the first times at least that I had seen it. It was at an AUSCRS meeting in Australia. It’s a really small, intimate meeting that’s made up mostly of people from Australia and New Zealand, and he said it in a way that made me understand it and I got it. And I thought it was really interesting and innovative and then he actually got a nice compliment from one of the doctors who said, you know, in all the meetings that I go to in the past decade or so, this has been one of the things that’s really rang the truest for me. So that solidified it in my mind that okay, somebody smarter than me is validating this idea and saying it’s as interesting as I think it is. So, I started to kind of track it from afar at that point, and then when the opportunity came and he started to build out the team, you know, I was one of the first people to talk to him about it, and, um, I wanted to join and he thought might be a good idea. And so, we kind of we kind of partnered up from there. In terms of where we are today, since I’ve joined about 2.5 years ago, we’ve built out a small team. Um, we are moving as fast as we can. We actually finished our pivotal FDA trial just recently and are preparing our package to submit to the FDA. So, we’ve really taken it from John’s idea to a reality and completed a study, and we’re working hard to make sure that we can help Glaucoma patients in a in a new and different way. And like many glaucoma treatments, this can be used with other treatments as well. So, we’re excited about it, and we think it’s gonna be a really nice tool for the glaucoma surgeon.

Dr. Ehsan Sadri:
Going to pivot to John. So, you had the friends and family around. You brought your team together, your board, your mentors, you’re asking all the right questions. And when you when you sat down and okay said this thing, there’s something here and you went to the to the next round of investments. How is that different? Did you need to have a lot of data behind you? Uh, if you’re talking to a young guy who doesn’t have that what was that hurdle like? Can you give me some nuances there?

Dr. John Berdahl:
I think that new entrepreneurs always underestimate the challenge of raising money. As doctors, we’re kind of used to people, you know, patients saying, Hey, whatever you say is what I’m gonna do. And that’s not necessarily the way the world works when it comes to fundraising. And so, raising money is a challenge in the way that I like to put it is competency is punished. And what I mean by that is that every goal you accomplish or every problem you solve, the next problem that you’re gonna face is gonna be bigger, right? So, the first problem for is CSF pressure and IOP, does CSF pressure matter in Glaucoma. Okay, we do a study, and we solved that or see that that’s true. Okay, now can we change pressure with goggles? Okay. We showed that in a few patients. Now we’ve got proof of concept. Now, the bigger problem is, how do we design a big study? How do we measure pressure with the goggles on? Okay, we got that figured out. Alright, how are we gonna commercialize this product? How are we gonna get insurers to pay for it? Which patients are actually gonna benefit? How we demonstrate that benefit. So, I think that most entrepreneurs, me included, if we knew how tall the mountain was, we may never start the journey. But, because it’s incremental and you solve it milestone by milestone, you can make progress. And so it’s hard, and it’s no joke and you absolutely have to have people around you that can help execute the idea. Remember, the idea is, you know, maybe 1% of it of the whole thing. The remaining 99% is real work, and it’s fun work. It’s gratifying work, but make no mistake, it’s work. And so, you need to have a dedicated team around you and treat them well. Treat them right and have everybody rowing in the same direction.

Dr. Ehsan Sadri:
That’s terrific. Matt, tell me a little about where you are now with the current stage of development, to the liberty you can talk about what you’re looking at, can you share with the audience where the current stage of their development the company is? And then also, you know, what’s the next few quarters, few years look like for the company?

