Glaucoma: I wish I had …
Summer 2024

by Ellen Stodola
Editorial Co-Director

Recent changes to training for residents in ophthalmology by the Accreditation Council for Graduate Medical Education (ACGME) have seen the addition of a requirement for trainees to perform five MIGS procedures as the primary surgeon. Meanwhile, requirements for tube shunts and trabeculectomy remain in place, but those in training can be the surgeon or assistant on five procedures to meet this requirement. Several surgeons weighed in on these changes, with a general consensus that it was time to account for these MIGS procedures and techniques in training requirements. 

Jessie Wang, MD, who recently completed her residency training at the University of Chicago, has plans to specialize in glaucoma and will be starting her fellowship at the Duke Eye Center shortly. Dr. Wang said that she was fortunate in training to gain experience with both MIGS and tube shunts. “The guidelines are changing to require MIGS, but you can just assist on tubes, and I think for most people it’s a positive change,” she said. “Many residents going into practice are doing comprehensive or another anterior segment specialty where they’ll be doing cataract surgery. I think it’s helpful for them to also have the skillset to perform angle-based surgeries, especially for parts of the country where access to a glaucoma surgeon might be limited.”

Even for those planning to go into glaucoma, Dr. Wang sees this change as positive because these surgeons will be getting more training in their chosen specialty. “Just because the requirement changed, it didn’t stop me from doing both,” she said. 

“Different surgeries can be introduced at different time points, depending on the clinical presentation and patient goals. In general, MIGS procedures can be introduced at earlier time points and can work better when you introduce them earlier in the disease. And for patients who need a tube or trab, they will probably eventually still need them at some point,” she said, adding that she doesn’t think MIGS makes tubes or trabs obsolete.

Dr. Wang gained experience with a variety of MIGS procedures during her residency, noting that she’s performed goniotomies the most. “I’m happy with the exposure I’ve gotten in my training thus far. We do a good number of lasers, phacos, MIGS, and tubes, and I’m looking forward to continuing those skills and to learning how to do trabs in fellowship,” she said. 

Arsham Sheybani, MD, also sees these changes to the ACGME requirements as a positive step. Though MIGS has been around for a while, it sometimes takes time for training programs to implement changes because they want to see if the surgery is going to have staying power. 

He noted that it’s important to be teaching the angle procedures to surgeons in training. He added that there’s value in having device representatives to explain the nuances of different products, but when you’re starting out, “to learn angle surgery, I think it should be taught surgeon to surgeon,” he said. 

Residency should be about teaching physicians to be the best comprehensive ophthalmologist, handling the bread and butter of almost everything, Dr. Sheybani said. It’s important to have experience, and it may be important to know how to do a tube.

Previously, a lot of physicians were learning angle surgery through device representatives, he said, and it was specific to each device. If there’s a MIGS minimum, the attending surgeon can teach angle procedures however they feel most comfortable teaching, and if there’s a specific device issue down the line, the rep would be helpful, he said. Dr. Sheybani noted the nuances of angle surgery, like when to treat the patient and with what procedure, ocular and systemic factors to consider, how to set up the scope, how to set up the visualization, the goniotomy, where to make the incision, and how to manage issues postoperatively. These are all important factors in the surgical process, and it’s important to take the time to ensure the surgeon knows what they’re doing and why. This is where faculty experienced in MIGS can provide more value than industry representatives who will be well versed on their specific product. 

“Since you need basic ophthalmic surgical skills to transfer into MIGS, there’s a basic skillset that, if you have it, it helps you with the variety of MIGS, so it’s important to have that foundation. But it doesn’t always mean that if you can do one, you can do them all. They all have their own learning curve,” Dr. Sheybani said.  

Dr. Sheybani said that there are patients and disease stages where performing angle surgery would carry an advantage over subconjunctival filtration surgery and vice versa. “The whole goal is to have a working knowledge of how to do a subconjunctival surgery, and it might be something where you’ll never do it again, but if you did it a couple of times in residency and you have a postop come in, you know what the normal should look like and what the tubes should look like.” Doing or observing five of those is good down the line even if you don’t ever do the surgery because there will be patients having these surgeries who will come to see you, he reiterated. 

Michael Boland, MD, PhD, and others worked on a paper published in 2021¹ proposing a different way to think about how glaucoma procedures were being logged because “that had not kept up with updates in glaucoma surgeries.” We’ve had multiple publications showing that a lot of MIGS are being done by non-glaucoma specialists, so it makes sense to have that as a skill for comprehensive ophthalmologists, Dr. Boland said. 

Dr. Boland said there will always be complaints among the specialties that residents don’t have enough training in specific areas. Another debate is as more people do fellowships, there’s been an expectation of, “We don’t have to do that training during residency because they’ll get that in fellowship.”

Dr. Boland’s paper proposed several categories of glaucoma procedures. “MIGS is a grab bag of procedures that are sometimes unrelated,” he said. The paper proposed glaucoma surgery ab externo for procedures like trabeculectomy and traditional tubes, which involve some manipulation of the conjunctiva and the sclera when you’re making a flap or tunnel. Those are core surgical techniques that are useful for anyone going into practice, he said. Then there is the ab interno category. That’s where most MIGS procedures fall, but the concept you want to make sure people understand is operating with a gonioprism, identifying structures in the angle, etc. Then there are other techniques left over like cyclodestruction, laser trabeculoplasty, and laser iridotomy. “But it was ab externo and ab interno that were the major categories of skills we’d want residents to have coming out of training.” He added that he thinks more about what skills and techniques those coming out of training should have rather than the specific procedures themselves.

Dr. Boland said that while it seems unlikely that the average comprehensive ophthalmologist is going to be doing trabeculectomy and tubes, the skills required for these surgeries are still important. That could be important for managing complications in other surgeries, open globe repairs, future procedures, etc. “Leaving those traditional glaucoma surgeries out I think leaves the trainees with fewer skills they can use to become better surgeons later,” he said. “You’re also wasting that first part of fellowship having to start from scratch on some of these procedures. I don’t know if that’s a big trade-off or not, but you’d rather have more skills coming in.”

In terms of updates to training that he wishes to see in the future, Dr. Sheybani said, “At some point, we’re going to have to consider drug delivery as a whole and not just in glaucoma.” This could span more than just retinal intravitreal injections. 

He also noted a decrease in laser iridotomies around the country. There is a requirement in training to perform four laser iridotomies as the surgeon. If the number of these procedures continues to trend down, it might make sense to relax this requirement to only having done one but having observed two or three, Dr. Sheybani said. “Other than that, from a teaching perspective, I don’t think there’s anything that has to be added that’s not there yet,” he said. “MIGS was just a big missing portion.” 

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About the physicians

Michael Boland, MD, PhD
Associate Professor of Ophthalmology
Mass Eye and Ear 
Harvard Medical School
Boston, Massachusetts

Arsham Sheybani, MD
Associate Professor of Ophthalmology and Visual Sciences
Washington University School of Medicine in St. Louis
St. Louis, Missouri

Jessie Wang, MD
Glaucoma Fellow
Duke Eye Center
Durham, North Carolina 

Reference

1. Qiu M, et al. Microinvasive glaucoma surgery in US ophthalmology residency: surgical case log cross-sectional analysis and proposal for new glaucoma procedure classification. J Glaucoma. 2021;30:621–628.

Relevant disclosures

Boland: None
Sheybani: AbbVie, Alcon, Glaukos, Nova Eye
Wang: None

Contact 

Boland: Michael_Boland@meei.harvard.edu
Sheybani: sheybaniar@wustl.edu
Wang: jessie.wang@duke.edu