Training a Glaucoma Specialist
Chat Highlights
May 28, 2003

Norma Devine, Editor

On Wednesday, May 28, 2003, Dr. Elliot Werner, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Training a Glaucoma Specialist."

Moderator:  Welcome back, Dr. Werner.  Tonight we will be discussing the training of a glaucoma specialist.   

Dr. Elliot Werner:  After medical school, there are four more years of training in ophthalmology.  Most glaucoma specialists then do at least another year of training in glaucoma, called a fellowship.

P:  Would you define fellowship training and its purpose?

Dr. Elliot Werner:  Fellowship training is subspecialty training that occurs after residency.  Most fellowships are offered at large academic centers, such as Wills or Scheie.  I did my fellowship in Vancouver at the University of British Columbia.  My mentor was Dr. Stephen Drance.

P:  Do fellows go to classes?  What does the training consist of? 

Dr. Elliot Werner:  Not usually.  Most training is clinical.  You see patients with your mentors and go to the operating room.  By the time you reach that stage, there aren't any more classes, but there are conferences where people get together to discuss things and review cases.

P:  What is the difference between a research fellowship and a clinical fellowship?  

Dr. Elliot Werner:  Most fellowships combine the two.  Most fellowships are more clinical in that you spend most of your time taking care of patients.  Some fellowships are strictly research and you spend most of your time in the lab.

P:  How many fellowships are available at Wills?

Dr. Elliot Werner:  I am not sure.  I think they generally take about four glaucoma fellows each year, but it might be more or less in different years, depending on who applies and the quality of the applicants.

P:  There are doctors who say they are a glaucoma specialist, but their names do not appear on the list of specialists on the Wills site.  Are they glaucoma specialists?

Dr. Elliot Werner:  To find glaucoma specialists, go to the web site of the American Glaucoma Society.  Not all glaucoma specialists are at Wills. There are lots of other top-notch ophthalmology centers and ophthalmologists in the area who do not practice at Wills.  The folks at Scheie, for example.

P:  I was talking about the AGS (American Glaucoma Society) list that appears as a link on the Wills site.

Moderator:  Yes, we have a link to the AGS website at our Glaucoma site:  www.glaucomaweb.org.

Moderator:  Does a doctor need to be a member of AGS to be a specialist?

Dr. Elliot Werner:  The AGS web site has a locate-a-specialist function. You can enter the name of a state and it will show you all the members in that state.  To join AGS, a doctor must have completed a fellowship in glaucoma, practiced at least three years, and published a certain number of papers in medical journals.  The doctor also must be recognized and have a reputation in his or her community as a glaucoma specialist.  The doctors must be recommended by the membership committee and voted in by the membership.

P:  But can't a doctor be a glaucoma specialist without being a member of AGS?  

Dr. Elliot Werner:  Most all recognized glaucoma specialists are members of AGS. In this free country of ours, anyone can call himself or herself whatever they like, but if they are not in AGS, they either have not been in practice for three years, or they don't have the formal training to be recognized.

P:  What kind of training do optometrists with "certificates" in glaucoma receive?  Do you know what it entails and what they learn?

Dr. Elliot Werner:  I have no idea.

P:  Do fellows mostly see cases in their specialty? 

Dr. Elliot Werner:  For the most part, yes.  That's the point of a fellowship: To spend all your time in one area and get really good at it.

P:  I know that fellows assist in surgery.  I've had a few of them.

Moderator:  Me, too.  I had fellows coming in to see my rare aqueous misdirection syndrome.  Do you often call them in on unusual cases?  

Dr. Elliot Werner:  Fellows need to see both the common and the uncommon to become expert in all phases of the disease.

P:  Does a glaucoma specialist need to maintain continuing education in the field?

Dr. Elliot Werner:  There is no specific certification for subspecialists in ophthalmology.  All MD's are required to get a certain number of hours of continuing medical education each year, but there is no specific requirement for glaucoma subspecialists.

P:  I don't know if this is off topic, but I'm wondering what other specialties there are in ophthalmology? 

Dr. Elliot Werner:  The generally recognized subspecialties are glaucoma, retina, cornea and external disease, pediatrics and strabismus, neurophthalmology, and oculo-plastic surgery.

P:  How does a glaucoma specialist stay abreast of new findings in glaucoma?

Dr. Elliot Werner:  By reading the medical journals, by going to medical meetings and conferences, and, most important, by teaching.  In order to teach, you really have to know your stuff and be up on the latest developments.

P:  Is there a place where we can search for glaucoma specialists in   countries outside the U.S. who trained at Wills?

Moderator:  You can search Wills Eye Hospital Society website:  www.wehsociety.org.  You can search by specialty, location, or name.

Moderator:  Do you know of any other way to find Wills-trained specialists?

Dr. Elliot Werner:  You might contact Dr. Spaeth's office.  He probably maintains a list of former fellows.