Matthew Larson:
Well, we think as we looked at the glaucoma market, we wanted to fit in where there’s a true unmet need, and there’s been a lot of innovation and glaucoma. It’s all been amazing, but most of it has been for the mild to moderate glaucoma patient, and so we know there’s also a big piece of that market that’s still having issues. And John, when John would say those are the patients, he’s still worried about and that those are the severe patients and normal tension, glaucoma patients. And because this is based on physics, we know we can help those patients. And so, we think that’s the market where we’re going to make the biggest dent. And, um, right now we’re working on getting our FDA approval. We’ve finished that study and preparing the package for the FDA. We don’t know when clearance will happen, but we have some pretty strong data to send to FDA and we think that with the safety profile of this device, we think that the FDA will look at it in a positive light and see the strong data that we have and hopefully we can get clearance. For the next couple of quarters that’s what we’ll be doing. Sending off that package pretty soon and then waiting for feedback questions back and forth, etcetera. At the same time, where we’ll be doing some other studies to look at specifically the normal tension glaucoma population. And so, we’ll be doing some studies only on those patients because we believe that’s where this is gonna be the biggest, best fit for this device,

Dr. Ehsan Sadri:
You know, I gotta tell you as a fellow glaucoma aficionado like John, I gotta tell you that this is gonna be a huge game changer for a lot of patients. Especially post COVID, people are having difficulty coming in, I think there is going to be a lot of value add to provide treatments. We’ve seen things like Bimatoprost SR and what the risks are now that implants are going in because there’s so much data behind patients not taking their drops. So, as a doctor, I’m really excited about that and just really providing, you know, better care and just less, you know, morbidity around the eye drops and costs all the other stuff. John, what do you think about that? I mean, we kind of didn’t really talk about the sort of deep dive why this matters but, do you feel like there’s a lot of traction for that for clinicians?

Dr. John Berdahl:
Yeah. And when we talked to clinicians, you know, that’s what we hear repeatedly. You know, as Matt talks about normal tension glaucoma and severe glaucoma, those are the patients that you know, if somebody comes in and their pressure is 25 and they’ve got mild glaucoma, we know that we’ve got a lot of tools to solve the problem for them currently. But if someone presents for the first time and their pressures 14 and their glaucoma is getting worse you’re looking at, you know, MIGS probably isn’t gonna lower the pressure that much, drops probably aren’t gonna lower the pressure that much, Xen might but they come with riel morbidity. And so, when you have a device that’s additive to anything that’s already been done and in addition it’s safe, we think that there’s a lot of the most vulnerable people out there, the most vulnerable patients with the worst glaucoma that we can actually help. And, you know primum non nocere, safety first, first do no harm, we think that that’s really an important concept for these patients that are holding on with aggressive and progressive glaucoma.

Dr. Ehsan Sadri:
That’s really good. I you know, I gotta tell you, I was really excited about that, John. Matt, I want to go back to you a little bit, as much as you’re comfortable. What was your last round like raising money where people were like Okay, now past the first phase of friends and family, who’s your biggest capital partners? Are you talking to them daily? What does that look like as far as managing expectations? You know, we like to talk about that a little bit as well. When you get an investor, how does that relationship change the chemistry of the of the company of the board?

Matthew Larson:
Yeah, we have some of the best investors you can have in anything, but especially in ophthalmology. You know, Flying L Partners and Visionary Ventures and Bluestem are the leads on our project, and we’re really excited to have them and they comprise the board as well. We’ve got Andy Corley as the Chairman, Dick Lindstrom and Bill Link from Flying L Partners as well. Jeff Weinhuff from Visionary Ventures is on the board, and Tyler Stowater from Bluestem Capital. And really, if you think about investing in ophthalmology, you couldn’t ask for better partners than that. They know the landscape. They are seeing most of the opportunities that that are coming through ophthalmology and so, having them really validates the project, and they’re amazing advisors. So, John and I and the team get to pick their brains and brainstorm together with them and use their experience to help guide the project.

Dr. Ehsan Sadri:
Terrific. Terrific. And then so this, you know, we always end with you’re sort of passing the baton. Both John and Matt, are really seasoned entrepreneurs. And so, if I’m a young entrepreneur, starting out, I’m intimidated, I don’t have any funding, but I might have a really phenomenal idea that will help patients and add value to marketplace. John, tell me, what are three or four things that you would pass on? And number 2, probably more important than number 1, How is John Berdahl different? Who is the new John Berdahl sort of as evolved versus the one that just had an idea?

