Eyeworld

72 | EYEWORLD | SUMMER 2024 G UCOMA Contact Boland: Michael_Boland@ meei.harvard.edu Sheybani: sheybaniar@wustl.edu Wang: jessie.wang@duke.edu Reference 1. Qiu M, et al. Microinvasive glaucoma surgery in US ophthal- mology residency: surgical case log cross-sectional analysis and proposal for new glaucoma procedure classification. J Glau- coma. 2021;30:621–628. Relevant disclosures Boland: None Sheybani: AbbVie, Alcon, Glaukos, Nova Eye Wang: None you can do one, you can do them all. They all have their own learning curve," Dr. Sheybani said. Dr. Sheybani said that there are patients and disease stages where performing angle surgery would carry an advantage over subcon- junctival filtration surgery and vice versa. "The whole goal is to have a working knowledge of how to do a subconjunctival surgery, and it might be something where you'll never do it again, but if you did it a couple of times in residency and you have a postop come in, you know what the normal should look like and what the tubes should look like." Doing or ob- serving five of those is good down the line even if you don't ever do the surgery because there will be patients having these surgeries who will come to see you, he reiterated. Michael Boland, MD, PhD, and others worked on a paper published in 2021 1 propos- ing a different way to think about how glau- coma procedures were being logged because "that had not kept up with updates in glaucoma surgeries." We've had multiple publications showing that a lot of MIGS are being done by non-glaucoma specialists, so it makes sense to have that as a skill for comprehensive ophthal- mologists, Dr. Boland said. Dr. Boland said there will always be com- plaints among the specialties that residents don't have enough training in specific areas. An- other debate is as more people do fellowships, there's been an expectation of, "We don't have to do that training during residency because they'll get that in fellowship." Dr. Boland's paper proposed several cate- gories of glaucoma procedures. "MIGS is a grab bag of procedures that are sometimes unrelat- ed," he said. The paper proposed glaucoma sur- gery ab externo for procedures like trabeculec- tomy and traditional tubes, which involve some manipulation of the conjunctiva and the sclera when you're making a flap or tunnel. Those are core surgical techniques that are useful for anyone going into practice, he said. Then there is the ab interno category. That's where most MIGS procedures fall, but the concept you want to make sure people understand is operating with a gonioprism, identifying structures in the angle, etc. Then there are other techniques left over like cyclodestruction, laser trabeculoplasty, and laser iridotomy. "But it was ab externo and ab interno that were the major categories of Dr. Wang gained experience with a variety of MIGS procedures during her residency, noting that she's performed goniotomies the most. "I'm happy with the exposure I've gotten in my train- ing thus far. We do a good number of lasers, phacos, MIGS, and tubes, and I'm looking for- ward to continuing those skills and to learning how to do trabs in fellowship," she said. Arsham Sheybani, MD, also sees these changes to the ACGME requirements as a positive step. Though MIGS has been around for a while, it sometimes takes time for train- ing programs to implement changes because they want to see if the surgery is going to have staying power. He noted that it's important to be teaching the angle procedures to surgeons in training. He added that there's value in having device representatives to explain the nuances of differ- ent products, but when you're starting out, "to learn angle surgery, I think it should be taught surgeon to surgeon," he said. Residency should be about teaching physi- cians to be the best comprehensive ophthalmol- ogist, handling the bread and butter of almost everything, Dr. Sheybani said. It's important to have experience, and it may be important to know how to do a tube. Previously, a lot of physicians were learning angle surgery through device representatives, he said, and it was specific to each device. If there's a MIGS minimum, the attending surgeon can teach angle procedures however they feel most comfortable teaching, and if there's a specific device issue down the line, the rep would be helpful, he said. Dr. Sheybani noted the nuances of angle surgery, like when to treat the patient and with what procedure, ocular and systemic factors to consider, how to set up the scope, how to set up the visualization, the goniotomy, where to make the incision, and how to manage issues postoperatively. These are all important factors in the surgical process, and it's important to take the time to ensure the surgeon knows what they're doing and why. This is where facul- ty experienced in MIGS can provide more value than industry representatives who will be well versed on their specific product. "Since you need basic ophthalmic surgi- cal skills to transfer into MIGS, there's a basic skillset that, if you have it, it helps you with the variety of MIGS, so it's important to have that foundation. But it doesn't always mean that if continued from page 70

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