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Clinical teaching across the Atlantic: Learning in action



Surgeons enjoy learning from each other, particularly as surgeons on one continent earn experience with a new device or technique and their peers on the other side of the Atlantic want to know more about it

A continuous, healthy exchange of clinical information and new ideas takes place between glaucoma surgeons in the United States and Europe every day. We enjoy learning from each other, particularly as surgeons on one continent earn experience with a new device or technique and their peers on the other side of the Atlantic want to know more about it. We are also continuously curious about the way our peers work, such as the flexibility or freedom they are permitted in devising the best treatment for each patient. Many factors influence how and why glaucoma surgery varies in our different parts of the world, but our commitment to sharing our experiences remains constant.

A “head start” on glaucoma devices and techniques

One reason so much teaching takes place across the miles is the disparity in access to glaucoma devices and techniques. Differences in the approval processed for FDA and CE Mark approval tend to make devices available in the EU before the US. The FDA requires proof of both safety and efficacy, whereas for CE Mark approval, researchers can supply safety data alone and track efficacy once the device is in the hands of practicing physicians.

Today, for example, European surgeons using the InnFocus MicroShunt (InnFocus) are drawing the interest of surgeons in the US, where FDA trials are now underway. The Hydrus microstent (Ivantis), which was FDA approved in August, also has been available in Europe for some time.

A few years ago, the XEN Gel Stent (Allergan) offered learning opportunities on both continents. XEN was available in Europe several years before US surgeons had access to it, so US surgeons were able to learn from their peers’ experiences. At the same time, the FDA clinical trial required use of mitomycin C on a sponge under the conjunctiva, which differed from the European approach of subconjunctival injection.

Both methods were effective, and now surgeons on the US feel comfortable using either approach because the data support both. While surgeons in the EU tend to have earlier access to devices used to treat glaucoma, American glaucoma surgeons may have more experienced with new techniques.

One reason is that certain MIGS techniques have been developed in the US. For example, Malik Y. Kahook at the University of Colorado invented the Kahook Dual Blade (New World Medical) instrument and technique for goniotomy. European surgeons have little or no experience with this MIGS procedure and are learning about it through their American peers. Gonioscopy-assisted transluminal trabeculotomy (GATT) is not used very much in Europe, either, so Americans with significant experience doing GATT are teaching EU surgeons.

Freedom and flexibility

In addition to access to new procedures, EU and US surgeons can differ in terms of the amount of freedom and flexibility they have to use those procedures and to explore new avenues. European surgeons have the flexibility to use multiple MIGS implants such as Hydrus and iStent, for instance, as well as to use those devices outside of cataract surgery. These approaches would not be reimbursed for surgeons in the US, but their European peers are more likely to be approved based on the balance of outcomes and costs.

The flexibility to use many MIGS devices as standalone procedures not only leads to different indications, but also reflects the trend in Europe for glaucoma surgeons to perform most glaucoma procedures, rather than turn them over to cataract surgeons. That trend, which generally results in more solo procedures than cataract-MIGS combinations, allows European surgeons to intervene in cases of advanced or aggressive glaucoma without waiting until the patient’s cataracts warrant surgery. US surgeons tend to be more flexible than their European peers in performing manipulations related to glaucoma procedures such as bleb work and needling at the slit lamp, rather than in the OR. This difference may be related to the costs of OR time in the US, compared to some European countries.

Learning experiences

In addition to following the literature, many surgeons take advantage of online videos of our peers’ talks and surgeries. Videos are welcome opportunities to get specific information in a very convenient format.

It is especially helpful to listen to peers with access to many surgical techniques and devices for glaucoma, so we can understand not only how they are used, but also how they are selected and/or combined. Because we do not have side-by-side comparisons of most glaucoma treatment modalities, and study designs vary for MIGS and other procedures, experienced surgeons’ perspectives on how they weigh treatment choices for their patients are particularly valuable.

Perhaps the richest source of learning is a face-to-face meeting at international conferences. For surgery in particular, small groups and workshop offer the important opportunity to ask questions about specific cases. Skype lectures are productive as well, but small workshops are most enjoyable for us as both attendees and lecturers for sharing experiences with peers, from close to home and far away.


Davinder S. Grover, MD, MPH, specializes in glaucoma and cataract surgery at Glaucoma Associates of Texas in Dallas.

Ingeborg Stalmans, MD, PhD, is head of the glaucoma unit at the University Hospitals Leuven (UZLeuven), Belgium

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