Fellowship Cornea/Retina HELP!

[eyestar]

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Hello everyone: I am looking for some input on whether I should do a fellowship.
I currently practice comprehensive ophthalmology. When I completed my residency 2 yrs ago, I was leaning towards doing retinal fellowship as I liked the retinal pathology. However, at that time, cataract surgery excited me and I had very little experience as primary retinal surgeon to choose between the two.
However, over the past 2 yrs, I have become bored with what I do. Most of my patients come for minor things like dry eyes, chalazion, contact lens issues etc which doesn't interest me. Pay is low and constant referrals to cornea or retina sucks as i would like to do more. Cataract patients are picky and they all want restor lenses or combined with refractive surgery for which I did not have training during my residency. (I live in an urban area)
Due to family, I have to be in suburban or urban areas. I loved doing retinal lasers during residency and enjoyed being in the OR for all retinal surgeries.
So, I have come to a conclusion that doing some fellowship will help in compensation, make me more attractive for hire as I have taken a recent maternity break as well.
More importantly, I want to do something that challenges me everyday and keeps me motivated to learn more.
Am I crazy? Any input appreciated. If I decide to apply for 2014, does anyone have any suggestions for what to do this year?
Thanks so much. Sorry for the long post rambling,

 

[eyestar]

Adding:
I would like to learn refractive surgery but have no interest in doing corneal transplant surgery. Are there fellowships that train you only for refractive- big institutions?

 

[Visionary]

I think you should do what you feel is right for you. Going back to fellowship after being out for a while is difficult, so you should consider that.

Now, I'll give you another nugget to chew on, from someone now over 3.5 years out. All medical practice becomes routine after a while. I enjoy what I do, don't get me wrong, but my days are pretty much the same. I can count on doing 10-20 injections, possibly a laser, seeing a handful of PVDs, and maybe, if I'm lucky, something interesting. You will never be more intellectually stimulated than you were in residency (or fellowship). So much is new for you then. That's where a lot of the excitement comes from. Once you're out, you tend to see the bread and butter cases the majority of the time. Even if you do academics, it becomes old. You have the research and teaching aspect to mix it up with, though.

 

[RestoreSight]

I can count on doing 10-20 injections, possibly a laser, seeing a handful of PVDs, and maybe, if I'm lucky, something interesting.

Visionary - just curious, Do you receive most of your patient base by referral in medical retina or did you build your own? I would be surprised if comps referred patients with AMD, DR, CRVO, CSCR, etc considering the rebursement involved.

 

[Visionary]

Visionary - just curious, Do you receive most of your patient base by referral in medical retina or did you build your own? I would be surprised if comps referred patients with AMD, DR, CRVO, CSCR, etc considering the rebursement involved.

Most of my referrals are from inside my group, actually, and they're all comprehensive. You'd be surprised. Yes, the reimbursements are good for medical retina, but not many comprehensive docs in metro areas even do injections (I can think of 2 where I am). To do it right, you need the imaging equipment, injection stock (which can be a sizable expense), and the like. Injections can also throw off the flow of an otherwise comprehensive clinic. The docs in my group never did injections. A couple did some retina lasers, but were more than happy to give them over to me. They would much prefer to tee up LASIK and premium IOL/Lensx patients. The higher volume comprehensive docs in my group see ~60 patients per day and bring in over $1 mil in collections per year.

 

[MstaKing10]

I think you should do what you feel is right for you. Going back to fellowship after being out for a while is difficult, so you should consider that.

Now, I'll give you another nugget to chew on, from someone now over 3.5 years out. All medical practice becomes routine after a while. I enjoy what I do, don't get me wrong, but my days are pretty much the same. I can count on doing 10-20 injections, possibly a laser, seeing a handful of PVDs, and maybe, if I'm lucky, something interesting. You will never be more intellectually stimulated than you were in residency (or fellowship). So much is new for you then. That's where a lot of the excitement comes from. Once you're out, you tend to see the bread and butter cases the majority of the time. Even if you do academics, it becomes old. You have the research and teaching aspect to mix it up with, though.

I really hope you are wrong but only time will tell. I'm one year out and can't imagine myself getting bored. The mix of pathology in clinic and challenge of surgery I think is a perfect blend for me. One thing that keeps things interesting is being in a large retina only referral practice in a relatively large urban area (non-academic), we tend to see a lot of interesting pathology that would normally go to a university setting (nearest university setting is about 1.5 hours away from us). We also see some trauma and indigent patients with advanced disease. In any case, I hope I don't get bored but who knows.

