The following transcript has been edited for clarity.

Shivani S. Kamat, MD: Hi everybody. Thank you so much for joining us today. My name is Shivani S. Kamat, MD, and we are here at the American Academy of Ophthalmology in New Orleans.

Mary Qiu, MD: I'm Mary Qiu, MD, and I’ve just co-moderated a session with Shivani Kamat at the Glaucoma Subspecialty Day, where we asked a series of fellowship directors to share their best surgical pearls. Here we have David Fleischman, MD, MS, the fellowship director from the University of North Carolina (UNC). David, would you like to share with us some of the pearls that you shared with the audience today?

David Fleischman, MD, MS: Sure. I had three general lessons that I wanted to get out of this. One was a limbic technique, a surgical technique that we use for trabeculectomies at UNC. And the first lesson that we get out of this is the importance of scar tissue formation and manipulation. So the tissue that is cut is going to scar most aggressively. We found that if we are able to intentionally control where Tenon's capsule lies against the sclera, we can have a nice posterior diffuse bleb, but still maintain a nice limbus-based surgery. Of course, you’d have to watch the video in order to make this make a little bit more sense. But the segue to this is what you are able to learn from doing something like this, which is you don't want to practice ophthalmology the same way that you did when you started your career and you want to continue to grow and learn. These things are very important.

I did note with our short-term data that it was not a perfect technique. Some of my patients still ended up getting wound leaks—less than my fornix-based technique, but still more than my limbus-based trab technique.

The last lesson then is that there are no secret weapons in ophthalmology and especially in glaucoma. There's usually a lot of hype over new devices. There's usually a lot of hype over new lenses and everything. And sometimes it works great and that's awesome. But a lot of times after 6 months, there's usually silence and then 6 months after that reality starts to set in. We need to have our eyes wide open and it needs to be bigger than our hearts when it comes to these things.

Dr. Kamat: I love that you talked about trabeculectomies. Basically your whole talk was about trabs and it’s a technique that, as we know as fellowship directors and just glaucoma specialists in general, that it's not necessarily being used in the same way that it used to be. And we have a lot of options now, like you mentioned, where we may not need to do the trabeculectomy initially the way we used to before, but I do think it's important that we teach our trainees the skill. How do you encourage trainees—your fellows—to continue doing it when they're on their own? Because when you're in the comfort of having your attending there, it's very different from doing the trab and managing it postoperatively on your own.

Dr. Fleischman: Right. I think the way to do it is to think of what is the purpose of the trab. The same way that a cataract surgery is to confront a cataract, a trabeculectomy is to confront a certain type of glaucoma. And I am all for MIGS. I am all for tubes. I am all for all of the different wonderful techniques that we have in glaucoma. But it turns out that a trabeculectomy is still a superior surgery for a type of glaucoma patient. And we in our field have become very good at matching the patient to the surgery or the surgery to the patient. We have a little bit less of these super-severe glaucomas that are being caught now because we're screening a little bit better. But when you get that patient with really advanced severe glaucoma, it is—by evidence and most studies—one of the best procedures. So you just have to do it and you just have to have the confidence that you'll know how to do it.

When you go through training, it is okay to reach out to your mentors and it’s okay to use videos and read magazines on how to do this stuff. I do that myself still before surgeries. Just have the confidence that you can keep on learning as you do the career. You have to provide that tool.

Dr. Qiu: Thank you so much for sharing all of your great pearls. I hope that everyone enjoyed the session in person or will tune in online to the webcast. And if any residents are out there and considering a career in glaucoma, please apply to our glaucoma fellowships! GP