March 2019


YES connect
ASCRS Clinical Survey results highlight key issues for young physicians

by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor

The survey asked, “During your training, how many manual corneal relaxing incisions have you performed (AK, LRI/PCRI)?” 1–3 years in training: 67% have not performed any; fellow: 29% have not performed any; <5 years in practice: 34% have not performed any

The survey asked, “How confident are you in the postoperative management of an unhappy toric IOL patient?” 1–3 years of training: 21% Very Confident or Confident; fellow: 36%;
<5 years in practice: 55%

The survey asked, “How confident are you in the postoperative management of an unhappy presbyopia-correcting IOL patient?” 1–3 years in training: 19% Very Confident or Confident; fellow: 32%; <5 years in practice: 37%
Source (all): ASCRS Clinical Survey

The 2018 ASCRS Clinical Survey addressed the experiences of young eye surgeons with refractive cataract surgery. The results are separated by trainees in years 1–3 of training, fellows, and physicians in practice for less than 5 years. Topics included corneal relaxing incisions, toric lens implantation, and managing the unhappy premium IOL patient.
In this month’s “YES connect” column, Zachary Zavodni, MD, Samuel Lee, MD, and Joan Kim, MD, review some of the results from the 2018 ASCRS Clinical Survey, which showed a lack of experience for many trainees and young physicians, leading to a lack of confidence in managing unhappy patients. Lenses are rapidly developing and changing, so the physicians in practice and those teaching current trainees may have experience with prior generations of lenses, leading to more complaints and making them hesitant to try the newer options. It is important for trainees and young surgeons to be able to work with teachers who can expose them to these technologies so that they can learn the advantages and pitfalls. This will help them develop the confidence to use these technologies in their patients. It will also expose them to the unhappy patient in a setting where they can learn how others deal with the issues that come up.

David Crandall, MD,
YES connect co-editor

Several data points in the 2018 survey identify young physicians’ experiences with corneal relaxing incisions, toric IOLs, and other lenses

The 2018 ASCRS Clinical Survey included a number of data points relating specifically to young physicians, including those in their first 1–3 years of training, fellows, and those in practice less than 5 years. Zachary Zavodni, MD, Salt Lake City, Joan Kim, MD, Skokie, Illinois, and Samuel Lee, MD, Sacramento, California, commented on some of the data related to experience with corneal relaxing incisions and lenses such as torics, multifocals, and EDOFs.

Corneal relaxing incisions in training

About one-third of fellows and those who have been in practice less than 5 years indicated that they did not perform manual corneal relaxing incisions in training (and 67% of those in years 1–3 of training have not).
Dr. Lee finds these results interesting and said that he thinks this is a significant number of physicians who are not performing corneal relaxing incisions. At his practice, Dr. Lee uses manual or laser-assisted relaxing incisions in about 40% of his cases. “It’s standard of care in my mind to do something to address the corneal astigmatism,” he said.
Dr. Zavodni said he finds it surprising that roughly a third of young surgeons have not performed corneal relaxing incisions. “Aside from being technically easy and low risk, LRI/AKs are an essential technique for any refractive cataract surgeon managing low amounts of regular astigmatism,” he said. “These data suggest to me that there are still a minority of providers who are not greatly concerned with the refractive outcome of their surgery.”
Dr. Kim thinks this is less surprising because in her experience, although she did learn how to create manual limbal relaxing incisions, she doesn’t find herself using them very often. “I don’t think this is an issue, though, because most visually significant astigmatism can be corrected with a toric IOL,” she said.

