Vitreo-retinal Fellowship

PURPOSE OF PROGRAM 

An outstanding two-year training program will be offered in the diagnosis and management of diseases of the retina. The fellow will participate in the care of patients from both the Truhlsen Eye Institute clinics and the Omaha Veterans Administration Hospital. 

The fellowship program will provide extensive experience in the treatment of medical and surgical vitreoretinal disorders. The fellow will have a tremendous volume of vitreoretinal surgical cases as the primary surgeon. This experience will encompass a broad range of disease processes, and will include straightforward as well as complicated patient management. In addition, the fellow will be provided with opportunities to participate in basic science and clinical vitreoretinal research. 

The fellow will staff the Retina clinic at the VAMC Eye Clinic on a weekly basis and will supervise in the management and surgical care of all retina patients at the VAMC Eye Clinic. 

Evaluation of the fellow’s progress during training is determined by periodic consultation throughout the year.  At the end of the training period, the director will meet with each other and with the fellow to arrive at a final evaluation.  Following successful conclusion of the fellowship, the fellow will receive a certificate recognizing his/her achievement. 

Goals of the Retinal Fellowship 

Medical Retinal Therapy 

A. Ophthalmoscopic Diagnosis 

The fellow will become proficient in the techniques of indirect ophthalmoscopy, scleral indentation, biomicroscopy and contact lens slit‑lamp examination of the retina and vitreous. This experience will be acquired through supervised examination of patients who have a wide variety of acquired and hereditary vitreoretinal diseases including peripheral retinal degenerations, retinal breaks and detachment, and maculopathy. 

B. Diabetic Retinopathy 

The fellow will become proficient in the management of all forms of diabetic eye disease. Laser therapy including focal and grid treatments as well as panretinal photocoagulation will be performed by the fellow employing the argon green, and tunable dye lasers. Indications and contraindications for treatment will be learned. Specific treatment considerations (including patient selection, photocoagulation strategies, etc.) will be stressed. The fellow will also become very familiar with the interpretation and employment of fluorescein angiography and other diagnostic tools in the management of diabetic eye disease. 

C. Inherited Retinal Dystrophies 

The fellow will learn to diagnose hereditary retinal diseases by examining a wide variety of patients in the outpatient clinic.  Electrophysiologic tests including dark adaptation, electroretinography (ERG) and electrooculography (EOG) are performed at the University of Nebraska Eye Clinic. The fellow will learn when to order and how to interpret these electrophysiologic studies. 

D. Fluorescein Angiography 

The fellow and the retina faculty will review and interpret all fluorescein angiograms ordered and processed at the Truhlsen Eye Institute and Veterans Hospital Eye Clinics. The fellow will become proficient in interpreting angiograms and establishing or confirming a diagnosis from angiography. In addition, the fellow will learn how to use angiography as an adjunct to photocoagulation therapy. Specific goals include: recognition and localization of choroidal neovascular membranes, accurate interpretation of post‑treatment angiograms, and recognition of various manifestations of diabetic retinopathy (including clinically significant macular edema, capillary nonperfusion, and proliferative retinopathy). Indications for and interpretation of Indocyanine Green (ICG) angiography will also be learned. 

E. Vascular Occlusive Disease 

The fellow will learn to diagnose and treat retinal venous and arterial occlusions. This includes proper medical workup for these conditions, as well as timing and technique in the treatment of macular edema and neovascularization as sequelae of retinal venous occlusion. 

F. Choroidal Neovascularization (CNV) 

The fellow will learn to diagnose and treat subretinal choroidal neovascular membranes.

G. Retinal Oncology 

The fellow will learn the medical and surgical treatment of posterior segment tumors including choroidal melanoma, retinoblastoma, choroidal hemangioma, and retinal angioma. 

H. Uveitis 

The fellow will learn the proper diagnosis, workup and treatment of posterior uveitis. The role of vitrectomy and vitreous biopsy in this condition will also be learned. 

