Resuscitating refractive surgery

With an ever-growing number of procedures, the need for education is essential.

By Nicole A. Lemanski, MD, Aaron Waite, MD and Guy M. Kezirian, MD

Refractive surgery has a problem. The problem is not a lack of potential for growth; it is not a need for public acceptance; nor is it a concern over the economics.

While these are valid issues, there is a more fundamental consideration: few paths exist for practicing ophthalmologists to acquire the skills needed to successfully practice modern-day refractive surgery.

Modern refractive surgery

The evolution of refractive surgery has been rapid. In 25 years the field has gone from limited incisional procedures, such as radial keratotomy for myopia, to a wide array of procedures that can correct nearly every refractive error at every refractive milestone — distance correction at ocular maturity, near correction for presbyopia, and refractive lens procedures for patients with dysfunctional lens syndrome and cataracts.

An underutilized technology

While broad-ranging capabilities allow patients to maximize their visual potential, such procedures can present a challenge for ophthalmologists. The current model for surgical training provides little opportunity for established, and by proxy, younger, ophthalmologists, to break into refractive surgery. According to a 2015 ASCRS survey, fewer than one-third of residents have ever seen a single LASIK case performed, let alone performed a LASIK procedure; 51% rated their knowledge of presbyopia-correcting IOLs as “poor or very inadequate” and 59% have implanted fewer than five toric lenses.¹ Similarly, most “cornea-refractive” surgical fellowships are more cornea than refractive.

Advances in refractive surgery have occurred so quickly that even experienced ophthalmologists underutilize current refractive technologies. In cataract surgery for example, fewer than 14% of all procedures involve implantation to correct astigmatism or presbyopia.² Additionally, not all cataract surgeons have access to an excimer laser to correct small amounts of residual refractive error that may exist after lens surgery. Even refractive surgeons have difficulty keeping up; those who devoted more time to laser refractive surgery may see their intraocular surgical skills decline.

There is a wide gap between what refractive surgery has to offer patients and what most ophthalmologists can provide. Given that 70% of all ASCRS members surveyed indicated that they wanted to learn refractive techniques, it seems clear that lack of opportunity prevents ophthalmologists from offering refractive surgery in their practices, thus limiting the growth of refractive surgery.

Facts and numbers

In 2010 roughly 60%³ of the 234 million adults in the United States⁴ were affected by refractive error. This means 115 million people between 18 and 65 years of age, and 23 million people over 65 years had the potential to benefit from refractive surgery; the 21- to 55- year-olds from a corneal procedure, and those ages 55 years and older, from a lens procedure.

With fewer than 1 million laser vision correction procedures performed in the US in 2011, less than 1% of those with refractive error were treated. In 2015, the adult population grew to 247 million,⁴ yet only 650,000 laser surgeries were preformed. When a field offers such life-enhancing benefits but serves such a small percentage of potential candidates, it is time to look for a new approach.

A solution

The Refractive Surgery Alliance (RSA) is a physician-funded organization whose mission is to expand the scope of physician education and bring the benefits of refractive surgery to a greater population. New this year is the RSA Master of Refractive Surgery program, a novel surgical training program targeted at practicing ophthalmologists. The program has four dimensions:

1) Business/Leadership Training. The Physician CEO program is offered for four, five-day sessions over nine months at the Kellogg School of Management at Northwestern University. It provides the skills necessary for the physician to take on the roles of entrepreneur and CEO.

2) Innovation and Translational Science. This dimension provides the technical background so physicians understand the capabilities and limitations of lasers, lenses, optics and materials, enabling surgeons to also be innovators. It is taught in four, three-day modules that repeat each year.

3) Essentials of Refractive Surgery. This online program has core principles (lectures, videos, digital materials, articles, and virtual reality surgical training) essential for the refractive surgeon.

4) Practical Dimensions in Refractive Surgery. This is an on-site, in-practice program offering participants clinical training, surgical skills and techniques essential to succeed as a refractive surgeon.

The Master of Refractive Surgery program provides the scientific knowledge and the clinical and business skills necessary to become a successful refractive surgeon. Participants are required to take all four parts. RSA supports its own educational endeavors.

This program does not try to replicate programs that already exist. Rather, it answers the question, “What do refractive surgeons need to know, and what skills do they need to succeed?”

The RSA anticipates an ever-increasing demand for refractive procedures that will provide vision independence from glasses and contact lenses. The program encompasses and teaches all aspects of refractive surgery: the basic science behind the procedures, the clinical, surgical and communication skills needed to successfully treat patients and the business knowledge of how to run a successful refractive practice.

As more ophthalmologists develop expertise in refractive surgery, demand for procedures will rise. Graduates from the program will be ready and able to meet that demand. OM

For more detailed information on the RSA program, please visit www.refractive alliance.com.

REFERENCES

About the Authors
	Nicole A. Lemanski, MD, practices cornea, refractive and anterior segment surgery in the practice of Mabel Cheng, MD, PLLC, in Niskayuna, N.Y., and is on staff at Albany Medical College and a member of the RSA executive committee.
	Aaron N. Waite, MD, is assistant professor of ophthalmology and Director of the Cornea, Cataract and Refractive Surgery Department at the University of Tennessee Hamilton Eye Institute in Memphis and medical director of the Mid-South Eye Bank. He also is a member of the RSA executive committee.
	Guy M. Kezirian, MD, MBA, FACS, is founder of the Refractive Surgery Alliance, a professional organization comprising refractive and cataract surgeons worldwide whose aim is to create an alliance of qualified, ethical refractive surgeons to promote refractive surgery through education, research, management and patient care. Dr. Kezirian is also founder of the Physician CEO program at Kellogg School of Management at Northwestern University, and SurgiVision® Consultants in Scottsdale, Ariz.