PURPOSE OF PROGRAM
A two-year training program will be offered in the diagnosis and management of diseases of the retina and vitreous. The program is under the supervision of Dr. Everett C. Madson at Midwest Eye Care and Dr. Eyal Margalit, Director of the Retina Service at the University of Nebraska Eye Specialties Clinic. The fellow will participate in the care of patients from both clinics and the Omaha Veterans Administration Hospital.
The fellowship program will provide extensive experience in the treatment of medical and surgical vitreoretinal disorders. This experience will encompass a broad range of disease processes, and will include straightforward as well as complicated patient management. In addition, the fellow will be provided with opportunities to participate in basic science and clinical vitreoretinal research.
The fellow will serve as a clinical instructor at the University Eye Specialties clinic. In addition to seeing patients in the outpatient clinic with Dr. Margalit and his resident(s), the fellow will be available for emergency consultation with the ophthalmology residents and staff. In addition, the fellow will be expected to lecture to the residents on a variety of vitreoretinal topics throughout the year. These lectures will be arranged with the chief resident and Dr. Thomas Hejkal, residency program director. The fellow will also be responsible for organizing a monthly retina clinical case conference. The fellow will also attend and occasionally present at scheduled conferences, journal clubs, and bi-monthly grand rounds at the University Eye Specialties clinic. The fellow may also be asked to lecture on vitreoretinal topics to the medical students at the University of Nebraska Medical Center.
The fellow will staff the Retina clinic at the VAMC Eye Clinic on a weekly basis and will supervise in the management and surgical care of all retina patients at the VAMC Eye Clinic. All emergent and scheduled vitreoretinal surgery for VA patients will be performed by the fellow, the VA senior resident and retina faculty at the VAMC or at Clarkson Memorial Hospital. Should the fellow require consultation regarding patient management, retina faculty will be available for this purpose.
The fellow will be given the opportunity to participate in clinical as well as basic science research during the fellowship. The department is actively involved in a number of vitreoretinal research projects at the University of Nebraska Medical Center. Should the fellow have a specific research interest, every effort will be made to facilitate an appropriate research project. The fellow will also have an opportunity to participate in clinical research during the fellowship. It is expected that the fellow will co-author at least one paper during a fellowship year.
The fellow will be allowed to attend one conference relating to vitreoretinal diseases during each of the two year fellowship. The tuition, hotel and travel expenses for this conference will be reimbursed by the UNMC Department of Ophthalmology and Visual Sciences.
Evaluation of the fellow’s progress during training is determined by periodic consultation throughout the year. At the end of the training period, both Directors will meet with each other and with the fellow to arrive at a final evaluation. Following successful conclusion of the fellowship, the fellow will receive a certificate recognizing his/her achievement.
Goals of the Retinal Fellowship
Medical Retinal Therapy
A. Ophthalmoscopic Diagnosis
The fellow will become proficient in the techniques of indirect ophthalmoscopy, scleral indentation, biomicroscopy and contact lens slit‑lamp examination of the retina and vitreous. This experience will be acquired through supervised examination of patients who have a wide variety of acquired and hereditary vitreoretinal diseases including peripheral retinal degenerations, retinal breaks and detachment, and maculopathy.
B. Diabetic Retinopathy
The fellow will become proficient in the management of all forms of diabetic eye disease. Laser therapy including focal and grid treatments as well as panretinal photocoagulation will be performed by the fellow employing the argon green, and tunable dye lasers. Indications and contraindications for treatment will be learned. Specific treatment considerations (including patient selection, photocoagulation strategies, etc.) will be stressed. The fellow will also become very familiar with the interpretation and employment of fluorescein angiography and other diagnostic tools in the management of diabetic eye disease.
C. Inherited Retinal Dystrophies
The fellow will learn to diagnose hereditary retinal diseases by examining a wide variety of patients in the outpatient clinic. Electrophysiologic tests including dark adaptation, electroretinography (ERG) and electrooculography (EOG) are performed at the University of Nebraska Eye Clinic. The fellow will learn when to order and how to interpret these electrophysiologic studies.
D. Fluorescein Angiography
The fellow and Dr. Margalit will review and interpret all fluorescein angiograms ordered and processed at the University of Nebraska and Veterans Hospital Eye Clinics. In addition, the fellow will review fluorescein angiograms with Dr. Madson, and Drs. Emig, Hellman and Ingvoldstad at Midwest Eye Care. The fellow will become proficient in interpreting angiograms and establishing or confirming a diagnosis from angiography. In addition, the fellow will learn how to use angiography as an adjunct to photocoagulation therapy. Specific goals include: recognition and localization of choroidal neovascular membranes, accurate interpretation of post‑treatment angiograms, and recognition of various manifestations of diabetic retinopathy (including clinically significant macular edema, capillary nonperfusion, and proliferative retinopathy). Indications for and interpretation of Indocyanine Green (ICG) angiography will also be learned.
E. Vascular Occlusive Disease
The fellow will learn to diagnose and treat retinal venous and arterial occlusions. This includes proper medical workup for these conditions, as well as timing and technique in the treatment of macular edema and neovascularization as sequelae of retinal venous occlusion.