To OP: Think long and hard before you choose a fellowship. Cornea and retina are very different fields. If you are tired of demanding/picky patients not sure why you are so interested in refractive surgery. I would think most cornea specialist end up doing mostly comprehensive ophthalmology/cataracts so not sure that would be the big change you are looking for. Retina has it's own challenges but is very rewarding. Not sure how difficult the application/interview process will be for you going forward since you will be a non-traditional candidate but there are enough fellowships out there that you may be able to find a good fit.

 

[mydodger]

However, over the past 2 yrs, I have become bored with what I do. Most of my patients come for minor things like dry eyes, chalazion, contact lens issues etc which doesn't interest me. Pay is low and constant referrals to cornea or retina sucks as i would like to do more.

You are the perfect position to answer a question that comes up often on the forums: What kind of income can a comprehensive Ophthalmologist expect in the first few years after residency? Is the pay horribly low and could you provide a precise number for what you or others you know are making?

Nobody is ever willing to actually say what they are making right out of residency and it would be helpful to many to have this information. Sorry to intrude on your thread and sorry that I have no answers to your questions, but good luck in your decision making.

 

[Visionary]

I really hope you are wrong but only time will tell. I'm one year out and can't imagine myself getting bored. The mix of pathology in clinic and challenge of surgery I think is a perfect blend for me. One thing that keeps things interesting is being in a large retina only referral practice in a relatively large urban area (non-academic), we tend to see a lot of interesting pathology that would normally go to a university setting (nearest university setting is about 1.5 hours away from us). We also see some trauma and indigent patients with advanced disease. In any case, I hope I don't get bored but who knows.

It's a fact of life that spans most career choices, to be honest. Like I said, I like what I do, but after a while anything you do becomes somewhat mundane. By now, I have know retina inside and out. There is very little that surprises me. I have protocols for almost anything I come across. The newness and challenge of retina that was there in residency, fellowship, and the first couple years of practice is not really there anymore. For me, it's more now about taking care of the patients, seeing them improve (when they do), and getting to know them. The fact that the lifestyle is great is also a big plus. I have a lot of time with my family and the money is good.

 

[RestoreSight]

Most of my referrals are from inside my group, actually, and they're all comprehensive. You'd be surprised. Yes, the reimbursements are good for medical retina, but not many comprehensive docs in metro areas even do injections (I can think of 2 where I am). To do it right, you need the imaging equipment, injection stock (which can be a sizable expense), and the like. Injections can also throw off the flow of an otherwise comprehensive clinic. The docs in my group never did injections. A couple did some retina lasers, but were more than happy to give them over to me. They would much prefer to tee up LASIK and premium IOL/Lensx patients. The higher volume comprehensive docs in my group see ~60 patients per day and bring in over $1 mil in collections per year.

After reading this maybe the OP should consider medical retina. What's the status of surgical retina vs medical retina. I hear a lot about medical retina becoming more and more popular. Is it just liking the OR or not that determines the final choice? Is the money better in medical retina? I always hear you lose money in the OR compared to a busy clinical medical retina practice.

 

[Visionary]

After reading this maybe the OP should consider medical retina. What's the status of surgical retina vs medical retina. I hear a lot about medical retina becoming more and more popular. Is it just liking the OR or not that determines the final choice? Is the money better in medical retina? I always hear you lose money in the OR compared to a busy clinical medical retina practice.

Medical retina is on the rise, you might say, primarily due to the explosion of intravitreal injection as a treatment of many retinal diseases. Medical retina, like glaucoma, now tends to accumulate patients that essentially stay with you, for relatively frequent visits, indefinitely. Very few patients with wet AMD, for instance, are able to get off of injections without having a recurrence. The injection volume has been overwhelming for many established practices. Medical retina is not for everyone, though. Some of us are surgeons at heart, and giving up surgery is a big deal. For me, it was the right choice, and I have no regrets (especially when that mac-on RD rolls into clinic at 4:30 on Friday, LOL!). You also have to find your niche. Not many all retina groups are hiring medical retina docs, as they want new surgeons coming in to share the call. The older docs are the ones who tend to drop surgery and go all medical. Most every medical retina doc I know is in with a comprehensive or multispecialty group, as I am. There are also very few medical retina fellowships compared to surgical. Not many would go through a surgical fellowship to not do surgery.

 

[ophthope]

Medical retina is on the rise, you might say, primarily due to the explosion of intravitreal injection as a treatment of many retinal diseases. Medical retina, like glaucoma, now tends to accumulate patients that essentially stay with you, for relatively frequent visits, indefinitely. Very few patients with wet AMD, for instance, are able to get off of injections without having a recurrence. The injection volume has been overwhelming for many established practices. Medical retina is not for everyone, though. Some of us are surgeons at heart, and giving up surgery is a big deal. For me, it was the right choice, and I have no regrets (especially when that mac-on RD rolls into clinic at 4:30 on Friday, LOL!). You also have to find your niche. Not many all retina groups are hiring medical retina docs, as they want new surgeons coming in to share the call. The older docs are the ones who tend to drop surgery and go all medical. Most every medical retina doc I know is in with a comprehensive or multispecialty group, as I am. There are also very few medical retina fellowships compared to surgical. Not many would go through a surgical fellowship to not do surgery.

