Eyeworld

DECEMBER 2023 | EYEWORLD | 75 G LESSONS LEARNED by Ellen Stodola Editorial Co-Director About the physicians Daniel Lee, MD Assistant Professor of Ophthalmology Sidney Kimmel Medical College Wills Eye Hospital Philadelphia, Pennsylvania Sameh Mosaed, MD Professor of Ophthalmology Glaucoma Fellowship Director Gavin Herbert Eye Institute University of California, Irvine Irvine, California Lucy Shen, MD Glaucoma Fellowship Director Mass Eye and Ear Associate Professor of Ophthalmology Harvard Medical School Boston, Massachusetts surgeons work on the most complex cataracts, including those with pseudoexfoliation, angle closure cases with shallow chambers, flaccid irises, end-stage optic nerves with split fixation, central scotomas, and limited visual potential eyes, she said. "These eyes have a much higher rate of complications and require much more preoperative chair time. These are not the 'fun' cataracts where everyone is enjoying the experi- ence and the postop clinic is all rainbows." Dr. Mosaed said she was lucky that she was taught how to do a solid trabeculectomy and is confident with that technique. "I think trabeculectomy requires the most nuance and experience of all the procedures in our toolkit," she said. "Unfortunately, I see many glaucoma- trained doctors who aren't comfortable with trabs, and they end up only offering Ahmed valves and MIGS to their patients." If a surgeon is well-trained and performs a high volume of trabeculectomies, complication rates are dramatically reduced, she said. While com- plications still occur, the "national averages" don't apply, as trabeculectomy techniques are L earning a variety of surgery techniques and clinical management approaches is important for surgeons in training. Several physicians discussed glaucoma training and some of the approaches being taught. The physicians also shared some of their personal experiences, including what they learned in training and since their training ended, and how these experiences have influ- enced them. Lucy Shen, MD, said it's important to continue to learn and improve surgery even after training. When you're in training, you're often focused on the numbers, like how many trabeculectomies or cataract surgeries you've done, and you don't really think about how to incorporate new surgical techniques into your repertoire, she said. There are always new technologies and surgical techniques being de- veloped. Once you are done with training, there are times where you have to reflect on what you've learned and think if you need to change to make your surgeries better because what you learned may not always work for your patient population or the surgical center that you're at, she said. Dr. Shen added that the types of procedures surgeons do in training will often depend on where they train. For example, she didn't do much angle-based surgery in training more than a decade ago but learned it after she was done with her fellowship. Daniel Lee, MD, said that he was exposed to a variety of approaches in glaucoma care in training. "This exposure provided me with insights into various treatment philosophies within glaucoma care and allowed me to explore a comprehensive range of therapeutic options," he said. "My existing constructs and beliefs on the 'right way' to treat glaucoma have been consistently challenged, which fostered the development of an open-minded approach as a clinician. Rather than forming rigid opinions, I've embraced a more adaptable stance, which I think is crucial in navigating a field where gray areas are commonplace and there are usually several paths to the goal." Sameh Mosaed thinks it is critical that train- ees be exposed to various surgical techniques and learn where to apply them. Glaucoma Lessons from glaucoma training continued on page 76 Dr. Shen (left) teaches glaucoma surgery to glaucoma fellow Christina Lieu, MD, in the OR at Mass Eye and Ear. Source: Lucy Shen, MD

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