Note:  Kathy Kuzmanich says patients may call her (215-928-3283) or send her e-mail (kkuzmanich@willseye.org) for a list of former fellows. 

Moderator:  The AGS lists members in other countries, too.

Dr. Elliot Werner:  There are lots of other excellent glaucoma training programs besides the one at Wills.  The European Glaucoma Society also has a web site.

P:  So all eye doctors that bill themselves as a glaucoma specialist have in common at least a one-year fellowship in glaucoma?  Must they have continuing education in glaucoma?

Dr. Elliot Werner:  Not necessarily.  The consumer needs to beware.  Not everyone who calls himself or herself a specialist really is.  There are no formal legal requirements to be a glaucoma specialist.

P:  Does a glaucoma specialist treat only glaucoma?

Dr. Elliot Werner:  It varies.  Some restrict themselves to glaucoma only.  Others will see other patients.  My practice is about 70% glaucoma and the other 30% is other eye problems.

P:  Do you believe that the glaucoma specialty is growing in numbers, shrinking, or staying the same among those entering ocular specialties?

Dr. Elliot Werner:  It seems to be growing, in that more and more fellows are being produced every year, far more than those who retire or die.  How many are actually needed by the public is another matter.

P:  The stipulation of publishing in journals (I assume refereed ones)  would seem to exclude many competent clinicians who don't do research. So isn't the AGS list somewhat less than comprehensive?

Dr. Elliot Werner:  That is possible, but almost all glaucoma fellows will publish several papers during and immediately after their fellowship, so they would qualify.  It would be very rare for someone to do a good fellowship and not meet the publication requirement.

P:  What usually happens to a fellow after his or her year is finished? 

Dr. Elliot Werner:  They go to work.  Some enter academic practice in medical schools.  Others go into private practice.

P:  Can patients make appointments with glaucoma specialists without referrals? 

Dr. Elliot Werner:  That depends on the specialist.  Many specialists will see patients who call on their own.  I will do that.  Some only see patients on referral.  It's a matter of individual preference.

P:  Do fellows cover for emergencies in the emergency room?  Is there a glaucoma specialist on call in emergency rooms? 

Dr. Elliot Werner:  It varies with the program.  Wills usually has a fellow on call for emergencies, but they don't take primary calls in the emergency room.  Other places do not have their fellows take calls.

P:  Do you see a possible need for additional glaucoma specialists because of the aging baby boomers?

Dr. Elliot Werner:  Hard to say.  I'm not an expert on demographics and requirements and distribution of medical personnel, so I really don't know.

P:  Can you say something about the training required for surgery that is specifically glaucoma-related.  Also, who is most likely to be able to perform such surgeries?  Do we need to be careful about locating a surgeon?

Dr. Elliot Werner:  Most basic residencies do an adequate job in training ophthalmologists to do straightforward glaucoma surgery.  Fellows usually get a much more intensive surgical-training experience.  In general, studies have shown that for all kinds of surgery there is a direct relationship between the volume of cases a surgeon does and the outcome, both in terms of good results and lower complication rates.

P:  Aren't there certain protocols that most ophthalmologists will follow?

Dr. Elliot Werner:  I don't understand.  Protocols about what?

P:  I mean courses of treatment.  I guess I would like to know how a glaucoma specialist's recommendations would vary from those of  another ophthalmologist who treats glaucoma patients.

Dr. Elliot Werner:  There are some protocols, such as the types of tests used for diagnosis, and the sequence of drugs, lasers and surgeries in treatment.  There aren't any formally recognized protocols that are universally followed, such as there are for chemotherapy of cancer.  There is a lot of variation in practice patterns among different specialists.

P:  You mentioned academic practice. What does that mean?

Dr. Elliot Werner:  Working in an academic medical center that usually is affiliated with a medical school such as Wills, Scheie, Hahnemann, etc.

P:  Would a consultant trained in the U.K. be considered as fully qualified in the U.S.? 

Dr. Elliot Werner:  That depends on how much training occurred in the U.S. The American Board of Ophthalmology does not recognize training done outside the U.S. or Canada.

P:  How does training of glaucoma specialists differ around the world, if it does?

Dr. Elliot Werner:  It doesn't differ all that much, but medical training as a whole can be quite different.  In most of Europe, for example, you don't have to go to college.  You go directly to medical school after high school.

P:  Should a patient with glaucoma and uveitis be followed by two specialists, or does the glaucoma specialist's training prepare him or her enough to competently manage both diseases?

Dr. Elliot Werner:  That depends on which is most severe.  Best to ask your glaucoma specialist what he or she thinks you should do.

Moderator:  Thank you for your time, Dr. Werner.

Dr. Elliot Werner:  Okay.  Thanks, everybody.  See you in June.

End of highlights for May 28, 2003.

On June 4, Dr. Wilson discussed "Optic Disc" in the Chat room. Click here for highlights of that meeting.

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