Medical Retina as fellowship

[John robs]

Good day,

This is my last year in Residency , and i am thinking of medical retina as a fellowship.

Do you agree that it has a very bright future with nice social life ? Because surgery is stress at the end !!

I think you will be doing injections and laser for most cases.

Any thought will be apperciated.

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[Bgladney]

Wouldn't plan on just practicing medical retina. Not very many of those opportunities out there. Retina Surgeons and even more generalists are providing retina injections in their practice so the need for someone to perform 100% medical retina is shrinking. Most commonly, I see a fellowship trained medical retina specialist also perform general ophthalmology (and cataracts).

 

[DrQuakerJack]

Are many comprehensive ophthalmologists performing intravitreal injections and PRP?

 

[Hanky]

Are many comprehensive ophthalmologists performing intravitreal injections and PRP?

Yes.

 

[DrQuakerJack]

Yes.

Are most medical retina trained or just on their own?

 

[MstaKing10]

Yes.

Not sure where you are practicing but in my area this is not common and may not be standard of care. Can you give some more details?

 

[speyeder]

Not sure where you are practicing but in my area this is not common and may not be standard of care. Can you give some more details?

I agree I'm not seeing this either. There is only one general ophthalmologist in my area performing injections.

 

[backrow]

Not sure where you are practicing but in my area this is not common and may not be standard of care. Can you give some more details?

PRP and injections are certainly within the standard scope of practice of a general ophthalmologist. Some choose to not do those procedures for a number of reasons to include availability of retinal surgeons.


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[hello lady!]

Not sure where you are practicing but in my area this is not common and may not be standard of care. Can you give some more details?

In residency nowadays we do hundreds and hundreds and hundreds of injections. I stopped counting retina lasers (focal, PRP, retinopexies) after 100. We had our own resident retina clinic where we managed all sorts of diabetic retinopathy, AMD, RVO, etc patients across 3 years under the supervision of a retina specialist with plenty of FA and OCT training. Do you think we really need a fellowship to manage these straightforward cases because I can't put a scleral buckle on a patient?

 

[John robs]

I think general ophthalmologist can do many things, they can do cataract, injections and refractive surgery !!

still, this doesnt affect medical retina doctors ,
Patients are more educated now and they need someone with specialty!!

So being aedical retina fellow nowadys is ++++

Dont forget that companies now are shifting toward injections , espicially with the Jetra and Luxturna

I am seeing a bright future , with good social life !!

 

[Slide]

I think general ophthalmologist can do many things, they can do cataract, injections and refractive surgery !!

still, this doesnt affect medical retina doctors ,
Patients are more educated now and they need someone with specialty!!

So being aedical retina fellow nowadys is ++++

Dont forget that companies now are shifting toward injections , espicially with the Jetra and Luxturna

I am seeing a bright future , with good social life !!

Not to nitpick, but you may want to do your research about medical retina and what future treatments you are referring to.

Not many people use Jetrea, and there is a consensus in a significant portion of the retina community that it is either worthless, or the cost is not worth it. Already, pneumatic vitreolysis is becoming a more popular and cheaper alternative.

Luxturna is injectible, but it's not a true "injectible" treatment you give in the clinic. You have to inject it underneath the macula after doing a vitrectomy and create a small bleb, similar to how you would inject subretinal tPa.

To other people reading, yes, general ophthalmologists will perform injections and PRPs, but more so in rural areas where access to retina is difficult or poor - the tricky part becomes then referring off someone that does have a complication from a procedure and thus requires surgical intervention. If you are in a more populous area, doing this is a good way to piss off your retina colleagues because despite surgery, medical retina is still a large bulk of the practice and revenue.

 

[John robs]

Not to nitpick, but you may want to do your research about medical retina and what future treatments you are referring to.

Not many people use Jetrea, and there is a consensus in a significant portion of the retina community that it is either worthless, or the cost is not worth it. Already, pneumatic vitreolysis is becoming a more popular and cheaper alternative.

Luxturna is injectible, but it's not a true "injectible" treatment you give in the clinic. You have to inject it underneath the macula after doing a vitrectomy and create a small bleb, similar to how you would inject subretinal tPa.

To other people reading, yes, general ophthalmologists will perform injections and PRPs, but more so in rural areas where access to retina is difficult or poor - the tricky part becomes then referring off someone that does have a complication from a procedure and thus requires surgical intervention. If you are in a more populous area, doing this is a good way to piss off your retina colleagues because despite surgery, medical retina is still a large bulk of the practice and revenue.

