An aging population with increasing prevalence of glaucoma combined with recent innovation in minimally invasive glaucoma surgery (MIGS) procedures have led to increased interest in glaucoma fellowships in recent years. According to SF Match, 101 fellowship positions were offered in 2021, compared to 79 positions in 2016.¹ Programs can be affiliated with academic departments or be established by private practices with a commitment to education. Here, Drs. Kamat and Provencher discuss how academic and private programs ensure their fellows are exposed to the latest technology.

Glaucoma Training in Academia: Dr. Kamat

The University of Texas Southwestern Medical Center in Dallas is among the largest ophthalmology training programs in the country; we have multiple sites and we train 2 glaucoma fellows a year. I recently accepted the roles of glaucoma service lead and director of the glaucoma fellowship at UT Southwestern and have been working to expand the training we offer our fellows to include the latest innovations in glaucoma surgery. I believe it is imperative for our trainees to gain substantial hands-on experience with a wide variety of techniques and devices that will enable them to care for their patients in their own practices after they graduate. I am extremely fortunate that my chair has been highly supportive in this mission and has directed resources toward our pursuit of this goal.

One of the biggest challenges facing glaucoma surgeons today is deciding which of a myriad of surgical options is the best choice for a patient needing intervention. For example, patients with mild disease, who may have a primary goal of relieving their medication burden, may be suited for an iStent (Glaukos) in combination with cataract surgery, or the newer iStent Infinite procedure, where 3 stents can be placed independent of cataract extraction. For mild-to-moderate disease, I favor options like Hydrus (Alcon) which spans a greater amount of the Schlemm’s canal and may offer more IOP-lowering capability. With more advanced disease, other great options include gonioscopy-assisted transluminal trabeculotomy and the Kahook Dual Blade (New World Medical), which may create even more outflow capacity. Patients with severe disease may benefit more from a Xen gel stent (Allergan/AbbVie) or be best served by more traditional interventions like a trabeculectomy or tube shunt.

In general, glaucoma surgeries fall into 2 categories: procedures that enhance the patient’s existing drainage system or procedures that create a new drainage system altogether. Most available MIGS procedures fall into the first category and therefore are best suited for patients who still have relatively milder disease with more intact downstream outflow. Patients with more severe disease often have such high levels of outflow compromise that they need a new drain entirely, requiring procedures from the second category such as traditional filtering surgeries. Naturally, fellows need to be exposed to a wide variety of glaucoma pathology and severity so they can grasp the nuances of preoperative decision-making.

Fellows also need to learn how to maintain a long-term perspective and appropriately counsel patients, because glaucoma is a chronic disease. I spend significant time teaching fellows that these options for intervention represent a total toolkit for addressing various stages of disease that the patient may reach in their lifetime. Even if a less invasive surgery becomes insufficient to prevent progression of glaucoma, that doesn’t mean we have failed the patient, because it worked for a particular stage of their disease. We simply need to move on to the next level of treatment for their individual situation.

MIGS is no longer a new concept, and the devices are constantly evolving. However, the fundamental principles and skill set remain the same: fellows must become facile working in the angle and using intraoperative gonioscopy effectively. I like to have trainees hone their intraoperative gonioscopy skills during a cataract procedure, for example, using the cannula to gently touch the trabecular meshwork to practice the motion. Mastering intraoperative gonioscopy and working with both hands simultaneously is half the battle. These key skills can be applied to each new device, helping to reduce the learning curve. I have found industry surgical representatives to be a helpful resource in adopting new techniques, and our fellows have found their wet labs, practice model eyes, and other training material to be valuable adjuncts to hands-on experience in the operating room (see sidebar). In addition, building these relationships during training creates a path to greater access to these representatives once fellows begin to practice on their own.

Glaucoma specialists are in high demand, and the need for well-trained surgeons will only continue to grow. I am hopeful that trainees will remain intrigued and excited by new innovations that keep our field stimulating and rewarding, as the need is great. I always stress to my fellows that these patients are your responsibility for the long haul. While they will experience both victories and setbacks along their journeys, your commitment to them must never waver. It is both a tremendous responsibility and privilege to guide these patients through such a chronic and relentless vision-threatening disease.

