Early in training, we ophthalmology students learn primarily from the decisions made by our attendings. We look to them for guidance on which medication, treatment course, or surgery a patient would benefit from the most. But as our training progresses from early residency to glaucoma fellowship, our autonomy and opportunities for decision-making increase greatly.

Glaucoma fellows today face a challenge that was not encountered by previous generations. In the past, glaucoma surgical training focused largely on perfecting trabeculectomies and, more recently, tube shunt surgeries. These procedures represented the gold standard, and they had to be mastered. Now, however, there is a wide array of surgeries for the glaucoma fellow to take into account. Although filtering and shunting procedures are still encouraged for refractory glaucoma, microinvasive glaucoma surgery allows surgeons to titrate surgical procedures based on the severity of each case and on the characteristics and wishes of each patient.


This shifting paradigm poses a challenge for the training glaucoma surgeon. As it is possible to perform only a finite number of surgeries during a fellowship training program, what portion of surgical training should be devoted to each procedure?

We often feel external pressure to sharpen our skills in many different areas of surgical glaucoma. We are asked to master the art of tube surgery and trabeculectomy, which are still necessary for refractory or severe glaucoma. But we are also encouraged to explore the immense undertaking of angle-based and subconjunctival microinvasive glaucoma surgery while simultaneously trying to maintain the cataract extraction skills we worked so hard to attain in residency. As ophthalmologists and microsurgeons, we are accustomed to extreme attention to detail and precision. The idea of learning a surgery but not entirely mastering it prior to starting practice can be nerve wracking.


What can we, as trainees, do to tackle this seemingly insurmountable task? The first step, as in many challenges in life, is acceptance. First, we should accept that we will not reproduce the training of our preceptors in traditional glaucoma surgery while maintaining our surgical load of cataract surgery and staying at the forefront of the novelties of glaucoma surgery. Trying to achieve all three of these feats is impossible.

Second, in the face of a wide range of options, we can try to find a common thread. The breadth of glaucoma surgeries performed today is much greater than it was for past generations, but there are common themes that traverse these procedures. If we cannot familiarize ourselves with each surgery, we must find similarities among them and hone those skills.

For example, some new bleb-forming procedures, such as Xen Gel Stent (Allergan) implantation, can teach us a great deal about bleb management (morphology, needling, and managing leaks). Although we may not perform as many trabeculectomies as our mentors did, we can still get comfortable with bleb management. Similarly, many of the angle-based procedures may seem quite different in their required skill sets and mechanisms. However, we can focus on mastering intraoperative gonioscopy, localizing angle structures, and threading the canal, as these skills can be applied to many angle-based procedures.


Although we cannot excel in as many surgical procedures as we would like, we can focus on what makes them all similar and use one surgery to learn the subtleties of others. Unfortunately, long-term data on these emerging surgeries is limited, and we do not know which will be most common in the next few decades. Thus, as trainees in the constantly fluid field of surgical glaucoma, we should try our best to hone a range of skills and not necessarily focus on mastering one specific type of surgery.