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Editors Selection IGR 17-3

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Comment by Philippe Denis on:

51038 Subspecialization in glaucoma surgery, Campbell RJ; Bell CM; Gill SS et al., Ophthalmology, 2012; 119: 2270-2273

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The study of Campbell et al. shows that a continuous and steady decline in the percentage of ophthalmologists providing incisional glaucoma surgery over the last 16 years in Ontario (1995-2010). The same trend is observed both in early-, mid- and late-career surgeons. Consequently, the number of higher volume ophthalmologists (> 100 procedures/year) has progressively increased during the same time period. In contrast, the proportion of ophthalmologists performing laser trabeculoplasty remained stable, though the mean number of laser procedures increased 120% over the study period. This is a very nice and interesting survey obtained from a singlepayer health care system in a large Canadian population. There is no information, however, regarding the type and number of peri-operative complications and the long-term surgical results (IOP control). Overall, the results of this study suggest implications for the utilization of healthcare resources and the quality of care delivered to patients. Greater glaucoma subspecialization may lead to geographic concentration of glaucoma surgeons. Is it useful to incentivize or require patients to go to high volume surgeons for glaucoma?

On the one hand, it is generally accepted that case volume may be a surrogate for quality (though it may not be equated with it!), and higher surgeon volume is thought to be associated with better results in peri-operative and long-term outcomes. This remains to be proven for glaucoma filtering surgery in large, prospective and comparative studies. Glaucoma is a leading cause of blindness worldwide. The majority of ophthalmologists opt for an initial medical treatment, but a number of glaucoma patients will require an operation, particularly in severe or advanced cases. It is important to know whether surgeon volume is associated with a better clinical outcome in incisional glaucoma surgery. On the other hand, there are potential unexpected consequences: the inconvenience of traveling long distances for appointments with the surgeon; having surgery away from the patient's social support network; having fewer trained surgeons in outlying areas,… In an economic climate where access to care is lacking for numerous patients, regionalization could place additional barriers between these patients and the care they should need.

This paper also has important implications for training and certification of residents and young surgeons, particularly as new surgical modalities such as ab interno approaches or glaucoma implants have expanded dramatically in the last decade. Surgical training is traditionally built on a strong foundation of didactic learning, observation, training under close supervision and repetition, with the final goal of having the trainee perform independently.In a limited timeframe, residents are not able to learn thoroughly different types of eye surgeries. One way to address this issue would be to offer subspecialty certification for practitioners, during their fellowship, so that patients could use certification as a criterion for selecting their surgeon.

Perhaps the future lies in the development of techniques that are more straightforward, technologybased and are not dependent on the mere technical skill of the surgeon's hand

Finally, there is no denying that glaucoma surgery today is more complex than it was twenty years ago with the advent of nonpenetrating surgical techniques, implantable drainage devices and sophisticated lasers to perform cyclodestruction. The learning curve for these techniques is long and often linked to the experience and skill of the surgeon. Perhaps the future lies in the development of techniques that are more straightforward, technology-based and are not dependent on the mere technical skill of the surgeon's hand.

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