Any way to mix med retina with a comprehensive practice and still do a significant number of cataracts?

 

[orbitsurgMD]

You won't get referrals from other general ophthalmologists and you might not be well thought of by retina docs who increasingly devote more time to medical retina, but optometrists would probably not care as long as you did good work, treated their patients well and promptly returned them.

 

[4ophtho]

Any way to mix med retina with a comprehensive practice and still do a significant number of cataracts?

What about a comprehensive doc doing some medical retina? I know that comprehensive docs in practice now didn't get as much exposure to injections like we do in residency today. I am sure some old school retina docs are uncomfortable with comprehensive docs doing injections. For a comprehensive docs that are graduating these days with plenty of exposure to anti vegf , how do retina folks feel about comps treating basic amd/rvo/csme etc? Would a comp doc in an urban/suburban setting be a pariah in their ophthalmology community for doing injections for uncomplicated cases even with a retina specialist nearby? For you retina docs that are familiar with the reimbursements, does it make sense for a comp to do injections (a few per week) or just plow through high volume of patients every day.

 

[Dusn]

The costs for doing office based retina are pretty significant: an FA, SD-OCT, B-scan, a good photographer. Plus the high-end injections are $2500 a pop. If you have trouble getting reimbursed for one of those, that cost comes out of your pocket. Avastin expires in a few weeks so you have to know that you're going to be using it. And actually giving the injection isn't the hard part; it's knowing the expected course of each disease and how and when to treat.

I actually rarely see retina patients treated by comprehensive but I would worry that the patients might end up being poorly managed and being treated without a plan, which can lead to some degree of permanent vision loss. I think specializing helps physicians see patients faster and more efficiently and provide better care.

Comprehensive docs are in a sense specialists, especially in cataracts and early management of other diseases. I do think it makes more sense financially and practically to see patients that you're most comfortable with so that you can see a high volume of them and manage them well. And the way to get the best of both worlds is to create multi-specialty groups.

 

[Visionary]

Dusn and OrbitsurgMD stated it well already. Unless there are no retina docs nearby, you won't find many comprehensive docs doing a significant amount of medical retina. Medicine in the real world today is about referral base and controlling overhead. It's just not practical to be a Jack of all trades nowadays. You end up half-arsing things. Good example is a guy I ended up seeing who had been receiving Avastin for wet AMD. Problem is he didn't have it. He had dry AMD without any signs of prior neovascularization (e.g., watermark on autofluorescence). That was an uncomfortable discussion.

 

[akinetopsia]

Dusn and OrbitsurgMD stated it well already. Unless there are no retina docs nearby, you won't find many comprehensive docs doing a significant amount of medical retina. Medicine in the real world today is about referral base and controlling overhead. It's just not practical to be a Jack of all trades nowadays. You end up half-arsing things. Good example is a guy I ended up seeing who had been receiving Avastin for wet AMD. Problem is he didn't have it. He had dry AMD without any signs of prior neovascularization (e.g., watermark on autofluorescence). That was an uncomfortable discussion.

Just curious - why was he being treated for wet AMD? It seems to me (as a technician), that OCTs would show just drusen & not subretinal fluid, and FAs would of course have macular hyperfluorescence both early in the laminar phase and in the lates, wouldn't they?

 

[MullerCell]

Sometimes it can be difficult to be sure if there truly is/was a CNVM present. I have certainly seen some of my partners patients that were previously treated with anti-VEGF agents who present to me several months after stopping injections with an involuted CNVM. In some instances you can't tell that they ever had a CNVM. The PED is flattened, the fluid gone, and all that remains are drusen and pigmentary changes with no leak on FA and no significant findings on OCT or AF. I look back to imaging from their initial visit and there is no question a CNVM is present; however, after responding well to treatment it is no longer detectable. This isn't the typical course, but I don't think you can say in hindsight that someone absolutely never had wet AMD and was being treated without cause unless you look at images from the time of presentation.

 

[intoxicatedtiger]

I'm a comprehensive doc in the Bay Area who does medical retina. There are close to 20 retina specialists within a 15 mile radius. My situation is a bit unique though. I'm in solo practice and most of my patients don't like to see English only docs because of a language barrier. I have an SD-OCT, FA, and my own laser. I perform my own FA's.

