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The Edmiston 6: Key rules for a successful refractive cataract fellowship

Premium and refractive procedures are gaining more exposure during private practice fellowships.

Traditionally, anterior segment fellowships have been more in line with a pure corneal track with exposure to penetrating keratoplasty, Descemet’s stripping endothelial keratoplasty, Descemet’s membrane endothelial keratoplasty, pre-Descemet’s endothelial keratoplasty, deep anterior lamellar keratoplasty and cross-linking. In the last few years, with the guidance of the SF Match process, private practice anterior segment fellowships have been growing at an increasing pace to include exposure to more common daily anterior segment conditions such as cataract and refractive procedures.

These latter fellowships give exposure to femtosecond laser-assisted cataract surgery and premium IOLs of all types currently approved in the U.S.: Symfony/Symfony toric extended depth of focus and low add multifocal IOLs such as ZLB00 (Johnson & Johnson Vision), ActiveFocus/ActiveFocus toric IOLs (Alcon), and enVista toric/Crystalens/Trulign (Bausch + Lomb). Refractive procedures such as PRK, LASIK, small incision lenticule extraction (Zeiss), ICL/toric ICL (STAAR) and Kamra (CorneaGen) are all part of the modern-day private practice anterior segment fellowship as well. There is less emphasis on pure corneal procedures with the exception of cross-linking for keratoconus and corneal ectasia. Premium and refractive procedures gain little, if any, attention during most residency tracks, so these newer private practice fellowships are gaining in popularity.

With the guidance of my colleagues Robert Weinstock, Rich Davidson and Bill Wiley, I was convinced to add my first anterior segment fellow to my practice in July 2018. Together, my current fellow Anna Edmiston and I created the “Edmiston 6 Rules” for a successful refractive cataract fellowship. I hope these can be a guide for current and future fellows as they venture into the premium world of refractive and refractive cataract surgery, or as the term is changing to premium vision correction surgery.

The Edmiston 6 Rules

1. Stay the course and pick your mentor’s brain. Follow your mentor’s recipe for success in the OR as it pertains to cataract surgery. Learn each single step of the procedure so that it can be done Karate Kid style with eyes closed, such that the muscle memory is to perfection. Remember, perfect practice leads to perfect. Learn as many intraocular maneuvers, phacoemulsification techniques, femtosecond laser applications, astigmatism management techniques and intraoperative aberrometry measurements as you can. And do as many procedures as you can during your 1 year, especially the ones your mentor does best.

2. Stay within your means. Complications do happen; learn how to handle them and not go beyond reason. Stay humble, follow the recipe and put in a three-piece IOL when appropriate, do the anterior vitrectomy when indicated, and never go beyond your means without proper training.

3. Be a sponge. Learn as much as possible, including MIGS devices, miLoop (Zeiss), Zepto (Mynosys), all femtosecond laser applications in both refractive and cataract surgery, excimer laser nomograms, SMILE, ICL technology, flap management in LASIK, PRK haze management and so on. And do as many procedures as you can.

4. Say “yes” to responsibilities. If you are lucky enough to be in a busy anterior segment fellowship, there are likely research projects, speaking engagements, clinical studies, staff office tasks and administrative leadership roles, among other opportunities that you can perform during your fellowship. If there is something your mentor cannot say “yes” to because he/she is busy, you can say “yes” to these things and reap the benefits of doing things that you would not normally be asked to do in this stage of your training.

5. Exercise. Yes, exercise! It might a quick fellowship with temptation to hold off on exercise and well-being, but doing such will only help keep you sharp and on your game to take on the new challenges and longer surgery days with higher volumes than you experienced during residency.

6. Seek constructive criticism. There is no crying in baseball! A 1- or 2-year fellowship is a short time for improvement, but take this opportunity to have a seasoned mentor give you advice. There is no interval that is too often to seek feedback and improvement.

I hope the Edmiston 6 Rules for anterior segment fellowship will set the foundation for improvement for all those going through a fellowship. I look forward to my next fellow this summer to keep the mojo going.

Disclosure: Jackson reports he is a consultant for Bausch + Lomb, Carl Zeiss Meditec, Alcon and Johnson & Johnson.

