01:11 Nahum describes his personal journey in MedTech and founding  EyeYon Medical.

04:00 The reasons we don’t hear about ophthalmology startups compared to other medical fields and if this changing.

08:10 Nahum explains what the cornea is. Why is it considered the window to the eye?

12:50 The story of EyeYon Medical and EndoArt, the company's main product.

17:45 EyeYon's initial fundraising experience when it was established 10 years ago. Did it involve the two products they are currently focused on? 

22:40  How did Nahum attract a VC from a very early stage.

26:40  What are the two different got-to-market strategies for EyeYon's products?

32:20 What are EyeYon's plans moving forward with EndoArt and beyond?

38:00 How does Nahum Ferera keep his work and life balance?

42:00  Words of wisdom Nahum would give to his 16 year old self. 

Tell us about you. What's your personal journey in med tech? How did you come to found EyeYon Medical a little before, during and now?

Nahum Ferera: I'm a biomedical engineer by profession. I always was fascinated about what make us move like we move, see what we see, how does it all comes together with our brain and the other body organs. I always was fascinated about technology, about electricity. And luckily, I found that in biomedical engineering that combine those two. It was very a pioneering bachelor degree back then. I think I was the fourth cohort in Tel Aviv University of the biomedical engineering, so it was quite hard. And when we were in the university, everybody asks us, are we electrical engineering? Do you want to join Intel? Do you want to join Applied Materials? So, you want to join Tower Semiconductor? Since we said, 'No, we are biomedical engineering'. Nobody really knew how to digest us in the first field. But I really like the field, and I felt fascinated about what the future can bring. Actually, my first position was while I was in the bachelor degree in the second year, I joined the company named Physical Logic. Actually, they wanted to save cost on IP management so they took a student to review all the different ideas they had back then, and to see if there is any written IP on that. It was a very very hard work. But it allowed me to really learn, bottom up, the industry; what has really existed, what was thought about and what the fascinating idea that human imagination can create to make our world a better place, to make people feel better, to see better and of course, healthier. And since then I assumed positions as a project manager, in different fields in cardiology, in the blood glucose monitoring, in variety of stages. And actually, EyeYon Medical is my first ophthalmology company.

The area of ophthalmology is really fascinating and I'll tell you why. It's probably one of the largest areas in medicine. I know that ophthalmologists are the top earners in medicine, but you don't really hear about many ophthalmology related startups. You hear about cardiology, and you hear about orthopedics and diabetes. Why do you think that is? And do you think that this is changing?

Nahum Ferera: First of all, vision is our dominant sense. It is responsible for more than 50% of the information we acquire. And we see that our eye is a very sensitive organ, but actually if we think about it, everyone will cut their eyes with laser, or do refractive surgery to remove eyeglasses. And cutting the eye with laser, just that alone is a huge innovation that's already very deeply implemented in ophthalmology.

We talked about cataract operations. When the eye lens is being replaced with plastic, actually, inside our eye, that's an artificial organ that every one of us would get someday. I mean, 60% about the age of 60, and 70% above the age of 70 have cataract surgery. That's the artificial part I think every human being will have someday and this is progressing. And this specific plastic piece of plastic is always progressing and there are very crazy ideas about it. We put tubes in the eye for glaucoma. Actually, there is a lot of innovation around it and it's progressing. I think, as in any other medical field, we are working with very traditional type of thinking so it takes time.

I can tell you that in our story, it took time to really digest that part of the eye can be replaced with a synthetic implant. But yes, I think it takes time but it's progressing. And if we really look on the eye, there are actually a lot of innovations. And I have to say that Israel is a fertile environment for that innovation. I'm part of a group of more than 60 startups in the field of ophthalmology in Israel. A lot has been done and you need to be done as well so.

Now you're saying you're 60 but that wasn’t the case 10 years ago.

Nahum Ferera: You're very right about it, I think it's growing. Eventually, as you said, eye surgeons always sit in the highest peak of earning because people are willing to pay for their vision. This is really booming; in the ophthalmology industry we see that. This is a very active industry, with companies and industry players, and industry strategic companies that acquire more and more startups and this is really booming industry. We are learning the eye, and there is still a lot to be learned. This is a really fascinating organ, transferring light to neuron activation and eventually vision. But we are close to almost replacing every part of the eye today for a better quality of life, which is in direct correlation with our vision.

