Eyeworld

JANUARY/FEBRUARY 2020 | EYEWORLD | 47 R Contact Flowers: Charles.Flowers@med.usc.edu Krueger: ronald.krueger@unmc.edu 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. Flow- ers said anyone who has completed an ophthal- mology 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 togeth- er 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 require- ments were established, it would require resi- dency 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 train- ing 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. 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 uncom- mon. But he said residents at the University of Southern California, where he serves as oph- thalmology residency program director, do a rotation with one of the nearby military centers to receive hands-on refractive surgery experi- ence 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 ulti- mately tells the patient) that they're going to be the primary surgeon and that you are going to supervise them throughout the whole pro- cedure, 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 proce- dure 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 estab- lish 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 Relevant disclosures Flowers: None Krueger: Alcon, Johnson & Johnson Vision, Bausch Health

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