Fellowship Program

I. Introduction

The purpose of this document is to provide guidelines for applicants for fellowship training in vitreo-retinal diseases and surgery.

II. Program Directors

1. Program Directors should be certified by the American Board of Ophthalmology or, in Canada, by the Royal College of Physicians and Surgeons, and specialize in the diagnosis and management of vitreo-retinal diseases. While a program with one instructor may be acceptable, a program with two or more instructors is preferred so that the fellow will be exposed to different techniques and philosophies.
2. There should be close supervision and adequate contact with the instructors. This is important:
   1. To receive direct feedback on the clinical evaluation of patients in order to enhance and clarify findings on the examination, and to assist in formulation of the proper diagnosis and management.
   2. To observe and assist vitreo-retinal surgeons in surgery. Careful supervision in the operating room is essential. Unsupervised surgery may promote independence, but this is not the primary purpose of fellowship training.
3. It is desirable that the fellowship be affiliated with an accredited ophthalmology residence program. The continued exposure to the other subspecialty areas, grand rounds, teaching conferences, and the academic atmosphere of a residency training program can greatly enhance the fellowship experience.

III. Duration of Fellowship Training

The fellowship should be at least one year in duration. This minimum of twelve months should be spent in clinical training, and should not include a block of time set aside for research or laboratory work. If time is to be allocated for research activity, the fellowship duration should be between 18 and 24 months.

IV. Medical Retinal Diseases

1. Content
   The fellow should be exposed to as broad a variety of retinal and vitreous conditions as possible. This experience should include ocular oncology and uveitis as well as macular disease, retinal vascular disease, retino-choroidal degeneration and hereditary diseases, and infectious retinal disease.
2. Fluorescein Angiography
   The principles of fluorescein angiography, including supervised independent interpretation of a large number (at least 250) of fluorescein angiograms are basic to the care of patients with retinal and choroidal disease. The ability to perform fluorescein angiography is optional, but understanding of the process and the management of allergic reactions is essential.
3. Electrophysiology
   The understanding of indications for electrography and electro-oculography is basic. The interpretation of the recordings is important in the management of a variety of retinal degenerative diseases.
4. Ultrasound
   The fellow should be familiar with the basic principles of A scan and B scan and should be able to perform B scan ultrasound examinations.
5. X-Ray, CT-Scan, MRI
   The interpretation of orbital x-rays, CT or MRI scans, especially for penetrating injury, and particularly to evaluate eyes with suspected intraocular foreign body, is basic.
6. Special rotations to enhance the basic knowledge of fundus and fluorescein photography, electrophysiologic tests and ultrasound are a desirable part of the retina-vitreous fellowship curriculum. V. Training of Vitreo-retinal Surgery.

All vitreo-retinal fellowships should include training in both vitreous and retinal surgery:

1. Rhegmatogenous Retinal Detachment
   All fellows should understand the features which differentiate rhegmatogenous and secondary retinal detachment. All fellows should perform personally and/or assist in surgical repair of rhegmatogenous retinal detachment to the point of being expert with localization of retinal tears, treatment of retinal tears, and the placement of scleral buckles. A minimum of 75 such cases is recommended.
2. Posterior Vitrectomy
   All fellows should assist in or personally perform posterior vitrectomy for a variety of indications, including complicated retinal detachment with proliferative vitreo-retinopathy, proliferative diabetic retinopathy, giant retinal tear, vitreous hemorrhage, retinal detachment, endophthalmitis, intraocular foreign bodies, and others. Participation in 100 or more such cases during fellowship training is recommended.
3. Ocular Trauma and Intraocular Foreign Bodies
   Fellowship training must include evaluation of eyes with both blunt and penetrating injury. The techniques for pre-operative evaluation, including specialized studies to search for a retained intraocular foreign body, are to be included. All fellows should assist in or personally perform repair of ruptured globes and removal of intraocular foreign bodies. The use of the giant magnet as well as the rare earth magnet and the use of vitreous forceps should be included.
4. Laser Photocoagulation
   1. Diabetic Retinopathy
      Knowledge of the indications and treatment of macular edema and proliferative diabetic retinopathy are essential. Each fellow should personally perform both panretinal photocoagulation and treatment for diabetic macular edema. Participation in the management of at least 50 cases is recommended.
   2. Other Retinal Vascular Diseases
      Panretinal photocoagulation or sectoral retinal photo-coagulation for vaso-proliferative disease due to non-diabetic causes, such as branch vein occlusion or central vein occlusion, is important.
   3. Choroidal Neovascular Membranes
      An understanding of the pathogenesis of choroidal neovascular membranes due to age-related macular degeneration, the ocular histoplasmosis syndrome, myopia, angioid streaks, or idiopathic conditions, is basic. The interpretation of fluorescein angiography and understanding of the indications for and anticipated results of laser photocoagulation are essential. The treatment of parafoveal choroidal neovascularization during fellowship training is recommended.

VI. The above criteria apply to fellowships in vitreo-retinal diseases and surgery. Certain fellowships may be designed for medical vitreo-retinal disease, and other disease, and others may be designed for surgical vitreo-retinal disease. However, such fellowship training should be very clearly defined and the diploma of completion should state the nature of the fellowship. The successful completion of a medical fellowship in vitreo-retinal disease does not imply a basic understanding of vitreo-retinal surgery. Similarly, a surgical fellowship in vitreo-retinal diseases does not necessarily imply a basic understanding of medical fellowship-retinal disease. Preferably, a vitreo-retinal fellowship should include both medical vitreo-retinal training and surgical vitreo-retinal training as outlined. It is the responsibility of the Fellowship Director to certify that the curriculum is adequate, preferably with these guidelines as minimum standards, and that the fellow has satisfactorily completed the fellowship.