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Corneal disease can result in profound visual loss, and corneal transplantation can provide near normal vision to many patients. Corneal surgery now more than ever encompasses a variety of diverse surgical procedures that go far beyond penetrating keratoplasty and frequently result in outstanding visual outcomes. For many decades, penetrating keratoplasty was the predominant procedure performed for many corneal disorders. Over the last decade, new techniques of lamellar surgery allow for replacing only the layers of the corneal that are abnormal and leaving the normal layers: endothelial keratoplasty (DSEK and DMEK) for endothelial disease; DALK for stromal disease; and ocular surface transplantation for epithelial disease. In addition keratoprosthetic devices, laser vision correction, collagen cross-linking, intrastromal implants are additional procedures that have greatly expanded the scope of practice of corneal surgeons.
I have been fortunate enough to have a career as a corneal surgeon and strongly recommend this field to any resident looking to subspecialize. The following concepts are what I feel have been important keys that I feel have helped me in my career as a corneal surgeon:
• Find a mentor. Most residents have the opportunity to work with several corneal surgeons during their residency. Identify the corneal surgeon who you believe has the willingness and wisdom to guide you during your residency and assist you in selecting the most appropriate fellowship for you. I was fortunate to have access to one of the most talented and skilled corneal surgeons and teachers in the United States during my residency. Dick Lindstrom was the director of the cornea service at the University of Minnesota. As a first year resident I sought out Dick’s guidance. He is a superb surgeon, great clinician and talented researcher. Dick was a tremendous mentor to me during my residency. He was always willing to take time to talk and give great counsel to me. Dick continues to be a trusted friend and advisor to this day.
Your fellowship is one of the most important years of your life. Seek the program and the fellowship director who is the best fit for your goals both as a fellow and a practicing corneal specialist. I have been fortunate to help train 45 corneal fellows during my career. I am a colleague, collaborator and friend to many of my former fellows, and I feel I learn as much from them as they learn from me after they finish and establish successful corneal practices.
• Practice your surgical techniques. The cornea, more than any structure of the eye, allows for the practice of surgical techniques. Eye banks are very willing to provide eyes for training. Take advantage of this opportunity. Beginning corneal surgeons often have trouble with efficiently tying sutures. As residents no longer perform a significant number of extracapsular cataract surgeries, they do not get the opportunity to master suturing. Hours of practice will make suturing second nature. This practice method can be utilized throughout a corneal surgeon’s career. As new techniques are developed, such as in the case DSEK and DMEK, eye bank eyes can be taken to the operating room and corneal surgeons can practice these procedures until they’re comfortable and ready to perform these surgeries on patients.
• Collaborate with colleagues both within and outside your practice. It is valuable to discuss surgical techniques and case management with other clinicians throughout your career. Having an ongoing interaction with other corneal surgeons whom you trust is an important asset. This collaboration has kept me current and continues to make me a better clinician and surgeon. Never be unwilling to learn, and always keep an open mind to new ideas and surgical techniques.
I have been fortunate to work with some very talented corneal surgeons who have guided and challenged me throughout my career. At the Cincinnati Eye Institute, we have many skilled cornea and cataract surgeons. My anterior segment partners such as Michael Nordlund, Robert Osher, Michael Snyder and Michael Hater continue to teach me surgical innovations.
It is more of a challenge but in many ways more important to seek colleagues outside of your practice as trusted advisors. Steve Lane, Eric Donnenfeld, Mark Mannis and Roger Steinert are a few of the many individuals that have taught, motivated and inspired me. I have found my continued interaction with these talented individuals invaluable to my career. I have also sought to reach out to the next generation of corneal surgeons to keep me current and on the cutting edge. Terry Kim and Barry Lee among others are the next wave of leaders, and I have enjoyed working with and learning from them.