So at the end you agree that medical retina is plus !

Jetrea and luxturna are examples only to what we will see in future , the trend is clear to shift for medical things and injections

 

[Slide]

So at the end you agree that medical retina is plus !

Jetrea and luxturna are examples only to what we will see in future , the trend is clear to shift for medical things and injections

I think you are misunderstanding my post. Luxturna requires a vitrectomy-you need to do it in the operating room. Hence, you need to be trained in surgical retina. You cannot do it in the office. Other than the mechanism and diagnosis, there is very little that is medical about administering it.

As for Jetrea, it’s not clear if it will be used in the future. The indications are very narrow and the success profile is not impressive. And, if your patients develop a macular hole or if it doesn’t close, guess what? Now they need a vitrectomy.

Yes, there are more medical options available in retina now and even more in the future, but the same can be said about surgical retina too. There are many exciting innovations being pushed, and when medical treatment fails, sometimes you can use your surgical skills to help your patients.

What I am getting is that do it for the right reasons. Medical retina can be just as stressful as surgical sometimes.

 

[John robs]

Yes, there are more medical options available in retina now and even more in the future, but the same can be said about surgical retina too. There are many exciting innovations being pushed, and when medical treatment fails, sometimes you can use your surgical skills to help your patients.

What I am getting is that do it for the right reasons. Medical retina can be just as stressful as surgical sometimes.

I am not talkingn about jetrea and luxturna per se

I am giving only examples

I agree surgical retina is better than medical in terms that you can use your surgical training
But that will be at the expanse of your social life and stress


Yes both are stressful , but medical is less

That what i am trying to say

Thank you

 

[MstaKing10]

In residency nowadays we do hundreds and hundreds and hundreds of injections. I stopped counting retina lasers (focal, PRP, retinopexies) after 100. We had our own resident retina clinic where we managed all sorts of diabetic retinopathy, AMD, RVO, etc patients across 3 years under the supervision of a retina specialist with plenty of FA and OCT training. Do you think we really need a fellowship to manage these straightforward cases because I can't put a scleral buckle on a patient?

Absolutely! You also did vitrectomy in residency, why stop at lasers and injections? Having done a procedure and managed patients in residency is not the same as having fellowship training and experience in that subspecialty. I suppose in smaller rural communities this makes sense. But if you are in a large metro area and plan on doing retina procedures you will be en exception not the rule.

 

[MstaKing10]

PRP and injections are certainly within the standard scope of practice of a general ophthalmologist. Some choose to not do those procedures for a number of reasons to include availability of retinal surgeons.


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Scope of practice and standard of care are two very different things. In a courtroom, scope of practice will not hold up if standard of care was violated.

 

[hello lady!]

To other people reading, yes, general ophthalmologists will perform injections and PRPs, but more so in rural areas where access to retina is difficult or poor - the tricky part becomes then referring off someone that does have a complication from a procedure and thus requires surgical intervention. If you are in a more populous area, doing this is a good way to piss off your retina colleagues because despite surgery, medical retina is still a large bulk of the practice and revenue.

Absolutely! You also did vitrectomy in residency, why stop at lasers and injections? Having done a procedure and managed patients in residency is not the same as having fellowship training and experience in that subspecialty. I suppose in smaller rural communities this makes sense. But if you are in a large metro area and plan on doing retina procedures you will be en exception not the rule.

I never understood why comprehensive guys doing anti-VEGF treatments piss off the retina community so much. They don't really make any money.

Of course comparing intravitreal injections to vitrectomies is nonsense. If I did 250-300 primary PPVs in residency and managed their post-op care you don't think I'd be able to do one after graduating? Most residents get 10-20; of course this isn't enough to practice this skill in the real world.

As a comprehensive doc, what am I "allowed" to treat without pissing of the subspecialists?

Dry eye? Do I have to refer anything that requires more than OTC artificial tears to cornea?
Glaucoma? Do I have to refer SLTs, Micropulse, MIGS to Glaucoma? Should I not treat these medically?
Plastics? Can I offer epilation? blepharoplasty? I attended a lecture at AAO where an oculoplastic literally said "Comprehensivists - please do not refer us your simple blephs. You should be doing this yourself."

Where do we draw the line?

I went into comprehensive ophthalmology to offer comprehensive care. I think it's ridiculous that a patient will be referred to 3-4 doctors to manage routine problems. 1 to manage glaucoma, 1 to manage dry eye, 1 to manage the intravitreal injections, and 1 to do the refractions.