Can you explain a little bit what the cornea is and why is it considered the window to the eye?

Nahum Ferera: The cornea is the window of the eye. It's the transparent part of the eye. When lights touch the eye, the first thing that it met is the cornea. Any damage to the cornea, results with blurred vision and pain as well. Cornea is one of the densest nerve organs in our human body, so it's very sensitive. The cornea is comprised of five different layers.

The outer layer is epithelium that our body knows how to regenerate. For example, in laser surgery, a part of the epithelium is removed and our human body know how regrow it. The main level of the cornea is actually collagen Type IV matrix. And this matrix is actually organized in a way that allow transparency of the cornea. And if this matrix is being changed, then the cornea becomes blurry. But what's most fascinating for us is that the cornea is protected from the inside by the endothelium. and this endothelium is one of the few layers that our body can never regenerate. As you probably know, most of our body is always regenerating. Our hair is always changing, our nails, our skin is changing. We are not the same person that when we were born. But the endothelium is one of the few layers that our body can ever regenerate. We are born with the (limited) number of cells in our endothelium and we will live with whatever is left out to it. Any damage to the endothelium is catastrophic. Any result of aging, genetic effect, also result with damage to the endothelium. And as you probably know, we're not programmed to live beyond the age of 60. Now that we go beyond that, there are solutions and there are a lot of resources and efforts trying to keep us functional. This endothelium is responsible for two mechanisms. It allows some fluids to enter the cornea. But it has active pumps to remove fluids from the cornea. This is how our corneas stay in the right humidity and get its nutrition. There are no blood vessels in the healthy cornea. But again, any damage to that endothelium results with either accumulation of fluids in the cornea, that results with destruction of that matrix and blur vision. Also, as I said, because it's a very nerve-dense organ damage to it results with a lot of pain as well. This is a very basic anatomical description of the cornea.

There is an interesting story about the invention of the intraocular lens, the IOL, which was invented by Dr. Ridley in World War Two who treated (RAF) Royal Air Force pilots.  And this one pilot in August 1940 had his canopy shattered and pieces of Perspex entered his eyes. And what doctor really noticed is that it was inert to the eye he had the idea for the IOL. The interesting thing is that it took him almost 10 years to do the first study, it was only in 1949. This leads to you. What is the interesting story behind EyeYon Medical and behind EndoArt, which is your main product?

Nahum Ferera: In cataract operation, we will replace the inner part of the eye, not the cornea, with a piece of plastic that was discovered. Exactly as you said, by observation of the side effects. In our case, Dr. Ofer Daphna and Dr. Arie Marcovich which are my cofounders, observed a side effect of a different therapy. When the retina, the inner part of the cornea, or actually the nervous system of the posterior part of our eyeball, is not located very well. One of the options is to inject silicone oil into the eyeball, just to fill it with silicone oil to keep everything in place. But in some cases,     part of the silicon oil migrated to the anterior part of the eyeball just beneath the cornea. And then, the endothelium was damaged. And you have a cornea without endothelium and the silicone oil beneath it. And the observation was that the cornea stayed clear. Now, you have a cornea without endothelium and it's clear. And that was very interesting. And again, I have to give the credit for Dr. Daphna who invented the technology actually and was the first one to observe it. And then, he came with the idea, why shouldn't we just replace endothelium with a synthetic variant?

Reminding you that today in 2021, the only way to replace the endothelium is taking a tissue from a deceased individual. And this is the most common organ transplant around the globe and the most ancient one as well by the way. And that's how the idea was born. But ideas are easy, implementation is hard. In my previous position, I was part of a multi-disciplinary technology. It was a combination of electricity, chemistry and biology, of course, everything all together. And here I thought, 'oh, that's, that's a simple idea. It's just material and we just need to find the hyper talent. And that's all.' And of course, I found out that it is tenuous journey. We've reached very far and I'm happy to speak about the achievement but it's a long journey. But today, nobody can argue that the endothelium can be replaced with a synthetic implant that we invented, because we have shown that in humans for the long-term and we're very proud of that.   