Dr. John Berdahl:
Yeah, great question. So, the first thing I would do is say, is my idea so embedded in me that I have to do something about it. Because, like we talked about the mountain of entrepreneurship is steep and long. And so, if you wake up repeated days and the first thing on your mind is this idea. It’s an itch you have to scratch then go for it. So, it has to be something that you won’t, you can’t give up one. Number two is then do some intellectual property work. Get either a patent search done, or if you know how to do it, do a patent search and determine if there’s market for this. Is it really solving an unmet need? And one thing that doctors don’t think about that much is how and who is gonna pay for it. And so that’s next. Then the third is once you got a sense of the intellectual property get a couple of close mentors and people that have, you know, have done it before people that you can trust and say, Am I making some good, prudent decisions here early on? Because I don’t I don’t think that you can do it without trusting other people. You know, if you just hold your ideas so close that it never has a chance to blossom. You need to involve other people. And then those other people are gonna help you figure out how to get it funded, how to design the work that you need to do. And that’s the first step and I would encourage you to do it. Go for it, right? We get one life. We get one swing at this. And the only thing that ever makes a difference in life is when some individual takes a risk and says I’m willing to be wrong and I’m willing to fail, but I’m gonna go for it because I only get one shot at this life. How have I changed over the last 10 years? I’m probably a little more pragmatic and I’m curious by nature. Actually, Gene de Juan gave me this piece of advice. He said, John, I’m interested in about everything but I have to say really disciplined to be both, to spend my time on things that are both interesting and important. And so I would say that 10 years ago I chased things just for the sake of curiosity 10 years ago and now I chase things that are both interesting and important, and that’s probably the biggest change for me personally.

Dr. Ehsan Sadri:
That’s terrific. For those of you listening write notes down. This is really good stuff. Matt, tell us your journey. How is the new and improved Matt versus 10 years ago? Other than the kids and the family and all that and managing all the family stuff, How are you different? What are some of things you would like to teach a young COO and president of the company? And just, you know, what are some things that I think will be effective in in, um, things you’ve done?

Matthew Larson:
Well, I don’t know if I’m much different from 10 years ago. I mean, we all learn from our experiences, and we all have opportunities and I feel like I’ve been blessed and had really good luck with the opportunities that I’ve had. When I think about, you know, a situation or a project, the first thing I always think about is the people, whether it be your mentors or the people that you work with. And you know, when you’re thinking about joining a new company or a new project, you want to pay attention to what kind of people they are, what the culture is and does that match with your belief set and do you bring skills that can help that. I always try to be open to new learning opportunities and continuously learn. We can get better every day and if we take a new challenge on to get new skills or take on a new project, I think that could only help us grow. And one thing that I remember someone teaching me early on was to steal shamelessly. Now that sounds bad, but what it really means is, you know, if you’ve got a boss or a co-worker who does something really well, don’t be afraid to just take that and use it for yourself. If they explain something really well, take some of the words they’re using or if they do something really well, you know, emulate that behavior. And when we think about the business side, I always think about thinking about the customer first. We want to listen to the customer. If we’re making a new device or have a new drug or whatever it is, you gotta listen to the data and what the customer is telling you, because we can all convince each other in in a in a room that this is the best thing ever. But if the customers not saying the same thing in those things don’t match up. And so those are the things I try to think about when I go through, go in a project and move forward on a project.

Dr. Ehsan Sadri:
That’s terrific. I want to say thank you both for coming on today with your busy schedules with the family and the craziness of Corona. I wish you and the family safe and just a wonderful successful year and it was just truly a pleasure to have you both on.

Dr. John Berdahl:
Ehsan and team, thanks for including us and Ehsan, thanks for the really kind words. The mean a lot. And we’re excited about what we got going. We think we’ve got a shot.

Matthew Larson:
Ehsan, Thanks for the opportunity. Really appreciate it. Equinox is excited to be a part of the OIS Podcast, and hopefully next time we can do it in person and not at each other’s, all at our own homes.

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