Toric IOL implantation

Based on the survey data relating to toric IOLs, 46% of physicians with 1–3 years of training have not performed toric IOL implantation (with the average of this group being nine toric cases). Meanwhile, 21% of fellows have not performed toric implantation (with the average of 17 cases), and 7% of those in practice less than 5 years have not performed toric implantation (though the average number of toric cases in this group is 32).
At first glance, the toric IOL data seem fairly reasonable, Dr. Zavodni said. “More than 90% of providers in their first 5 years of practice have used toric lenses, and more than 90% of these same providers are either ‘confident’ or ‘very confident’ in preop and implantation techniques,” he said.
He added that though the resident group may be lacking in confidence with toric IOLs, this metric improves greatly once surgeons gain early experience.
Dr. Lee said that in his practice, about 20% of his cataract surgeries include toric lenses. “If you’re exposed to this technology, it’s easy to pick up and can be used for a large percentage of patients,” he said.
Additional survey data identifies young physicians’ experience with multifocal and EDOF IOLs. For those with 1–3 years of training, 75% had not performed surgery with these types of lenses (with an average of one case performed); in the fellow group, 36% had not performed surgery with multifocal/EDOF lenses (with an average of eight cases); and for those young physicians in practice less than 5 years, 29% had not performed any of these cases (with an average of 17 cases).
Dr. Zavodni said that he is not surprised by the overall use of multifocal and EDOF lenses. “About a third of young surgeons in the first 5 years of practice are not using these lenses,” he said. “I think this is in large part because most surgeons in this demographic were training during a time when high-add multifocals were leading to a large number of patient complaints.”
He added that there has been a recent shift to low-add multifocals and EDOFs, which result in overall higher patient satisfaction. “I think surgeon use of these lenses will consequently expand slowly with time,” he said. “Residents in training today are seeing a higher percentage of happy multifocal patients in their attending clinics, and I expect that will lead to higher adoption rates moving forward.”
Dr. Kim said that training is a great time to start using this technology since the attending surgeon can help guide decision making and avoid any pitfalls. “In addition, companies are willing to provide free trial lenses for patients so that residents and fellows can become more confident using this technology,” she said.
“It takes more time, thought, and energy during preoperative and intraoperative planning, though, which might also contribute to the lower rates of implantation,” Dr. Kim said, adding that she finds that residents and fellows can be so consumed with getting their surgical volume that they don’t take the time to consider the potential benefits from offering these other options.

Unhappy patients

When asked about confidence in managing unhappy patients (toric and presbyopia-correcting IOL patients), the majority of respondents in the three groups (physicians with 1–3 years of training, fellows, and those in practice less than 5 years) seemed to be neutral or unconfident in their abilities. For physicians in practice less than 5 years, 55% were confident or very confident with managing the unhappy toric IOL patient, but the percentage of confidence in the other groups fell below 40%, as did confidence in handling the unhappy presbyopia-correcting IOL patient in all three groups.
Dr. Zavodni said that he found this data most concerning. “Only 55% and 37% of providers were confident in managing unhappy toric and presbyopia-correcting lens patients, respectively,” he said, adding that he thinks this would be a good area of focus in educational programming.
“The two biggest challenges facing the premium IOL cataract surgeon are managing residual postoperative refractive error and aligning patient expectations with clinical outcomes,” Dr. Zavodni said.
He added that it’s difficult to manage the unhappy premium IOL patient whose expectations are not met. “With regard to something as simple as residual refractive error, I suspect that part of the poor confidence in young surgeons stems from the fact that not all refractive cataract surgeons are well versed in corneal excimer ablation surgery,” he said. “We should do a better job of training our non-LASIK surgeons about excimer candidacy, as that will allow the young cataract surgeon to be more confident in recommending corneal ablation as a backup plan for unhappy patients.”
Additionally, Dr. Zavodni said there are newer technologies that can be used to help cataract surgeons nail their refractive outcomes, including intraoperative aberrometry and postop IOL modifications.
Dr. Lee finds that a majority of people who have a successful toric or presbyopia-correcting IOL are happy, so dealing with complications may be rare. But it could be infrequent enough that physicians may not get enough experience managing such patients, he said. Since patients may be unhappy for a variety of reasons, Dr. Lee said actions like managing dry eye/ocular surface issues, making sure the measurements are accurate, and knowing how to do laser refractive surgery enhancement can all be important.
In addressing the need to manage patients postoperatively, Dr. Kim stressed that “prevention is key.” Preparing for every potential outcome and correcting for that prior to surgery is essential and worth taking the extra time to help prevent postoperative issues, she said.
To build confidence, she recommended choosing straightforward cases. Dr. Kim also said to make sure patients are out of contact lenses for a period of time prior to measurements and to use multiple methods to confirm the axis and amount of astigmatism.
“Optimization of the ocular surface cannot be stressed enough,” she said. For torics, consider the type of lens material, as some studies have shown a higher rate of rotation with one type over others. She also suggested getting a macula OCT to rule out any subtle retinal pathology that may contribute to symptoms postoperatively.

Editors’ note: Drs. Kim, Lee, and Zavodni have no financial interests related to their comments.

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ASCRS Clinical Survey results highlight key issues for young physicians ASCRS Clinical Survey results highlight key issues for young physicians
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