Just imagine that for cataract population, you will need to wait for someone to die to take his inner part of the eye. I mean, a very complicated procedure to implant it in the other eye if that Sir Ridley wouldn't observe that phenomenon back then. That's the type of change and disruption we planned to do in cornea industry.

You started the company with this vision, right? That was the beginning. But during the 10 years, you created another product and you launched and brought it to market. When you fundraised for the company at the beginning 10 years ago, what was the story behind that fundraising? And did it involve these two products?

Nahum Ferera: When the company was established, it was established in the incubator of the Jerusalem Hebrew University, back then it was Van Leer incubation. And we got those two patents, two ideas, together form a model, the tech transfer of the Clalit. Because they were related in a way, they're both of the cornea, but they are very different products, very different devices. And your question is the right question. When we started the company, this EndoArt was a crazy idea. Nobody knew that it would work or not. And the second part of the Hyper-CL that was captured in the moment, was said to be more a realistic idea that has a very straightforward way to achieve.

We did initiate the work on the Hyper-CL. The Hyper-CL, targeting a very interesting unmet need, where most of our topical drops are being wasted and are not effective enough. And there is no device to keep those drops in place. And that is what the Hyper-CL does. It has a unique design that acts as a drop depot to increase bioavailability of topical drops.

In the first year, we focused on the Hyper-CL to reach a fundable milestone, to show that there is a real company with a real product here and even a product in the pipeline that might be a real game changer that nobody knows yet. And there is that gap after incubation to get the first believer from VCs and others. We wanted to reach to something that can really show the ability of the product to work.

Luckily, I was able to get an investment from an angel investor that owns the largest manufacturer for contact lenses and eyeglasses in Israel, Biovision Group. I get an investment and actually a factory of my own to manufacture everything I wanted. That was a very good start. But along the way, there was always debate how to select between those two and to navigate. I have to say that nobody knows what would happen if we choose differently. But we got all the way here, because we chose to keep those two on the right regimen between those two. And once the EndoArt was found to be working and became a reality, the understanding of the board was that we are focusing on the EndoArt.

The Hyper-CL is an interesting product that we might become a spin off, or sell as a business unit, or maybe be part of the company pipeline. But the thing that's important, and it was hard work for me to explain how to choose between those two, and to highlight the benefits of having two products and not just one.

You just completed a $25 million round. But you started as an incubator company, you moved with external funding from an angel. But then you attracted a VC from a very early stage and a very prominent one, from Pontifax. What did you do in order to convince them at that early stage, before you had the dream product in place that you are funding ready for your perfectly investable company?

Nahum Ferera: So first of all, in the first meeting, I didn't convince them. it took three or four meetings to convince them. They met me in several stages. Also, I have to say that Triventures together with Pontifax led the first financial round. I think we came at the right time for them. Having a product that is already CE approved and show the company's abilities and a dream product that showed there is something interesting, a disruptive technology. And this is what Pontifax really looked for at in the beginning. I knew that we wouldn't be able to show human results in the incubation time, even with the EndoArt. I wanted to show that the company has the capabilities by showing that on a more simple product but having the other technology in place and showing the first signs that there is a real thing here.

That all together convinced that this is something to look into. And again, it wasn't easy. It took several meetings and having other VCs as well to fall in love with the company and maybe convince Pontifax. It's always a result of a long-lasting relationship and networking. I can say that even for the latest round as well, which was led by one of the largest ophthalmology strategic companies.

You need to prove yourself every time and they are looking into that. I mean, if you meet him one time, and you say something in that meeting and a year after that, nothing happens, that's a bad sign. Those VCs that I am lucky to work are all professionals with either its Pontifax, Triventures, Rimonci are Chinese focused ophthalmology company or the strategic company that led the last round. They know that sometimes it takes more time and there are bad surprises and sometimes good surprises. But if you keep persisting, they'll appreciate it.

Hyper-CL lens is a little bit consumer-y, just because it kind of ties into contact lenses while EndoArt  is very much a surgery. It's replacing a very well-known surgical need. Are there two different strategies for these products or are you kind of building on top of each other for it to go to market?

