Eyeworld

SEPTEMBER 2021 | EYEWORLD | 85 G Reference 1. Singh K, et al. Trabeculecto- my must survive! Ophthalmol Glaucoma. 2021;4:1–2. Relevant disclosures Herndon: None Hoguet: None Junk: None Singh: None cedures, there is a continued strong emphasis on learning trabeculectomy as well as drainage device implantation and mastering the perioper- ative care of those undergoing filtration surgery. Each surgeon has a different way of doing things and different procedures they like more than others, and this leads to greater collective departmental experience with all available options. "Our philosophy is that we want to do the best procedure for the patient," he said. This means working as a team and figuring out collectively which procedure makes sense, then figuring out who the best doctor is to do that particular procedure among the group of glau- coma specialists. "Given the explosion of new options, it is unlikely that any single glaucoma specialist can fully master every single glau- coma procedure," Dr. Singh said. He has been heartened to see that his patients are generally grateful when told that based on his knowledge, there is a recommended procedure for them that is best performed by one of his colleagues, and other patients are similarly appreciative when he takes on their care to perform a proce- dure at the request of one of his colleagues. Dr. Singh's advice to trainees is to learn as many different types of procedures as possible but also realize that they are part of a commu- nity. It is completely fine to ask a colleague with more experience with a particular procedure to help out and repay the favor by taking on cases that others ask them to do given their expertise. There are so many different options in the glaucoma surgical space now that MIGS has Kuldev Singh, MD, is director of the Glauco- ma Service at the Stanford University School of Medicine. "There are a lot of newer procedures that have been recently introduced and there are only a certain number of patients an individ- ual doctor can see," he said. "So, if they're doing more of one procedure, they're probably doing less of another." Dr. Singh stressed the impor- tance of not forgetting to train new surgeons in traditional procedures. He mentioned a piece that he coauthored 1 with Louis Pasquale, MD, and Mark Sherwood, MD, that touched on numbers from AUPO on trabeculectomy procedures being performed. Dr. Singh noted the decrease in the median num- ber of trabeculectomy and EX-PRESS Glauco- ma Filtration Device (Alcon) procedures from 2014–2015 compared to 2018–2019, and he noted that aqueous shunt procedures in those years were relatively stable while the number of primary surgeon ab interno angle procedures increased. Dr. Singh said what's being taught in train- ing is largely dependent on what the teaching surgeon is doing themselves. "That's just the nature of training," he said. Dr. Singh has been the director of the glau- coma fellowship at Stanford University since 1995, and he said the program currently has one 1-year clinical fellow and two 2-year com- bined clinical and research fellows at any given time. He said the program tries to tailor the fellowship to the trainee's clinical and academic interests, "but all of them get the same breadth and depth of clinical training over 1 or 2 years depending upon the path they have chosen." Dr. Singh said the introduction of new devices may impact training. If, for example, a new procedure is introduced that surgeons use for the types of patients who previously would have undergone trabeculectomy, surgeons may try this novel approach for a period of time. For that given year, those who are training may get substantial experience with the new procedure, which may or may not withstand the test of time, but this exposure will come at the expense of trabeculectomy training. Dr. Singh said he and his eight glaucoma colleagues at Stanford all have unique skills and practice patterns. While the department has embraced MIGS pro- continued on page 86 "Glaucoma patients are all unique, so the more clinical and surgical patients a trainee encounters, the more opportunities to learn." —Ambika Hoguet, MD Contact Herndon: leon.herndon@duke.edu Hoguet: ashoguet@eyeboston.com Junk: AJunk@med.miami.edu Singh: kuldev@yahoo.com

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