• Join and participate in ophthalmic organizations. By being active in the various ophthalmic societies you can keep your education current and allow you to help shape your field. The American Academy of Ophthalmology is vital to all ophthalmologists and should be supported. With regard to corneal surgery itself, the American Society of Cataract and Refractive Surgery (ASCRS) and its Corneal Clinical Committee, the Cornea Society and the Eye Bank Association of America (EBAA) are the most important organizations to the field of corneal surgery. Be active in these organizations and seek leadership positions. Corneal surgeons’ involvement is desperately needed and vital to the assurance that the eye banking system in the United States continues to be successful at providing an adequate amount and a high quality of corneal tissue for our patients. The EBAA needs physician leadership for the development of medical standards, for the accreditation of Eye Banks and for interaction with the Food and Drug Administration, to name a few of the important physician activities. The Cornea Society is an essential organization for education and policy making for the specialty of cornea. Numerous committee positions are available for physician involvement. ASCRS is the educational and political voice for all anterior segment surgeons and its Corneal Clinical Committee is yet another opportunity to participate in corneal education and policy making. It is important to attend major meetings to continue progressing your education. It is also very rewarding to work in these organizations’ committees and lead the educational efforts to shape the future of corneal surgery. Engagement in the activities in these societies will not only make you a better corneal surgeon but will make you a more well-rounded person, particularly in the areas of business, politics and process.
• Stay current with new techniques. It is easy to get complacent and not adopt new surgical techniques especially later in one’s career. For most of my career, penetrating keratoplasty made up the vast majority of the corneal surgery that I performed. As stated above, the last decade has seen new, innovative surgical procedures. It wasn’t easy to learn all these new techniques. Change can be difficult. If surgeons don’t continue to stay current, like learning the latest endothelial keratoplasty techniques or the DALK procedure, their patients won’t receive the best surgical options and eventually the field will pass the surgeon by. Surgeons should challenge themselves to be on the cutting edge and perform the most innovative surgeries like they did just after their fellowship and also seek modifications or improved instrumentation to make the procedures safer, easier and better. A surgeon should continue to evaluate where he is in comparison to the rest of his colleagues throughout his career.
• Diversify your practice. In order to avoid the potential monotony of what you do, it is worthwhile and stimulating to develop a variety other aspects to your activities in addition to patient care.
1. Be active in clinical research and teach at major meetings. Every busy clinician has potential data that can be evaluated and reported. The involvement in clinical research keeps you current and involved. The concept of being “academic” has certainly changed over the years. One does not have to have an appointment at a university to be “academic.” I know clinicians who practice at universities who do not publish papers, contribute to textbooks or present at meetings. Their entire effort is the delivery of patient care. On the other hand, I know clinicians in private practice who conduct clinical research, publish papers and book chapters and present at meetings and are involved in the major ophthalmic organizations. Which is the more “academic” clinician? We all have something to contribute.
2. Work with industry as a consultant or become involved in clinical trials. Lately some individuals in government and the press portray interaction with industry as a negative activity. On the contrary, I have found collaboration with industry to be valuable for me and a benefit to my patients. It is an opportunity to help develop new products, and physician involvement is critical for this development. Working with industry also allows my patients access to the latest technology or medications. I have found that the majority of patients are interested in clinical research and are supportive of my involvement.
• Find balance in your life. One of the most difficult challenges we all have is finding the right balance between work, family, friends and personal interests. Maintaining surgical skills and devoting your life to patient care takes significant time out of your life. We should all remember to allot and protect time for family and for ourselves. This proper balance keeps you grounded. Life outside your practice should be as fulfilling as your work life. Family and close friends help stabilize your life and keep things in the right perspective. It is easy to get too caught up in career and forget those who have stood beside you. Make time for them while you can and don’t put it off until later, as later may never come.
Being a corneal surgeon is an enormously fulfilling career and one that allows a surgeon to make a tremendous impact on the quality of life of patients. The above keys have helped to make my career interesting, rewarding and given me the ability to provide what I hope has been the highest of quality of care for my patients. REVIEW
Dr. Holland is the director of cornea services at Cincinnati Eye Institute and a professor of ophthalmology at the University of Cincinnati. He served as the president of the American Society of Cataract and Refractive Surgery from 2011 to 2012, and was a member of the Executive Committee and now serves as the program chair. He was a member of the Board of Trustees for the American Academy of Ophthalmology. He has been the Secretariat of the AAO’s Annual Meeting. He was awarded the AAO’s Life Achievement Honor Award in 2012. Contact Dr. Holland ateholland@holprovision.com.
