Comprehensive doing trabs/shunts

[eyehope]

Any thoughts on comprehensive guys performing glaucoma surgeries (mainly trabs)? I guess a lot depends on residency experience and comfort level.

Background: I've been out of residency for a few years. Never really considered glaucoma (it was kind of malignant at my program), but there is a big need for a glaucoma surgeon here (average wait for an appt is 2-3 months). In residency, I performed less than a dozen glaucoma surgeries (mostly trabs, some express shunts, one tube). I could possibly observe some surgeries at a nearby academic center (to see if there are newer surgical techniques - in particular, conj closure). Obviously, I will not have the benefit of learning all the clinical and surgical nuances without doing a glaucoma fellowship. But, with a family, it would be very tough going back for a fellowship (and perhaps tough to match without any research).

1. Any reason why a comprehensive should not perform an uncomplicated trabeculectomy w/MMC? I would refer out complicated uveitic, NVG (tubes), re-ops trabs to glaucoma. My main concern is legal- ie, if the trab fails (which is bound to happen), the patient loses vision and wonders why I didn't refer to glaucoma earlier.

2. Is it ethical to market yourself as someone who does glaucoma surgery without a fellowship? Perhaps a dumb question; but with our field becoming more and more sub-specialized, I think it's a valid one.

3. Should I just suck it up and apply for fellowship?

Thoughts? I especially welcome them from our local glaucoma MDs on here.

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[Mirror Form]

Any thoughts on comprehensive guys performing glaucoma surgeries (mainly trabs)? I guess a lot depends on residency experience and comfort level.

Background: I've been out of residency for a few years. Never really considered glaucoma (it was kind of malignant at my program), but there is a big need for a glaucoma surgeon here (average wait for an appt is 2-3 months). In residency, I performed less than a dozen glaucoma surgeries (mostly trabs, some express shunts, one tube). I could possibly observe some surgeries at a nearby academic center (to see if there are newer surgical techniques - in particular, conj closure). Obviously, I will not have the benefit of learning all the clinical and surgical nuances without doing a glaucoma fellowship. But, with a family, it would be very tough going back for a fellowship (and perhaps tough to match without any research).

1. Any reason why a comprehensive should not perform an uncomplicated trabeculectomy w/MMC? I would refer out complicated uveitic, NVG (tubes), re-ops trabs to glaucoma. My main concern is legal- ie, if the trab fails (which is bound to happen), the patient loses vision and wonders why I didn't refer to glaucoma earlier.

2. Is it ethical to market yourself as someone who does glaucoma surgery without a fellowship? Perhaps a dumb question; but with our field becoming more and more sub-specialized, I think it's a valid one.

3. Should I just suck it up and apply for fellowship?

Thoughts? I especially welcome them from our local glaucoma MDs on here.

Hmm, have you finally been out of residency long enough to forget how painful trabs are? But seriously, there's nothing professionally or ethically wrong w/ a comprehensive guy doing trabs, especially phaco/trabs (i'm comprehensive btw, not glaucoma). One glaucoma guy I know frequently tries to convince all the comprehensive doc's that we should do more phaco/trabs.

The thing is though, if you're trying to "build up a name" for yourself in the community, then it might not be a good idea. You don't want all the cataract patients to go see the guy across the street b/c betty told everyone at the knitting club about how you blinded her with a phaco/trab.

 

[OMD]

I'm comprehensive and have no problems with it. Stick to the simple ones and do the ones that come through your door at first. Don't go advertising that you are a "glaucoma guy." For one, you don't want the complicated ones, and another, build your skill on the easier ones. I stick to express trabs and Ahmeds. I now get some referrals from retina guys with secondary glaucoma needing tubes and I do most of my practice's simple trabs. Refer the reops, really complicated ones, etc. I think you will be surprised that if it is an underserved specialty where you work, some of your outside referring docs will be glad to have someone to take the easier ones instead of waiting 2-3 months for an appt and then another few months for surgery from the existing glaucoma docs.

 

[Shnurek]

Layman opinion: If optometrists can do some of those procedures in Oklahoma/Kentucky and have done thousands of them then you should be more than capable to do them as well.

 

[Visionary]

Layman opinion: If optometrists can do some of those procedures in Oklahoma/Kentucky and have done thousands of them then you should be more than capable to do them as well.