As a recent grad, I've done over 100 injections (including the management decisions that comes along with the procedure), and close to 200 retinal lasers in residency. Given that ACGME tells me that I'm qualified to perform cataract surgery after 84 cases, I would like to think that I'm qualified to practice basic retina. And I doubt anyone would argue that cataract surgery doesn't come with its own management challenges, subtleties, and intricacies either. In addition, many cornea fellows graduate with less than 50 PKs, and glaucoma fellows with less than 50 trabs, and they're still qualified to perform these procedures.

If you are going to do medical retina or anything else out of your "qualification," it is of utmost importance that you stay up to date with the studies, techniques, and drugs. Also, be prepared to face the same medicolegal scrutiny as subspecialists.

The main issue with comprehensive docs providing subspecialty care is the volume. I perform only about 3-5 injections a month. Obviously, almost no one will refer you any medical retina. The only patients you'll see will be the ones you generate for yourself. Hence, you will most likely not be exposed to difficult, challenging, refractory cases. Nevertheless, I would hope that with good residency training, we should be able to evaluate and initiate treatment on bread and butter patients according to standard of care. Don't get me wrong, I still refer out patients that I think are iffy or if I'm not sure how to further proceed with care. My retina colleagues are still more than happy to take my referrals. Still, if someone presents with vision loss, PED with SRF on OCT, and obvious CNVM on FA, I would like to believe that I won't be doing anything different than my retina colleagues the majority of the time. Of course, I won't have the knowledge or experience of someone who has performed 5000 injections, but that's also the case for my cataract surgeries as well, which is supposed to be my specialty.

In terms of cost, overhead, and flow, it's not that bad. I can get same day Avastin delivery from my local compounding pharmacy, and I can get free overnight Lucentis or Eylea delivery from my vendor. My vendor gives me a 120 day grace period to pay my bill. Medicare pays my drug claim within 2 weeks without much resistance or difficulty. Hence, I never have to shell out $2,000 per drug before Medicare pays me first. I usually have one Avastin and one Eylea in my fridge, which I usually end up using within a month.

In my 2+ years of private practice, all my patients have done ok so far. Although, I'm not sure how my practice will evolve when new therapeutics arrive in the future. Especially, the ones that require ICG for evaluation and management.

In terms of losing referrals, I personally don't care. As a comprehensive doc, I'm a firm believer that as long as you provide good, friendly, ethical care, you should have no problem putting food on your plate. And as most of you in private practice know, there are plenty of docs in the community that lack said traits. As a subspecialist who relies on referrals from other ophthalmologists, it might be a different story. But as a general ophthalmologist, PCPs, optometrists, and word of mouth should be enough to keep you afloat. Although, I don't think a retina guy has sent me a single cataract since I started practice. That's ok. I'm still doing alright.

Almost no retina colleague will ever openly bad mouth you to yourself or to anyone else. After all, you still are a referral source to them, and they wouldn't want to lose your referrals completely. I'm still on friendly terms with my retina colleagues, to whom I refer my patients. The camaraderie feels genuine enough to me. Although, if I was clearly doing something incorrectly, I would ceratinly hope that they would let me know.

Finally, I would imagine not all subspecialists are the same either. I definitely know of one retina specialist in my area whom I would prefer to treat my mother myself rather than to refer to this person.

 

[Eyefixer]

Wait, are you the guy with a blog 🙂?

 

[intoxicatedtiger]

yup🙂

 

[Eyefixer]

NICE!!!!! I read your blog religiously last year! Good good stuff! If I every consider private practice, I will use it as a template! Good to have you here.

 

[Visionary]

Sometimes it can be difficult to be sure if there truly is/was a CNVM present. I have certainly seen some of my partners patients that were previously treated with anti-VEGF agents who present to me several months after stopping injections with an involuted CNVM. In some instances you can't tell that they ever had a CNVM. The PED is flattened, the fluid gone, and all that remains are drusen and pigmentary changes with no leak on FA and no significant findings on OCT or AF. I look back to imaging from their initial visit and there is no question a CNVM is present; however, after responding well to treatment it is no longer detectable. This isn't the typical course, but I don't think you can say in hindsight that someone absolutely never had wet AMD and was being treated without cause unless you look at images from the time of presentation.

What you say is true, but the case I described was still actively being treated without any signs of CNV. I've been watching him for over a year without treatment. Can I say with 100% certainty there was never a membrane? No, but in my experience, if a patient has ever had fluid, there is a water mark on AF. Didn't pass the smell test, IMO.

 

[Visionary]

I'm a comprehensive doc in the Bay Area who does medical retina. There are close to 20 retina specialists within a 15 mile radius. My situation is a bit unique though. I'm in solo practice and most of my patients don't like to see English only docs because of a language barrier. I have an SD-OCT, FA, and my own laser. I perform my own FA's.

