At this point, you are done with your first or maybe even second year of ophthalmology residency. The light at the end of the tunnel is near, but there is a question as to whether to pursue a fellowship or not. You have likely completed over a decade of training by now, and adding an extra year or two might seem daunting! However, there are advantages: a fellowship adds specialized knowledge, and this knowledge is valuable.
A fellowship year (or years in some cases) will allow you to concentrate on the areas of ophthalmology you might be interested in, like surgery, and bypass areas that you would like to avoid, like strabismus measurements (in my case). Fellowship training will make you more marketable whether you choose academics, private practice, or a managed practice (such as Kaiser Permanente) setting. Moreover, fellowship affords you choice, and a glaucoma fellowship will always be useful; after all, 2% of the Medicare-aged patient population has glaucoma.
What are your chances of matching to a glaucoma fellowship?
Compared to previous years, glaucoma fellowships are becoming more competitive due to market demand, job security, and the availability of minimally invasive glaucoma surgery (MIGS) procedures. Of course, top-ranked programs are harder to get into; however, I have yet to meet one candidate who went unmatched in glaucoma. In 2018, 84 positions were offered via the San Francisco fellowship match, and 12 of those went unfilled and were left up for grabs. In addition, there are a few private fellowships not associated with San Francisco Match that can be applied to directly. Same trend continued into 2019 and 2020. Therefore, your odds in glaucoma are encouraging compared to other subspecialties.
Glaucoma fellowship facts and FAQs
Is glaucoma fellowship competitive?
Glaucoma fellowships are becoming more competitive. In 2020, according to the SF Match statistics, there were 92 positions offered in glaucoma and 86 positions filled.
How long is glaucoma fellowship?
Glaucoma fellowships are one year long. There is a option of an additional research year at several academic institutions for candidates interested in an a research oriented pathway.
How do I apply to glaucoma fellowship?
Applying for glaucoma fellowship is done through the SF Match Central Application Service (CAS) and by contacting programs directly to learn about additional materials and requirements.
For more on why to pursue glaucoma fellowship, check out our article “Why Ophthalmology Residents Should Pursue the Glaucoma Specialty.”
Choosing glaucoma
In residency, pay attention to your glaucoma patients early on and see if you enjoy continuity of care. With the unfortunate progression of the disease, as there is no cure, success is typically measured in maintaining vision (in some cases poor to start) versus return of vision loss. Compare clinic flow to other subspecialties: glaucoma clinic feels like a primary care setting with the same patients returning quite frequently. You get to know them and their families socially and emotionally, and for me that was the highlight of the day.
Glaucoma as a specialty
Why are glaucoma job postings taking over? Precise diagnostics and availability of MIGS are the keys to the rising demand for glaucoma specialists.
2% of the Medicare-aged patient population have glaucoma, and half are undiagnosed. Patients are there for you even if you start your practice from scratch. Second, large practices would like to keep referrals within the system and prefer their own glaucoma specialist on staff. Third, MIGS has emerged as a rival to conventional glaucoma surgery. Glaucoma has become the specialty where multiple gadgets and new devices are approved on an annual basis. As a result, the demand in the industry and research sector has spiked, and you have a surgical specialty in high demand by patients, research, and industry involvement.
This is not to say that glaucoma cannot be a challenging specialty. You will see many of your patients undergo continued vision loss despite all your efforts. Complication rates are high for trabs and tubes, and you will face those in your career no matter how careful or great of a surgeon you are. My clinics tend to be overbooked by 20%, and with a rising number of patients, it is a challenge to keep it flowing efficiently.
How to prepare for glaucoma fellowship during ophthalmology residency
It is important to develop a solid foundation in ophthalmology residency. Start with BCSC and build from there.
Surgical training: learn the fundamentals . . . and everything else
In residency I would suggest focusing on the different surgical techniques for the same procedure that attendings might offer. Some specific examples to keep in mind include:
- MIGS ab externa vs ab interna
- Permanent sutures vs release sutures
Pay attention to the instruments (forceps, scissors, kelly punch) that are used and advantages of one over the other.
In addition, postoperative care is especially important in glaucoma. Make sure to focus on the frequency and length of drops, length of follow-up and small tricks of the trade: using pilocarpine, for example, during the postoperative period following trabectome. Pay attention if steroids or NSAIDs or both are used during the postoperative period for a particular surgical procedure and for how long.
Exam techniques
Perform gonioscopy on every patient and confirm findings with a senior resident or attending if possible. Gonioscopy.org is an excellent tool to see interesting and unusual findings. Grading angles can be an art in itself—choose one system and stick to it. Review grading techniques on gonioscopy.org.
