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Ophthodoc2018

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I am in my 2nd year of ophthalmology residency. Up until now, I was pretty set on doing either a medical retina or surgical retina fellowship. But as time has gone on, I realized that am actually not that interested in retina. The far periphery is daunting, endophthlamitis is scary af (maybe it is a case of me being in training haha). Additionally, if I were to go into surgical retina, I would always miss the idea of doing cataracts, general comprehensive stuff. The idea of doing injections after injections, with the occasional laser/PRP does not really entice me that much. I love operating, and I feel like the way things are going with retina, it is becoming more of an office-procedure field vs. OR heavy field. On top of that, I did not realize how terrible the fellowship was up until I came into training and saw the retina fellows get crushed on a daily basis.

I have heard great things about glaucoma for the past couple of years, but I always kind of ignored it. I hear the job market is great and there is a lot of innovation going on. But I also do hear that the postop management is terrible and sometimes you don't get the instant gratification.. What I like the most is the idea of still being able to practice comprehensive ophthalmology. With that being said, I have a few questions:

1. What is your perspective on the field (pros and cons?)
I am going to comment on my personal perspective, and leave out the typical “build rapport with your patients” type of comments.
Pros: you can combine with cataract surgery, several new procedures that are cool/fun to do, higher income potential than most (except retina and possibly plastics)
Cons: dealing with a frustrating chronic disease, some patients often unhappy, postop complications after trabs/tubes can be a pain in the rear end and can slow down your clinic if you have to tap or reform a postop

2. Theoretically, there should be a lot of innovation/new surgeries/procedures in glaucoma since the actually cause of glaucoma is unknown. Is this true or am I mistaken?
A lot of cool research is going on, and if you end up in academics/research, glaucoma is probably where you want to be. However, we are far from a paradigm shift in glaucoma. Surgically, new procedures are coming out every day. However, all procedures aim at lowering IOP by enhancing filtration (most procedures) or decreasing aqueous production (cyclodestruction) - mechanisms are not “too innovative”.
3. Is MIGS going to last? People love doing these surgeries, but are there any proven long-term outcomes?
MIGS is here to stay, as a group but not the individual procedures. No procedure has the proven track record of trabs or tubes, but the time when only these invasive procedures were the only available options in the glaucoma surgeon’s armamentarium is long gone, with a recent trend to surgically intervene at much earlier points in the disease course.
4. I have heard that salaries are pretty high and steadily increasing (not as high as retina but higher than other ophtho). Why is this the case? How do you expect them to be in the next 10-30 years?
I think it is supply and demand. The demand is huge, now that every comprehensive ophthalmologist and optometrist has an OCT and would do an RNFL for any slightly suspicious nerve, and would want to send to a glaucoma specialist to confirm or refute the diagnosis. So it is now possible to diagnose glaucoma earlier than ever. Add to that aging America, with more glaucoma being diagnosed in the elderly. Every practice wants a glaucoma specialist. The demand is real, and the salaries are better than ever for glaucoma. What is going to happen in the future is a mystery. No one predicted that glaucoma would be “the new retina” 15 years ago (a bit of an exaggeration).
5. I have heard that the job market is good? Why is it good? Are not enough people going into glaucoma fellowship or is there just a huge demand/shortage for glaucoma?
The demand. See above.
6. How competitive is glaucoma fellowship? Can I theoretically choose my location for fellowship? Do OKAPS matter?
The few top programs are always going to be competitive, even in less desirable subspecialties. However, I think everyone who wants to do a glaucoma fellowship will be able to do one. As for the top ones, I think the biggest factor is connections.

I know I asked a lot from y'all, Thank you so much for your advice!
 
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I can report on the job side of glaucoma and confirm what Fascia Lata said. Essentially, there are so many glaucoma patients that most practices looking for a comprehensive ophthalmologist would happily take a glaucoma specialist who does some comprehensive and pay them more. With many glaucoma fellows getting some refractive cataract experience in residency and some even in their fellowships, glaucoma fellows can come out with a very diverse surgical skillset.

Compensation is rising for glaucoma surgeons currently and I expect it to continue on this path. 10+ years from now it is hard to say where it will be. It seems demand will be up but reimbursements will likely have fallen and then there is the debate about medicare as a whole going on. As a note, if you finish residency in 2021 and will be done with your glaucoma fellowship in 2022; I would expect your base salary offers from private practices to be in the $275,000 range as an average with a range of $250-325,000. Hospital based positions in the $350,000+ area. There is also the potential for outliers.
 
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As an Optometrist please go into Glaucoma and move to the Midwest. We need you.
 
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What is income potential for glaucoma? Is income potential more for glaucoma than say comprehensive? I know this is highly variable but perhaps a rough approximate.
 
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What is income potential for glaucoma? Is income potential more for glaucoma than say comprehensive? I know this is highly variable but perhaps a rough approximate.
Too many factors to really give numbers. For the first couple of years, I would guess you would make more than your comprehensive colleagues. This mostly to do with higher base salaries and getting busier more quickly with glaucoma patients piled on you from the practice. Even then a comprehensive colleague could be taking over for a retiring surgeon and in a smaller area and be busier right off the bat. After the first couple of years there are too many factors to really give a good number. Some of the factors:

-location
-volume
-conversion rate for premium lenses/femto cases
-ability to do refractive cases
-injection schedules for those in more rural practices
-practice model (co-management)

Long term it is really up to you how much you make and whether you seize investment opportunities through partnership or surgery center ownership.
 
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Thank you all for your informative responses.

Ideally I want to have a diverse skillset / practice. One of the reason I like glaucoma is the idea of doing comprehensive. Such as cataracts, refractive surgery (although not nearly as much as Cornea docs), VERY mild cases of intravitreal injections, PRP. I am well aware that it is important not to cross certain boundaries though.
I must say that I have not seen any glaucoma specialist practicing the full spectrum of comprehensive ophthalmology like you outlined. Cataract surgery is fair game. In fact, cataract surgery is a glaucoma surgery on its own. But injections, PRP, and LASIK are certainly out of the glaucoma specialist scope and offering these means that you would severely limit your glaucoma referrals. I even know colleagues who work in remote undesirable areas in the middle of no where who would never expand their scope that much. Moreover, in order for you to become a trustworthy glaucoma specialist who comprehensive guys are comfortable sending their patients to, you need to devote most of your practice to glaucoma. You don’t see everything in fellowship, even in top fellowships. It takes considerable time and practice to get really good at managing glaucoma confidently and safely. I believe when people mention “you can still do comprehensive” as one of the pros of glaucoma, they simply mean cataract surgery (and possibly DR screening for your glaucoma patients). I would say if this expansive scope is something that is really important to you, comprehensive should be the way to go.
 
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When you say" base salary offers" are these starting offers? Then after a bit of time you buy into practices etc. Thanks!
Yes, I mean starting offers. Then after a period of time buying into the practice.

Per what Fascia Lata said, I agree that I don't know any glaucoma docs who are doing injections currently. I do know 3 I can confirm who are doing LASIK cases because they've built up an interest in it but are also in markets with few LASIK providers but a fair amount of younger patients. I think this is possible but takes a unique practice situation to execute. Interest in refractive outcomes is growing amongst glaucoma surgeons.

I think the point FL was making is that if you're 100% comprehensive you would see more volume of those sub-specialty patients vs. if your practice is 50% comprehensive your volume of "dabbling" would be halved from a comprehensive ophthalmologists volume given equally busy practices.
 
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