In this installment of Interventional Mindset, Drs. Venkateswaran, Mueller, and Hura review pearls for refractive surgeons interested in incorporating new refractive surgery techniques into their practice.
Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.
Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.
5 steps for adopting a new surgical technique
1. Invest time in watching surgical videos of the new technique.
For surgeons interested in integrating a new surgical procedure or technique into their practice, Dr. Hura recommended watching as many videos on YouTube, Instagram, and social media as possible to become familiar with looking at the procedure while listening to narration from experienced surgeons.
2. Join an organization with educational resources.
Then, he advised surgeons to become a member of the American Academy of Ophthalmology (AAO) and/or the American Society of Cataract and Refractive Surgery (ASCRS), as both offer members educational resources, such as instructional videos and tutorials on how to adopt new techniques.
3. Seek out wet labs/resources from the companies offering the new technology.
Next, Dr. Hura highlighted the value of getting in touch with industry as they often have local representatives available to familiarize surgeons with new technology, facilitate hands-on simulations and peer-to-peer discussions, as well as provide online modules for reviewing technical aspects of procedures.
4. Shadow high-volume surgeons performing the procedure of interest.
Most importantly, Dr. Hura encouraged surgeons to visit established high-volume surgeons for a few days to observe the nuances of the procedure as it is being performed. Further, this can open up the potential for a mentorship opportunity when forging a relationship with an experienced surgeon by having someone as a point of contact for any future questions.
5. Build a foundation for success with careful patient selection and post-operative monitoring.
Lastly, Dr. Venkateswaran advised surgeons, especially when they are navigating the first several cases, to ensure that they pick the best-matching patient personality, are in operating rooms where they feel comfortable, give the patient adequate anesthesia, and potentially even stage the procedures a few weeks apart (if medically necessary) to make time for fine-tuning the technique.
Similarly, she also recommended that surgeons carefully monitor patients post-operatively to better understand how their surgical techniques result in refractive outcomes and how the procedure can be tweaked to optimize the results.
Surgical pearls for newcomers to ICL surgery
While discussing tips for integrating new technologies, Dr. Mueller added that, particularly for surgeons new to implantable collamer lens (ICL) surgery, determining the correct sizing can be a challenge. When deciding on the best size, he encouraged surgeons to factor in which instrument(s) they will use to take white-to-white diameter measurements; or if they will perform ultrasound biomicroscopy (UBM) or ultrasound to determine sulcus-to-sulcus measurements.
As a follow-up, Dr. Venkateswaran asked Drs. Hura and Mueller if their standard of care for ICLs is generally a same-day bilateral procedure. Dr. Hura explained that he typically performs ICLs as a same-day bilateral procedure, but if a patient prefers to proceed with one eye at a time, he will often encourage spacing the eyes apart by only 1 to 2 weeks. There can often be a large degree of anisometropia if the fellow eye that has yet to be operated on likely will be without correction in the interim period between both surgeries.
Subsequently, when organizing the first case featuring a new technology or procedure, Dr. Mueller emphasized the benefit of looking for patient personalities and anatomies that could minimize the chance of complications. For example, he advised surgeons performing their first ICL procedure to make sure that the anterior chamber depth is relatively large (3.4mm to 3.6mm).
The value of diagnostic assessments prior to surgery
In Dr. Hura’s experience, when it comes to refractive surgery, there are three factors to consider:
- Proper patient selection, including thoroughly understanding all diagnostic testing, the benefits and limits of any given surgical procedure, and understanding long-term outcomes.
- The surgery itself, variations on procedural technique to adapt to each patient’s behavior as needed, and understanding how to navigate potential intraoperative complications if they arise.
- The art of refractive surgery, including how to establish and build rapport with patients and create an amazing patient experience from start to finish.
He explained that while most surgeons understand that surgical experience and knowledge come with repetition, this is equally true for clinical acumen as well. It is important to have a comprehensive understanding of topography, tomography, epithelial maps, ultrasound, and how these diagnostic tests mesh with the patient’s refraction, pachymetry, and ocular anatomy.
The more one masters the understanding of pre-operative diagnostics, the more confident they will feel in offering refractive procedures and achieving favorable surgical outcomes, meeting both the surgeon's and patient’s expectations.
What’s on the horizon for refractive surgery?
As refractive surgery continues to evolve, diagnostics will continue to advance in concert. Dr. Hura highlighted epithelial thickness mapping as an example of a diagnostic modality that has continued to evolve and has garnered more and more interest as surgeons seek to understand the dynamic remodeling that can take place in response to underlying keratoconus-spectrum disorders, contact lens use, and refractive surgery.
He predicted that in the future, lenticule extraction will likely become more prevalent and that lenticule addition, refractive indexing, modular intraocular lenses (IOLs), variations of post-operative adjustment of IOLs, and pharmacological treatments to address presbyopia and dysfunctional lens syndrome might all play a pivotal role in the next decade of refractive surgery.
Final thoughts
Due to the constantly evolving nature of technology, Dr. Hura noted that refractive surgeons have to be lifelong learners as innovation and constant change in refractive surgery are a guarantee. In addition to staying up-to-date with the latest literature and understanding upcoming technology in the pipeline, it can be helpful to attend meetings and build a network of like-minded surgeons who can share their personal clinical and surgical experiences.
Dr. Venkateswaran added that one of the reasons she feels inspired to keep building her practice and stay at the forefront of technology is because her peers and colleagues keep pushing the envelope, thereby motivating her to continue enhancing her surgical proficiency.
To close, she explained that to successfully integrate new techniques, surgeons need to be curious and passionate, as refractive surgery is dynamic, and technological advancements bring continuous innovation to the field.