Obviously if the patient is extremely complex they need the care of a specialist, but simply needing monthly Eylea for run of the mill wet AMD isn't some rare 1 in a million disease process that can't be handled by a generalist.

 

[MstaKing10]

I never understood why comprehensive guys doing anti-VEGF treatments piss off the retina community so much. They don't really make any money.

Of course comparing intravitreal injections to vitrectomies is nonsense. If I did 250-300 primary PPVs in residency and managed their post-op care you don't think I'd be able to do one after graduating? Most residents get 10-20; of course this isn't enough to practice this skill in the real world.

As a comprehensive doc, what am I "allowed" to treat without pissing of the subspecialists?

Dry eye? Do I have to refer anything that requires more than OTC artificial tears to cornea?
Glaucoma? Do I have to refer SLTs, Micropulse, MIGS to Glaucoma? Should I not treat these medically?
Plastics? Can I offer epilation? blepharoplasty? I attended a lecture at AAO where an oculoplastic literally said "Comprehensivists - please do not refer us your simple blephs. You should be doing this yourself."

Where do we draw the line?

I went into comprehensive ophthalmology to offer comprehensive care. I think it's ridiculous that a patient will be referred to 3-4 doctors to manage routine problems. 1 to manage glaucoma, 1 to manage dry eye, 1 to manage the intravitreal injections, and 1 to do the refractions.

Obviously if the patient is extremely complex they need the care of a specialist, but simply needing monthly Eylea for run of the mill wet AMD isn't some rare 1 in a million disease process that can't be handled by a generalist.

Ultimately its up to you how to run your practice. Managing wet AMD patients is our bread and butter, thats how we make our living.

I trained at a retina fellowship where we did a lot of phaco/IOL. Staffed residents on it. I did hundreds in residency. And in practice I have had to do them on a select group of patients (ie. those with complex PVR RD, diabetics with TRD, silicone oil filled eyes etc.). I'm actually quite good at it. So what if I started doing straight cataract surgeries? Maybe put in an occasional toric or multifocal. While I'm in there might as well throw in an istent. What would my comprehensive colleagues think of that? Certainly its within my scope of practice. And compared to some of the bad apple docs in my community I'm actually better at it so patient outcomes may in fact be better.

It's an interesting discussion. Not sure what the right answer is and I'm sure depending on your practice and location the answer may be different from one situation to the next.

 

[backrow]

Ultimately you should do what is best for each individual patient. Sometimes that may mean referring someone to a retina specialist that is a “routine” wet AMD injection and other times that may mean injecting them yourself.

Referring a patient out for something you could do is not without risk and cost to the patient. Depending on the patient it may mean they get in a car wreck they otherwise wouldn’t have because they are stubborn and continue to drive despite your warnings since they had to drive across town/to a different town/across the State for this referral.

For a different patient with a great support system that referral may be easy. For another who still works and has no car and lives in an area where the transportation system sucks it may mean an extra day out of work and loss of income.

It’s easy to sit here and paint with broad strokes, but we must remember that every situation is different and what works in “your neck of the woods” may not work in someone else’s.


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[hello lady!]

Ultimately its up to you how to run your practice. Managing wet AMD patients is our bread and butter, thats how we make our living.

I trained at a retina fellowship where we did a lot of phaco/IOL. Staffed residents on it. I did hundreds in residency. And in practice I have had to do them on a select group of patients (ie. those with complex PVR RD, diabetics with TRD, silicone oil filled eyes etc.). I'm actually quite good at it. So what if I started doing straight cataract surgeries? Maybe put in an occasional toric or multifocal. While I'm in there might as well throw in an istent. What would my comprehensive colleagues think of that? Certainly its within my scope of practice. And compared to some of the bad apple docs in my community I'm actually better at it so patient outcomes may in fact be better.

It's an interesting discussion. Not sure what the right answer is and I'm sure depending on your practice and location the answer may be different from one situation to the next.

Honestly if you wanted to manage comprehensive patients and due routine cataracts (+/- premium, MIGS, etc) I would have no issues with it. If you had patients who really didn't have any other providers (or just an optom) and they said they trusted you surgically? Go for it. Oftentimes it's hard for patients to find a doc who they really trust.

I've never stolen a retina patient from another practice. I only perform these treatments on those who are a patient of mine or the practice. If you weren't stealing patients and had good phaco results, who is to get mad at that?