Dilate every patient and draw the optic nerve. Compare your drawings to disk photos.
Grading C:D ratio is an excellent exercise in consistency. Just remember every one sees C:D ratio differently, so focus on your own consistency, not comparison to your colleagues.
Surgical techniques
The more the merrier! Scrub in with as many attendings and fellows as you can. Our techniques are dictated by the institutions where we trained, and you will notice that quickly.
Print out the surgical templates for each attending prior to the cases and read them through, as those highlight the instruments and techniques used. Repetition is key.
Equipment and instruments
Minimally and micro-invasive glaucoma surgeries (MIGS) are all the rage nowadays. Talk to your attendings and establish an algorithm of their approach to choosing a particular gadget. With so many MIGS available, it is time to begin learning which are most appropriate for different patients and why.
Familiarize yourself with the various options, including:
- Stents and microstents
- Tissue excision
- Trabectome
- Gonioscopy assisted transluminal trabeculotomy (GATT)
- Ab interno canaloplasty
- Endoscopic cyclophotocoagulation (ECP)
Contrast and Compare
Write down notes and highlight differences of approach from one physician to the next. Observe their clinics, see if you enjoy their approach, and ask questions. Here are some questions to start with:
- How do you determine frequency of follow-up?
- How do you determine frequency of imaging?
- What are the ominous signs of progression?
- How can one best counsel the patient about chronicity of the disease?
- How does one accurately assess compliance of the patient?
- If a complication happens, what is the most effective way to discuss it?
- How do you encourage good compliance and follow-up?
Finding the right glaucoma fellowship for you
How do you choose the right fellowship spot for yourself? Your residency mentors will point you in the right direction of suitable fellowships for you. They know the advantages and disadvantages of each program. They also know your strengths and weaknesses.
It is hard or even impossible to choose the right fit based solely on one interview day, and even less so if done virtually (e.g., via Zoom). Personally, I would review each program systematically in the following manner.
First, in order to assess surgical volume, ask for surgical logs and previous graduates’ contacts.
When assessing the breadth of surgical training, evaluate the fellowship’s use of conventional glaucoma surgery versus MIGS (i.e., what proportion of each is taught). Also see if you can find out if previous fellows were certified on a certain procedure.
Find out what clinic types you will be involved in (e.g., attending, fellow-run). WIll you have the ownership and continuity of care for a particular subset of patients? I would encourage you to strongly consider programs where you have your own patients, and not only the attending’s.
Determine the ratio of attendings to fellows with an eye to how many attendings and mentors you will work with directly. Even if there are 20 attendings, you will only be working with a few. Is there someone available at all times when you are on-call or in-clinic, so you can review treatment plans?
Also factor in research and clinical components, location—particularly if you are taking family into consideration—and travel, as these are all significant variables that you will need to evaluate.
Additionally, consider your approach to the job search at the end of fellowship and how helpful the program and mentors are when it comes to supporting fellows’ search for employment. For example, will they call and act as a reference, and do they keep their own fellows?
Finally, the prestige of the program is the last point to be concerned about; while it might assist in choosing between options you consider to be equally good in all other respects, it should not be your first consideration.
What is AUPO Certification and is it important ?
Standards for glaucoma fellowship training are established and maintained by the Association of University Professors of Ophthalmology (AUPO). The subspecialty standards for glaucoma were developed by the American Glaucoma Society (AGS) and serve as the basis for fellowship program evaluation.
The AGS, which is made up of fellowship-trained glaucoma specialists, functions with the mission of expanding glaucoma education and research and providing the highest level of care to glaucoma. To protect the public, institutions, and trainees, the AUPO ensures fellowship programs remain in full compliance with these AGS guidelines. The AGS’s subspecialty appointed representatives periodically review and update the guidelines.
The American Glaucoma Society supports and endorse the fellowship training compliance program of the AUPO. Membership in the AGS requires completing training within a AUPO-compliant fellowship.
Your glaucoma fellowship
Congratulations—you’ve matched! Now what? Be present, be available, and don’t be afraid to ask questions. This is the last opportunity you will have with a multitude of knowledgeable mentors available all at once. Don’t forget to teach the residents and medical students around you—you will soon appreciate how much you learn from them as well.
Reading and research in fellowship
Academically, didactics during your fellowship are important. Your program will provide a list of critical literature to read; make a realistic schedule and read them.
During the first month of fellowship, I read the resident glaucoma manual as a refresher. Continue rereading your resident manuals for other subspecialties throughout the year.
During the second month, read The Glaucoma Book, which is a practical, evidence-based approach to patient care. During the third month, read the Shields Textbook of Glaucoma, which is an essential classic, and continue fostering your clinical skills and ability to detect subtle physical findings.
