17 July 2010
Posted in Pearls in Ophthalmology
By George O. Waring IV, MD
By George O. Waring IV, MD
Beginning a fellowship in corneal-refractive surgery can be an intimidating experience as residents often have limited exposure to this subspecialty during their training. Just like starting your residency in ophthalmology, the learning curve can be steep- but you will get there. Sit down with your preceptor on the first day and define the goals and expectations of your fellowship. The objectives of a corneal-refractive fellowship can broadly be divided into patient and procedure selection, surgical technique, and communication with refractive patients.
Patient and Procedure Selection
The primary considerations in patient and procedure selection for refractive surgery are assessing risk factors for the development or exacerbation of keratoectasia, providing optimal optics, and screening out certain personality types. First and foremost, the fellow should become facile with interpretation of corneal maps (keratometric, anterior and posterior elevation, and corneal thickness). This skill is largely pattern recognition, and therefore a beginning fellow should make it a priority read about the interpretation of the different types of corneal maps and then practice as much as possible.
A clear understanding of risk factors for the development or exacerbation of keratoectasia after corneal refractive surgery is imperative. The fellow should familiarize themselves with the many keratoconus risk factor grading scales, and develop their own systematic method of determing candidacy. Other preoperative considerations include, but are not limited to pupil size, pre-existing dry eye and blepharitis, anterior basement membrane, corneal scars, lens changes, amblyopia, nystagmus and systemic co-morbidities.
The refractive fellow should also understand how each procedure affects corneal curvature and overall optics. For example, a moderate hyperope with steep keratometry would not be a good candidate for corneal refractive surgery, but may be a good candidate for a refractive lens exchange. In recent years, many new excimer laser ablation profiles have been introduced which may correct or preserve higher order aberrations (HOA). An understanding of wavefront aberrometry and the indications for conventional, aspheric or custom profiles are important for addressing HOA. The refractive fellow should learn the optical and mechanical principles distinguishing different excimer and femtosecond lasers.
Finally, it is a good idea to avoid corneal refractive surgery in patients who have hyper-perfectionist, obsessive-compulsive or “type AAA” personality types. These traits can be subtle, and difficult to detect during a single preoperative exam. However, personality screening is an important consideration in patient selection.
Communicating with Refractive Surgery Patients
Communicating effectively with refractive surgery patients is an important skill. Patients seeking elective refractive surgery tend to have different “needs and wants” than many of the patients that we treated on a non-elective basis during residency, and the expectation level tends to be high. Most refractive patients have researched the procedures prior to presentation, and are in your office because of “word of mouth”. Whether it is dealing with healing after PRK, or neuroadaptation after monovision, patient reassurance is an integral part of refractive surgery. Clear communication regarding patient expectation and possibility of post-procedure treatments is important. A basic approach is to under-promise and over-deliver. Typically, this is best learned by direct observation from one’s preceptor.
LASIK may look easy, but it is a surprisingly complex procedure. Approach corneal refractive procedures in a step wise manner, similar to cataract surgery, where each step builds on the prior. The Refractive Surgery volume of the Academy’s Basic and Clinical Science Course is an excellent basic reference and should be read before starting your fellowship. Surgical videos of corneal refractive surgery are an effective way to gain exposure to basic and new techniques. Also, reading the peer reviewed literature such as the Journal of Refractive Surgery is a sure-fire way to stay current on evolving techniques and technology.
Although there is a movement toward femtosecond laser flap creation, a well rounded fellow should also become facile with a blade microkeratome. In addition, the subspecialty of refractive surgery is quickly becoming more lens based, and therefore a fellow should invest time and energy into gaining exposure and experience with phakic IOLs, refractive lens exchanges (basic phacoemulsification for cataract surgery will hone these skills) and post-refractive IOL calculations.
There are many “tools in the tool-box” for vision corrective surgery such as conductive keratoplasty, Intacs® corneal inlays, and astigmatic keratotomy- try to get as much exposure to these surgical modalities as possible. The management of refractive surgery complications is important. The refractive fellow should learn to identify and manage post operative complications such as epithelial ingrowth, slipped flaps, striae, deep lamellar keratitis, transient light sensitivity, infections and keratoconus after corneal refractive surgery.
The treatment of presbyopia is an emerging “sub-sub specialty” and therefore a refractive fellow should become familiar with a reliable method of determining ocular dominance and the different surgical treatment options and indications.
In addition to the basics listed above, there are other considerations when starting a cornea refractive surgery fellowship. Take advantage of any opportunity to complete laser and other refractive technology certification. Also, pay attention to laser operation and trouble shooting, don’t rely on the OR staff as the surgeon is ultimately responsible.
Try to identify special areas of interest and pursue research early on with the goal of submitting abstracts to conferences and/or the peer reviewed literature. Look for teaching moments and lecture opportunities with residents. Teaching refractive surgery is always appreciated by the residents who may have minimal exposure to this discipline, and teaching solidifies your knowledge base.
Finally, most fellows will be sitting for the written boards and applying for a job during their fellowship. Begin preparation for both early in the year and budget your time accordingly as both tasks are top priorities. Fellowship preceptors are usually aware of these critical processes; however, it is a good idea to communicate clearly about time expectations for studying and interviews.
Fellowship training in the rapidly evolving subspecialty of refractive surgery is a rewarding experience. Clearly defining your goals early on will enhance fellowship training experience, and likely result in a satisfying and productive career in refractive surgery.