Glaucoma
September 2021
by Ellen Stodola
Editorial Co-Director
When it comes to training, there are many techniques for future glaucoma surgeons to learn. In addition to traditional surgeries like trabeculectomies and tube shunts, there are MIGS procedures and other newer technologies. Ophthalmologists working in different training programs around the country commented on how they approach the surgical training experience and which procedures are included.
Ambika Hoguet, MD, said that even when updates happen and new technologies come to market, the focus of a glaucoma fellowship remains the same: clinical diagnosis, medical management, laser management when needed, surgical decision-making (when to proceed with surgery and which surgery to perform), surgical skills, and postoperative care. Dr. Hoguet works with a glaucoma training program at Ophthalmic Consultants of Boston/Tufts/New England Eye Center.
“The new devices add to our clinical decision-making,” she said. This involves examples of when to choose one MIGS device over another. “We think it is important to include the trainees in this discussion,” she said.
Dr. Hoguet said her program has the benefit of a large faculty who perform a diverse array of glaucoma procedures. “By making sure the trainees get to spend time with each faculty member, they are naturally exposed to the new techniques and devices available to us,” she said.
Even with the variety of newer options, Dr. Hoguet said traditional surgeries are still emphasized. “A good glaucoma specialist needs to be very comfortable with these procedures,” she said. “Many of our patients need intraocular pressures that are lower than what MIGS can deliver or they do not qualify for MIGS.” This is why it’s important to make sure fellows understand the clinical decision-making behind choosing a trabeculectomy or tube (or alternative surgery) and are comfortable with the surgery itself and all postoperative care, she said.
“Glaucoma patients are all unique, so the more clinical and surgical patients a trainee encounters, the more opportunities to learn.”
Ambika Hoguet, MD
When it comes to MIGS procedures, rather than focus on specific devices, Dr. Hoguet said her program makes sure trainees are comfortable working in the angle. “Once they are, most of the MIGS procedures can be performed with ease,” she said. “That being said, we have the benefit of a large faculty and are able to give them firsthand surgical exposure to most of the newer MIGS devices.”
In addition to surgical exposure, Dr. Hoguet highlighted important non-surgical skills that glaucoma trainees learn. Diagnostic testing is important, she said, especially newer testing modalities that are not yet widely used, like corneal hysteresis and ganglion cell analysis. She added that teaching trainees to think critically, such as with journal clubs and clinical conferences, is another important focus.
Dr. Hoguet said the location of a training program may have an impact on what is taught. “Location can be important, as the patient population a clinic serves ultimately affects the disease severity and can dictate what procedures we choose,” she said, adding that many of the MIGS procedures have coverage limitations for specific insurance companies. “A busy program is the most likely to give the most exposure,” Dr. Hoguet said. “Glaucoma patients are all unique, so the more clinical and surgical patients a trainee encounters, the more opportunities to learn.”
Anna Junk, MD, works with a group of 12 glaucoma specialists at Bascom Palmer Eye Institute. “Everyone has a slightly different practice and different surgical preference,” she said. “Fellows get exposure to all the different MIGS on the market as they rotate. Traditional procedures including cataract extraction, trabeculectomy, tubes, CPC, and goniotomies are still the majority of procedures in our program.”
She noted that there is not a specific mandate from the Association of University Professors of Ophthalmology (AUPO) on the number of MIGS procedures that needs to be taught, but her program uses frequent wet labs as a training tool for fellows learning new procedures.
Dr. Junk thinks MIGS has been a major factor to attract residents to the glaucoma field and has become an important additional treatment modality for glaucoma specialists.
Dr. Junk noted other non-surgical skills that are covered in training: clinical skills, peer review, manuscript preparation, and clinical research.
Kuldev Singh, MD, is director of the Glaucoma Service at the Stanford University School of Medicine. “There are a lot of newer procedures that have been recently introduced and there are only a certain number of patients an individual doctor can see,” he said. “So, if they’re doing more of one procedure, they’re probably doing less of another.” Dr. Singh stressed the importance of not forgetting to train new surgeons in traditional procedures.
He mentioned a piece that he coauthored1 with Louis Pasquale, MD, and Mark Sherwood, MD, that touched on numbers from AUPO on trabeculectomy procedures being performed. Dr. Singh noted the decrease in the median number of trabeculectomy and EX-PRESS Glaucoma Filtration Device (Alcon) procedures from 2014–2015 compared to 2018–2019, and he noted that aqueous shunt procedures in those years were relatively stable while the number of primary surgeon ab interno angle procedures increased.
