Clinical Pearls: Steps To Learning New Procedures

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8 min read

Familiarize yourself with techniques available to ophthalmologists for implementing new refractive surgery procedures into clinical practice.

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:
  1. Proper patient selection, including thoroughly understanding all diagnostic testing, the benefits and limits of any given surgical procedure, and understanding long-term outcomes.
  2. 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.
  3. 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.
Nandini Venkateswaran, MD
About Nandini Venkateswaran, MD

Dr. Nandini Venkateswaran is a member of the Cornea and Refractive Surgery Service at the Massachusetts Eye and Ear Infirmary and an Instructor of Ophthalmology at Harvard Medical School. She is a fellowship-trained cataract, cornea and refractive surgeon. Dr. Venkateswaran earned her medical degree with a distinction in community health from the University of Rochester School of Medicine and Dentistry, where she was inducted into the Alpha Omega Alpha medical honor society. She completed her Ophthalmology residency at the Bascom Palmer Eye Institute/University of Miami, after which she completed a fellowship in cornea, external disease and refractive surgery at Duke University.

Dr. Venkateswaran truly enjoys employing her clinical and surgical expertise and research background to treat patients with a compassionate, customized and multidisciplinary approach. She specializes in complex cataract surgery, femtosecond laser assisted cataract surgery with intraoperative aberrometry, most advanced techniques in corneal transplantation (DMEK, DSAEK, DALK, PKP), laser refractive surgery (LASIK and PRK), corneal cross-linking, anterior segment reconstruction (including secondary IOL implantation and iris repair), dry eye disease and ocular surface lesions and tumors.

Dr. Venkateswaran is an active member of the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery and currently serves on several committees in these organizations. She has co-authored over 40 peer-reviewed publications and numerous book chapters early in her career. She has received several awards for her excellence in research and clinical care and has presented her scientific work at numerous national and international meetings.

Outside of work, Dr. Venkateswaran enjoys spending time with her friends and family, learning to cook, and riding her peloton bike.

Nandini Venkateswaran, MD
Brett Mueller II, DO, PhD, PCEO
About Brett Mueller II, DO, PhD, PCEO

Brett H. Mueller II, DO, PhD, PCEO is a board-certified and fellowship-trained ophthalmologist who specializes in and has performed thousands of cataract and refractive eye surgeries. With advanced fellowship training in refractive surgery through the world college of refractive surgery and visual sciences, he hones a comprehensive range of skill sets needed to diagnose, address, and treat the full spectrum of refractive surgery.

After receiving his undergraduate degree from Texas A&M University, he then received his medical degree and PhD from the University of North Texas Health Science Center. His scientific work and academic accomplishments enabled him to author over 45 publications and book chapters, present at national and international meetings, and be a recipient of several grants (including an NIH grant). He was then accepted to attend an ophthalmology residency at the University of Louisville, where he developed a reputation for being a leader amongst his colleagues, serving as chief resident, and a skilled surgeon. After finishing residency training, Dr. Mueller then completed a one-year refractive, cataract, and anterior segment fellowship through the Refractive Fellowship Network and the World College of Refractive Surgery and Visual Sciences. He now specializes in state-of-the-art laser-guided cataract surgery and advanced lens implants that reduce or eliminate the need for glasses. He also specializes in the full spectrum of refractive surgery, which includes: modern LASIK, SMILE, EVO-ICLs, Refractive Lens Exchange, PRK, and Cross-Linking.

Brett Mueller II, DO, PhD, PCEO
Arjan Hura, MD
About Arjan Hura, MD

Dr. Arjan Hura is a cataract, refractive, and anterior segment surgeon at the Maloney-Shamie Vision Institute in Los Angeles, CA. Dr. Hura is passionate about providing his patients with the highest possible medical and surgical vision care and is committed to the American Academy of Ophthalmology‘s mission of protecting sight and empowering lives. His research and clinical interests include working with the latest cutting-edge technology to constantly try to improve patient outcomes.

Prior to joining MSVI, Dr. Hura completed his fellowship at the Cleveland Eye Clinic where he performed the full spectrum of vision correction, including advanced lens laser cataract surgery, laser vision correction through LASIK, PRK, and SMILE, implantable contact lenses, corneal cross-linking, and MIGS surgery.

During his residency at the University of Cincinnati, Dr. Hura was involved in several award-winning research studies and investigator-initiated trials. He received a National Eye Institute grant to present at ARVO during his internship, and he presented at ASCRS during all three years of his ophthalmology residency and was awarded Best Paper of Session at ASCRS 2019.

Arjan Hura, MD
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