As a recent grad, I've done over 100 injections (including the management decisions that comes along with the procedure), and close to 200 retinal lasers in residency. Given that ACGME tells me that I'm qualified to perform cataract surgery after 84 cases, I would like to think that I'm qualified to practice basic retina. And I doubt anyone would argue that cataract surgery doesn't come with its own management challenges, subtleties, and intricacies either. In addition, many cornea fellows graduate with less than 50 PKs, and glaucoma fellows with less than 50 trabs, and they're still qualified to perform these procedures.

If you are going to do medical retina or anything else out of your "qualification," it is of utmost importance that you stay up to date with the studies, techniques, and drugs. Also, be prepared to face the same medicolegal scrutiny as subspecialists.

The main issue with comprehensive docs providing subspecialty care is the volume. I perform only about 3-5 injections a month. Obviously, almost no one will refer you any medical retina. The only patients you'll see will be the ones you generate for yourself. Hence, you will most likely not be exposed to difficult, challenging, refractory cases. Nevertheless, I would hope that with good residency training, we should be able to evaluate and initiate treatment on bread and butter patients according to standard of care. Don't get me wrong, I still refer out patients that I think are iffy or if I'm not sure how to further proceed with care. My retina colleagues are still more than happy to take my referrals. Still, if someone presents with vision loss, PED with SRF on OCT, and obvious CNVM on FA, I would like to believe that I won't be doing anything different than my retina colleagues the majority of the time. Of course, I won't have the knowledge or experience of someone who has performed 5000 injections, but that's also the case for my cataract surgeries as well, which is supposed to be my specialty.

In terms of cost, overhead, and flow, it's not that bad. I can get same day Avastin delivery from my local compounding pharmacy, and I can get free overnight Lucentis or Eylea delivery from my vendor. My vendor gives me a 120 day grace period to pay my bill. Medicare pays my drug claim within 2 weeks without much resistance or difficulty. Hence, I never have to shell out $2,000 per drug before Medicare pays me first. I usually have one Avastin and one Eylea in my fridge, which I usually end up using within a month.

In my 2+ years of private practice, all my patients have done ok so far. Although, I'm not sure how my practice will evolve when new therapeutics arrive in the future. Especially, the ones that require ICG for evaluation and management.

In terms of losing referrals, I personally don't care. As a comprehensive doc, I'm a firm believer that as long as you provide good, friendly, ethical care, you should have no problem putting food on your plate. And as most of you in private practice know, there are plenty of docs in the community that lack said traits. As a subspecialist who relies on referrals from other ophthalmologists, it might be a different story. But as a general ophthalmologist, PCPs, optometrists, and word of mouth should be enough to keep you afloat. Although, I don't think a retina guy has sent me a single cataract since I started practice. That's ok. I'm still doing alright.

Almost no retina colleague will ever openly bad mouth you to yourself or to anyone else. After all, you still are a referral source to them, and they wouldn't want to lose your referrals completely. I'm still on friendly terms with my retina colleagues, to whom I refer my patients. The camaraderie feels genuine enough to me. Although, if I was clearly doing something incorrectly, I would ceratinly hope that they would let me know.

Finally, I would imagine not all subspecialists are the same either. I definitely know of one retina specialist in my area whom I would prefer to treat my mother myself rather than to refer to this person.

Sounds like a good setup for you, and I'm glad it works. Definitely outside the norm, though. I'm interested in how you manage to get single Avastin syringes compounded. What happens to the rest? Do they store it for you? Unless you freeze it, it typically will start to denature after a few weeks. I treat bilateral patients same day, so I even have two lots on hand at a time. That's 60-70 syringes per lot.

 

[intoxicatedtiger]

I get it at Leiters. They sell individual stock 0.20ml doses for $45 each. In residency, the oncology pharmacy did the same thing. They dispensed individual doses in tb syringes. Im sure there are plenty of compounding pharmacies that do that. Worse comes to worse, you can have Leiters overnight you to where you are.

 

[eyestar]

Great responses. It's true that I prefer not to see patients who are extremely picky and who do not have any major eye pathology. Refractive is probably out.
It's interesting that the comp doc in bay area is able to do retina. I too did more retinal lasers than most residents ( 450!) but little exposure to injections. So it would have been nice if I had the same level of confidence for injections - then I could probably get away with not doing a fellowship .
However, unless you have your own practice- if you join a group of comprehensive docs and you market yourself for retina- they would be hesitant to put in the overhead cost of buying all equipment oct, fa for you to do laser / injections especially when you are not fellowship trained . And the retina group would never hire you. So job market is tough unless you are in some small town where there is a huge demand for retinal specialist.

