Training Plan

The fellowship program in retinal, vitreous and macular disease is organized according to the following:

1. Retinal Detachments and Peripheral Degenerations

Fellows will learn the technique of indirect ophthalmoscopy, scleral indentation, examination of the vitreous by slit-lamp biomicroscopy and contact lens examination of the macula with slit-lamp and fundus contact lens. This experience is acquired by supervised examination of patients who have peripheral retinal degenerations, retinal detachments, retinal tears, and all types of macular disease. There are over 25,000 outpatient visits per year on the Vitreoretinal Service. Indirect ophthalmoscopy and slit lamp biomicroscopy can be recorded on dedicated video instruments kept in the Retina Clinic.

2. Imaging

The technique and interpretation of high-resolution optical coherence tomography, autofluorescence, and stereoscopic fluorescein angiography for the diagnosis of diseases of the posterior pole of the eye is acquired in coordi­nation with the Photography Service of the Department of Ophthalmology. Each 1st year Vitreoretinal fellow directs an imaging conference once a week during the academic year. This conference is attended by staff members of the Service as well as by fellows and residents in the Department of Ophthalmology.

Imaging is performed with two Heidelberg Spectralis SD-OCT machines on a regular basis for OCT, FA/ICG, and autofluorescence studies. State of the art TopCon and Zeiss SD-OCT units are also readily available.

3. Hereditary and Congenital "Tapetoretinal" Disease

The Vitreoretinal fellow learns the diagnosis of hereditary, famili­al and congenital retinal disease by evaluating patients as they are seen on the Service. The appropriate genetic and electrophysiologic tests (dark adaptation, electroretinography and electro-oculography) are performed by the Electrophysiology Service of the Department of Ophthalmology under the direction of Dr. Stone). Dr. Stone has an active ophthalmic genetics research laboratory, and encourages participation in research projects by the fellows.

4. Surgery of Retinal Detachments and Peripheral Retinal Degenerations

Patients with varying and progressively more complex retinal detachments and retinal degenerations leading to detachment are studied and examined by the fellows as the patients are referred to the Service. Surgery is performed by a fellow under the direct supervision of the staff in the operating room. Primary scleral buckling procedures and pneumatic retinopexies are also performed. Post-operative care is directed by the staff surgeon but also seen and followed by the fellow who was involved in the surgery.

5. Treatment of Diabetic Retinopathy

The diagnosis and selection of patients with diabetic retinopathy for treatment is performed as patients are referred to the Service. The necessary clinical judgment in selecting patients who can be expected to benefit from laser photocoagulation, anti-VEGF therapies, and/or surgical intervention is acquired by examination of patients and consultation with the faculty. Clinical, translational and animal research projects in diabetic retinopathy are also available with Dr. Sohn.

6. Macular Disease

The Vitreoretinal Service evaluates over 2000 new patients a year with macular disease. The majority are patients with age-related macular degeneration (AMD) associated with aging but a wide variety of other macular diseases are seen during the year. Fellows play an integral part in the evaluation and treat­ment of all patients. Fellows gain an understanding of the role of genetic research in AMD and macular dystrophies with application to clinic patients through the Carver Lab. In addition, there is are numerous research studies being carried out including phase I, II, and III trials in AMD that fellows have the opportunity to be involved with.

7. Laser Photocoagulation

Fellows develop skills in treating a wide range of retinal and choroidal vascular diseases in addition to managing peripheral retinal tears using multiple wavelengths of visible and intrared laser for photocoagulation. Green and infrared indirect laser ophthalmoscopes are available for use.

Two Pascal lasers are used regularly in the retina clinic.

8. YAG Laser

A Nd:YAG laser is readily available.

9. Cryopexy and Cryosurgical Treatment of Retinal Disease

Patients are treated under supervision of the staff on an outpatient basis (treatment room or minor operating room), in the ambulatory surgery center, or in the main operating rooms.

10. Vitroretinal Surgery

Approximately 700 major vitreoretinal surgeries are performed annually. Proliferative diabetic retinopathy, epiretinal membranes, full thickness macular holes and rhegmatogenous retinal detachments are the leading indications though endophthalmitis, proliferative vi­treoretinopathy cases, diabetic traction detachments, vitreous hemorrhages, subretinal hemorrhage from AMD and other etiologies are also included.

State of the art equipment includes the Alcon Constellation System, B&L Stellaris System, vertical/horizontal/curved scissors, bipolar tissue manipulator, automated Sutherland scissors and forceps, unimanual bipolar diathermy, argon endophotocoagulator, indirect laser, intraocular cryoprobe, silicone oil, perfluorocarbon liquids, etc. Dedicated surgical suites are equipped with Zeiss microscopes. Fellows learn to perform surgery using the state-of-the-art Zeiss Resight System, BIOM Widefield Viewing System and various macular lenses.

Available vitrectomy platforms include 20, 23, and 25 G technology. Bimanual technique is also taught with assistance of chandeliers and/or lighted instruments. Fellows have the opportunity to trial new instrument under development with leading companies.

During the Fellowship, the majority of surgical procedures will be performed by the Fellow under the direct supervision of a member of the faculty. Intraoperative digital recordings can be made on all cases for presentations and improvements in techniques.

11. Ultrasound

The Echography Service is run by Dr. Boldt. There are two technicians with over 30 years of combined experience in standardized echographic techniques. Fellows are expected to learn echographic techniques in the surgical management of vitreoretinal disease, and have both didactic and hands-on training in ocular echography.

12. Tumors

Experience in evaluation of metastatic tumors, melanomas, and vascular tumors will be gained under direct supervision of Dr. Boldt. We are a clinical center for the COMS, and have acted as the Photographic Reading Center for this study since its inception. Fellows participate in the evaluation and brachytherapy for approximately 30 uveal melanomas a year. They also participate in the screening and treatment of approximately 6 new patients with retinoblastoma a year.

13. Pediatric Eye Disease

Retinopathy of prematurity screening is performed by the pediatric service and laser for ROP is performed by several members of the retina service. Opportunities to interact with the NICU service are available. Fellows specifically interested in pediatric dis­ease can get experience in these areas.

14. Posterior Uveitis

Drs. Folk, Sohn, and Mahajan have a special interest in inflammatory diseases of the choroid and retina. Patients are evaluated and treated by the fellows in conjunction with the faculty. Experience in diagnostic vitrectomy and administration of chemotherapeutic agents will be gained. Clinical trials for new therapies targeting posterior uveitic diseases are readily available for participation by fellows.

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