Oculoplastics combined with retina fellowship

[futureEyeDoc_south]

I have noticed that its not uncommon for some attendings to have completed two fellowships. One combo that I have seen is oculoplastics and neuro-ophthalmology; I imagine one reason for this may be how frequently oculoplastic surgeons see ptosis patients in clinic, although they definitely treat more conditions than just ptosis. I am curious if it is feasible to complete oculoplastics and a different second fellowship, such as retina (more likely medical retina over surgical). I am honestly very interested in both oculoplastics and medical retina and am considering the feasibility of applying to both. Does anyone know if this has been done before and what the career outlook for someone with this background might be? Is there a place in private practice or academics for someone with this background?

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[TheLesPaul]

If you want to do comprehensive ophthalmology + a bit of medical retina, and a bit of basic plastics -- then you don't need a fellowship, just get experience in residency and do comp. If you really want to be a retina or a plastics person, you have to pick one. There is little overlap, your referral streams will be all messed up, you won't really be excellent at either (the journals don't even reference each other), and you will be wasting overhead by splitting your efforts.

Plastics + neuro nowadays happens most commonly when the applicant wants a second crack at a slot at the other 50% of programs that were not open the first year s/he applied.

 

[Dusn]

Uveitis + retina. Sure.
Plastics + retina makes no sense.

Neuro + retina might have some overlap. You could basically be the dumping ground for unexplained vision loss. Right now referrers just flip a coin to decide if they’re going to send to neuro or retina. And inevitably the coin flip always picks the wrong specialty.

 

[Slide]

I have noticed that its not uncommon for some attendings to have completed two fellowships. One combo that I have seen is oculoplastics and neuro-ophthalmology; I imagine one reason for this may be how frequently oculoplastic surgeons see ptosis patients in clinic, although they definitely treat more conditions than just ptosis. I am curious if it is feasible to complete oculoplastics and a different second fellowship, such as retina (more likely medical retina over surgical). I am honestly very interested in both oculoplastics and medical retina and am considering the feasibility of applying to both. Does anyone know if this has been done before and what the career outlook for someone with this background might be? Is there a place in private practice or academics for someone with this background?

If you want to do a little of everything, do comprehensive. Factoring out that these two sub specialties are the most competitive, the little overlap between the fields mean you won’t get really good at both in your practice. The only thing I can see with overlap surgically is if you do lots of orbit and buckling surgeries and enucleations. Clinically, your work flow and your efficiency would be so disjointed and nonsensical.

Even if you could make it work (that’s 3-4 grueling years of fellowship total btw), it would be very hard for you to find a place in either academics or private practice. You will find out when you are in practice is that you either do everything in your field ok (even as a specialist), or you tend to have a niche and do it really well. It’s called a practice for a reason - the more you work in a certain specialty even after training, the better you get.

I knew an older attending in my retina fellowship that claimed to be able to do everything, despite being a neuro-ophthalmologist. What he claimed and his actual results could not be further apart - the older generation could have claimed to do so 40 years ago because there wasn’t that much to do, but now there’s so much granular stuff you have to know, that kind of cavalier attitude can lead to malpractice today.

 

[percyeye]

How common is it for comprehensive Docs to do almost everything nowadays? In undergrad I worked for a group where a comprehensive guy would do LASIK, cataracts, blephs, and injections and did not do a fellowship and be quite busy. This was in the Midwest where there wasn't as much competition. But it seems there are less and less "fully comprehensive" docs out there.

 

[Slide]

How common is it for comprehensive Docs to do almost everything nowadays? In undergrad I worked for a group where a comprehensive guy would do LASIK, cataracts, blephs, and injections and did not do a fellowship and be quite busy. This was in the Midwest where there wasn't as much competition. But it seems there are less and less "fully comprehensive" docs out there.

Not as much from what I’m seeing in the community. Mostly cataract surgery, lasers, and MIGS/blepharoplasties in the younger generation. In the rural areas you’ll of course see this more frequently.

With the amount of knowledge and skill sets increasing for specialties, it’s really too much for comprehensive to keep up with. What passed as “comprehensive” back in the day would not probably be acceptable as standard of care these days.

 

[TheLesPaul]

A "blepharoplasty" by a comp guy != a real blepharoplasty in many instances. There is large variance even within oculoplastics fellowships. You have to pick what you are good at. I imagine something similar is true in retina -- it's not just about injecting Avastin all day.

 

[Equality]

Dr Renelle Lim at Yale Smilow Cancer Center did oculoplastics fellowship and two years of oncology fellowship, which is basically medical retina with plaque surgery (so not vitreoretinal). She practices all aspects of oncology including orbital tumors and periorbital tumors plus of course choroidal/iris melanoma, etc. Obviously she has an unusual combination of training , but that also makes her uniquely equipped to handle the oncology cases at an academic center.