My first job out of residency was working with a guy who practiced comprehensive ophthalmology but did occasional focal lasers only( no prp, no injections). I was so eager to do some retinal lasers. However,there was no FA availability or imaging. He was hesitant to buy them for me.

 

[Visionary]

Great responses. It's true that I prefer not to see patients who are extremely picky and who do not have any major eye pathology. Refractive is probably out.
It's interesting that the comp doc in bay area is able to do retina. I too did more retinal lasers than most residents ( 450!) but little exposure to injections. So it would have been nice if I had the same level of confidence for injections - then I could probably get away with not doing a fellowship .
However, unless you have your own practice- if you join a group of comprehensive docs and you market yourself for retina- they would be hesitant to put in the overhead cost of buying all equipment oct, fa for you to do laser / injections especially when you are not fellowship trained . And the retina group would never hire you. So job market is tough unless you are in some small town where there is a huge demand for retinal specialist.

My first job out of residency was working with a guy who practiced comprehensive ophthalmology but did occasional focal lasers only( no prp, no injections). I was so eager to do some retinal lasers. However,there was no FA availability or imaging. He was hesitant to buy them for me.

Yeah, I wouldn't market yourself as medical retina without having done a fellowship. I, and others I know, have joined a comprehensive group out of fellowship that has invested in equipment without question. Doesn't take a rocket scientist to realize the revenue potential of bringing retina into a group. There are very few comprehensive docs in metropolitan areas who do any significant amount of medical retina. Intoxicatedtiger even admitted doing very little. Unless you do a lot, the equipment costs and overhead can be an issue, though it depends on your situation.

I've heard your type of anecdote before. Must have been an older doc. I can't imagine anyone in this day and age doing focal laser without FA/OCT. Some of the old guard still do CL exams to evaluate for edema and ETDRS criteria to treat. ETDRS is overkill, and SD-OCT is so much more sensitive than a SL exam can ever be. I consider myself to have a pretty keen eye, but that darn machine proves me wrong more often than I'd like to admit. I've known of more docs who do PRP and retinopexy than focal. Criteria for the former are more straightforward, and the process is less risky than focal.

 

[guttata]

Great responses. It's true that I prefer not to see patients who are extremely picky and who do not have any major eye pathology. Refractive is probably out.
It's interesting that the comp doc in bay area is able to do retina. I too did more retinal lasers than most residents ( 450!) but little exposure to injections. So it would have been nice if I had the same level of confidence for injections - then I could probably get away with not doing a fellowship .
However, unless you have your own practice- if you join a group of comprehensive docs and you market yourself for retina- they would be hesitant to put in the overhead cost of buying all equipment oct, fa for you to do laser / injections especially when you are not fellowship trained . And the retina group would never hire you. So job market is tough unless you are in some small town where there is a huge demand for retinal specialist.

My first job out of residency was working with a guy who practiced comprehensive ophthalmology but did occasional focal lasers only( no prp, no injections). I was so eager to do some retinal lasers. However,there was no FA availability or imaging. He was hesitant to buy them for me.

If you join a fairly large group of comprehensive docs, it would make more financial sense to invest in the equipment rather than refer out. Retina patients = high RVUs. Most of the equipment have multiple purposes - nowadays, you need an OCT, preferably spectral domain. With a large group, they would have no problems paying off the OCT with glaucoma patients, glaucoma suspects, and in-house retina patients. A fundus camera/FA can double up for fundus photos. With decent volume, they could pay off the argon laser too.

Injections are not difficult. However, you need to keep up to date with current knowledge. When I trained, I remember more use of steroids/lasers, now it is anti-vegf/lasers or even just anti-vegf. I have been told compounded avastin lasts up to 90 days if properly stored.

It sounds as if you are bored with work. Fellowship may help, but everything becomes routine after a while. If you want complex patients, go work in an academic center. After a few years there, you may be wishing for the routine again.

 

[90 diopter]

Yeah, I wouldn't market yourself as medical retina without having done a fellowship. I, and others I know, have joined a comprehensive group out of fellowship that has invested in equipment without question. Doesn't take a rocket scientist to realize the revenue potential of bringing retina into a group. There are very few comprehensive docs in metropolitan areas who do any significant amount of medical retina. Intoxicatedtiger even admitted doing very little. Unless you do a lot, the equipment costs and overhead can be an issue, though it depends on your situation.

