Fellows report increasing surgical experience during training

Among the evolving trends in practice patterns of North American vitreoretinal surgery fellows from 2010 to 2018 is that fellows are reporting an increasing number of surgical cases where they are the primary surgeon, said Robert Gizicki, MD, FRCSC, DABO, of the University of Toronto.

However, there is also a trend toward fewer fellows reporting data, he said.

Dr. Gizicki said this survey is distributed to vitreoretinal fellows in their second year of training as part of the ASRS Fellows Forum meeting. The objectives of the meeting itself are numerous: to provide an intensive review of current vitreoretinal treatments, to allow fellows to meet and interact with peers, to encourage research, and to introduce fellows to industry.

The Annual Fellows Forum Survey is approximately 150 questions covering practice patterns in management of age-related macular degeneration (AMD), diabetic retinopathy (DR), retinopathy of prematurity (ROP), vitreoretinal interface disease, retinal detachment, vitreoretinal surgery, and future practice plans.

"This survey provides the basis for educational discussions during the overall meeting," Dr. Gizicki explained.

From 2010 to 2018 there has been a decline in the number of respondents, from a high of 89 fellows in 2010 to 71 in 2018. Fellowship length, structure, supervising mentors, and practice settings remained virtually unchanged.

Diagnostic Modalities

Overall, the use of diagnostic modalities has steadily increased, with about 80% of fellows gaining experience with the technologies in 2018. When fellows were asked whether optical coherence tomography angiography (OCT-A) could replace intravitreal fluorescein angiography, the overwhelming majority do not believe so, with about 75% responding 'no' in 2018 and about 78% responding 'no' in 2017.

However, a growing number of fellows did think OCT-A would replace FA in macular telangiectasia (22% and 21% in 2017 and 2018, respectively) and neovascular age-related macular degeneration (18% and 22% in 2017 and 2018, respectively).

The initial drug choice for treatment of subfoveal choroidal neovascularization membrane secondary to AMD has consistently remained bevacizumab, but there is a clear increasing use of aflibercept with a correlating decrease in the use of ranibizumab, Dr. Gizicki said.

Monthly and PRN dosing have decreased, while treat and extend has increased.
By 2012, anti-vascular endothelial growth factor (VEGF) had become the treatment of choice as an initial approach for central diabetic macular edema (DME), and by 2017 almost 100% of fellows were using anti-VEGFs for initial treatment.

Most fellows are routinely using anti-VEGFs before recommending vitrectomy for proliferative DR, and most fellows use a bimanual technique during pars plana vitrectomy for tractional retinal detachment.

Regarding ROP, fellows have not varied responses much over the course of the study: about half have done screening in fellowship (about 58% in 2018), and Dr. Gizicki said it is likely once in practice there would be more screening.

About half the fellows have had exposure to surgical training for ROP, and about 60% have had experience performing laser or cryotherapy for ROP. However, about 40% of fellows do not plan to manage ROP after fellowship.

Surgical Experience

Fellows are increasing their surgical experience, Dr. Gizicki said.

"Management of retinal detachment increasingly involves vitrectomy and with pneumatic retinopexy or scleral buckling in select cases," he said. By 2018, about 60% of fellows also had performed 20 or fewer scleral buckle procedures, but the number of fellows who had performed more than 50 scleral buckle procedures decreased from about 33% in 2013 to about 15% by 2018.

Retinal detachment management has also remained fairly stable between 2010 and 2018, with a slight decrease from 60% to 50% of fellows using pneumatic retinoplexy to treat phakic patients with macula on superior retinal detachment with adjacent tears, but primary vitrectomy increased to about 20% for the same condition in 2018.

By 2018, about 70% of fellows would use primary vitrectomy in a pseudophakic patient with macula on superior retinal detachment with two adjacent tears (pneumatic retinoplexy would be used by about 30% of fellows, which has remained fairly stable over the course of the survey.

Job Search Post-Fellowship

When looking for employment post-fellowship, location and partner personalities were the most important factors for fellows, Dr. Gizicki said.

"Starting salary, the ability to do research, and the ability to do high volume surgery were less important, which has not changed from 2010," he said.

The majority of fellows (60%) are heading to private practice, which is a sharp increase from 2010, where fewer than 30% of fellows went into private practice.

There was a decrease in the percentage of fellows opting to work at academic institutions (<10%) in 2018, after a high of almost 40% in 2014.

Starting salaries have slowly increased, with just over 50% of fellows reporting a starting salary of more than $225,000 in 2018 (compared to about 45% in 2010), with fewer than 10% of fellows reporting a starting salary of $175,000 or less (compared to just over 10% reporting that salary in 2010).