Eyeworld

84 | EYEWORLD | SEPTEMBER 2021 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Leon Herndon Jr., MD Chief of Glaucoma Duke Eye Center Duke University Durham, North Carolina Ambika Hoguet, MD Ophthalmic Consultants of Boston Boston, Massachusetts Anna Junk, MD Professor of Ophthalmology Bascom Palmer Eye Institute University of Miami Miller School of Medicine Miami, Florida Kuldev Singh, MD Professor of Ophthalmology Director of the Glaucoma Service Stanford University Medical Center Palo Alto, California of the MIGS procedures can be performed with ease," she said. "That being said, we have the benefit of a large faculty and are able to give them firsthand surgical exposure to most of the newer MIGS devices." In addition to surgical exposure, Dr. Hoguet highlighted important non-surgical skills that glaucoma trainees learn. Diagnostic testing is important, she said, especially newer testing modalities that are not yet widely used, like cor- neal hysteresis and ganglion cell analysis. She added that teaching trainees to think critically, such as with journal clubs and clinical confer- ences, is another important focus. Dr. Hoguet said the location of a training program may have an impact on what is taught. "Location can be important, as the patient pop- ulation a clinic serves ultimately affects the dis- ease severity and can dictate what procedures we choose," she said, adding that many of the MIGS procedures have coverage limitations for specific insurance companies. "A busy program is the most likely to give the most exposure," Dr. Hoguet said. "Glaucoma patients are all unique, so the more clinical and surgical patients a trainee encounters, the more opportunities to learn." Anna Junk, MD, works with a group of 12 glaucoma specialists at Bascom Palmer Eye Institute. "Everyone has a slightly different practice and different surgical preference," she said. "Fellows get exposure to all the different MIGS on the market as they rotate. Traditional procedures including cataract extraction, trabe- culectomy, tubes, CPC, and goniotomies are still the majority of procedures in our program." She noted that there is not a specific man- date from the Association of University Profes- sors of Ophthalmology (AUPO) on the number of MIGS procedures that needs to be taught, but her program uses frequent wet labs as a training tool for fellows learning new procedures. Dr. Junk thinks MIGS has been a major fac- tor to attract residents to the glaucoma field and has become an important additional treatment modality for glaucoma specialists. Dr. Junk noted other non-surgical skills that are covered in training: clinical skills, peer review, manuscript preparation, and clinical research. What's currently taught in glaucoma training programs? W hen it comes to training, there are many techniques for future glaucoma surgeons to learn. In addition to traditional surgeries like trabeculectomies and tube shunts, there are MIGS procedures and other newer technologies. Ophthalmologists work- ing in different training programs around the country commented on how they approach the surgical training experience and which proce- dures are included. Ambika Hoguet, MD, said that even when updates happen and new technologies come to market, the focus of a glaucoma fellowship remains the same: clinical diagnosis, medical management, laser management when needed, surgical decision-making (when to proceed with surgery and which surgery to perform), surgical skills, and postoperative care. Dr. Hoguet works with a glaucoma training program at Ophthal- mic Consultants of Boston/Tufts/New England Eye Center. "The new devices add to our clinical de- cision-making," she said. This involves exam- ples of when to choose one MIGS device over another. "We think it is important to include the trainees in this discussion," she said. Dr. Hoguet said her program has the benefit of a large faculty who perform a diverse array of glaucoma procedures. "By making sure the trainees get to spend time with each faculty member, they are naturally exposed to the new techniques and devices available to us," she said. Even with the variety of newer options, Dr. Hoguet said traditional surgeries are still emphasized. "A good glaucoma specialist needs to be very comfortable with these procedures," she said. "Many of our patients need intraocular pressures that are lower than what MIGS can deliver or they do not qualify for MIGS." This is why it's important to make sure fellows under- stand the clinical decision-making behind choos- ing a trabeculectomy or tube (or alternative surgery) and are comfortable with the surgery itself and all postoperative care, she said. When it comes to MIGS procedures, rather than focus on specific devices, Dr. Hoguet said her program makes sure trainees are comfort- able working in the angle. "Once they are, most

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