Glaucoma Training in Private Practice: Dr. Provencher

At our large private practice, we have several attending glaucoma specialists. Our fellows rotate through various “blocks” with different surgeons, gaining a wealth of hands-on experience while still having enough one-on-one time to take a deep dive into how each attending practices. We find that many starting fellows have great cataract surgery skills but are less experienced with MIGS or angle-based surgeries and are seldom proficient with more traditional incisional glaucoma surgeries. As the field expands, there is more and more to learn. Fellowships are becoming crucial and are certainly in high demand.

When it comes to teaching angle-based surgery, most of us take a stepwise approach. Before the fellows ever step into the operating room, I encourage them to perform gonioscopy on nearly every patient in clinic. They should get as familiar with angle anatomy as possible. I highly recommend the website gonioscopy.org, managed by Dr. Wallace Alward of the University of Iowa’s Carver College of Medicine. At the time of cataract surgery, we can introduce angle surgery by positioning the patient for gonioscopy and having the trainee use a blunt instrument to maneuver in the angle and get used to working in the space. This is a safe way to introduce what is the most challenging part of angle surgery: understanding the anatomy and getting a good view. Practicing with the gonioscopy lens and both hands, as Dr. Kamat noted, is paramount.

In preparation for their first MIGS cases, trainees can review online videos, which are available for nearly every MIGS procedure. When it comes to trying individual devices, we help the fellows to set up wet labs with the company representatives. They will have model eyes designed for each specific MIGS device that trainees can use under the microscope to do a stenting, dilating, or cutting procedure. Once trainees have met these objectives and have directly observed the attending performing the procedure, they perform the MIGS procedure on a real patient, under close guidance with an attending surgeon.

Industry is invested in physicians getting comfortable with the different procedures; therefore, they typically have the appropriate models and training methods applicable to their specific device. When it comes to adopting new technologies after residency, these industry relationships become extremely important. This is also part of what I do myself when I’m learning a new procedure. As Dr. Kamat mentioned, it can be a challenge to then learn which MIGS is appropriate. This undoubtably takes mentorship and time in the clinic to hone, but the Association of University Professors of Ophthalmology is currently working on a more comprehensive MIGS curriculum to flatten this learning curve.

When it comes to teaching more traditional filtering-type surgeries like a drainage device, trabeculectomy, or even a less invasive filtering option like Xen, model eyes are available for trainees to practice making scleral flaps or tunneling tubes. Scleral dissection is a more technically challenging surgery; therefore, models or cadaver eyes can be helpful. Improving suturing skills is an important part of fellowship as well. This can be done with cadaver eyes, but splitting a case with a fellow and allowing them to close can also provide extra experience, even though the fellow is not performing the entire surgery.

Training in a private practice may allow new physicians quicker access to new devices due to less bureaucracy. Understandably, there are barriers in academia when it comes to working with industry, which is meant to mitigate conflict and bias. Private practice training might not have as much structure or academic rigor, but there is typically more exposure to early technology and trainees learn how to learn outside of an academic setting.

Although there are minimum requirements that fellows and residents must meet, these benchmarks tend to lag behind technology. Without exposure to attendings who do various procedures, trainees can have gaps in their knowledge when they leave fellowship. I encourage trainees to identify what those gaps are and talk to their mentors to arrange learning opportunities. Whether it is setting up wet labs or gaining exposure at meetings, these learning habits are important to staying up to date in a rapidly evolving field. GP

Shivani S. Kamat, MD, is an assistant professor of ophthalmology, glaucoma service lead, and director of the glaucoma fellowship at the University of Texas Southwestern Medical Center in Dallas, Texas. She reports no relevant disclosures. Reach her at Shivani.Kamat@utsouthwestern.edu.

Lorraine M. Provencher, MD, is a glaucoma specialist at Cincinnati Eye Institute in Ohio She reports no relevant disclosures. Reach Dr. Provencher at lprovencher@cvphealth.com

Reference

1. Association of University Professors of Ophthalmology. Ophthalmology fellowship match statistics & demographics Dec 2021. March 20, 2022. Accessed June 21, 2023. https://aupo.org/news/2022-03/ophthalmology-fellowship-match-statistics-demographics-dec-2021