GLAUCOMA 38 EWAP MARCH 2024 often,” he said. “These would likely be hypotony-related issues like flat chambers, choroidals, overfiltering blebs, leaks, etc. Visually significant MIGS complications such as cyclodialysis clefts, prolonged IOP rises, and recurrent reflux bleeding are uncommon, and one may go through their residency and fellowship without encountering them.” He added that these complications are often more distressing, as patients are often not adequately prepared for them. MIGS is often presented to patients as the “safer” option with an easier recovery. As glaucoma doctors, we spend a lot of our time contending with blindness at one end of the disease spectrum, he said. “This may cause us to underemphasize the risks of procedures in the ‘safer’ end of the spectrum and downplay the concerns and fears of a patient who is about to undergo them.” An important lesson that Dr. Mosaed has learned is that there are some patients who will never be happy. “It has taken me 20 years to learn that lesson,” she said. Some patients can be extremely negative, and this can lead to a bad experience for the practice and surgeon. The single most important thing that determines the outcome of any case is the doctor-patient relationship. This is even more important than IOP, technique, and complication rates, she said. If you have a difficult, negative patient, almost no outcome will make them happy. Conversely, if you have a mutually respectful relationship with a patient and you have spent adequate time explaining things in detail, even if they require a revision or develop some unfortunate outcomes, they are likely to understand that you have done your best for them. Dr. Mosaed said that it may be that a physician is not a good match for a particular patient. A lot of it comes down to personality and style. “A patient may not like my style, but they might like another doctor,” she said. For this reason, Dr. Mosaed said it’s important to know other doctors in the community. With her experience training residents and fellows in the Irvine area for 20 years, Dr. Mosaed said that more than 80% of her fellows have gone into practice in Orange County within a 10- to 15-mile radius. “If I’m going to send a patient out to one of my former fellows, I know they’re going to be well served,” she said. “It’s a mark of pride when you put out a well-trained fellow who will serve glaucoma patients for another 30 years.” Dr. Mosaed said that even with her experience, she is still learning new skills. Last year, she decided to incorporate the Yamane technique into the fellowship training for the glaucoma fellows. “I don’t do Yamane well because I use it so infrequently. The opportunity to use it comes up every couple of years. You can’t get good at it if you’re doing it like that,” Dr. Mosaed said. “I would have liked to know how to do a Yamane IOL or an efficient scleral - fixated IOL technique so as not to have a pit in my stomach every time I see the PXE material on the capsule at the start of the case,” she said. She partnered with a cornea doctor to give her glaucoma trainees the opportunity to go to the OR and train in Yamane cases. “Even though I think most glaucoma training programs say this isn’t the place or time to learn cataract techniques, I have to disagree with that because it’s such a big part of the glaucoma surgeon’s practice.” Dr. Mosaed added that she ensures that fellows are certified on femtosecond cataract surgery as well. Dr. Shen added that “teaching fellows is not a one-way street.” For example, Dr. Shen said she learned ways to use the Malyugin ring from her fellows, as she had previously used mostly iris hooks in training. In addition to learning surgical skills, Dr. Shen stressed the importance of learning how to have discussions with patients, and she will encourage her fellows to join her in the room when she discusses surgical complications or getting consent from patients. The learning does not stop at the end of training, she said. “A lot of times when we finish fellowship, we think things are set in stone, and they’re certainly not.” Those people who continue to learn, adapt, modify, and question become better surgeons, she said. “When people finish fellowship and join a practice, they may feel the need to prove that they can be on their own, but the truth is that’s a good time to continue the learning and show vulnerability and reach out. We all have questions, and glaucoma is a very humbling field,” she said. “I did that, and I tell my fellows not to be shy. Feel free to ask questions. It’s a good culture that’s quite important in the glaucoma community.” EWAP Editors’ note: Dr. Lee is Assistant Professor of Ophthalmology, Sidney Kimmel Medical College, Wills Eye Hospital, Philadelphia, Pennsylvania, and has interests with Allergan, Glaukos,New World Medical, Nicox, Olleyes, Ocular Therapeutix, and Santen. Dr. Mosaed is Professor of Ophthalmology, Glaucoma Fellowship Director, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California, and has interests with AbbVie, Alcon, Sight Sciences, and Skye Bioscience. Dr. Shen is Glaucoma Fellowship Director, Mass Eye and Ear, Associate Professor of Ophthalmology, Harvard Medical School, Boston, Massachusetts, and declared no relevant financial interests.
RkJQdWJsaXNoZXIy Njk2NTg0