Dr. Singh said what’s being taught in training is largely dependent on what the teaching surgeon is doing themselves. “That’s just the nature of training,” he said.
Dr. Singh has been the director of the glaucoma fellowship at Stanford University since 1995, and he said the program currently has one 1-year clinical fellow and two 2-year combined clinical and research fellows at any given time. He said the program tries to tailor the fellowship to the trainee’s clinical and academic interests, “but all of them get the same breadth and depth of clinical training over 1 or 2 years depending upon the path they have chosen.”
Dr. Singh said the introduction of new devices may impact training. If, for example, a new procedure is introduced that surgeons use for the types of patients who previously would have undergone trabeculectomy, surgeons may try this novel approach for a period of time. For that given year, those who are training may get substantial experience with the new procedure, which may or may not withstand the test of time, but this exposure will come at the expense of trabeculectomy training. Dr. Singh said he and his eight glaucoma colleagues at Stanford all have unique skills and practice patterns. While the department has embraced MIGS procedures, there is a continued strong emphasis on learning trabeculectomy as well as drainage device implantation and mastering the perioperative care of those undergoing filtration surgery. Each surgeon has a different way of doing things and different procedures they like more than others, and this leads to greater collective departmental experience with all available options. “Our philosophy is that we want to do the best procedure for the patient,” he said. This means working as a team and figuring out collectively which procedure makes sense, then figuring out who the best doctor is to do that particular procedure among the group of glaucoma specialists. “Given the explosion of new options, it is unlikely that any single glaucoma specialist can fully master every single glaucoma procedure,” Dr. Singh said. He has been heartened to see that his patients are generally grateful when told that based on his knowledge, there is a recommended procedure for them that is best performed by one of his colleagues, and other patients are similarly appreciative when he takes on their care to perform a procedure at the request of one of his colleagues.
Dr. Singh’s advice to trainees is to learn as many different types of procedures as possible but also realize that they are part of a community. It is completely fine to ask a colleague with more experience with a particular procedure to help out and repay the favor by taking on cases that others ask them to do given their expertise.
There are so many different options in the glaucoma surgical space now that MIGS has become popular, said Leon Herndon, MD, but he agreed that it’s important not to lose sight of traditional glaucoma surgeries. At the teaching program at Duke University, Dr. Herndon said there is a nice balance between traditional surgeries and MIGS.
When making the decision on which surgery to perform, Dr. Herndon said he tries to help trainees risk stratify which patients would be good candidates for MIGS and which are more severe and therefore candidates for the more traditional approach.
With the COVID-19 pandemic, surgeries were limited, and a lot of trainees were not getting surgical experience, Dr. Herndon said. In order to continue to teach traditional surgery, an educational series at Duke University focused on trabeculectomy and tubes. Several webinars went into detail on the history and basics of the procedures, as well as complications that can occur. Dr. Herndon noted that this was a successful training approach and had good representation, even incorporating some of the fellows into the presentations.
Overall, Dr. Herndon said glaucoma specialists are typically fairly conservative when it comes to adopting new technologies. Some may be slower to convert to new procedures and want to see more data. The Duke University program has 16 fellowship-trained glaucoma specialists, which offers a mix of those performing MIGS and those more focused on traditional procedures. Dr. Herndon noted that he has experience in many of the MIGS procedures available. “I think it’s important, and I think our fellows are looking for opportunities to make up their minds for themselves on which of these MIGS will work in their practices when they get out [of training].”
About the physicians
Leon Herndon Jr., MD
Chief of Glaucoma
Duke Eye Center
Duke University
Durham, North Carolina
Ambika Hoguet, MD
Ophthalmic Consultants of Boston
Boston, Massachusetts
Anna Junk, MD
Professor of Ophthalmology
Bascom Palmer Eye Institute
University of Miami Miller School of Medicine
Miami, Florida
Kuldev Singh, MD
Professor of Ophthalmology
Director of the Glaucoma Service
Stanford University Medical Center
Palo Alto, California
Reference
- Singh K, et al. Trabeculectomy must survive! Ophthalmol Glaucoma. 2021;4:1–2.
Relevant disclosures
Herndon: None
Hoguet: None
Junk: None
Singh: None
Contact
Herndon: leon.herndon@duke.edu
Hoguet: ashoguet@eyeboston.com
Junk: AJunk@med.miami.edu
Singh: kuldev@yahoo.com
