January-February 2020


Yes Connect
Insights on young eye surgeons’ exposure to laser vision correction

by Liz Hillman Editorial Co-Director

The 2019 ASCRS Clinical Survey asked, “Given your training and/or other experience you have received thus far, how would you rate your confidence with laser vision correction?”
Source: ASCRS


In the 2019 ASCRS Clinical Survey, ophthalmologists in residency, fellowship, or their first 5 years of practice were asked to rate their comfort with and exposure to a number of surgical procedures. While Young Eye Surgeons (YES) members continue to report increasing confidence with toric and presbyopia-correcting intraocular lenses, there was a surprise in the survey. It revealed a new low—only one-third of U.S.-based YES members stated that they were confident performing laser vision correction or had personally performed LASIK, PRK or SMILE. With the perennial popularity of laser corneal refractive surgery, it is surprising that our U.S.-based residents have such little exposure in residency.  
Although many residents will not go on to perform refractive surgery in their careers, understanding the indications, safety, and technical aspects of laser vision correction procedures is a critical part of a comprehensive ophthalmic education. The 2019 ASCRS Clinical Survey results show that we are failing our residents in this aspect. Laser vision correction education should not be an optional part of residency, and we owe our residents a better experience. This month, we asked two academic refractive surgeons to share how they handle the integration of surgical refractive care in a teaching setting. Following their advice would be a start toward a better resident experience in corneal refractive surgery.

Julie Schallhorn, MD
YES Connect Co-Editor

Resident exposure to laser vision correction is a nuanced topic. Residents might wish for more hands-on training, but as an elective, out-of-pocket procedure, patients are more likely to choose a surgeon already in practice. There is also no standard among residency programs for how much exposure to laser vision correction—observed or hands-on—that residents receive.
As such, it’s not surprising to Charles
Flowers, MD, or Ronald Krueger, MD, that 38.8% of YES members who responded to the 2019 ASCRS Clinical Survey said they were confident or very confident with this type of refractive surgery. Non-U.S. YES respondents were more confident (45.8%) compared to their U.S. counterparts (33.3%). The majority of U.S. residents, fellows, and surgeons within their first 5 years of practice had only observed cases (33%).
“I think residency programs have not, historically, trained their residents in refractive surgery,” Dr. Krueger said. “Now there is an ACGME [Accreditation Council for Graduate Medical Education] mandate that every resident participate or see 10 cases in order to have their residency qualifications met.”
But is that enough?
“It’s still very minimal,” Dr. Krueger said.
According to Drs. Krueger and Flowers, residency training programs are not standardized across the board in how they expose residents to refractive surgery/laser vision correction. Programs are also figuring out how best to incorporate laser refractive surgery into training.
“Most of the older generation had the philosophy that you should never operate on a 20/20 eye. Someone correctable to 20/20 should be perfectly happy with glasses or contact lenses. That’s the old view of a generation or more ago,” Dr. Krueger said. “As things have progressed and refractive surgery has hit the mainstream of ophthalmology and has a significant involvement in many practices around the country, there is more realization that it is here to stay. There is still some of that old guard mentality in some residency programs, but most are becoming more progressive and saying that we need to make sure that our residents have training in this area.”
Most residency training, Dr. Flowers said, is done at Veterans Affairs and public hospitals, where elective, cash-pay procedures are uncommon. But he said residents at the University of Southern California, where he serves as ophthalmology residency program director, do a rotation with one of the nearby military centers to receive hands-on refractive surgery experience as well as a rotation with faculty members where they gain observational exposure.
Dr. Flowers is trying to develop an indigent patient refractive surgery teaching fund to allow residents to perform LASIK for free, charging only cost, he said.
Dr. Krueger, who recently became director of the Stanley M. Truhlsen Eye Institute at the University of Nebraska and was director of refractive surgery at the Cleveland Clinic for 20 years prior, said he allowed residents to perform refractive surgery under his guidance, provided they recruited the patient.
“You need to tell the resident (who ultimately tells the patient) that they’re going to be the primary surgeon and that you are going to supervise them throughout the whole procedure, and walk them through the workup, the surgical procedure, and the followup,” Dr. Krueger said. “I think this approach is the most successful, and the reason we did it that way is because refractive surgery is the kind of procedure that can only be done by one set of hands. Since the decision to do laser vision correction is personalized and elective, the surgeon needs to be the one who is talking to the patient. So if residents really want to learn refractive surgery, they first need to recruit the patient, then establish a relationship and basis of trust throughout the workup, surgery, and followup.”
Dr. Krueger said the resident-performed surgeries were to be viewed as subsidized and therefore offered at a cheaper rate to the patient. He said this approach was effective, however, not every resident pursued it.
“It’s not something that every community ophthalmologist has to be familiar with if that’s not going to be their future practice focus,” Dr. Krueger said. “If a graduating resident thinks a given patient should have LASIK or the patient expresses interest in refractive surgery, then because it’s elective, they can always recommend and send them to someone who does it.”
Even if a young ophthalmologist does not have significant hands-on experience, Dr. Flowers said anyone who has completed an ophthalmology training program in the U.S., if they are comfortable doing intraocular surgery, they are more than capable of doing refractive surgery. The preop workup and postop management for laser vision correction have steeper learning curves than the actual surgical procedures, Dr. Flowers said.
“That’s what you can garner, if you are working with faculty who are seeing these patients, you want to pay attention to how the faculty identify a candidate, how he puts together the surgical plan, and how he manages the patient through that process,” Dr. Flowers said.
If residents think they are not getting the exposure they want to refractive surgery, Dr. Krueger said they should make opportunities to visit, assist in research, and perform chart reviews with practicing physicians who offer laser vision correction. For those already in practice, Dr. Krueger suggested a fellowship or observership. Although he doesn’t think specific subspecialty training should be required to perform laser vision correction, he did advocate for standards that could help validate refractive surgery expertise.
In terms of ACGME requirements, both Drs. Flowers and Krueger said if new requirements were established, it would require residency programs to come up with a model that would allow residents to perform the surgery, which might be difficult for some programs. Dr. Krueger said because myopia is not a disease that must be surgically corrected, he thinks that certain aspects of laser vision correction training may not being required of all residents.
“Young eye surgeons offering refractive surgery need to be able to sell the procedure in order to get their patient to want to have the surgery done. What better way to start than as a resident. ... Finishing residency with a skillset of not only knowing how to do the surgery or how to pick a candidate but also knowing how to approach them and how to coach them through the procedure is the real skill to learn. There is a lot of art behind the presentation and execution of refractive surgery, and getting an early start in residency best equips one for future success,” Dr. Krueger said.

About the doctors

Charles Flowers Jr., MD
Associate professor of clinical ophthalmology
USC Roski Eye Institute
Keck School of Medicine
University of Southern California
Los Angeles, California

Ronald Krueger, MD
Stanley M. Truhlsen Eye Institute
University of Nebraska
Medical Center
Omaha, Nebraska

Relevant disclosures

: None
Krueger: Alcon, Johnson & Johnson Vision, Bausch Health


Flowers: Charles.Flowers@med.usc.edu
Krueger: ronald.krueger@unmc.edu

Insights on young eye surgeons’ exposure to laser vision correction Insights on young eye surgeons’ exposure to laser vision correction
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