I've heard your type of anecdote before. Must have been an older doc. I can't imagine anyone in this day and age doing focal laser without FA/OCT. Some of the old guard still do CL exams to evaluate for edema and ETDRS criteria to treat. ETDRS is overkill, and SD-OCT is so much more sensitive than a SL exam can ever be. I consider myself to have a pretty keen eye, but that darn machine proves me wrong more often than I'd like to admit. I've known of more docs who do PRP and retinopexy than focal. Criteria for the former are more straightforward, and the process is less risky than focal.

Curious: do you still do an FA on every patient who requires a Focal? I've noticed that the local retina docs I refer out to aren't doing angiograms nearly as often.

 

[Visionary]

Curious: do you still do an FA on every patient who requires a Focal? I've noticed that the local retina docs I refer out to aren't doing angiograms nearly as often.

Yes. I never do a focal or a PRP, for that matter, without an FA. Perhaps as a time saver, a lot of docs have, wrongly, adopted OCT as a replacement for FA. It's not. The two tests give you very different information. OCT only shows you the anatomy, whereas FA shows you the physiology. You can see leaking MAs on FA that are not apparent clinically. Also, there are many MAs that are clinically apparent, but aren't actually leaking. With FA, you can see areas of ischemia in the periphery, as well as in the macula. I use FA to guide my focal (only leaking MAs), grid (patchy macular ischemia), and PRP (peripheral ischemia). IMO, to do otherwise is lazy and, quite frankly, a disservice to your patients. It baffles me how many docs have given up on FA, even in university settings. Until doppler OCT becomes available, FA is an essential tool for diagnosis and treatment of retinal disease. *steps off soapbox*

 

[90 diopter]

Yes. I never do a focal or a PRP, for that matter, without an FA. Perhaps as a time saver, a lot of docs have, wrongly, adopted OCT as a replacement for FA. It's not. The two tests give you very different information. OCT only shows you the anatomy, whereas FA shows you the physiology. You can see leaking MAs on FA that are not apparent clinically. Also, there are many MAs that are clinically apparent, but aren't actually leaking. With FA, you can see areas of ischemia in the periphery, as well as in the macula. I use FA to guide my focal (only leaking MAs), grid (patchy macular ischemia), and PRP (peripheral ischemia). IMO, to do otherwise is lazy and, quite frankly, a disservice to your patients. It baffles me how many docs have given up on FA, even in university settings. Until doppler OCT becomes available, FA is an essential tool for diagnosis and treatment of retinal disease. *steps off soapbox*

I thought so. What you described was the standard of care where I trained, but the private practice retina guys around here seem more lax when it comes to doing FA. Thanks for the input.

 

[RestoreSight]

Yes. I never do a focal or a PRP, for that matter, without an FA. Perhaps as a time saver, a lot of docs have, wrongly, adopted OCT as a replacement for FA. It's not. The two tests give you very different information. OCT only shows you the anatomy, whereas FA shows you the physiology. You can see leaking MAs on FA that are not apparent clinically. Also, there are many MAs that are clinically apparent, but aren't actually leaking. With FA, you can see areas of ischemia in the periphery, as well as in the macula. I use FA to guide my focal (only leaking MAs), grid (patchy macular ischemia), and PRP (peripheral ischemia). IMO, to do otherwise is lazy and, quite frankly, a disservice to your patients. It baffles me how many docs have given up on FA, even in university settings. Until doppler OCT becomes available, FA is an essential tool for diagnosis and treatment of retinal disease. *steps off soapbox*

From the looks of things at this years ARVO it's going to be some time before Doppler oct shows any clinical utility, definitely not a replacement for FA. The combined SLO/OCT/FA +\- AO are showing promise and OCT angiography is pretty spectacular in terms of anatomy, but does not show leakage. Retinal oximetry also is promising, but doubtful as a replacement for FA/ICG

 

[Visionary]

From the looks of things at this years ARVO it's going to be some time before Doppler oct shows any clinical utility, definitely not a replacement for FA. The combined SLO/OCT/FA +\- AO are showing promise and OCT angiography is pretty spectacular in terms of anatomy, but does not show leakage. Retinal oximetry also is promising, but doubtful as a replacement for FA/ICG

Good point. 👍

 

[MstaKing10]

Yes. I never do a focal or a PRP, for that matter, without an FA. Perhaps as a time saver, a lot of docs have, wrongly, adopted OCT as a replacement for FA. It's not. The two tests give you very different information. OCT only shows you the anatomy, whereas FA shows you the physiology. You can see leaking MAs on FA that are not apparent clinically. Also, there are many MAs that are clinically apparent, but aren't actually leaking. With FA, you can see areas of ischemia in the periphery, as well as in the macula. I use FA to guide my focal (only leaking MAs), grid (patchy macular ischemia), and PRP (peripheral ischemia). IMO, to do otherwise is lazy and, quite frankly, a disservice to your patients. It baffles me how many docs have given up on FA, even in university settings. Until doppler OCT becomes available, FA is an essential tool for diagnosis and treatment of retinal disease. *steps off soapbox*

I mostly agree with you and follow those concepts with the exception of patients with diabetic macular edema who are being treated with anti-VEGF therapy. This population is ever growing and I don't believe that FA is necessary in them as frequently. Perhaps this has contributed in part to utilizing OCT more often than FA, not necessarily laziness or time saving. Unless there is a lack of response, worsening, or some other issue, I don't believe FA is necessary on every follow up visit for these patients.