You're not actually a layman, you're a pre-optometrist. And no optometrist anywhere can perform trabs/tubes. Get your facts straight.

 

[Shnurek]

What exactly are trabs? I thought you meant selective laser trabeculoplasty. Also a poster on SDN said that at my school students practiced trabs/sutures:

Haha, good catch Shnurek. I do go to SUNY.

I can only speak of SUNYopt because I haven't gone through any other program, but... I know that I'm planning to leave NY to practice in a state with a lot more rights so I'm really thankful that I get to learn how to do injections, suture, trabs, etc. even if we don't get to practice the techniques a lot. We learn about everything that any state can do as of now because we have to know them for boards. But you're absolutely right that for those staying in NY (unless you're in a VA), it's frustrating to think that you're 'wasting' all this time learning and studying all the things you won't be able to do in the near future. :/

 

[KHE]

What exactly are trabs? I thought you meant selective laser trabeculoplasty. Also a poster on SDN said that at my school students practiced trabs/sutures:

Another example of how people should be sure they know what they're talking about before posting.

 

[Mirror Form]

What exactly are trabs? I thought you meant selective laser trabeculoplasty. Also a poster on SDN said that at my school students practiced trabs/sutures:

If you read the first few posts of this thread, it should have been pretty obvious trabs are not the same thing as SLT. Trabs are a form of surgery for glaucoma that have a significant rate of bad complications (like all forms of glaucoma surgery).

 

[Eyefixer]

What exactly are trabs? I thought you meant selective laser trabeculoplasty. Also a poster on SDN said that at my school students practiced trabs/sutures:

I think you are ready to take optometric surgical boards!!!

 

[Eyefixer]

Firstly, optometrists don't have complications, period. Ophthalmologists do. Secondly, he will practice at school with trabs/sutures and stuff before he gets to cut someone for reals .

If you read the first few posts of this thread, it should have been pretty obvious trabs are not the same thing as SLT. Trabs are a form of surgery for glaucoma that have a significant rate of bad complications (like all forms of glaucoma surgery).

 

[Shnurek]

Lol thats why I used the qualifier "Layman opinion:". Then visionary stated that I am not a layman because I am pre-optometry OK never mind then.

 

[Meibomian SxN]

Any thoughts on comprehensive guys performing glaucoma surgeries (mainly trabs)? I guess a lot depends on residency experience and comfort level.

Background: I've been out of residency for a few years. Never really considered glaucoma (it was kind of malignant at my program), but there is a big need for a glaucoma surgeon here (average wait for an appt is 2-3 months). In residency, I performed less than a dozen glaucoma surgeries (mostly trabs, some express shunts, one tube). I could possibly observe some surgeries at a nearby academic center (to see if there are newer surgical techniques - in particular, conj closure). Obviously, I will not have the benefit of learning all the clinical and surgical nuances without doing a glaucoma fellowship. But, with a family, it would be very tough going back for a fellowship (and perhaps tough to match without any research).

1. Any reason why a comprehensive should not perform an uncomplicated trabeculectomy w/MMC? I would refer out complicated uveitic, NVG (tubes), re-ops trabs to glaucoma. My main concern is legal- ie, if the trab fails (which is bound to happen), the patient loses vision and wonders why I didn't refer to glaucoma earlier.

2. Is it ethical to market yourself as someone who does glaucoma surgery without a fellowship? Perhaps a dumb question; but with our field becoming more and more sub-specialized, I think it's a valid one.

3. Should I just suck it up and apply for fellowship?

Thoughts? I especially welcome them from our local glaucoma MDs on here.

12 trabs? Is that the number you performed solo or does that include observing also?

As someone who refers glaucoma surgery out, I would not think it was odd that you performed trabs/shunts and not had a fellowship training. I would assume you would list that under the procedures you perform.

 

[Mirror Form]

12 trabs? Is that the number you performed solo or does that include observing also?

As someone who refers glaucoma surgery out, I would not think it was odd that you performed trabs/shunts and not had a fellowship training. I would assume you would list that under the procedures you perform.

Isn't it great having all this valuable input from optometry?

 

[200UL]

Layman opinion: If optometrists can do some of those procedures in Oklahoma/Kentucky and have done thousands of them then you should be more than capable to do them as well.