 

[speyeder]

In residency nowadays we do hundreds and hundreds and hundreds of injections. I stopped counting retina lasers (focal, PRP, retinopexies) after 100. We had our own resident retina clinic where we managed all sorts of diabetic retinopathy, AMD, RVO, etc patients across 3 years under the supervision of a retina specialist with plenty of FA and OCT training. Do you think we really need a fellowship to manage these straightforward cases because I can't put a scleral buckle on a patient?

What you learn about retina in residency pales in comparison to the knowledge you gain doing a fellowship. And what appears straight forward may not necessarily be so because you lack the depth of experience to differentiate it from something more complicated.

With how rapidly the field of retina is changing and advancing it would be hard for a general ophthalmologist to keep up to date and provide the best care for most retinal conditions.

 

[hello lady!]

What you learn about retina in residency pales in comparison to the knowledge you gain doing a fellowship. And what appears straight forward may not necessarily be so because you lack the depth of experience to differentiate it from something more complicated.

With how rapidly the field of retina is changing and advancing it would be hard for a general ophthalmologist to keep up to date and provide the best care for most retinal conditions.

I think you're being too theoretical here. What has rapidly changed about AMD treatment that a generalist can't keep up with?

Is this true of all conditions? Should we be passing off all pathology to a dedicated specialist? Do I lack the depth of experience to treat that mild-moderate open angle glaucoma case?

 

[Dusn]

I'm medical retina. It's been a good field. I do cataracts as well but it's getting harder and harder to find the time to fit cataracts in because the retina part keeps getting busier. I would like to not completely lose my surgical skills, however.

I try to teach my residents as much as I can and I think many of them would do an OK job at medical retina without a fellowship. It does seem like it would be inefficient, however. The more you focus on one area in your practice, the better and more efficient you'll get at it.

I can't predict the future. I'd just recommend keeping your spending low (like almost as low as residency) and savings high your first few years out of residency and in not too many years you'll have saved/invested enough that you won't have to worry too much about future changes in the field.

 

[Slide]

I think you're being too theoretical here. What has rapidly changed about AMD treatment that a generalist can't keep up with?

Is this true of all conditions? Should we be passing off all pathology to a dedicated specialist? Do I lack the depth of experience to treat that mild-moderate open angle glaucoma case?

I agree that overall, do what's best for the patient, which means if something AMD related is straight-forward and it would work better for the patient to see you, I personally have no objections. I have several colleagues that do that and I don't mind because I know it's nearly a two hour drive for those patients to see me, so I would rather have them maintain compliance with their generalist. Satellite clinic helps the burden on those patients but it's not perfect. I don't see generalists performing injections in more rural/suburban areas as a threat because, due to economies of scale, it's not a major revenue maker if it's done intermittently.

I start raising my eyebrows when a patient is treatment resistant to initial treatment and nothing is changed about the diagnostic or treatment process (which should trigger an automatic retina referral in my opinion, which is from what it sounds like what you do anyway). In my city and surrounding area, I'm not pissed or mad at generalists doing injections unless it becomes a major part of their practice. However, we (I mean our ophthalmology community in general) feel it's better continuity of care. Like Dusn said, you get more efficient and better at managing things medically and surgically if need be so. I refer or send back patients for other related issues such as glaucoma/ocular HTN, dry eyes, cataract, etc. to their generalist because it's more efficient and better care for them. AMD is one of my bread and butter conditions to treat, but not the only one - I see plenty of things and surgery is a big part of my practice. Hence, why I am ok with it.

For medical retina ophthalmologists, I can see how generalists doing injections routinely could piss them off. Injections and PRP is the lifeblood of a medical retina ophthalmologist so losing these opportunities would naturally not be great for their bottom line. The same goes for medical retina doing cataracts too - in the end, patients are all coming from overall the same pool.

It may be a moot point anyway because depending on where you live, the risk of litigation/medicolegal issues may make it not worth it.

 

[DrZeke]

In residency nowadays we do hundreds and hundreds and hundreds of injections. I stopped counting retina lasers (focal, PRP, retinopexies) after 100. We had our own resident retina clinic where we managed all sorts of diabetic retinopathy, AMD, RVO, etc patients across 3 years under the supervision of a retina specialist with plenty of FA and OCT training. Do you think we really need a fellowship to manage these straightforward cases because I can't put a scleral buckle on a patient?