F. Choroidal Neovascularization (CNV)
The fellow will learn to diagnose and treat subretinal choroidal neovascular membranes. Familiarity with the underlying disease processes leading to CNV formation (e.g.; Age‑related macular degeneration, POHS ... etc.) will be stressed. The implications of the Macular Photocoagulation Study (MPS), studies related to photo dynamic therapy, and studies related to the use of anti vascular endothelial growth factor drugs will also be emphasized.
G. Retinal Oncology
The fellow will learn the medical and surgical treatment of posterior segment tumors including choroidal melanoma, retinoblastoma, choroidal hemangioma, and retinal angioma.
The fellow will learn the proper diagnosis, workup and treatment of posterior uveitis. The role of vitrectomy and vitreous biopsy in this condition will also be learned.
I. Retinopathy of Prematurity
The fellow will perform weekly ROP screening examinations with the UNMC Retina Clinic Director and an ophthalmology resident in the Neonatal ICU. Proper examination technique and staging according to the International Classification of ROP will be mastered. The fellow will also participate in the laser and cryo treatment of infants who have reached threshold and prethreshold diagnoses. The fellow will become familiar with the technique of indirect laser ophthalmoscopy using the Iris diode laser indirect ophthalmoscope. The fellow will also learn of the indications for vitrectomy in ROP.
The fellow will become proficient in the use of A and B‑scan ultrasonography facilitating the accurate recognition and measurement of conditions including retinal and choroidal tumors; retinal, choroidal and posterior vitreous detachments, foreign bodies and optic nerve drusen.
K. Macular Disorders
The fellow will be provided with a broad experience covering a wide range of macular disorders. A special emphasis will be placed on the diagnosis and treatment of Age‑related Macular Degeneration (ARMD).
L. Posterior Segment Infections
The fellow will learn to diagnose and treat a variety of infectious processes including CMV retinitis, toxoplasmosis, and acute retinal necrosis.
Surgical Retinal Therapy
Proper training in the treatment of vitreoretinal disease mandates surgical "hands‑on" experience. The fellow is expected to actively participate in the surgical management of all patients and not merely be an observer. During the first six months the fellow will function primarily as an assistant while learning the various stages and mechanics of various vitreoretinal procedures. During this time, the fellow will gradually perform more phases of the operation as his/her surgical expertise allows. During the second six months the fellow will act as primary surgeon in the majority of cases performed. The rate of progression for an individual fellow is at the discretion of the directors who actively supervise all cases performed during the fellowship.
A. Retinal Detachment Repair
The fellow will become proficient in the proper examination and drawing of retinal detachments. An understanding of the different types of detachment (rhegmatogenous, tractional, serous, and combined) will be acquired. The fellow will also learn proper surgical management of retinal detachments. An emphasis will be placed on a proper scleral buckling technique including choice of buckling element, buckle placement, drainage of subretinal fluid, and pneumatic retinopexy used in conjunction with scleral buckling.
B. Proliferative Diabetic Retinopathy
The fellow will learn appropriate timing of surgery and become familiar with surgical techniques employed to treat fibrovascular proliferation, relieve vitreoretinal traction and evacuate vitreous hemorrhage. The fellow will also become proficient in the use of endolaser photocoagulation and endodiathermy. A spectrum of surgical disease processes ranging from straightforward to complicated will be encountered during the fellowship.
C. Proliferative Vitreoretinopathy (PVR)
The fellow will learn to recognize and treat the full spectrum of proliferative vitreoretinapathy. Appropriate timing of surgery and the principles of successful reattachment will be learned as well. In addition, the fellow will become experienced in the use of vitreous substitutes (including silicone oil, long-acting gases, and liquid perfluorocarbon.) The fellow will also learn how to perform peripheral dissection and membrane peeling. Indications for and complications of relaxing retinotomy, internal drainage of subretinal fluid, and removal of subretinal bands will also be learned. The fellow will become proficient in the various techniques for outpatient air/fluid exchange and post‑operative laser photocoagulation.
The fellow will learn how to accurately diagnose and treat endophthalmitis. In addition, the fellow will gain a firm understanding of how to obtain an appropriate sample for culture purposes and will learn principles of antibiotic selection and delivery.
The fellow will become proficient in the surgical technique and indications for pars plana lensectomy. In addition, the fellow will learn how to perform secondary IOL placement, removal of retained lens fragments and proper management of displaced intraocular lenses following cataract surgery.
The fellow will learn appropriate timing and technique in the surgical management of posterior segment trauma, including removal of intraocular foreign bodies and repair of posttraumatic retinal detachments.
G. Retinopathy of Prematurity
The fellow will learn appropriate surgical management of patients with Stage IV and V retinopathy of prematurity.
H. Miscellaneous Vitreoretinal Surgery
In addition to the specific procedures listed above, the fellow will also participate in a variety of other vitreoretinal surgical cases including vitreous biopsy, management of choroidal hemorrhage and effusion, and plaque brachytherapy for choroidal melanoma and retinoblastoma.
Applications for the retina fellowship should reach us before the beginning of September, because we plan to interview selected applicants during October and November in order to meet the deadline for submitting the match list in December. Information and forms relating to the Fellowship Matching Program can be obtained from: Ophthalmology Fellowship Match, P.O. Box 7584, San Francisco, California 94120-7584, (415) 447-0350.
985540 Nebraska Medical Center
Omaha, NE 68198-5540