Nahum Ferera: First of all, the company is focused on the EndoArt, because this is a real game changer. Although there is a huge market need for sure. And the superiority of the EndoArt over a tissue is in so many aspects, that we will spend the rest of our conversation just to speak about that. But if you go about for availability, if you talk about the simplicity of the procedure, the type of physician that can perform the EndoArt, the fact there is no disease transfer. There are so many advantages.

But still, this market is actually controlled today by eye banks. And that's a very puzzling way to reach the market. Because the big players, the industry, the companies doesn't know how to handle this part of the industry. Because eye banks are responsible for tissue donation, they are so-called nonprofit organization but actually they are very profitable. The cornea alone cost $5,000. This is a very lucrative market. That alone was a big challenge for me to convince and to bring industry players to say, hey, there's a new ocean here that you might have held off, but you never tapped into. It's not glaucoma, it's not cataract, it's not dry eyes, it's not laser. It's not a new product to replace an industry you are already working in and have marketing people active in that area.

This is a new ocean, that creates a new opportunity and this is how it's actually needs to be presented. And that's a new challenge. And I think that this is especially with COVID, facilitate part of the processes I was working on for many years. Because first of all, there was no donation of corneas and the existing corneas in the eye banks. If you don't implant them within 10 days, then they cannot use them anymore. There was a huge shortage of corneas. And also, people in the industry, and even eye banks understood that corneas are part of the past. They understood that they would never eliminate corneal blindness just by harvesting cornea and distributing them.  And some of the eye banks saw the activity and became an investment entity in medical devices and actually keen on investment in EyeYon and partnering with EyeYon. This is a very interesting thing that happened. And even industry players looking on that area as well. And we see more and more devices in the field of cornea because that's now the future: replacing the cornea with synthetic medical devices.

Are you piggybacking on the existing system of eye banks, in terms of, going to market?

Nahum Ferera: We might use some of that infrastructure. But actually, this is just a new product for cornea physicians that can be distributed by the medical device companies. But we are piggybacking on the existing procedure. Because today, the physician knows how to replace the material. He needs to wait for a donation, he needs to be very sensitive and well experienced to use the tissue. And he knows that he has a few tries to put it in place but he's   thing. But now we get an off-the-shelf synthetic sterile implement. And this is why I think physicians are so enthusiastic about it. This is a new thing. But in ophthalmology, it's new information in ophthalmology. And actually, we're being approached by a physician who wrote the next textbook, and they're writing new chapters about the synthetic material. But we are relying on existing trends in ophthalmology, which are replacing only the endothelium with a minimally invasive procedure. A thing that the cornea physician do for almost 10 years today.

There are about 200,000 corneal transplantation a year versus millions of patients in need. I did not think about these banks as competitors. But coming to think about it, then the way that you currently do or practice medicine is the main competition. So what is next? What are your plans moving forward with EndoArt and beyond?

Nahum Ferera: First of all, I'm sharing with you that EndoArt is CE approved. That was not published yet, but I believe we will publish it very soon. That was actually a great achievement of the team in a short time, so we got that. We are even closer to the market than we thought. The next step is actually performing lots of clinical trials all around Europe, Asia, and hopefully soon in the US. We're granted breakthough designation by the FDA in 2020. That's a special, unique, route for innovative technologies targeting real unmet needs.

And in parallel in 2021, we're granted the clean channel by the NMPA. That's the equivalent out in China. We are currently the only ophthalmology company that got both. We are very proud of that. And that's what we are going to do in the next two years. This means expand clinical trials, because we need to learn the procedure. Even now, that we have technology that is working, we need to standardize the procedure, to teach physicians to properly choose patients. Again, you ask me about the strategy. When you establish a company, you think, 'Well, I will do the First-in-Human, we will be successful, and then we're going to exit. And then you do that and the day after that nothing's happened. And saying okay, you've done just the first new patient. What about the next 20, 30 patients? One patient is not enough and then you got that. And then do 30 patients and the results looks pretty good. And then, day after that nothing happens. And then, it goes on and you get CE approval; and for that also we got FDA approval. Then we get breakthrough resignation, now we got another CE approval. It's not really true that nothing has happened because a lot is happening in the background and you get more and more attention and being interviewed by friend Gali. And you got more money invested in the company, so things are happening, but this is long-term. And everyone needs to bear it in mind. I thought that before the age of 35, I will do my first M&A or first exit, and now I am closer to 40. And I hope and I still know that out of my mind, that might just not happen, and just continue and focus on the technology. But we need to look on the journey and enjoy the journey and really amazing things are happening. As we are speaking, there are more than 20 patients with the EndoArt in their eye, seeing better, feeling better and that's a lot. That's a lot for me and for the company. We are going and we are progressing. But there are more to come and more changes to come. If we look on what's next is just expanding the clinical trial, validating the technology, as much as possible.

