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Glaucoma Dialogue IGR 14-3

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Comment by Remo Susanna Jr on:

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

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Attempts to evaluate the trends in glaucoma surgery sub-specialization are to be welcomed. Using a well-designed population-based study in Ontario Canada, the authors concluded that there is reduction of the percentage of early- and late - career ophthalmologists providing incisional glaucoma surgery from 35% in 1995 to 19% in 2010. Also, over the same period, the mean number of incisional surgeries performed per surgeon doubled and the percentage of incisional glaucoma operations provided by high-volume surgeons rose from 23% to 59%. The percentage of ophthalmologists performing laser trabeculoplasty was stable, around 50% but the mean number of laser procedures performed per year increased 120% over the study period.

The authors suggest some reasons for that, taking into account that Ontario physicians receive payment from insurance services only through OHIP (Ontario Health Insurance Plan) and cannot bill the patient.

• The fellowship training opportunities have grown;
• Other surgeries are more remunerative per unit time;
• Glaucoma surgery carries more risk of complications;
• Medico legal risks.

Furthermore, symptoms in glaucoma (primary open angle) and worsening of the quality of vision usually starts after surgery which makes this kind of surgery less rewarding to the patient and surgeon. Although the results of this study cannot be extrapolated to other areas of the world, it has the merit to call the attention for the fact that the number of glaucoma surgeons are decreasing in Ontario and suggest some reasons for that. In the next future new public policies will be necessary to make these surgeries more attractive to the ophthalmologists in other places where the same trend are occurring. It would be worth for the readers if the authors had compared the glaucoma surgeon honorarium with other kind of eye surgeries as cataract and refractive surgeries in 1995 and 2010.

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