EyeWorld India September 2017 Issue

September 2017 20 EWAP FEATURE by Ellen Stodola EyeWorld Senior Staff Writer AT A GLANCE r "UUFOEJOH B USBJOJOH DPVSTF BOE àOEJOH B NFOUPS BSF UXP HPPE XBZT GPS DPNQSFIFOTJWF PQIUIBMNPMPHJTUT UP MFBSO OFX SFGSBDUJWF QSPDFEVSFT r *O BEEJUJPO UP MFBSOJOH B OFX QSPDFEVSF LOPXJOH IPX UP DIPPTF UIF SJHIU QBUJFOU JT FYUSFNFMZ JNQPSUBOU r -FBSOJOH SFGSBDUJWF QSPDFEVSFT XJMM BMMPX TVSHFPOT UP IFMQ UIFJS QBUJFOUT XIP NBZ OFFE GVSUIFS DPSSFDUJPO GPMMPXJOH DBUBSBDU TVSHFSZ How to start performing refractive surgery Physicians discuss expanding the practice of the comprehensive ophthalmologist to include more procedures I n this changing ophthal- mic environment, with new technologies and innovations, many ophthalmologists are beginning to incorporate a wide variety of procedures into their practice scope. Comprehensive ophthalmologists are doing more than just cataract surgery and are learning refractive and corneal refractive procedures, including PRK and LASIK. Elizabeth Yeu, MD , Virginia Eye Consultants, Norfolk, Virginia; Kathryn Hatch, MD , Massachusetts Eye and Ear, Waltham, Massachusetts; and Gregory Parkhurst, MD , Parkhurst NuVision, San Antonio, Texas, commented on why it could be valuable for ophthalmologists to offer more procedure options, tips for learning to perform these refractive surgeries, and how to incorporate them into practice. Why perform corneal refractive surgery? With the increasing popularity of refractive cataract surgery, patient expectations run high, Dr. Hatch said. Sometimes even with surgi- cal planning and newly available technologies, patients don’t end up on refractive target, so laser vision correction is a handy tool. Corneal refractive surgery is proven to deliver high quality uncorrected vision, with a very low side effect profile, Dr. Yeu said. “If nothing else, refractive cataract surgeons will have a skill set and option to help correct surprises from refractive errors after cataract surgery.” Before even getting into the topic, Dr. Parkhurst thinks it’s important to define what refractive surgery is. “The field is expand- ing with a lot of innovations and several recent [U.S. Food and Drug Administration] approvals,” he said. In the past, Dr. Parkhurst said, refractive surgery was limited in definition to procedures like LASIK and PRK, but now encompasses additional procedures, some of which are applicable to the three milestones of human vision de- velopment. The first milestone, he said, is ocular maturity. This means that a child has completed physical growth, and the eye has stopped changing. This usually occurs between ages 18 and 20. Once that milestone has been reached, you can use a number of procedures, he said, like small incision lentic- ule extraction (SMILE, Carl Zeiss Meditec, Jena, Germany), LASIK, PRK, crosslinking, and phakic IOL implantation to treat the distance vision in a permanent way. The second milestone, Dr. Parkhurst said, is presbyopia, and the third is cataracts. “Refractive surgery is expand- ing and becoming a subspecialty,” he said. “While we think that every ophthalmologist should involve themselves in refractive surgery in some way, there are various ways to participate.” He added that what’s happening in refractive surgery is similar to other subspecialties, with expanding ways to perform surgery. Best ways to learn A skills transfer course could be helpful for surgeons wanting to learn the new technical skills need- ed for corneal refractive surgery, Dr. Yeu said. She recommended at- tending a thorough didactic course and supplementing it with other didactic courses to understand some of the nuances involved with these surgeries and how to manage potential complications. Surface ablation procedures are technically easier than LASIK, she added. With regard to learning this, Dr. Hatch thinks that a cornea and refractive fellowship is ideal. Learning laser vision correction is relatively straightforward for the anterior segment surgeon, she said, but finding good candidates, treat- ing the ocular surface, and having the ability to manage problems are key. “I think it’s great if someone can start with a training program,” she said. However, for those who have been out of training for many years and who are not necessarily going to do a corneal fellowship before doing laser vision correc- tion, Dr. Hatch suggested taking a course and investing time with an experienced surgeon to learn as much as possible. The best way to gain exper- tise is first to find a mentor, Dr. Parkhurst said. He suggested visit- ing practices where a physician is willing to sit by your side and provide direct instruction on how to perform various procedures and select the correct procedure for each patent. “Getting access to that kind of training goes beyond what you can access at a weekend train- ing course or hear at a lecture,” he said. It involves a hands-on, deep dive into the procedure. Dr. Parkhurst said there are a number of advanced training pro- grams available, but he noted that there are only a handful of refrac- tive surgery fellowships available in the U.S. today. Additionally, he said that many corneal fellowships are heavy in training for corneal pathology, transplants, and other corneal procedures, so refractive surgery training may need to be specifically sought out by the individual. A well-trained anterior