I. Retinopathy of Prematurity 

The fellow will perform weekly ROP screening examinations with the UNMC Retina Clinic Director and an ophthalmology resident in the Neonatal ICU. Proper examination technique and staging according to the International Classification of ROP will be mastered. The fellow will also participate in the laser and cryo treatment of infants who have reached threshold and prethreshold diagnoses. The fellow will become familiar with the technique of indirect laser ophthalmoscopy using the Iris diode laser indirect ophthalmoscope.  The fellow will also learn of the indications for vitrectomy in ROP. 

J. Ultrasonography 

The fellow will become proficient in the use of A and B‑scan ultrasonography facilitating the accurate recognition and measurement of conditions including retinal and choroidal tumors; retinal, choroidal and posterior vitreous detachments, foreign bodies and optic nerve drusen. 

K. Macular Disorders

The fellow will be provided with a broad experience covering a wide range of macular disorders. A special emphasis will be placed on the diagnosis and treatment of Age‑related Macular Degeneration (ARMD). 

L. Posterior Segment Infections 

The fellow will learn to diagnose and treat a variety of infectious processes including CMV retinitis, toxoplasmosis, and acute retinal necrosis.  

Surgical Retinal Therapy 

Proper training in the treatment of vitreoretinal disease mandates surgical "hands‑on" experience. The fellow is expected to actively participate in the surgical management of all patients. The trainee will have a large volume of surgical cases as the primary surgeon. 

A. Retinal Detachment Repair 

The fellow will become proficient in the proper examination and drawing of retinal detachments. An understanding of the different types of detachment (rhegmatogenous, tractional, serous, and combined) will be acquired.  The fellow will also learn proper surgical management of retinal detachments. An emphasis will be placed on a proper scleral buckling technique including choice of buckling element, buckle placement, drainage of subretinal fluid, and pneumatic retinopexy used in conjunction with scleral buckling. 

B. Proliferative Diabetic Retinopathy 

The fellow will learn appropriate timing of surgery and become familiar with surgical techniques employed to treat fibrovascular proliferation, relieve vitreoretinal traction and evacuate vitreous hemorrhage. The fellow will also become proficient in the use of endolaser photocoagulation and endodiathermy. A spectrum of surgical disease processes ranging from straightforward to complicated will be encountered during the fellowship. 

C. Proliferative Vitreoretinopathy (PVR)

The fellow will learn to recognize and treat the full spectrum of proliferative vitreoretinapathy. Appropriate timing of surgery and the principles of successful reattachment will be learned as well. In addition, the fellow will become experienced in the use of vitreous substitutes (including silicone oil, long-acting gases, and liquid perfluorocarbon.) The fellow will also learn how to perform peripheral dissection and membrane peeling. Indications for and complications of relaxing retinotomy, internal drainage of subretinal fluid, and removal of subretinal bands will also be learned. The fellow will become proficient in the various techniques for outpatient air/fluid exchange and post‑operative laser photocoagulation. 

D. Endophthalmitis

The fellow will learn how to accurately diagnose and treat endophthalmitis. In addition, the fellow will gain a firm understanding of how to obtain an appropriate sample for culture purposes and will learn principles of antibiotic selection and delivery. 

E. Lensectomy

The fellow will become proficient in the surgical technique and indications for pars plana lensectomy. In addition, the fellow will learn how to perform secondary IOL placement, removal of retained lens fragments and proper management of displaced intraocular lenses following cataract surgery. 

F. Trauma 

The fellow will learn appropriate timing and technique in the surgical management of posterior segment trauma, including removal of intraocular foreign bodies and repair of posttraumatic retinal detachments. 

G. Retinopathy of Prematurity 

The fellow will learn appropriate surgical management of patients with Stage IV and V retinopathy of prematurity. 

H.  Miscellaneous Vitreoretinal Surgery 

In addition to the specific procedures listed above, the fellow will also participate in a variety of other vitreoretinal surgical cases including vitreous biopsy, management of choroidal hemorrhage and effusion, and plaque brachytherapy for choroidal melanoma and retinoblastoma. 

Applications for the retina fellowship should reach us before the beginning of September, because we plan to interview selected applicants during October and November in order to meet the deadline for submitting the match list in December.  Information and forms relating to the Fellowship Matching Program can be obtained from:  Ophthalmology Fellowship Match, P.O. Box 7584, San Francisco, California 94120-7584, (415) 447-0350.