Glaucoma: Lessons Learned
December 2023
by Ellen Stodola
Editorial Co-Director
Learning a variety of surgery techniques and clinical management approaches is important for surgeons in training. Several physicians discussed glaucoma training and some of the approaches being taught. The physicians also shared some of their personal experiences, including what they learned in training and since their training ended, and how these experiences have influenced them.
Lucy Shen, MD, said it’s important to continue to learn and improve surgery even after training. When you’re in training, you’re often focused on the numbers, like how many trabeculectomies or cataract surgeries you’ve done, and you don’t really think about how to incorporate new surgical techniques into your repertoire, she said. There are always new technologies and surgical techniques being developed. Once you are done with training, there are times where you have to reflect on what you’ve learned and think if you need to change to make your surgeries better because what you learned may not always work for your patient population or the surgical center that you’re at, she said.
Dr. Shen added that the types of procedures surgeons do in training will often depend on where they train. For example, she didn’t do much angle-based surgery in training more than a decade ago but learned it after she was done with her fellowship.
“It’s important to resist the external and internal pressures that may tempt you to rush through a procedure. Always remain present and methodical with every step.”
Daniel Lee, MD
Daniel Lee, MD, said that he was exposed to a variety of approaches in glaucoma care in training. “This exposure provided me with insights into various treatment philosophies within glaucoma care and allowed me to explore a comprehensive range of therapeutic options,” he said. “My existing constructs and beliefs on the ‘right way’ to treat glaucoma have been consistently challenged, which fostered the development of an open-minded approach as a clinician. Rather than forming rigid opinions, I’ve embraced a more adaptable stance, which I think is crucial in navigating a field where gray areas are commonplace and there are usually several paths to the goal.”
Sameh Mosaed thinks it is critical that trainees be exposed to various surgical techniques and learn where to apply them. Glaucoma surgeons work on the most complex cataracts, including those with pseudoexfoliation, angle closure cases with shallow chambers, flaccid irises, end-stage optic nerves with split fixation, central scotomas, and limited visual potential eyes, she said. “These eyes have a much higher rate of complications and require much more preoperative chair time. These are not the ‘fun’ cataracts where everyone is enjoying the experience and the postop clinic is all rainbows.”
Dr. Mosaed said she was lucky that she was taught how to do a solid trabeculectomy and is confident with that technique. “I think trabeculectomy requires the most nuance and experience of all the procedures in our toolkit,” she said. “Unfortunately, I see many glaucoma- trained doctors who aren’t comfortable with trabs, and they end up only offering Ahmed valves and MIGS to their patients.” If a surgeon is well-trained and performs a high volume of trabeculectomies, complication rates are dramatically reduced, she said. While complications still occur, the “national averages” don’t apply, as trabeculectomy techniques are so highly individual and surgeon dependent. “Many patients walk into the clinic with end-stage low-tension glaucoma only to reveal that they have undergone several back-to-back MIGS surgeries with no reduction in their disease progression,” she said.
It is unfortunate that glaucoma-trained doctors are really not doing trabeculectomies, Dr. Mosaed said, so they are uncomfortable with the concept. “I think in order to be comfortable with any surgery, not just trabeculectomy, you have to do it frequently to keep building on your skills.” Not all trabeculectomies are equal, and even in people who do them regularly, there are a lot of different techniques and approaches. “I inherit a lot of patients who had trabeculectomies 20 or 30 years ago, and I can appreciate that certain techniques end up with better outcomes than others. I can’t overemphasize how sad it is that most glaucoma-trained surgeons do not do trabeculectomies anymore.”
Source: Lucy Shen, MD
Dr. Shen agreed on the importance of teaching trabeculectomy and tube shunt surgery as well as revisions of trabeculectomies and tube surgeries in training. At her institution, she said there are many of these challenging glaucoma surgeries, so trainees have the opportunity to learn a lot. Furthermore, trainees work with several attendings at her institution and learn different approaches to trabeculectomies and tube surgeries.
Dr. Shen added that for trainees learning angle-based surgery, it’s important to get a good view while manipulating the goniolens and working with the dominant hand inserting a device or cutting trabecular meshwork.
In terms of which MIGS procedures to learn, Dr. Mosaed said that gonio surgery techniques are very similar, so it may make sense to focus on learning one procedure very well and adapt from there. “You have to understand how to get a good gonio view,” she said, adding that it’s important to also know how to be comfortable transitioning from phaco and directing your attention to the angle. “What I’ve found is even though we teach our trainees pretty much every MIGS approach there is, either implant-based or non-implant-based, many surgeons, once they get out into practice, pick one that they’re most comfortable with and stick with that.”
In Dr. Lee’s fellowship training, he said the existing MIGS options were the Trabectome
(MicroSurgical Technology), iStent (Glaukos), and ECP. “Most of the current MIGS options have been introduced subsequent to my training. By trial and error, I had to learn when and how to implement all of the new surgical options,” he said.
Dr. Lee’s criteria for considering a new procedure is: 1) it must make sense, 2) it must be safe, and 3) it must be reversible. “I think the last point on reversibility is an important factor that more surgeons should consider when contemplating a new technique,” he said. “It is inevitable we will face surgical complications. Think twice before jumping in if there is no easy way out.”
