April 2013




Glaucoma editor's corner of the world

Interest growing for glaucoma fellowships

by Erin L. Boyle EyeWorld Senior Staff Writer

There's a bull market in glaucoma fellowships, and this issue's "Glaucoma corner of the world" focuses on the reasons behind this change. Resident enthusiasm for glaucoma is critical to fellowship programs and for providing the academic and private practice specialists to care for the growing number of glaucoma patients. We are exceedingly fortunate this month to have the expertise of Drs. Rhee, Gedde, and Costarides to analyze this phenomenon. The rise of MIGS procedures is highlighted as one of the reasons for increased interest in glaucoma fellowships. MIGS devices and procedures not only give hope to patients but also to glaucoma specialists and others who use them. Finally, there are elegant and safe procedures to help glaucoma patients. The relatively high rate of complications associated with trabs and tubes may have discouraged residents from pursuing a glaucoma fellowship in the past.

One of the challenges for glaucoma fellowships has been integrating cataract surgery. Some programs emphasize cataract surgery but many seem to actively avoid it with cataract surgery referred to other departments. This has been discouraging for glaucoma fellows as only the most complex cataracts are left for the glaucoma service. However, cataract surgery is a key element in glaucoma carewhether in private practice or an academic setting. Another reason for giving cataract surgery a prominent place in glaucoma teaching is that MIGS procedures often need to be done in conjunction with cataract. Renewed interest in glaucoma among residents will hopefully trigger a virtuous cycle in the field. More glaucoma specialists will lead to innovations and improvements in glaucoma careincluding more advances in surgical technology. Ultimately, the excitement in glaucoma will cause even more residents to pursue fellowship training. But the most compelling reason for specializing in glaucoma is cited at the end of the articlehelping patients stave off a blinding, incurable disease.

Reay Brown, MD, glaucoma editor


Dr. Gedde (right) mentors residents Brandon Parrot, MD, and Amy Schefler, MD. Source: Steven J. Gedde, MD

The amount of residents applying for glaucoma fellowship programs is rising, curbing a decade-long trend during which interest in specializing in glaucoma was falling, experts say.

The reasons for that rise are most likely multifactorial, said Douglas J. Rhee, MD, assistant professor, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston. A major factor could be the simultaneous rise of minimally invasive glaucoma surgery (MIGS), including the Trabectome (NeoMedix, Tustin, Calif.), canaloplasty, iStent (Glaukos, Laguna Hills, Calif.), and EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas), all of which typically have fewer complications than filtration surgery.

"I believe that the fact that there are so many new procedures makes glaucoma more interesting to residents," Dr. Rhee said. "Even though they've always liked doing a trabeculectomy and a tube, what we really need to drum up interest are things that are not only safe but very effective. I think all the new procedures we have out currently pass the rigors that we would like for safety. But whether they are effective are notthat seems to be a big draw for a lot of folks."

Anastasios P. Costarides, MD, associate professor of ophthalmology, Firman Professor of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, is director of Emory's glaucoma fellowship program. The number of applicants in the subspecialty at the institution has approximately doubled in the past two to three years, he said. While many factors appear to impact that increase, he said the new surgical procedures are introducing potential changes to a subspecialty that had been holding steady with new technology.

"I think MIGS is something that excites applicants. I think having greater opportunities to treat patients helps," he said. "And I think there is excitement about the possibility that MIGS will change the way we manage some of our glaucoma patients."


Steven J. Gedde, MD, professor of ophthalmology, Bascom Palmer Eye Institute, Miami, is residency director there. In that role, Dr. Gedde said he has counseled many residents on selecting a fellowship program. Based on his curiosity as to why residents pick certain career pathways, he conducted a survey study on the topic. His study "Factors Affecting the Decision to Pursue Glaucoma Fellowship Training" was published in the Journal of Glaucoma. A survey was sent to every graduating ophthalmology resident in 2003. Surveys were completed by 215 (49.2%) residents, including 135 (62.8%) who were pursuing fellowships. Among residents undertaking fellowship training, only 17 (12.6%) selected glaucoma, while 118 (87.4%) chose other subspecialties.

"Fellowship match statistics had demonstrated that the percentage of ophthalmology residents seeking fellowship training had steadily increased during the decade prior to the survey. However, there was a downward trend in the proportion applying for glaucoma fellowships," Dr. Gedde said. "It was unclear why graduating ophthalmology residents were choosing other subspecialty areas over glaucoma, particularly retina, cornea, and oculoplastics. But we've been seeing something quite different in recent years. Just as we were wondering a decade ago why there was a lull in enthusiasm, now we wonder why there is a renewed interest in glaucoma fellowship training."

Since 2008, applications to Bascom Palmer Eye Institute's glaucoma fellowship program have risen by 50%, Dr. Gedde said. The Association of University Professors of Ophthalmology Fellowship Compliance Committee (AUPO FCC) is the nonprofit professional medical organization that establishes ophthalmology training standards in fellowship programs. It also tracks rates of glaucoma fellowship applications. According to information from its San Francisco Matching Program, in the past three years, the number of applications to glaucoma fellowships across the country has increased. While a representative of the program would not release specific numbers, the largest increase occurred from 2011 to 2012.

A total of 51 glaucoma fellowship programs exist with San Francisco Match. In the last five years, three programs have been added.


In addition to the rise in surgical innovations in glaucoma, another factor in increased interest could be economics, Dr. Rhee said. Since the recent economic troubles have impacted most ophthalmic subspecialties, glaucoma has held steady, he said. "I think that the compensation for glaucoma doctors isn't changing. We rise slowly at the level slightly below inflation, which is better than some fields," he said.

Dr. Costarides asked his program's two glaucoma fellows, a resident who has selected glaucoma and a senior resident matched in a glaucoma fellowship program, why they chose the subspecialty. "There are various reasons," he said. "I think one of them is that there is more opportunity in glaucoma than there was demographically. I think there are better jobs out there and the ability to choose where you live. I think people have seen the value in doing a glaucoma fellowship in the sense that it's very good training, even if you want to do general ophthalmology, since there are so many glaucoma patients and many that are managed in general practices. The fellowship will clearly improve your ability to manage these patients. And many general ophthalmologists are not comfortable doing glaucoma surgery."

Drs. Costarides, Gedde, and Rhee all said that the chronicity of care could be another reason residents are attracted to the subspecialty. Glaucoma specialists can see patients over 30+ years, often their entire careers. They must be emotional healers, understanding the full impact of the loss of vision. That role should not be taken lightly, Dr. Rhee said, and is an important aspect to the subspecialty. "[Glaucoma specialists] stand in the face of blindness," he said. "We stand in front of death of the eye, death of the ganglion cell, and we say, 'No, I am going to stop you. I am not going to let you take this person.' Unfortunately, I say that with every patient, and the other side wins far too often. But the point is that we are treating a disease in which if we are not here, patients will go blind or lose vision. We make a big difference. For those of us who choose it, I think we love it because we're proud of that."


Gedde SJ, Budenz DL, Haft P, Lee Y, Quigley HA. Factors affecting the decision to pursue glaucoma fellowship training. J Glaucoma. 2007;16(1):81-87.

Editors' note: Dr. Costarides has financial interests with Glaukos (Laguna Hills, Calif). Drs. Gedde and Rhee have no financial interests related to this article.

Contact information

Costarides: a.costarides@emoryhealthcare.org
Gedde: 305-326-6435, sgedde@med.miami.edu
Rhee: 617-573-3670, douglas_rhee@meei.harvard.edu

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