Reflections on the Glaucoma Fellowship Match

When reflecting on the evolution of glaucoma training, one of my glaucoma attendings often describes his fellowship experience nearly 2 decades ago. Back then, he says, enthusiasm for glaucoma was dwindling. Conferences often felt somber and focused primarily on techniques for trabeculectomy. He speculates that some patients might have had a better experience slowly going blind than dealing with the complications from the surgical procedures of that time.

With the advent of MIGS and the new school of interventional glaucoma, the 2024–2025 match has been the most competitive yet for glaucoma fellowship. At the time of this writing, only 11 unmatched glaucoma spots remain, compared to 14 in cornea and 28 in retina,¹ making glaucoma the most competitive of the three most popular fellowships. Without having the exact numbers, I have heard that there were more than 80 glaucoma applicants, the highest number yet. Applicants are aware of the aging population and the immense need for skilled glaucoma and cataract surgeons. As the demand for glaucoma fellowships surges, it is essential to evaluate what each program offers to prospective fellows.

NO FELLOWSHIP IS PERFECT, BUT ALMOST ALL PROVIDE ADEQUATE TRAINING

Before I entered the interview season, full of anticipation and joy, I thought I would create a personal spreadsheet that meticulously rated each program. I planned to record surgical experience, clinical experience, location, extra clinical work, and overall feel. Although I gave up on this endeavor after my first interview, I realized early on that no program is perfect. A program may provide a fantastic surgical experience but also hours of patient in-basket requests or a less than ideal location. Some areas may have high rates of tube shunt surgery and trabeculectomy but low rates of cataract surgery or vice versa.

I valued glaucoma services at institutions that had a reputation for skilled surgeons who take on tough cataract and anterior segment cases. I also wanted a high volume of cataract cases to ensure that I was closer to becoming an expert by graduation. However, when making my rankings, I felt that every program would train me adequately. It was not like interviewing for residency, when I had the possibility of being stuck in a program or location I did not want to be for 4 years. Even at the bottom of my fellowship list were programs that I would have been ecstatic to attend for residency. The fellowship process has a way of making applicants feel wanted. Often, the faculty is selling the program to candidates as they are selling themselves to the program. In the end, I ranked programs mostly on their overall feel and am extremely happy with where I matched, partially because the faculty seemed skilled and approachable.

TRABECULECTOMY rates SEEM TO BE DECLINING

It has been echoed for some time now that trabeculectomy rates are declining. Performing many of these procedures during fellowship has thus become a premium. Recent studies have shown that the decline in trabeculectomy rates corresponds with a rise in MIGS procedures during the past decade.^2,3 Among the lowest numbers at places I interviewed, glaucoma fellows were expected to perform only four or five trabeculectomies; at the highest volume, this number was around 45. In my experience, most programs have their glaucoma fellows perform about 15 trabeculectomy cases on average.

Some glaucoma specialists refer to trabeculectomy as a dying art form, but there is no better method for consistently lowering a patient’s IOP to the single digits. Postoperative management can be a roller coaster and a skill in its own right. I am happy to be performing enough trabeculectomy procedures to feel my skills are adequate. I cannot say for certain if the individuals who train in the next decade will have the same level of comfort and expertise with this critical surgery.

USE OF XEN GEL STENTS AND MIGS ADOPTION VARY

Tube shunts remain a cornerstone of glaucoma surgery, with nearly every fellowship program providing trainees with ample opportunity to perform this procedure. What surprised me is that other surgical offerings vary greatly. Some institutions perform Hydrus Microstent (Alcon) implantation exclusively, whereas others perform only goniotomy. Some programs rely on the Xen Gel Stent (AbbVie), whereas others have stopped using this device.

At some institutions I met with, MIGS is performed in conjunction with most cataract surgeries; others have fewer combined cases in 1 year of fellowship than I will finish residency with. Postoperative management of a patient who has undergone cataract surgery combined with MIGS varies as much as the procedure does. As a future glaucoma surgeon, I believe it is valuable to gain experience with all available techniques. I hope future randomized controlled trials compare many of these techniques head to head to establish standardized best practices.

THE FUTURE OF GLAUCOMA IS IN GOOD HANDS

I would be remiss not to mention all the great people I met on the interview trail. Everyone I spoke to seemed exceedingly bright, kind, and driven. The glaucoma fellowship applicants created a group chat to share photos and insights from their interviews. If an interview day ended early, the next logical step was to socialize with fellow applicants at a local brewery and exchange war stories from residency. By my last few interviews, I felt as if we had become one large glaucoma family. I am sure I will remain friends with many of the people I met on the interview trail, and I look forward to seeing them at future conferences.

As I reflect on my journey through the fellowship match, it is evident to me that the field of glaucoma is in a transformative phase. Compared to the melancholic stories of glaucoma’s past, the outlook has never been brighter. Future patients will be in good hands.