I remember it like it was yesterday. Six months ago, I implanted my first Visian Implantable Collamer Lens (ICL; STAAR Surgical) in a patient with a glasses prescription for -18.00 D. During her preoperative visit, the patient described a life in which she constantly depended on her thick glasses and contacts. As a mother of three, she recalled numerous times when she had to get up in the middle of the night and hunt for her glasses while her children cried for her. She also described how she had resorted to sleeping in her contacts—a confession that’d make any eye care provider cringe. As I started to explain to her how dangerous this was, she told me, “Doctor, I know it’s wrong. But if you were completely blind and your kids needed you, what would you do?”
Figure | Drs. Mueller and Parkhurst in the OR.
As I sat at the surgical microscope, looking into her eye and preparing to perform my first bilateral ICL procedure, I started to get nervous. I had already performed more than 600 cataract surgeries in residency, as a practicing comprehensive ophthalmologist for 1 year, and now as a refractive surgical fellow; however, in this moment I felt like a second-year ophthalmology resident performing my first cataract surgery all over again. I kept thinking about this 30-year-old mother of three entrusting me with her eyes. She did not have cataracts, glaucoma, or macular degeneration. What she had was a significant amount of myopia, and all she wanted to was to experience the world without being completely dependent on glasses or contacts to see. As I started to make my first incision, one thought kept racing through my mind: This surgery requires absolute perfection.
A LACK OF EXPOSURE
According to the Accreditation Council for Graduate Medical Education, in 2019 there were 115 ophthalmology programs that graduated 468 residents.1 Looking at the council’s standards for ophthalmology residents to graduate with a core competency in refractive surgery, the requirements fall amazingly short. The current requirement is to perform or assist in six keratorefractive procedures, which includes observing an attending perform a limbal relaxing incision.2 In 2019, the national median for graduating US residents for total keratorefractive surgical procedures performed as the primary surgeon was two.1 The national median for either LASIK or PRK performed by graduating US residents as the primary surgeon was zero.1 The lack of exposure to refractive surgery during residency leaves many ophthalmologists uninformed about state-of-the-art refractive surgery, so they may not consider it as a career choice.
With the volume of cataract surgeries that will be needed to treat the baby boomers and the new refractive IOLs becoming available, surgeons must understand the full spectrum of corneal and lens refractive surgery in order to treat these patients properly. Many residents complete a cornea fellowship to gain refractive surgery experience, yet much of their time as cornea fellows is spent performing corneal transplants and treating external diseases. It is no wonder, then, that a leading company that sells excimer lasers in the United States reported that fewer than 400 lasers are used to perform more than 500 refractive procedures per year and only 8% of cataract procedures are done with premium IOLs (including torics).3
GAINING REFRACTIVE SURGERY EXPERIENCE
My refractive surgery journey began with a stint in general ophthalmology. When I graduated from residency, I knew I wanted to be an excellent cataract surgeon. I joined a comprehensive ophthalmology practice with the hopes of gaining refractive surgery experience; however, I quickly realized that would not be the case. I found it unsettling to offer premium lenses because I knew that, if I did not hit my target, I did not have the adequate training (or technology, for that matter) to perform a corneal refractive procedure to get my patients across the finish line. Realizing the significant gap in my training and wanting more refractive surgery experience in general, I joined the Refractive Surgery Alliance (RSA). Through this network, I came into contact with Greg Parkhurst, MD. Dr. Parkhurst offered me his first private Refractive Surgery Fellowship at Parkhurst NuVision in San Antonio, Texas (Figure).
I am now 7 months into this fellowship, and I have performed more than 2,200 ophthalmic laser procedures, the majority being laser cataract surgery and LASIK, in addition to more than 80 ICL procedures (including many toric ICLs). I can honestly say that this is one of the best decisions that I could have ever made for my future career as a refractive surgeon. Learning to be a refractive surgeon and approaching and counseling every patient with a refractive mindset is, for me, essential to deliver excellent vision to patients. I have come to learn that refractive surgery is significantly more demanding than general ophthalmology because the only acceptable outcome is perfection. The focus on performance rather than on the treatment and prevention of disease requires a high skill level and a refractive mindset. Refractive surgery is far more than just stepping on the pedal of an excimer laser, and a focused fellowship is necessary.
So, as I sat at the operating scope ready to make the first incision in my first ICL procedure, my confidence was bolstered by having my mentor Dr. Parkhurst at my shoulder, guiding me through each step. This is how refractive surgery training should be performed. This is how the wealth of knowledge should be passed from experienced refractive surgeons to the next generation of ophthalmologists.
Over the past 5 years, multiple private refractive surgery fellowships have popped up across the country, with more to come. Several well-known refractive surgeons throughout the United States have recognized the void that exists for refractive surgery training in residency programs. The RSA has developed an innovative curriculum for fellowships that recognize the multidimensional skillset required to perform as a refractive surgeon. This curriculum goes beyond clinical and surgical training to include extensive exposure to innovation and technology, didactic programs on the full scope of corneal and lens-based refractive surgeries, and business training with the Physician CEO program at the Kellogg School of Management at Northwestern University. My fellowship at Parkhurst NuVision is one of the RSA fellowship program beta sites.
A TREMENDOUS ADVANTAGE
On postoperative day 1, my first-ever ICL patient who had lived her whole life as a -18.00 myope, was brought to tears by her new ability to see the world clearly. It was then that I truly realized how amazing and fulfilling it is to be a refractive surgeon. The same fulfillment happens with all cataract patients who achieve spectacle independence and report that they have not seen so well in decades. With the burgeoning cataract population and the advanced technologies in lens surgery, the ability to deliver great unaided vision to patients is a tremendous advantage.
I hope that this message resonates with current residents who are interested in becoming refractive surgeons. There are many ophthalmologists who perform refractive surgery, but not all are true refractive surgeons. If you want to be a refractive surgeon, seek out a specialized fellowship and find a mentor who excels in this space. Your patients’ lives, along with your own future and success, will be bright as a result.
1. Ophthalmology Case Logs: National Data Report. ACGME. bit.ly/MEMueller1. Accessed February 1, 2020.
2. Required Minimum Number of Procedures for Graduating Residents in Ophthalmology. ACGME. bit.ly/MEMueller2. Accessed February 1, 2020.
3. Freeman W. Market Scope 2018 Ophthalmic Surgical Instrument Report. A Global Market Analysis for 2017 to 2023. St. Louis, MO: Market Scope; January 2018.