I just want to say that I did 100s of injections in residency and I did 50 or so indirect laser PRP for diabetes and a few barrier retinopexy for holes. Many people think that because they did that in residency that makes them qualified to treat retina out in the community. Many people think "if it's wet, inject" and that's what medical retina is all about. I think that's just oversimplification.

I'm currently doing my fellowship in uveitis at a larger academic center with a widespread variety of pathology and can see what retina people here are treating and can honestly say looking back that I was exposed to a very limited part of retina in my residency due to the demographic. In addition, we didn't do a lot of fundus or imaging conference and I think it makes a difference. You would be surprised how many people cannot really read or utilize OCT/FA in a practical sense after you listen to experts talk about this stuff. Even in places where you have experts teaching you, it's easy to make mistakes without dedicated training. We all see plenty of great doctors refer things erroneously.

Liability wise, unless I'm in a place where there is no retina people around, I wouldn't be quick to take over from them.

 

[MullerCell]

Agree that some current/recent residents that have an interest in retina and are at programs with good exposure can manage bread and butter retina with injections and lasers. However, the vast majority of practicing general ophthalmologists have no interest and their retina skill level definitely atrophies over time. The majority of the comprehensive ophthalmologists in my area are pretty clueless when it comes to retina and if they suspect something abnormal, they just refer it and let me figure it out.

As a comprehensive ophthalmologist doing lasers and injections, you will likely piss off retina specialists in your area if you do all the easy stuff and then only want to send them the complex patients you can't handle. They especially won't be enthusiastic to bail you out when you get an endophthalmitis after an injection. A good relationship with retina can really benefit and grow your anterior segment practice. An adversarial one can significantly hurt you. We see LOTS of patients with cataracts and other anterior segment pathology and will steer them to our best referral sources.

Most comprehensive practices without retina specialists also aren't going to want to make the investment in equipment (OCT, wide field FA, OCT angiography, ect) and lack the ability to efficiently buy/inventory/bill all of the expensive medications that we use without a downside risk if you screw up and don't get paid or don't get paid fast enough. It was suggested earlier that injections don't make any money....That's because you aren't doing it right.

In the end, it likely isn't worth it.

 

[Eye-eye]

Theoretical question that's only vaguely related to this post:
Say you do a surgical retina fellowship, and want to do mostly retina, but also enjoy refractive surgery. Let's say you even do a fellowship in cornea/refractive. You want to live in a rural area and run your own practice, and the place you're thinking of is relatively far away from any other OMD but has some optoms. Would it be reasonable to do retina but also see if the optoms would be willing to throw you some cataracts and LASIK patients? I'm guessing this would piss off whoever they used to send them to, but if you're closer, I wonder to what extent. I love the retina, but also love the immediate satisfaction of refractive surgery, so I'm wondering if there's a feasible hybrid, especially for a more rural doc.​

 

[ocularis]

I think in a rural setting it's feasible. A lot will depend on how close the nearest refractive and retina guys are, or if you are rural enough that anything you do is a plus to the geographic area and patients cannot find similar services nearby (that being said, how large can your volume of this very niche stuff be when it's not particularly populated?). If it's a competitive area, you may shoot your volume of both retina and refractive but if no one near is doing either then I'm sure optoms would be happy to refer. Bottom line - I think it's possible, you just have to balance your priorities. I think everyone dreams of doing it all, we inherently like it from an academic perspective, but once you specialize deeply into a sub-specialty, you will have more than enough on your plate to keep your mind from wandering.

 

[Eye-eye]

I think in a rural setting it's feasible. A lot will depend on how close the nearest refractive and retina guys are, or if you are rural enough that anything you do is a plus to the geographic area and patients cannot find similar services nearby (that being said, how large can your volume of this very niche stuff be when it's not particularly populated?). If it's a competitive area, you may shoot your volume of both retina and refractive but if no one near is doing either then I'm sure optoms would be happy to refer. Bottom line - I think it's possible, you just have to balance your priorities. I think everyone dreams of doing it all, we inherently like it from an academic perspective, but once you specialize deeply into a sub-specialty, you will have more than enough on your plate to keep your mind from wandering.

Thank you! The only thing I do wonder about it patient volume, but at the same time, age- and DM-related retinal diseases are super prevalent, and retina docs seem to have their patients back pretty frequently for continual management, so I would think it would be easy to build up a reasonably full retina practice fairly quickly even in many rural locations. As for refractive and cataracts, those are also super common, so I would think that it wouldn't be too hard to fit some of those cases in as well. I think I just like the idea of retina (which I find visually and medically fascinating) + more "quick-fix" surgeries like cataracts and LASIK. It seems like retina is trending more and more medical and less surgical, and adding some 20-min surgeries to essentially restore sight (i.e., cataracts) seems like a wonderful way to add some surgery and balance out the week. Who knows, though? I'll figure out what I'm really passionate about once I'm really doing it day in and day out in residency (god willing).