Traditionally, anterior segment fellowships have been more in line with a pure corneal track with exposure to penetrating keratoplasty, Descemet’s stripping endothelial keratoplasty, Descemet’s membrane endothelial keratoplasty, pre-Descemet’s endothelial keratoplasty, deep anterior lamellar keratoplasty and cross-linking. In the last few years, with the guidance of the SF Match process, private practice anterior segment fellowships have been growing at an increasing pace to include exposure to more common daily anterior segment conditions such as cataract and refractive procedures.

These latter fellowships give exposure to femtosecond laser-assisted cataract surgery and premium IOLs of all types currently approved in the U.S.: Symfony/Symfony toric extended depth of focus and low add multifocal IOLs such as ZLB00 (Johnson & Johnson Vision), ActiveFocus/ActiveFocus toric IOLs (Alcon), and enVista toric/Crystalens/Trulign (Bausch + Lomb). Refractive procedures such as PRK, LASIK, small incision lenticule extraction (Zeiss), ICL/toric ICL (STAAR) and Kamra (CorneaGen) are all part of the modern-day private practice anterior segment fellowship as well. There is less emphasis on pure corneal procedures with the exception of cross-linking for keratoconus and corneal ectasia. Premium and refractive procedures gain little, if any, attention during most residency tracks, so these newer private practice fellowships are gaining in popularity.

With the guidance of my colleagues Robert Weinstock, Rich Davidson and Bill Wiley, I was convinced to add my first anterior segment fellow to my practice in July 2018. Together, my current fellow Anna Edmiston and I created the “Edmiston 6 Rules” for a successful refractive cataract fellowship. I hope these can be a guide for current and future fellows as they venture into the premium world of refractive and refractive cataract surgery, or as the term is changing to premium vision correction surgery.

The Edmiston 6 Rules

1. Stay the course and pick your mentor’s brain. Follow your mentor’s recipe for success in the OR as it pertains to cataract surgery. Learn each single step of the procedure so that it can be done Karate Kid style with eyes closed, such that the muscle memory is to perfection. Remember, perfect practice leads to perfect. Learn as many intraocular maneuvers, phacoemulsification techniques, femtosecond laser applications, astigmatism management techniques and intraoperative aberrometry measurements as you can. And do as many procedures as you can during your 1 year, especially the ones your mentor does best.

2. Stay within your means. Complications do happen; learn how to handle them and not go beyond reason. Stay humble, follow the recipe and put in a three-piece IOL when appropriate, do the anterior vitrectomy when indicated, and never go beyond your means without proper training.

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3. Be a sponge. Learn as much as possible, including MIGS devices, miLoop (Zeiss), Zepto (Mynosys), all femtosecond laser applications in both refractive and cataract surgery, excimer laser nomograms, SMILE, ICL technology, flap management in LASIK, PRK haze management and so on. And do as many procedures as you can.

4. Say “yes” to responsibilities. If you are lucky enough to be in a busy anterior segment fellowship, there are likely research projects, speaking engagements, clinical studies, staff office tasks and administrative leadership roles, among other opportunities that you can perform during your fellowship. If there is something your mentor cannot say “yes” to because he/she is busy, you can say “yes” to these things and reap the benefits of doing things that you would not normally be asked to do in this stage of your training.

5. Exercise. Yes, exercise! It might a quick fellowship with temptation to hold off on exercise and well-being, but doing such will only help keep you sharp and on your game to take on the new challenges and longer surgery days with higher volumes than you experienced during residency.

6. Seek constructive criticism. There is no crying in baseball! A 1- or 2-year fellowship is a short time for improvement, but take this opportunity to have a seasoned mentor give you advice. There is no interval that is too often to seek feedback and improvement.

I hope the Edmiston 6 Rules for anterior segment fellowship will set the foundation for improvement for all those going through a fellowship. I look forward to my next fellow this summer to keep the mojo going.

Disclosure: Jackson reports he is a consultant for Bausch + Lomb, Carl Zeiss Meditec, Alcon and Johnson & Johnson.