Standardizing the protocol and achieving quality approval in the most important geographies, which is of course, US and China, which is a very interesting market for us. And we were talking about the debate between the Hyper-CL and the EndoArt. But there is also a debate between China and US. Things are changing. When I established the company, it was very straightforward to go for the CE and then the FDA and then the sky is the limit. But today, I think China becomes a real interesting opportunity. The need is huge. The advancements of technologies in medical device is booming. That's also something that I always believe in parallel working.

Because sometimes you get a letter from the FDA, they want a lot of extensive GLP trials. And if you rely only on that day, you cannot focus on China. It's really important to work in parallel, and that also relates to different products inside the company, and different market that you're active in. You need to be focused, but still having a plan B and having at least two routes in parallel. I think that's the key for success.

Being a CEO of a startup is very time consuming. How do you balance your work and life?

Nahum Ferera:             I know that in other startups, or maybe this is more related to software, that work from early morning to later on. I don't believe in that. EyeYon is a multinational company. During the recent financing round. I worked in three different time zones.

And, I got calls from China at 4AM. And I was working with US very late at night and even before going to sleep, I shared it. I sent everything to US because I knew that actually this is just the beginning of their day and if I will wait for tomorrow morning, I will get a reply 2 days and after that. I actually, I had three clocks in in my mind to work with.

But having said that, I am strong believer of work/life balance. I mean, at EyeYon nobody needs to come in at a specific hour or go out on a specific hour. If someone wants to work from home, that's not a problem at all. I think it's very important to work and to enjoy family as well. By the way, I'm a father of four amazing kids, young kids; so you need to have your work/life balance. And eventually that gives the employee to be happier and more productive. Because if you look on EyeYon team, we are very robust and people work here together for 5 years. And then, I think the average time is like five years. It's very unusual for a startup and I think work/life balance is part of it. But still if we need to speak at 5am in the morning, because that's what the NMPA decided that you don't talk with the Chinese government, you do that. And if a top physician in the US, want to work to speak at 3pm after he finishes his clinic, which is reasonable, that's sometimes 11pm in Israel. You need to agree to that and you need to be flexible. And that allows work/life balance. You go out at 3pm. Take the children from kindergarten to spend quality time. But the price you pay is that after everybody goes to sleep, you speak with the US. And before everybody wakes up in Israel, China's already half-awake too so. That's the key. And we are not any more in a time, where your time in the office is in correlation to your productivity. We are not in a factory facility that you are 8 hours in the facility, manufacturing 400 lenses. That's not the case in startups. Flexibility is the key for productive work life balance, which is super important for all of us. Eventually, we need to enjoy what we are doing.

If you could go back to your 16-year-old self, what words of wisdom would you give to you? And I'm adding to this, you're not allowed to say, 'it takes longer than anticipated', something else.

First of all, I think I knew even back then that I really believe in work hard play hard. I mean, we prepare to work hard. And then, you get the results for it. I mean, eventually, in the bible, we have that phrase, [42:42 - Quote from Hebrew Bible]. I truly believe that. I mean, there are no shortcuts. So I might be saying it's longer than anticipated. And eventually if I have to say one more thing, I think that finding the right team around you is the right thing to do. Because eventually, everyone in the office is better than me in some aspects. And in multidisciplinary innovation like biomedical innovation. Because we are actually in the at the edge of the most complicated thing, we are replacing part of the most amazing creation in the world. And multidisciplinary innovation requires a multi-talented team and that's the key for success.

We're really doing the impossible here. We're replacing the only material but part of the body that our body can never regenerate. And that can only be done with a team that wake up, thinking about solutions, and going to sleep thinking about, what should we do next? How can we do it better?
Those are the tips for that 16 years old boy.

Nahum Ferera's Profile on LinkedIn

EyeYon Medical's Website