GLAUCOMA EWAP MARCH 2024 37 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 experience 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 complications still occur, the “national averages” don’t apply, as trabeculectomy techniques are so highly individual and surgeon dependent. “Many patients walk into the clinic with end-stage low-tension glaucoma only to reveal that they have undergone several back - to - back MIGS surgeries with no reduction in their disease progression,” she said. It is unfortunate that glaucoma - trained doctors are really not doing trabeculectomies, Dr. Mosaed said, so they are uncomfortable with the concept. “I think in order to be comfortable with any surgery, not just trabeculectomy, you have to do it frequently to keep building on your skills.” Not all trabeculectomies are equal, and even in people who do them regularly, there are a lot of different techniques and approaches. “I inherit a lot of patients who had trabeculectomies 20 or 30 years ago, and I can appreciate that certain techniques end up with better outcomes than others. I can’t overemphasize how sad it is that most glaucomatrained surgeons do not do trabeculectomies anymore.” Dr. Shen agreed on the importance of teaching trabeculectomy and tube shunt surgery as well as revisions of trabeculectomies and tube surgeries in training. At her institution, she said there are many of these challenging glaucoma surgeries, so trainees have the opportunity to learn a lot. Furthermore, trainees work with several attendings at her institution and learn different approaches to trabeculectomies and tube surgeries. Dr. Shen added that for trainees learning angle-based surgery, it’s important to get a good view while manipulating the goniolens and working with the dominant hand inserting a device or cutting trabecular meshwork. In terms of which MIGS procedures to learn, Dr. Mosaed said that gonio surgery techniques are very similar, so it may make sense to focus on learning one procedure very well and adapt from there. “You have to understand how to get a good gonio view,” she said, adding that it’s important to also know how to be comfortable transitioning from phaco and directing your attention to the angle. “What I’ve found is even though we teach our trainees pretty much every MIGS approach there is, either implant-based or nonimplant-based, many surgeons, once they get out into practice, pick one that they’re most comfortable with and stick with that.” In Dr. Lee’s fellowship training, he said the existing MIGS options were the Trabectome (MicroSurgical Technology), iStent (Glaukos), and ECP. “Most of the current MIGS options have been introduced subsequent to my training. By trial and error, I had to learn when and how to implement all of the new surgical options,” he said. Dr. Lee’s criteria for considering a new procedure is: 1) it must make sense, 2) it must be safe, and 3) it must be reversible. “I think the last point on reversibility is an important factor that more surgeons should consider when contemplating a new technique,” he said. “It is inevitable we will face surgical complications. Think twice before jumping in if there is no easy way out.” Dr. Lee has learned that maintaining patience and an unwavering presence of mind are paramount in reducing complications. “As a new surgeon, we may sense the scrutiny of the OR staff as they assess your skill. Unfortunately, your perceived competence as a surgeon is often linked to how quickly you can get through a case,” he said. “It’s important to resist the external and internal pressures that may tempt you to rush through a procedure. Always remain present and methodical with every step. You will encounter cases that will frustrate you from time to time. Do not betray your patients by trying to impress those around you. Play the long game; in time your skill as a surgeon will shine through if you focus on delivering consistently high - quality care.” He added that complications that are highlighted in training are likely the ones that the training facility encounters the most. “Academic institutions, in general, will perform a higher proportion of filtering procedures and tube shunts, and thus trainees will be exposed to related complications more
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