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Comment by Robert Feldman on:

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

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Campbell and co-authors evaluated the proportion of ophthalmologists in Ontario, Canada performing glaucoma surgery under the public health system over time and found that there was a decreasing proportion of ophthalmologists performing incisional surgery while the proportion providing laser surgery remained stable. Over the tenyear study period, the total number of incisional cases remained stable, but the higher volume glaucoma surgeons averaged higher numbers of cases.

The results of this study are important as it may be an early indicator of the increasing subspecialization of incisional glaucoma surgery, while more simple care, including laser surgery (trabeculoplasty), is continued by a broader group of physicians. This arrangement provides good access to care for the non-surgical cases and theoretically better surgical results for the cases requiring incisional surgery. There has been no study to date, though, demonstrating this is true for glaucoma surgery, but it has been demonstrated in other surgical fields.^1-3 The down side to this paradigm shift is potential lack of access to subspecialized care in rural areas without a busy glaucoma surgeon.

It would be interesting to know whether there is a change in the number of fellowship-trained glaucoma specialists, which may be driving the trend toward referral for surgery. This availability may make it unnecessary for a general ophthalmologist to perform these difficult time-consuming cases, which may not be as rewarding as other cases the general ophthalmologist may perform. The fact that newer ophthalmologists have a lower rate of performing incisional glaucoma surgery suggests that they are less comfortable doing so coming out of residency, and those physicians who wish to perform this surgery may be going on to further training. If this trend continues, incisional glaucoma surgery may fall out of the purview of the non-subspecialist.

The study was a retrospective evaluation from the Ontario health systems single payer data base, a data source extensively used for studies in other areas of medicine that includes information for all health care in the province. There are the usual limitations of database searches, i.e., coding errors, administrative errors, or elimination of any care occurring outside the system (for example, in neighboring provinces or countries with a different payer source). The results also may not be generalizable to other locations within or external to Canada as the health care systems are different and surgeon incentives vary.

The public policy implications will become clearer as the outcomes of these surgeries both for the patient and the system are determined in future studies. What we know now is that, at least in Ontario, the quality, financial or other incentives are leading to fewer surgeons performing incisional glaucoma surgery, with those performing incisional surgery doing so at a higher volume. If this same trend is occurring elsewhere in other systems, it is possible that general ophthalmic training is no longer adequate to prepare our surgeons for this type of surgery.

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