One of the most common questions I get asked by our medical students and residents is the reason why I decided to become a glaucoma specialist. I loved all the ophthalmology subspecialties, but I found my home on the glaucoma rotation. I hope some of my personal thoughts below may provide insight into whether glaucoma is the right fit for you!
The doctor-patient relationship
Often we underestimate the impact of patients we see as trainees on our own career paths. I know for a fact my 93-year old patient who developed choroidal effusions and hypotony requiring multiple anterior chamber reformations after a tube shunt is one of the reasons I chose Glaucoma.
Some residents may have been exposed to the same patient and realized Glaucoma was not for them. However, during the complex two-month post-operative course, I had the privilege of meeting a different grandchild every visit (she had more than a dozen), and each time she introduced me to them as her doctor (smiling the whole time). I realized in those moments that this was what I wanted to do.
The tube shunt placement was routine (although still exciting as a third-year resident); however, the pre-operative considerations (was this surgery going to change her quality of life) and post-operative care were complicated and made our relationship even stronger. The importance of the doctor-patient relationship, trust, expectations, and continuity of care separated my glaucoma rotation from the rest and confirmed my interest in the Glaucoma subspecialty.
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Continuity of care
I am still in awe of the number of patients who remember my daughter’s name or tell me they loved the restaurant I recommended at our last visit—these conversations, although brief, weave a foundation upon which our intermittent follow up visits are built. As this is the case just two years into practice, I really look forward to continuing to build upon these relationships.
More than half the people who have glaucoma remain undiagnosed; this is approximately 1.5 million people in America. Improved screening protocols in primary care offices and community centers, in conjunction with telemedicine and artificial intelligence, will play an important role in identifying glaucoma earlier.
Surgery and procedures
In the past decade, the number of glaucoma procedures has significantly multiplied. Besides trabeculectomy and tube shunts, there are now an increasing number of minimally-invasive glaucoma surgeries we can offer patients that span a variety of techniques (transconjunctival vs. trabecular meshwork based vs. suprachoroidal space, for example). The breadth of surgery and the ability to personalize a surgical approach for a patient is an important way of adding diversity to the day-to-day life of a surgeon.
Glaucoma specialists have a good balance of clinical and surgical volume; laser procedures (iridotomy and trabeculoplasty) can complement the clinic day as well.
The art of disease management
My mentor used to joke that the reason he went into glaucoma was because the glaucoma BCSC (Basic and Clinical Science Course textbook) was the shortest. Of course, the reasons for this are likely multifactorial, but I reason that part of this is that it is difficult to summarize much of glaucoma decision-making into absolutes and protocols.
There are dozens of ways to perform a trabeculectomy, and there is a finesse and art to the post-operative management as well. Surgery is often half the battle; the other is post-operative care. Additionally, with the variety of surgeries and medications that are available, glaucoma specialists have the increasing ability to personalize patients’ medical treatment in a way that aligns better with their pathophysiology and personal and financial needs.
Therefore, I believe glaucoma specialists are not just ‘plumbers that lower eye pressure’ but instead are artists managing a complex disease.
The future is evolving
There are so many things to look forward to in the field!
- Sustained release medications—whether a conjunctival ring or intracameral injection or depot implant—these will definitely be a part of our near future.
- I am optimistic that our future also includes treatments that have the potential to reverse nerve damage and are independent of intraocular pressure (IOP).
- The glaucoma surgeons’ armamentarium will continue to grow; continued improvement in safety and efficacy of procedures will encourage earlier surgical intervention and potential for a more personalized approach.
Enhanced understanding of the disease
Some day I hope to tell my patient whose glaucoma is progressing at an IOP of 11 (with a negative neurologic workup) why this is happening—is it related to her perfusion pressure and/or cerebrospinal fluid flow and/or her lamina cribrosa? I would love to be able to offer my patients more insight into their disease and expand treatment options, as we further understand what glaucoma truly is, and the modifiable factors that contribute to this disease. I am optimistic that we will continue to answer these important questions, but we need the brightest and most enthusiastic multi-disciplinary teams to continue to work on this!
Mentorship and collegiality
I noticed early on that glaucoma specialists love sharing patient experiences. Often these stories are the most difficult cases rather than the easy successes you may think would be shared. My mentors and colleagues are some of the most talented, passionate, yet humble people I have had the pleasure of knowing. Glaucoma can be a challenging disease, and it is an honor and privilege to be able to learn and share openly with colleagues. The glaucoma community has been an unexpected ‘perk’ of becoming a glaucoma specialist.
How does one become a glaucoma specialist?
Glaucoma fellowship is one-year in duration, after completion of a three-year ophthalmology residency (at least, conventionally). Guidelines and standards for glaucoma fellowships are reviewed by the Association of University Professors of Ophthalmology (AUPO) Fellowship Compliance Committee, in conjunction with the American Glaucoma Society. Specific requirements for fellowships can be located at the AUPO website. The diverse range and number of procedures performed during fellowship are summarized in this particular AUPO report.
Who would make a great glaucoma specialist?
This is, of course, a matter of personal opinion. Given everything I have mentioned above, glaucoma would be a great fit for someone who is interested in a balance of surgical and medical ophthalmology, providing continuous care for patients with a chronic (asymptomatic or symptomatic) disease, developing long-term patient relationships, and continuing to improve the current standard of care!
I hope this article gave some wandering souls clarity and insight. In case it is not obvious, I love what I do each and every day. And I hope you find your ‘home’ in the ophthalmology specialty that best suits you, as this is not just a professional decision but also a personal one.