Dr. Lee has learned that maintaining patience and an unwavering presence of mind are paramount in reducing complications. “As a new surgeon, we may sense the scrutiny of the OR staff as they assess your skill. Unfortunately, your perceived competence as a surgeon is often linked to how quickly you can get through a case,” he said. “It’s important to resist the external and internal pressures that may tempt you to rush through a procedure. Always remain present and methodical with every step. You will encounter cases that will frustrate you from time to time. Do not betray your patients by trying to impress those around you. Play the long game; in time your skill as a surgeon will shine through if you focus on delivering consistently high-quality care.”
He added that complications that are highlighted in training are likely the ones that the training facility encounters the most. “Academic institutions, in general, will perform a higher proportion of filtering procedures and tube shunts, and thus trainees will be exposed to related complications more often,” he said. “These would likely be hypotony-related issues like flat chambers, choroidals, overfiltering blebs, leaks, etc. Visually significant MIGS complications such as cyclodialysis clefts, prolonged IOP rises, and recurrent reflux bleeding are uncommon, and one may go through their residency and fellowship without encountering them.” He added that these complications are often more distressing, as patients are often not adequately prepared for them. MIGS is often presented to patients as the “safer” option with an easier recovery. As glaucoma doctors, we spend a lot of our time contending with blindness at one end of the disease spectrum, he said. “This may cause us to underemphasize the risks of procedures in the ‘safer’ end of the spectrum and downplay the concerns and fears of a patient who is about to undergo them.”
An important lesson that Dr. Mosaed has learned is that there are some patients who will never be happy. “It has taken me 20 years to learn that lesson,” she said. Some patients can be extremely negative, and this can lead to a bad experience for the practice and surgeon. The single most important thing that determines the outcome of any case is the doctor-patient relationship. This is even more important than IOP, technique, and complication rates, she said. If you have a difficult, negative patient, almost no outcome will make them happy. Conversely, if you have a mutually respectful relationship with a patient and you have spent adequate time explaining things in detail, even if they require a revision or develop some unfortunate outcomes, they are likely to understand that you have done your best for them.
Dr. Mosaed said that it may be that a physician is not a good match for a particular patient. A lot of it comes down to personality and style. “A patient may not like my style, but they might like another doctor,” she said. For this reason, Dr. Mosaed said it’s important to know other doctors in the community. With her experience training residents and fellows in the Irvine area for 20 years, Dr. Mosaed said that more than 80% of her fellows have gone into practice in Orange County within a 10- to 15-mile radius. “If I’m going to send a patient out to one of my former fellows, I know they’re going to be well served,” she said. “It’s a mark of pride when you put out a well-trained fellow who will serve glaucoma patients for another 30 years.”
Dr. Mosaed said that even with her experience, she is still learning new skills. Last year, she decided to incorporate the Yamane technique into the fellowship training for the glaucoma fellows. “I don’t do Yamane well because I use it so infrequently. The opportunity to use it comes up every couple of years. You can’t get good at it if you’re doing it like that,” Dr. Mosaed said.
“I would have liked to know how to do a Yamane IOL or an efficient scleral-fixated IOL technique so as not to have a pit in my stomach every time I see the PXE material on the capsule at the start of the case,” she said. She partnered with a cornea doctor to give her glaucoma trainees the opportunity to go to the OR and train in Yamane cases. “Even though I think most glaucoma training programs say this isn’t the place or time to learn cataract techniques, I have to disagree with that because it’s such a big part of the glaucoma surgeon’s practice.” Dr. Mosaed added that she ensures that fellows are certified on femtosecond cataract surgery as well.
Dr. Shen added that “teaching fellows is not a one-way street.” For example, Dr. Shen said she learned ways to use the Malyugin ring from her fellows, as she had previously used mostly iris hooks in training.
In addition to learning surgical skills, Dr. Shen stressed the importance of learning how to have discussions with patients, and she will encourage her fellows to join her in the room when she discusses surgical complications or getting consent from patients.
The learning does not stop at the end of training, she said. “A lot of times when we finish fellowship, we think things are set in stone, and they’re certainly not.” Those people who continue to learn, adapt, modify, and question become better surgeons, she said. “When people finish fellowship and join a practice, they may feel the need to prove that they can be on their own, but the truth is that’s a good time to continue the learning and show vulnerability and reach out. We all have questions, and glaucoma is a very humbling field,” she said. “I did that, and I tell my fellows not to be shy. Feel free to ask questions. It’s a good culture that’s quite important in the glaucoma community.”
About the physicians
Daniel Lee, MD
Assistant Professor of Ophthalmology
Sidney Kimmel Medical College
Wills Eye Hospital
Philadelphia, Pennsylvania
Sameh Mosaed, MD
Professor of Ophthalmology
Glaucoma Fellowship Director
Gavin Herbert Eye Institute
University of California, Irvine
Irvine, California
Lucy Shen, MD
Glaucoma Fellowship Director
Mass Eye and Ear
Associate Professor of Ophthalmology
Harvard Medical School
Boston, Massachusetts
Relevant disclosures
Lee: Allergan, Glaukos,New World Medical, Nicox, Olleyes, Ocular Therapeutix, Santen
Mosaed: AbbVie, Alcon, Sight Sciences, Skye Bioscience
Shen: None
Contact
Lee: daniellee@willseye.org
Mosaed: smosaed@hs.uci.edu
Shen: Lucy_Shen@meei.harvard.edu