 

[ocularis]

So to your point, I think comp + medical retina (fellowship trained) would be more feasible in a rural setting and flows together quite well as you state above, certainly a more common practice scenario then being both a surgical retina and refractive guy. Adding in vit's AND refractive adds a whole additional layer. If no one is offering either of those services nearby, though, then even those can only be an added benefit to your practice.

 

[Dusn]

yes, they should have a fellowship or at least very strong focus on medical retina as being the majority of their patients in private practice in order to learn. I train residents at a top 10 ophtho program. They may be treating patients on their own but they have no idea what they're doing when it comes to retina. They don't get the long term follow up of their patients. They're just kicking the patients down the line to the next resident who will rotate through the following month. They assume that everything that looks like fluid on the OCT gets an injection or that anything that looks abnormal on an OCT is the cause of the patient's vision problem.

 

[speyeder]

yes, they should have a fellowship or at least very strong focus on medical retina as being the majority of their patients in private practice in order to learn. I train residents at a top 10 ophtho program. They may be treating patients on their own but they have no idea what they're doing when it comes to retina. They don't get the long term follow up of their patients. They're just kicking the patients down the line to the next resident who will rotate through the following month. They assume that everything that looks like fluid on the OCT gets an injection or that anything that looks abnormal on an OCT is the cause of the patient's vision problem.

I couldn't agree more. I too train residents at an upper tier program and most are not good at retina, through no fault of their own. They simply don't have enough exposure. A four month rotation during their residency is not enough for them to feel comfortable treating retina patients on their own.

 

[ocularis]

Neuroguy, I am not sure where you are in the training process, but IMHO, while all of this is certainly theoretically possible, you will not at the end of the day be a surgical retina guy and high volume refractive guy, it's just not how it works out there. Looking through your posts it seems like you maybe undecided on medical speciality so far? If that's the case, don't worry, ophtho is an outstanding field and you will find your primary interest and direction once you get to residency. If you are really torn and want a little bit of it all, you will do comprehensive and you can do refractive without fellowship even, If you want retina and cataracts/refractive stuff then you will do medical retina fellowship + comp, if you want surgical retina then you will just do surgical retina (which is like 80% medical retina anyway, so you get your fill of the clinical component), if you want heavy refractive you will do a refractive/cornea/anterior segment fellowship and see comp as well. You'll figure it out and you will be happy with your choice, busy enough, and not feel like you are missing out. Just trust us on this one. People do multiple fellowships out there, but it's things that flow together naturally, and retina and refractive is just not a winning combination.

 

[Eye-eye]

Neuroguy, I am not sure where you are in the training process, but IMHO, while all of this is certainly theoretically possible, you will not at the end of the day be a surgical retina guy and high volume refractive guy, it's just not how it works out there. Looking through your posts it seems like you maybe undecided on medical speciality so far? If that's the case, don't worry, ophtho is an outstanding field and you will find your primary interest and direction once you get to residency. If you are really torn and want a little bit of it all, you will do comprehensive and you can do refractive without fellowship even, If you want retina and cataracts/refractive stuff then you will do medical retina fellowship + comp, if you want surgical retina then you will just do surgical retina (which is like 80% medical retina anyway, so you get your fill of the clinical component), if you want heavy refractive you will do a refractive/cornea/anterior segment fellowship and see comp as well. You'll figure it out and you will be happy with your choice, busy enough, and not feel like you are missing out. Just trust us on this one. People do multiple fellowships out there, but it's things that flow together naturally, and retina and refractive is just not a winning combination.

Thank you for the thoughtful reply. I'm a med student (year 2), and was debating between ophtho and neurosurgery last year, but realized over the summer that I actually want to see my wife occasionally and get to sleep once in a while . (It's more than that, obviously but that's certainly a part of it.) It's true, I know I'll have time down the road. I just like looking ahead at the possibilities. In all honesty, it's one of the few things keeping me sane during the craziness of STEP prep. I feel like I need to get a 260 or something to get in (which I know isn't true, but still), so I come here to fantasize about the future. And hopefully glean some good information in the meantime.

Thank you again!