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Comment by Ivan Goldberg on:

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

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We inhabit a medico-economic environment that is relatively shrinking despite increasing demands, expectations and needs. Multiple currents stress health care delivery and potentially cut across the patient-clinician therapeutic alliance, so vital to optimal outcomes in the management of chronic conditions such as the glaucomas.

We inhabit a medico-economic environment that is relatively shrinking despite increasing demands, expectations and needs

While glaucoma drainage procedure numbers have not increased over the past 20 years with more potent and less intrusive medications and improved laser trabeculoplasty techniques and access, the unchanged intense peri-operative supervision plus need for meticulous technique have not facilitated success. Do these trends push incisional glaucoma surgery into the hands of fewer and fewer ophthalmologists, specifically those with glaucoma Fellowship training? This is the question addressed by Campbell et al. in their timely use of data from Ontario's universal Health Insurance Plan over the period 1995-2010. While their results are unsurprising, they raise the challenges of training, accreditation and certification for professional associations and their training programs, of rational doctor human resource utilization for health care resource providers, of patient expectations for politicians and bureaucrats and of medicolegal implications for health care insurers.

Over this 15-year period, throughout Ontario, the overall number of incisional glaucoma interventions remained reasonably static for a population that possibly increased slightly (the authors do not mention this specifically). However, the proportion of ophthalmologists performing such surgery almost halved (35% to 19%) and the mean number of operations performed per ophthalmologist still offering such a service, doubled, particularly among those performing more than 100 drainage operations annually.

Also assessed was the proportion of ophthalmologists performing laser trabeculoplasty. This remained steady: 48% in 1995 to 50% in 2010. Half the ophthalmic workforce in Ontario offered an in-clinic laser intervention to supplement their glaucoma medical management in 1995, and half continued to do so 15 years later, with the overall number of laser procedures rising slightly during this period.

We inhabit a medico-economic environment that is relatively shrinking despite increasing demands, expectations and needs

These figures confirm a global impression of increasing sub-specialization of incisional glaucoma surgery, surgery that for success requires skills well beyond the technique itself. Vocational training programs still regard this is a core competency for all participants. Better results require a threshold for frequency of performance. As fewer ophthalmologists perform these surgeries, by default they become concentrated in the hands of those with glaucoma fellowship training. Increasingly patients need referral from their usual ophthalmologist to an interventional glaucoma sub-specialist raising questions of accessibility including geographic, especially in countries like Canada (and Australia). From a patient's perspective, there are the conflicting wishes for easy access versus increased chances for an optimal outcome. Expectations and medico-legal ramifications follow. On the one hand, more glaucoma Fellowship positions increase the number of available sub-specialists to meet community needs, on the other hand each position intrudes into the training experience of vocational trainees and accelerates the movement towards sub-specialization of glaucoma surgery. How does this resolve?

Vitreo-retinal surgery has become the sole domain of sub-specialists. Ask the authors, is glaucoma surgery heading towards the same goal? What does that imply for recognition by professional associations or accreditation authorities?

By using a population-based approach, enabled by a province-wide data base (even with the possible distortions of coding errors), this paper highlights recognized trends that pose significant challenges for us all. The paper provides no answers. It sets out a clear trend, a trend that is global and that requires thoughtful addressing. It is a most welcome addition to our evidence base.

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