Grand rounds and clinics
Attend all grand rounds, even if not in glaucoma. It will help you with passing the boards and allow you to refresh your knowledge. Learn the fundamentals and add relevant details specific to glaucoma and how you plan to practice.
At the end of each clinic, review all the charts and imaging, and discuss borderline or problematic cases with your attending.
Hone your assessment skills
Continuously review gonioscopy.org videos for interesting and unusual cases. At this point, your introspection and self-directed assessment will guide you to focus on particular topics that require additional mastery.
Medications
Treatment for glaucoma can include a range of medications in conjunction with supplements and diet and lifestyle changes, with new research and recommendations emerging regularly. Become as well versed as possible in all of the areas.
With regards to glaucoma medications, become familiar with:
- Prostaglandins
- Beta-Blockers
- Alpha-Agonists
- Muscarinic Agonists
- Rho-Kinase Inhibitors
- Carbonic Anhydrase Inhibitors
- Osmotic Diuretics
- Cannabinoids
- Fixed-Combination Medications
Surgical training
From day one in your fellowship, you will be transitioning to performing glaucoma filtration and MIGS procedures from under the close supervision of your mentors to entirely on your own. Watch Eyetube and YouTube videos, read books on specific surgical topics, and observe as much surgery as you can. Consider setting up a wet lab for MIGS at your institution; companies will be eager to help, as they too are interested in your training.
At this point in your training, the quality of the surgery performed, not quantity, becomes priority! You will learn the mechanics of surgical maneuvers quickly, but nuanced technique, management of complications, and postoperative care will take significant time investment.
You should hone your skills in: cataract surgery, trabeculectomy, available MIGS, and tube shunt surgeries.
Make copies of your operative reports and take notes on each mentor’s approach to complications and postoperative paradigms. Do not rely on your memory; photocopy or take digital HIPAA compliant images.
Learn to listen and have the difficult conversations
A glaucoma diagnosis can trigger a scope of emotions, including fear, frustration, confusion, anger, and hopelessness. With the progressive nature of the disease, it is crucial to become comfortable with assessing the patient’s mental and emotional well-being and referring to the proper resources, be it a therapist or low-vision specialist.
Whenever the opportunity arises, practice your interviewing skills to gain confidence in asking questions that address the person as whole and their family relationships, living situation, daily activities, hobbies, and support system. Learn to listen closely, make eye contact, and gauge body language. Rehearse having the difficult conversations about complications and vision loss, with an emphasis on patient education to progression as well as treatment options.
Developing an assuring presence and fluid interviewing style will serve you throughout your career.
Understanding how your front-line colleagues approach glaucoma is more important than ever. Download Eyes On Eyecare's free 2023 Glaucoma Report to see how your peers diagnose, treat, and manage this condition!
Tips and tricks for succeeding in glaucoma fellowship
Coding and billing
Pay attention to coding and billing. This skill will be important after graduation, and not many programs pay enough attention to this massive aspect of practice.
Start with the American Academy of Ophthalmology primer on billing and coding, which will instruct you on how to properly code by level of examination as well as with respect to surgical procedures.
Learn to perform OCT
If you have not done so in residency, learn how to perform visual fields and optical coherence tomography (OCT) imaging yourself. Technicians will routinely come to you with questions related to performing these common imaging modalities, and you will be expected to know the answers. This is a skill that has saved my overbooked clinic time and time again and continues to serve me well!
Stay connected to mentors
Finally, keep your mentors’ mobile phone handy because, although you will graduate, they will remain your lifeline for many decades to come. These relationships forged in fellowship training will last forever. One brief phone call from your mentors on your behalf might mean a new career opportunity in the future or serve as a lifeline when challenging clinical conundrums appear.
Getting ready for your future in glaucoma
Glaucoma patients tend to be older and will age with you—I still have dedicated patients with glaucoma who traveled six hours from my residency training to follow me to my fellowship, and then on to my first job in academics, and the private practice where I am now. Glaucoma patients are loyal, and I get to know their families and social situations quite well. In addition, if you choose a program with training in pediatric glaucoma, you will cover all the age brackets from newborns to nonagenarians.
If you’re interested in a field with a balance of surgical and medical ophthalmology where you can develop long-term patient relationships and operate on the forefront of medical technology, this specialty might be an excellent fit for you—and you will be an excellent fit for your patients. I hope these tips help you throughout your fellowship and beyond!
The Ultimate Guide to Ophthalmology Fellowships
This article is part of our series on ophthalmology fellowships, designed to support new ophthalmologists as you navigate the early days of your specialty. The below guides walk you through each specialty.