How embarrassing. This person has zero credibility on anything eyecare related. Again, express your opinion if you have actual knowledge on a topic. I do not care if you are pre-optometry or post-optometry - as usual your comments make the pro-surgery optometry group look like idiots. Please do not practice near me or any of my family. I would not want someone like you to take care of my dog.
In all seriousness, this does point out that MDs often will limit scope of practice because they are concerned with competence / outcomes / results / patients . Shnurek takes the approach, "I should be able to do the surgery (which I clearly do not understand) because the lawmakers who I bought off say I can."

 

[eyehope]

We've gotten a little off of topic.

Honestly, my main concern is surgical consistency, especially with the flap closure. It appears the miniExpress is getting more and more use, lowering the risks of post-op hypotony, hyphema, choroidals, etc.

To the person who asked about surgical numbers, those are primary surgeries (completing all of the surgery, although ACGME has a different definition). If I counted all the glaucoma surgeries I was involved (assisted) in, it is a much higher number. While assisting is useful, IMO, the surgical outcomes in glaucoma surgery is more surgeon dependent (than other surgeries such as cataract - I'm not saying skill does not matter for cataract surgery, but it matters more for glaucoma surgery). I'm guessing that the majority of comprehensive do not perform trabs/shunts.

 

[Shnurek]

How embarrassing. This person has zero credibility on anything eyecare related. Again, express your opinion if you have actual knowledge on a topic. I do not care if you are pre-optometry or post-optometry - as usual your comments make the pro-surgery optometry group look like idiots. Please do not practice near me or any of my family. I would not want someone like you to take care of my dog.
In all seriousness, this does point out that MDs often will limit scope of practice because they are concerned with competence / outcomes / results / patients . Shnurek takes the approach, "I should be able to do the surgery (which I clearly do not understand) because the lawmakers who I bought off say I can."

Lol you are acting like this is some holy forum. Anybody off the street can make an account and post their opinion. Calm down. Of course I don't know anything. I haven't even started optometry school but you seem to care so much about what I say, which is the funny part. If you really think ODs aren't qualified to do certain things then let them and let malpractice lawsuits take them down without any effort from you.

 

[200UL]

Lol you are acting like this is some holy forum. Anybody off the street can make an account and post their opinion. Calm down. Of course I don't know anything. I haven't even started optometry school but you seem to care so much about what I say, which is the funny part. If you really think ODs aren't qualified to do certain things then let them and let malpractice lawsuits take them down without any effort from you.

As I have said before, lack of malpractice suits has nothing to do with quality of care.

Eyehope is not worried about getting sued. He is worried about delivering quality care and how he would be perceived completing glaucoma surgeries by his peers.

Eyehope, I do agree with you glaucoma surgery can be more challenging for some than cataract surgery. There is much more "feel" involved. I do believe any decent cataract surgeon can learn it, however. I say watch a lot of videos, consider returning to assist you previous attendings for a few days, go to the lab and create many flaps and practice your conj closures, and go for it.

 

[Meibomian SxN]

Isn't it great having all this valuable input from optometry?

Willl he be receiving referrals from you? That's what I thought.....

We've gotten a little off of topic.

Honestly, my main concern is surgical consistency, especially with the flap closure. It appears the miniExpress is getting more and more use, lowering the risks of post-op hypotony, hyphema, choroidals, etc.

To the person who asked about surgical numbers, those are primary surgeries (completing all of the surgery, although ACGME has a different definition). If I counted all the glaucoma surgeries I was involved (assisted) in, it is a much higher number. While assisting is useful, IMO, the surgical outcomes in glaucoma surgery is more surgeon dependent (than other surgeries such as cataract - I'm not saying skill does not matter for cataract surgery, but it matters more for glaucoma surgery). I'm guessing that the majority of comprehensive do not perform trabs/shunts.

Thanks. And I believe you're right about comprehensives not performing trabs/shunts. Might be a niche for you if you find a good comfort zone. Good luck.

 

[Zorro12]

From a fellowship trained glaucoma specialist out of fellowship 5 years. It is nice to see you want to help the patients you know are getting worse. Unlike some providers who SLT, drop, SLT, drop, SLT, drop and say, sorry you are going blind, at least you want to take another step. Your problem is your extremely limited exposure not only to the surgeries, but more importantly the post-op management. Another poster mentioned he does "uncomplicated" Ahmeds and X-press shunts. I think this is fine if you know what you are doing and had reasonable experience with the procedures. The general problem is you do 12-15 as a resident, then go into practice, practice is slow, and the next person you see that actually needs surgery is 12-18 months after your last surgery. You have now forgotten how to do said surgery (but can see easliy on eyetube, etc...), but also all of the finer points of post-op mgmt. You really need to consider that your 1st 20 or so surgeries are going to be difficult, and may be disasters. Most of the patients I operate on do not have much nerve reserve for surgical misadventures and that is alot of potential blinding without attending back-up like you had as a resident.

