You’ve made it to your dream residency, and one final decision awaits your academic journey. Fellowship: yay or nay?
Approximately 65% of US ophthalmology residents apply for a fellowship, a statistic that has nearly doubled over the last fifteen years. According to AUPO’s 2021 fellowship data, of 440 rank lists submitted for fellowship, 375 resulted in a match (65 without a match); 297 were US graduates, 12 Canadian graduates, and 66 international graduates.
Residents are exposed to every subspecialty through most ophthalmology residency programs; however, whether to pursue a fellowship is a discussion in and of itself.
The major fellowships offered in the United States are:
- Retina
- Cornea/refractive/anterior segment
- Glaucoma
- Pediatrics
- Oculoplastics
- Neuro-ophthalmology
Other less common fellowships, which won’t be discussed here, include uveitis, ocular pathology, and global ophthalmology. The most common fellowship with the largest number of spots is vitreoretinal diseases and surgery.
Here, we’ll summarize each of these major fellowships, its pros and cons, and for whom this would be a good fit. We’ll then follow up with a quiz to help narrow it down for you.
Retina
For those who love a fast-paced clinic, retina fellowship is for you! Retina is arguably one of the more remarkable fields. Vitreoretinal specialists often see diverse pathology, which may require systemic workup (e.g., diabetes, hypertension, sarcoidosis, syphilis, etc.).
There are “medical retina” (one-year programs) and “surgical retina” (traditional two-year programs) fellowships, with the difference being the ability to do vitreoretinal surgery (e.g., retinal detachment repair, macular surgery, etc.).
A retina specialist typically sees a lot of macular degeneration, diabetic retinopathy, and retinal detachments, which inevitably means your patient population tends to be a bit older than average.
There is a major reliance on technology and imaging in retina (e.g., optical coherence tomography, fluorescein angiography, etc.). Additionally, you may be doing a lot of intravitreal injections and lasers. Surgical emergencies (such as macula-on retinal detachments) are vision-threatening but can usually be triaged and managed during daytime hours within 12 to 24 hours.
Generally, retina is a high-earning specialty with high patient volumes and complex pathology.
Cornea, refractive, and anterior segment surgery
There is a broad spectrum within this field. On one end are cornea-specific techniques (e.g., corneal transplant); these patients tend to be with corneal scars or dystrophies, usually resulting in poor vision. Cornea transplants, in turn, can yield phenomenal visual outcomes as it treats the underlying opacity and disease. Cornea specialists also deal with a lot of dry eye diseases and usually see a broad spectrum of ages and diverse pathology.
On the other end of the spectrum is “refractive” surgery. These procedures include laser vision correction (e.g., LASIK, PRK, SMILE) to reduce a patient’s need for glasses or contact lenses. This is a lucrative aspect of the specialty given it is cash-pay and offers a high earning potential.
Glaucoma
The glaucoma specialist primarily deals with optic nerve-related diseases and frequently sees their patients because they require a lot of eye pressure monitoring. They manage a lot of eye drops and often perform lasers and surgeries to manage eye pressures.
Given the progressive nature of glaucoma, a decent portion of a specialist’s patient load may be legally blind or worse. Glaucoma can continue to progress despite normal eye pressures, and the glaucoma specialist guides their patients through this disease process.
There are numerous novel innovations within the field, which have resulted in the area of MIGS, or “minimally invasive glaucoma surgery.” A few glaucoma emergencies require immediate treatment to prevent vision loss (e.g., laser peripheral iridotomy for acute angle-closure glaucoma).
Pediatrics
The pediatric ophthalmologist commonly manages premature infants (e.g., retinopathy of prematurity), amblyopia, and strabismus. The pediatric ophthalmic examination requires patience and deliberate practice.
Pediatric ophthalmology has a high marketplace demand with a typical low supply of pediatric ophthalmologists.
Oculoplastics
This field can be pursued from either ophthalmology or plastic surgery residence routes. Oculoplastic surgeons deal with extraocular and periorbital techniques. The formal American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) is a two-year fellowship providing advanced eyelid, orbit, tear duct, and facial cosmetic and reconstructive surgery training.
Most oculoplastic surgeons do not perform cataract surgery but instead focus on extraocular pathology's medical and cosmetic aspects (i,e., thyroid orbitopathy decompression or blepharoplasty).
Neuro-ophthalmology
This neurological and ophthalmic focus is an integration of neurology and ophthalmology. It is focused on the visual pathway, and most neuro-ophthalmologists manage ophthalmic disorders related to the nervous system. Common conditions include idiopathic intracranial hypertension, thyroid eye disease, tumors, strokes, migraines, multiple sclerosis, or traumatic brain injury.
They focus heavily on a thorough neuro-ophthalmological exam and rely heavily on imaging (such as MRI). Surgeries performed by neuro-ophthalmologists vary based on training locations but can include optic nerve sheath fenestration, temporal artery biopsy, or orbital biopsies.
Neuro-ophthalmologists generally see fewer patients in clinic but spend more time with each patient, as history, physical, and testing are critical to attaining a diagnosis.
Conclusions
Now that you’ve gained a glimpse into each subspecialty, the quiz below will help you determine with which you most align. Of course, there are a lot of nuances to the above, and factors such as patient volume, salary, types of patients, and types of surgery can be highly variable depending on your practice setting and geography.