Renelle Lim, MD

Dr. Lim is Director of the Ocular Oncology Program. Dr. Lim completed her fellowships in Ocular Oncology and Oculoplastic and Orbital Surgery at Wills Eye

medicine.yale.edu

 

[futureEyeDoc_south]

Dr Renelle Lim at Yale Smilow Cancer Center did oculoplastics fellowship and two years of oncology fellowship, which is basically medical retina with plaque surgery (so not vitreoretinal). She practices all aspects of oncology including orbital tumors and periorbital tumors plus of course choroidal/iris melanoma, etc. Obviously she has an unusual combination of training , but that also makes her uniquely equipped to handle the oncology cases at an academic center.

Renelle Lim, MD

Dr. Lim is Director of the Ocular Oncology Program. Dr. Lim completed her fellowships in Ocular Oncology and Oculoplastic and Orbital Surgery at Wills Eye

medicine.yale.edu

Wow that's so interesting, thanks for sharing I didn't know this existed. Definitely going to explore this more.

 

[futureEyeDoc_south]

@Equality What would the primary department be for someone who gets hired after completing an ocular oncology fellowship? Since there seems to be a lot of retina training in that fellowship I imagine you would primarily be part of the retina department? There also seems to be combined medical retina/ocular oncology fellowships.

Also, if one were to do this ocular oncology fellowship, it seems like there are still a number of surgical procedures that are part of the training. Can you get hired by a retina group and have a dedicated OR day to do these procedures? I'm imagining a significant proportion of the clinic visits would be dedicated to bread and butter medical retina, with a smaller proportion dedicated to onc visits, and then the OR day would be dedicated to doing cases for onc patients.

 

[Equality]

For an ophthalmic oncologist, cases that require surgery would be uveal melanoma that require radiation plaque placement and removal (two separate surgeries), biopsy of lesions, and management of retinoblastoma that require EUA +/- intravit/intracameral injections in babies. Ocular surface cancers may need biopsies or excision too that you may do if you choose to do conj tumors. As a retina person, you probably won't be doing enuc, excision of periocular or orbital neoplasm, and other oculoplastic cases even if they are related to cancer.

The department hiring depends on the structure of the institution. Wills has very strict division between oncology and retina (and among all other subspecialties) so as an oncologist you belong to the oncology group. Retina people within Wills refer onc cases to onc. At Yale, the ophthalmology department is just one department, so the oncologist belongs to the overall ophthalmology service.

Duke has a great oncology fellowship led by a very nice mentor whose primary training is retina but now practices onc only (no vitrectomy). In general if you want to practice oncology only, you need to belong to a big group like a university setting or a giant private practice like the RGW. Retina Specialist Ophthalmologists | RGW | Eye Surgeons & Doctors MD VA DC

 

[Slide]

@Equality What would the primary department be for someone who gets hired after completing an ocular oncology fellowship? Since there seems to be a lot of retina training in that fellowship I imagine you would primarily be part of the retina department? There also seems to be combined medical retina/ocular oncology fellowships.

Also, if one were to do this ocular oncology fellowship, it seems like there are still a number of surgical procedures that are part of the training. Can you get hired by a retina group and have a dedicated OR day to do these procedures? I'm imagining a significant proportion of the clinic visits would be dedicated to bread and butter medical retina, with a smaller proportion dedicated to onc visits, and then the OR day would be dedicated to doing cases for onc patients.

To answer the second part, it is possible to have OR time as medical retina, but it becomes a bit of a catch-22. In order to build a practice large enough to have a dedicated OR day once a week for oncology, you’d need to have enough volume to generate it. This would mean you need to see a lot of oncology in your practice, which would take away from your medical retina practice to a point where it’s not sustainable. However, if you increase the medical retina volume, that leads less space/room for your oncology patients, and thus less regular OR time.

Practically, it’s not feasible in most places, academic and private, to have this kind of set up. Most of the oncology would be funneled to your care and the medical retina stuff would be picked up by others. Typically ocular oncologists have a surgical subspecialty as their wing specialty. This is also why you see many ocular oncologists double as surgical retina - vitrectomy opens up what you can manage, like PIOL or doing transvit FNAB.

 

[ophtho838]

plastics + retina would be a very weird practice and the overhead would be incredibly high given there is very little overlap with the patients, equipment, examination, and processes. Plus, when you apply for the second fellowship and, you'll get a lot of side-eye and may not match since both fellowships are competitive and people are going to question your motivation/seriousness.