If I may quote the omnipresent (on this forum), "you don't know what you don't know". I see all kinds of poor outcomes come in from part time glaucoma surgeons. ie 5mm of tube in the eye, tubes bouncing off endothelium, tube erosion (documented) nobody bothered to recover -> endophthalmitis, unrecognized tube exposure, tube plates placed 4mm posterior to limbus, wound leaks unrecognized, eyes abandoned (not revised) due to hypotony, it goes on. Then I see the results of well done surgeries that fail due to faulty post-op management, ie dosing topical steroids is not the same for a tube or trab as it is for a cataract. You are reading this saying of course I am not an idiot, the people with the above complications are saying the same thing.

A few last points. As a frame of reference I did about 160 incisional glaucoma surgeries (not cataracts) during my fellowship year, and saw almost every post-op from day 1- infiniti from multiple surgeons. That is alot of post-op mgmt. Second, I don't use the Express shunts (less cost effective in our ASC and generally more cost to the patient), but I know how to cut a flap. You will likely have less issues with the Express from a hypotony/inflammation stand point, but the failure is usually posteriorly, and not at the flap. Remember, there are worse things than a glaucoma surgery that doesn't work. Lastly, please do not mangle all of the conj and assume is will be peachy keen for the glaucoma guy for the re-op. If primary trab, try to go superior or supero nasal to preserve superotemp for a second trab or a BGI so I don't need to go inferonasal. Good luck, choose your cases wisely, and while you can kill an eye intraop, the make or break is usually post-op.

 

[orbitsurgMD]

From a fellowship trained glaucoma specialist out of fellowship 5 years. It is nice to see you want to help the patients you know are getting worse. Unlike some providers who SLT, drop, SLT, drop, SLT, drop and say, sorry you are going blind, at least you want to take another step. Your problem is your extremely limited exposure not only to the surgeries, but more importantly the post-op management. Another poster mentioned he does "uncomplicated" Ahmeds and X-press shunts. I think this is fine if you know what you are doing and had reasonable experience with the procedures. The general problem is you do 12-15 as a resident, then go into practice, practice is slow, and the next person you see that actually needs surgery is 12-18 months after your last surgery. You have now forgotten how to do said surgery (but can see easliy on eyetube, etc...), but also all of the finer points of post-op mgmt. You really need to consider that your 1st 20 or so surgeries are going to be difficult, and may be disasters. Most of the patients I operate on do not have much nerve reserve for surgical misadventures and that is alot of potential blinding without attending back-up like you had as a resident.

If I may quote the omnipresent (on this forum), "you don't know what you don't know". I see all kinds of poor outcomes come in from part time glaucoma surgeons. ie 5mm of tube in the eye, tubes bouncing off endothelium, tube erosion (documented) nobody bothered to recover -> endophthalmitis, unrecognized tube exposure, tube plates placed 4mm posterior to limbus, wound leaks unrecognized, eyes abandoned (not revised) due to hypotony, it goes on. Then I see the results of well done surgeries that fail due to faulty post-op management, ie dosing topical steroids is not the same for a tube or trab as it is for a cataract. You are reading this saying of course I am not an idiot, the people with the above complications are saying the same thing.

A few last points. As a frame of reference I did about 160 incisional glaucoma surgeries (not cataracts) during my fellowship year, and saw almost every post-op from day 1- infiniti from multiple surgeons. That is alot of post-op mgmt. Second, I don't use the Express shunts (less cost effective in our ASC and generally more cost to the patient), but I know how to cut a flap. You will likely have less issues with the Express from a hypotony/inflammation stand point, but the failure is usually posteriorly, and not at the flap. Remember, there are worse things than a glaucoma surgery that doesn't work. Lastly, please do not mangle all of the conj and assume is will be peachy keen for the glaucoma guy for the re-op. If primary trab, try to go superior or supero nasal to preserve superotemp for a second trab or a BGI so I don't need to go inferonasal. Good luck, choose your cases wisely, and while you can kill an eye intraop, the make or break is usually post-op.

