Sitting down with... Mr. Auger

Graham Auger, BsC, MBChB, PhD, RCOphth

Consultant Ophthalmologist at Sheffield Teaching Hospitals, NHS Foundation Trust (UK); Royal Hallamshire Hospital, NHS Trust, (UK). Mr. Auger is a pioneer in glaucoma management and is the first doctor in Europe to use the TrabEx+ device.

What originally drew you to the field of ophthalmology?

Cataract surgery!?When I saw this amazing surgery as a medical student, I instantly wanted to be able to perform this incredible sight restoring operation.?It is great that we can now combine this operation with quick and safe solutions to glaucoma.

What do you see as the main challenge that ophthalmologists face today?

As a doctor working in the UK, unfortunately, I have to say it is governmental politics, and not just for ophthalmologists but for all doctors.?Reduced funding and training coupled with the increasing numbers of patients requiring our services is making it more and more difficult to provide the care we would ideally like to offer our patients. To this end, we need quicker and more effective ways to treat our patients. TrabEx+ is a great example of supporting this idea.

What types of cases do you deal with in your practice, and how many surgeries do you perform annually?

I am a glaucoma and cataract surgeon and I have weekly lists for both.?I guess the most common glaucoma operation I am performing is still trabeculectomy - between 1-3 surgeries every week.?Trabeculectomy is still a great operation and the gold standard, in my opinion.?TrabEx+ is probably my second most common surgical intervention for glaucoma and serves a specific set of patients really well.

What was your journey into angle-based glaucoma surgery?

As a newly qualified consultant I wanted to start performing angle-based glaucoma surgery knowing its importance in the treatment pathways of our patients. Trabectome had evidenced efficacy and I had seen multiple procedures done with the device whilst I was registrar to a local consultant. This was my entry into the MIGS angle-based surgery, which has evolved into my use of the TrabEx+ device later.

What motivated you to transition to TrabEx+?

The Sheffield Teaching Hospitals had a lovely new cataract centre which was built across town at the other hospital site where we did not y perform glaucoma surgery at that time.?Unfortunately, we only had one base unit for the Trabectome.?We were looking for a new solution and that’s where TrabEx+ came in. This was the right direction for me since I was already familiar with the procedure. The advantages being that TrabEx+ does not require a unique power unit and the device’s I/A fluidics tubing is compatible with all phacoemulsification machines.?So, it was immediately available at our second site without a need for a capital investment.

How do you go about choosing a new procedure?

Before anyone performs a new procedure, of course, you need to prepare yourself. The first important step is to do your research to solidify what you want to do and why. This includes reviewing clinical efficacy and safety and pros and cons, as well as understanding the learning curve and how this procedure will affect your patient group.

What are your recommendations for surgical preparation?

There are many steps to this. To start, it is important to listen to and talk to trainers, watch videos, and practice with model eyes to familiarise yourself with the positioning of your hands, the grip on the device, and the surgical manoeuvres. Then, you need to familiarise yourself with and get accustomed to the positioning of the patient in order to get a great view and access to the angle – and don’t forget about the correct equipment, such as left- or right-handed gonioprism. Practice, and then practice some more.

The next step is the selection of patient. You should make your initial choices strategically in order to allow you to gain confidence. With TrabEx+, you would ideally want someone who is sensible and still; I would choose a patient with primary open angle glaucoma. The patient should have a reasonably deep anterior chamber and I would recommend starting with either a pseudophakic patient or doing a combined cataract-glaucoma procedure.

Finally, once you proceed to do the surgery, don’t forget to record your surgery to identify areas for improvement.?

What advice do you have for the next generation of ophthalmologists currently in training?

That is challenging to answer succinctly!?I will base it on my experience with UK trainees and limit myself to two points.

1. Choose a sub-specialty early and tailor your training and CV to get you in a good position for employment.
2. If you choose glaucoma, consider applying to our fellowship program at Sheffield.?HaHa, not sure if I’m allowed to advertise like that!

Did you miss our webinar with Mr. Auger? Watch it now on-demand – Mr. Auger talks about his journey to angle-based surgery and shares his experiences with Trabectome and TrabEx+.