However, in all new patients or those I am considering laser intervention, FA is key. I don't think one test is more important than the other in these situations, rather, the picture that arises from putting together the information gleaned from the FA/OCT/Exam are critical in guiding therapy. Have recently acquired wide field angiography at our practice and look forward to using it for really targeting areas of ischemia.

 

[Visionary]

I mostly agree with you and follow those concepts with the exception of patients with diabetic macular edema who are being treated with anti-VEGF therapy. This population is ever growing and I don't believe that FA is necessary in them as frequently. Perhaps this has contributed in part to utilizing OCT more often than FA, not necessarily laziness or time saving. Unless there is a lack of response, worsening, or some other issue, I don't believe FA is necessary on every follow up visit for these patients.

However, in all new patients or those I am considering laser intervention, FA is key. I don't think one test is more important than the other in these situations, rather, the picture that arises from putting together the information gleaned from the FA/OCT/Exam are critical in guiding therapy. Have recently acquired wide field angiography at our practice and look forward to using it for really targeting areas of ischemia.

Love this. 👍 Exactly the way I approach it. As to the DME patients, if I'm already treating them, I don't normally FA either. Don't normally FA NVAMD patients I'm already treating. I will turn to ICGA in resistant cases of NVAMD, though. I also repeat FA in patients I suspect have worsening DME related to peripheral ischemia. I've treated DME folks with peripharal scatter laser and even outright PRP with great success, because the DME was a result of VEGF levels derived from the peripheral ischemia, rather than leaking MAs.

 

[azzarah]

Any area that you practice will lose its excitement after a while. In retrospective, I wish I could just do general ophthalmology. The benefit of cornea is that you will always have refractive surgery as back up for a source of self-pay income. On the other hand, if you don't like dealing with high-maintenance patients, cornea/refractive surgery may not be the way to go....

 

[MR1]

Any area that you practice will lose its excitement after a while. In retrospective, I wish I could just do general ophthalmology. The benefit of cornea is that you will always have refractive surgery as back up for a source of self-pay income. On the other hand, if you don't like dealing with high-maintenance patients, cornea/refractive surgery may not be the way to go....

Oh the all time retina favorite patient. Just got their LASIK and very happy but then get a retinal detachment. Talk of buckles and myopic shifts, for sure cataract formation. Always a fun informed consent.

 

[MR1]

Love this. 👍 Exactly the way I approach it. As to the DME patients, if I'm already treating them, I don't normally FA either. Don't normally FA NVAMD patients I'm already treating. I will turn to ICGA in resistant cases of NVAMD, though. I also repeat FA in patients I suspect have worsening DME related to peripheral ischemia. I've treated DME folks with peripharal scatter laser and even outright PRP with great success, because the DME was a result of VEGF levels derived from the peripheral ischemia, rather than leaking MAs.

Essentially I agree. My opinion is all "new" NVAMD get a FA. Even with a classic clinical appearance and fluid on OCT, I think having a FA show the leakage is good for proper care. In case later on you question the diagnosis or have resistance to treatment. Does figuring out the type of CNV matter, probably not. I only do ICG on someone I suspect has CSR or PCV, otherwise reserve for treatment resistant NVAMD.

As far as DME, I know the recent PATS survey showed most don't do FA on all of these but if I am going to treat someone with DME regardless of with what I still think having a FA is good to evaluate for macular ischemia and peripheral ischemia. I know scatter PRP is hot now for DME and RVO and although the studies aren't great, they do make me think.

Now I don't think your follow up patients need FA's unless you think something is weird. Just all new patients that will be getting something done need one in my opinion.

As far as doing medical retina as a comprehensive ophtho. I only think this works if you are very rural or have a niche, such as you are and speak Korean and have a population that likes to come to you for that reason.

 

[MedEye]

NICE!!!!! I read your blog religiously last year! Good good stuff! If I every consider private practice, I will use it as a template! Good to have you here.

Where can I find the blog?

 

[orbitsurgMD]

Google iballdoc blogspot. You should get a top page hit.

 

[MedEye]

Google iballdoc blogspot. You should get a top page hit.

I found it. Thanks.