As practitioners in a demanding, highly technical, and ever-changing field, retina specialists tend to be curious lifelong learners. Those who have mentored younger colleagues also know that learning often goes both ways. Here I provide the perspective of an educator working with retina fellows, covering the ways in which retina training is changing, what aspects remain the same, and what veteran retina specialists may learn from the next generation of fellows.

PURSUING THE ACADEMIC PATH

Early in my medical training, I was fascinated with internal medicine, and I decided to specialize in ophthalmology after developing a keen interest in treating surgical retina and uveitis patients. Choosing the academic path came down to the type of work I enjoy doing: the complexity of cases in uveitis and surgical retina, the variety of problems available to solve, and the ability to work with trainees, convinced me to join academia. For example, in a given week, we can see a case of progressive outer retinal necrosis retinal detachment in an uncontrolled HIV/AIDS patient, followed by a patient with immunotherapy-induced uveitis, alongside obliterative autoimmune vasculitis patients, secondary lens evaluations, and bread-and-butter retina cases of macular degeneration, diabetes, and retinovascular disease. While similarly complex patients present outside of academic practices, this consistent level of complexity is a feature of many academic locations.

One of the most rewarding aspects of being a mentor is seeing residents and fellows move through challenges and gain independence as surgeons and practitioners. I will never forget one of my first trainees: He was concerned that his surgical growth was not progressing as expected, and he started to worry that he was not going to hit his stride as a fellow. Then one night, toward the second half of his first year of fellowship, we were operating on a difficult intraocular foreign body case together. I watched him “level up” before my eyes as he completed the case start to finish with me in the assistant chair the whole time — globe closure, lensectomy, foreign body removal, repair of the retina, and even lens implantation. When I broke scrub, I walked out of the operating room, and I can only describe the feeling as “electrifying” to see him utilize all the tools and techniques we had worked on over the previous several months and have everything come together in perfect execution. Even though it was late at night, I was fist-pumping the air because he had absolutely nailed a very complex procedure. To top it off, the patient’s vision improved to 20/40 a few weeks later. At that moment, my fellow’s accomplishment was more meaningful than anything I’d done in my own career up to that point; in the years since, training the next generation has become an addiction of mine, a part of the journey that I can’t live without.

LEARNING GOES BOTH WAYS

It is not uncommon for new mentors to be anxious about the process. Initially, it’s normal for there to be a fair amount of double-checking a trainee’s work and making extra rounds on all the patients. But over time, mentors develop an intuition on when to intervene and when to trust the fellow’s judgment. I would describe it as a graded process that is different with each fellow and each situation. I think I have learned that each fellow has a uniquely individualized journey and that teaching styles and areas of focus must change with each fellow. While some may be naturals early on, there are others who require more guidance and structure to become the most polished version of themselves. Using vitreoretinal surgery as an example, fellows need to learn many procedures, including how to handle lighting and guide the eye under the widefield viewing system. Mastering these nuanced points will take time; it is typical for me to guide the fellow for the first 6 months in the operating room, followed by a second 6 months when they continue to master the techniques.

One of the most stressful aspects of mentorship at the beginning is to get every fellow to the same base level competence. After enough interactions, mentors can typically adjust their mentorship strategy for each individual fellow as needed. Eventually, mentors will learn when to be more relaxed and trust their trainees in performing certain tasks. By their second year, fellows are often doing amazing things. There will be points when trainees are really struggling, and the mentor needs to be ready to take over. At the end of the day, it is always very gratifying to see each fellow mature into an expert retina specialist.

I think I understand surgery and our field far deeper now, thanks in no small part to training fellows. Through the process of communicating the mechanics to our fellows or responding to their questions of the “why,” I have been forced to contemplate surgery or the science of our field with greater depth both in the clinic and in the operating room. Over time, I have learned to be less critical and more nurturing toward the fellows. I see the value in taking a more nuanced and nurturing approach as a mentor, which builds more solid, trusting relationships and makes for a more productive learning environment.

THE CHANGING LANDSCAPE

The field of surgical retina, and consequently the fellowship training programs, have evolved tremendously in the past 2 decades. Advances in medical therapy for many of the major retinal diseases — eg, age-related macular degeneration (AMD), retinal vein occlusion, and diabetic macular edema — have both improved treatment outcome and reduced disease onset. Use of anti–vascular endothelial growth factor (VEGF) drugs has revolutionized the field. More advanced devices are also available for imaging and treatment. While these are all positive developments, the fast pace of technological advances has also collectively increased the need to expand the training of retina specialists.

Retina surgery has also changed over time, reflecting a shift from longer cases in epic retinal detachment repairs or trauma-related cases to greater efficiency with those types of cases and new frontiers such as drug delivery devices, gene therapy, and secondary lens implantation, to name a few. We also do more primary vitrectomy procedures today than scleral buckling. On the other hand, while our philosophical surgical approaches to retinal detachment and diabetic traction retinal detachments are essentially the same as in the late 1990s and early 2000s, we are now much more efficient in performing these surgeries.

Finally, the variety of presentations we see has changed as treatment has evolved. For example, fewer patients today progress to neovascular glaucoma and require urgent vitrectomy. Similarly, retinal vein occlusion can now be controlled by anti-VEGF therapy, which reduces the progression of the disease to advanced presentations. Retina fellowships will have to continue evolving as new technologies come online.

THE FUTURE OF THE RETINA SUBSPECIALTY

Many retinal diseases, such as retinal detachment, diabetic eye diseases, and AMD, are unlikely to go away, as long as cures remain elusive. But many novel treatments, such as gene therapy, are currently in the pipeline with the promise to improve patient outcomes and provide longer term solutions for diseases such as wet AMD (Table 1).

In the world of uveitis and immune modulation, we can expect more tools for autoimmune disease — systemic therapy and hopefully local agents to the eye as well. Uveitis remains something of a niche, but promising avenues include gene therapies and immunomodulators that target mTOR inhibition, small molecule inhibitors, cytokine targeting strategies, Nf-kB, or IL-17A signaling pathways.

Telemedicine will also likely become more mainstream in the future, enabling retina specialists to reach more patients sooner. This innovation will likely change how clinics are run by reducing the number of screenings and replacing visits with more advanced and challenging cases.

STAYING CURRENT ON NEW RESEARCH AND TREATMENTS

Learning from peers by attending conferences is one of the best ways to stay up to date with developments in the field. Although retina specialists’ philosophical approaches to treatment generally stay the same, their knowledge base can evolve through exposure to new research and via discussions and debates with fellow retina specialists. As a rule, it is important to remain open to being surprised by novel or counterintuitive findings.

Staying on top of the medical literature is an admirable but not always realistic goal, given the amount of time and energy needed to identify even one impactful article. By attending congresses, we are likely to be exposed to research well before it makes it through peer review. Learning from one another, as we do in our formal training, is valuable throughout our careers. In addition, continuing to take on challenging cases and pushing ourselves to learn new treatment approaches is pivotal as we develop as retina specialists.

ADVICE FOR ASPIRING MENTORS

Because being a mentor takes so much time and effort, a strong sense of purpose and passion is essential. By investing in the next generation, we ensure the continuation of our field; at the same time, we also gain a deeper insight into our own craft through training others. Mentoring students challenges us to view retinal diseases differently and pushes us to become better educators and practitioners.

Although not every aspiring mentor will have the right environment to start a fellowship, fellowships are ultimately the best settings for a mentorship. An alternative is to work with residents as an adjunct faculty member, which serves to break up the monotony of practice and invigorate the mentor’s career. In addition, there are opportunities to work with industry in an educational capacity through involvement in research and the publication and presentation of data. RP