All you write may be true, but in some places, patients cannot or will not travel to see a glaucoma subspecialist, and it is impractical for a glaucoma specialist to have clinics in more remote areas, yet patients have uncontrolled glaucoma and are losing vision and will likely continue to lose vision unless filtered. Who will take care of them? Comprehensive ophthalmologists have to, that is who.

I do not solicit glaucoma referrals, but I get them all the same. I have a neuroophthalmology practice but am comfortable with medical and surgical management of glaucoma, but there are things I very much prefer not to do, setons and bleb needling are among them. I do know how involved post-filtering management can become and have had to manage complications of my own surgeries and those of many others who operate long distances from where their patients live but whose patients cannot drive or travel easily to be seen by their surgeons, particularly in emergencies or with complications that require frequent followup.

160 incisional surgeries is unrealistic for an ophthalmology resident, and even for a fellow (as Class 1, primary surgeon, in a typical one-year glaucoma fellowship, anyway). Following all postops is fairly typical fellow's duty. I am sure your fellowship gave you considerably more case experience in your subspecialty than your residency, as it should, but it is simply unrealistic to think that all glaucoma surgeries can only be the domain of fellowship-trained glaucoma subspecialists, their numbers and availability simply do not meet the need.

To answer the OPs questions:
1. No.
2. No.
3. Only if you want to market yourself as fellowship-trained in glaucoma and do complicated cases as a referral practice. Keep in mind, you will not get other local ophthalmologists referring glaucoma to you if you compete with them by doing cataract surgery.

 

[Zorro12]

All you write may be true, but in some places, patients cannot or will not travel to see a glaucoma subspecialist, and it is impractical for a glaucoma specialist to have clinics in more remote areas, yet patients have uncontrolled glaucoma and are losing vision and will likely continue to lose vision unless filtered. Who will take care of them? Comprehensive ophthalmologists have to, that is who.

I do not solicit glaucoma referrals, but I get them all the same. I have a neuroophthalmology practice but am comfortable with medical and surgical management of glaucoma, but there are things I very much prefer not to do, setons and bleb needling are among them. I do know how involved post-filtering management can become and have had to manage complications of my own surgeries and those of many others who operate long distances from where their patients live but whose patients cannot drive or travel easily to be seen by their surgeons, particularly in emergencies or with complications that require frequent followup.

160 incisional surgeries is unrealistic for an ophthalmology resident, and even for a fellow (as Class 1, primary surgeon, in a typical one-year glaucoma fellowship, anyway). Following all postops is fairly typical fellow's duty. I am sure your fellowship gave you considerably more case experience in your subspecialty than your residency, as it should, but it is simply unrealistic to think that all glaucoma surgeries can only be the domain of fellowship-trained glaucoma subspecialists, their numbers and availability simply do not meet the need.

To answer the OPs questions:
1. No.
2. No.
3. Only if you want to market yourself as fellowship-trained in glaucoma and do complicated cases as a referral practice. Keep in mind, you will not get other local ophthalmologists referring glaucoma to you if you compete with them by doing cataract surgery.

Your situation appears to be different than the ops. You are comfortable with glaucoma surgery and post-op mgmt. The op stated they had limited experience as a resident, and have been out of residency for some time. I personally don't think it would be advisable to to a trab, or any surgery for that matter, if your comfort level is minimal or non-existent. When I was in academics we felt our residents could do a primary tube or trab, but as I mentioned, I usually would get a call 12-18 months after graduation with questions about how to do the first glaucoma surgery since leaving residency.

As for your distance argument. In the last year I have done surgery on patients from 4 states, with the average drive from those out of my home state being 2 hours each way. Clearly, there is a need for people who want to do the surgeries, but many lack the desire to manage the patients post-op (and doing 3 phacos instead of one trab/tube is much better financially).

In regards to getting no referrals from local docs. Basically, this is true to an extent. I get some referrals from MDs out of our practice (large subspecialty group). However, most of our competition either has their own fellowship trained doc or they send to a University Medical Center, 4 hours away. It really sucks for the patient because the competition does not want the patient to know care can be delivered close by, so they tell them the only place to go is to the academic institution.

In the ops case, maybe some workshops/wet labs at the academy, and know some one to talk to about navigating post-op mgmt may make the situation doable without a fellowship.