Today approximately 125 1- and 2-year retina fellowships are offered in the United States, with only about one-fifth of these programs currently described as medical retina-only fellowships. Will the growing domination of medical retina lead to an increasing demand for medical fellowships and a reduction in the demand for surgical fellowships?

Philip J. Rosenfeld, MD, PhD, who in 2004 resurrected the medical retina fellowship at the Bascom Palmer Eye Institute in Miami, Florida, continuing an earlier tradition of medical retina training established by esteemed founding member J. Donald Gass, MD, says that it’s too soon to know for sure. However, he adds, even if the percentage of medical fellowships should increase in future, it’s essential that the discipline of retina surgery always continue to be highly valued by specialists who pursue medical retina training.

“I encourage every medical fellow applicant who talks with me to explore the possibility of pursuing complete fellowship training – that is, of going on to complete at least a 1-year fellowship in surgical retina,” says Dr. Rosenfeld, adding that although most surgical fellowships are 2-year programs, a few outstanding 1-year surgical programs still exist. “I felt my surgical training was valuable and it made me a better medical retina specialist. Only with training in both disciplines can you make an educated decision regarding how you want to want to approach your career. I know that some fellows are eager to complete their training and head out into the professional world, but I don’t understand why there’s such a rush. Both the journey and the career should be fun and rewarding.”

“There is so much you can do now in medical retina, and you will likely be able to do even more in the future,” adds Dr. Rosenfeld, pointing to recent successful phase 2 results of a study examining pharmacologic treatment of dry AMD.¹ “But why wouldn’t you want to increase your options by acquiring as much knowledge and being as fully trained as possible?”

Christina Y. Weng, MD, MBA, who was mentored by Dr. Rosenfeld during her surgical retina fellowship at Bascom Palmer, and who now directs the surgical retina fellowship program at Baylor College of Medicine in Houston, Texas, says that she also likes the idea of well-rounded fellows and believes that options for retinal surgeons also will likely increase.

“Although there has been a trend toward less surgery in the field, as indicated by Medicare billing rates and other data, I believe surgical training will always be important,” says Dr. Weng. “Many pathologies, at least for the foreseeable future, will continue to require surgical intervention. There are no pharmaceutical or medical approaches at this time, for retinal detachments or epiretinal membranes, for example. There are also developments on the horizon that suggest that the number and range of surgical procedures may expand in the future.”

One such important development is gene therapy, says Dr. Weng, noting that the first FDA-approved genetic modifying therapeutic just became available this year.

“A lot of gene therapies currently require that genetic material be placed underneath the retina, and the only way to do that right now is with surgery.”

INCREASED COLLABORATION

Dr. Rosenfeld and Dr. Weng envision a future in which surgical specialists and medical specialists will work more collaboratively both within and among practices.

“There will be certainly be a place for medical specialists like me in the future, who wish to concentrate on medical retina,” says Dr. Rosenfeld, “Especially if they are surrounded by exceptional surgeons, like I am here at Bascom Palmer. And opportunities for collaboration among surgical and medical specialists are only likely to increase. To give one example, we are conducting trials involving embryonic stem cell transplantation for the treatment of macular diseases. Not only has input from my surgical colleagues been very valuable, but stem cell procedures in the future will likely require a high degree of interaction between us.”

Dr. Rosenfeld and his colleagues also are involved in research focused on a treatment for macular telangiectasia (MacTel) type 2. “Although the treatment is technically a medical one, the device is sutured into the pars plana. So, once approved, this is a treatment that will require both surgical and medical management and oversight.”

Dr. Weng, who also anticipates a future of greater collaboration, finds that she is resistant to the idea of thinking of specialists as “purely surgical” or “purely medical.”

“It’s possible that the number of medical fellowships will increase and surgical fellowships will decrease, because supply will follow demand, as in any field,” says Dr. Weng. “But I’d rather think of more innovative ways to address the changes in the field that have taken place during the past decade. Training should reflect the actual professional landscape. If you are spending 90% of your time doing surgery in a surgical fellowship, that probably does not accurately reflect what you will face in practice. Our duty as fellowship directors is ensure that the next generation of retina specialists is prepared for what they’ll encounter. For now, that may mean spending more time teaching our trainees how to manage medical retina.”

CREATIVE LEARNING METHODS

Dr. Weng says that given the current decline in surgical procedures, surgical fellows also will likely see fewer surgeries during training than fellows did in the past, and will have to supplement their training in creative ways.

“We may have had the luxury of having 700-800 surgical cases during fellowships in the past, but surgical fellows probably won’t operate on that number these days. That doesn’t mean they can’t graduate feeling secure and competent; they will simply have to take advantage of outlets that provide an educational experience that is perhaps less traditional.”

Because repetition is critical when specialists are first learning very delicate surgical maneuvers, Baylor fellows have access to the Eyesi surgical virtual reality simulator, which allows them to practice vitreoretinal procedures without the risk of complications for patients. Dr. Weng also encourages the use of various multimedia libraries, retina forums in which specialists can exchange surgical videos and photos, and social media specialty groups and webinars.

Neither Dr. Weng nor Dr. Rosenfeld believes that medical and surgical specialists will have any tendency to be in competition with one another in the future. Instead, they will work together more closely, and likely engage in more referrals both within and among subspecialties. Whether their primary focus is medical or surgical, fellows should prepare for a future of increasing specialization, with an emphasis on collaboration and adaptability.

“There is going to be an enormous amount of work in the future,” says Dr. Rosenfeld, “Already there are not even enough retina specialists in the United States to meet the future demand for injections. Our roles will continue to evolve in interesting ways and become increasingly interdependent. I don’t see the future of retina as being either medical or surgical — we are going to work as a team moving forward.” RP

REFERENCE

1. Apellis Pharmaceuticals Announces that APL-2 Met its Primary Endpoint in a Phase 2 Study in Patients with Geographic Atrophy, an Advanced Form of Age-Related Macular Degeneration. Press release. Available at http://www.apellis.com/pdfs/Press%20Release%20FILLY%2012%20Month%20Results%20FINAL%20FINAL%20170823.pdf