Clinical Fellowship

Cornea/External Disease, Anterior Segment, and Refractive Surgery

2023-2025

Duration:

2 years: July 1, 2023 –June 30, 2025

Positions:

One

Supervisors:

Setareh Ziai, MD, FRCSC (Clinical Fellowship Director); Mona, Koaik, MD, FRCSC; Kashif Baig, MD, MBA, FRCSC; Saama Sabeti, MD, MPH, FRCSC

Application:

This position is offered through the SF Match (Program #4733) and uses its Central Application Service (CAS). Interested and qualified applicants should submit a personal statement, curriculum vitae, and three confidential reference letters through CAS. Non-CAS documents include medical school/residency transcripts and should be submitted to Ginette Snook, Departmental Education Program Coordinator. American/foreign medical graduates must contact Ginette Snook, Departmental Education Program Coordinator regarding the application process, which involves the Postgraduate Medical Education Office. Applications for the 2023-2025 cycle are due on Friday, October 14, 2022. Interview notifications will be made by October 31, 2022. Interviews will be held virtually in November 2022. The Match takes place December 2022.

Description:

The University of Ottawa Eye Institute offers a two-year post-residency fellowship in Cornea/External Disease, Anterior Segment, and Refractive Surgery. This is a demanding, hands-on, clinical/surgical fellowship with research and teaching obligations. Medical, surgical, and research activities take place at the Eye Institute, a 60,000-square-foot facility that spans two floors of the General Campus of the Ottawa Hospital. Overall, about 15,000 surgical eye cases and a total of 120,000 patient encounters occur every year at the Eye Institute (General Campus) and the Eye Care Centre (Riverside Campus). Training also takes place at Precision Cornea Centre (PCC), a subspecialty clinic located 2.5 km from the Eye Institute. PCC is a referral centre for corneal and anterior segment pathology exclusively. Finally, training also takes place at the adjacent Children’s Hospital of Eastern Ontario (CHEO) for pediatric cornea and anterior segment surgical cases. The fellowship produces a well-rounded subspecialist comfortable in managing complex cases using clinical acumen and surgical versatility acquired in an innovative teaching environment.

Competition between fellows and residents is a concern in many programs. This fellowship has been crafted to mesh with the residency program so that both the resident and Fellow experience superb medical and surgical training.

Objectives:

To develop expertise in medical/surgical management of disorders in Cornea, Anterior Segment. and Refractive Surgery.
To further develop medical teaching skills.
To develop a habit of constant learning and innovation.
To develop an understanding of the research process from design to publication.
To develop practice management knowledge (EMR, billing, scheduling, etc.).

Surgery:

Cornea/Anterior Segment: The Fellow will assist, perform, and later teach the following partial list of surgeries in both adult and pediatric settings: full-thickness penetrating keratoplasty (PK), endothelial keratoplasty (EK: DSAEK, DMEK, DWEK/DSO), deep anterior lamellar keratoplasty (DALK), superficial anterior lamellar keratoplasty (SALK), lamellar and full-thickness keratoprostheses (KPros), iris reconstruction, dislocated lenses/IOLs, IOL exchange, secondary IOLs (iris-sutured, scleral-sutured, glued, anterior chamber supported, iris-claw, transconjunctival intrascleral haptic fixation), piggyback IOLs, artificial iris implants, ocular surface reconstruction with amniotic membrane, simple limbal epithelial transplantation, anterior segment trauma, and limbal/pars plana approaches to anterior vitrectomy. Each surgical case is recorded digitally in high definition for teaching and presentation purposes. An advanced wet lab facility is available for the Fellow to enhance surgical skills and is used by the Attendings to investigate new and experimental surgical techniques. The wet lab is well equipped with surgical microscopes with video cameras, phacoemulsification machines, corneal instruments, an EyeSi Surgical Simulator, and dedicated personnel to run the facility.

Cataract:

This is not a fellowship in developing cataract skills as it is expected that the Fellow has mastered basic and intermediate phacoemulsification skills during their residency training. Residents on the Anterior Segment Rotation usually get priority to assist/perform cataract surgery and must achieve the objectives that have been set up for the Rotation. However, the Fellow is expected to be fully involved with the pre-operative assessment and post-operative follow-up of cataract patients to gain familiarity with issues surrounding advanced technology IOLs.

Refractive:

The Fellow will actively participate in the evaluation of patients seeking femtosecond LASIK, PRK, PTK, and CXL. The VISX Star S4 IR excimer laser and IntraLase femtosecond laser are used in the refractive suite. Training on the use of these two laser platforms will occur early in the first fellowship year. A dedicated Refractive Surgery team is in place to coordinate clinical trials, patient interactions, and the clinic/surgery schedule. Furthermore, PCC is partnered with a private refractive surgery centre, Herzig Eye Institute, located adjacent to PCC. This centre offers advanced diagnostics and the full spectrum of refractive surgery (cornea-based: SMILE, both WG- and TG-LASIK/PRK, PTK, ISRS, CXL; lens-based: ICL, RLE, FLACS, cataract surgery) using ORA and the VisuMax, Mel90, iFS, VISX, and Catalys lasers.

Schedule:

Year 1: The Fellow will work with the 4 attending surgeons and be involved with clinics, all surgical consults, ocular surface surgery (minor operating room), and laser vision correction.
Year 2: In addition to Year 1 responsibilities, the Fellow will perform intraocular surgery 3 times a week.

Clinics:

The Fellow is expected to be present at the Eye Institute or PCC, regardless of scheduled clinical activities, between 8:00am and 4:30pm, Monday to Friday. All absences must be approved in advance. When not involved in clinical or surgical duties, time must be used to further academic pursuits such as research and teaching. When a Supervisor is away on vacation or conference leave, the Fellow can participate in another Supervisor’s clinic/OR, do research, teach, take vacation, and/or perform another pre-approved academic activity.

Teaching:

The Fellow is expected to teach residents and medical students informally in clinics and the operating room, and more formally in lectures. The Fellow plays an active role in teaching residents by reviewing suturing techniques in the wet lab at the beginning of an Anterior Segment Rotation and helping to ensure resident teaching objectives are met during the rotation. The Fellow is responsible for organizing journal clubs throughout the year and presenting interesting cases during PCC International Rounds. In addition, the Fellow is expected to do an informal, five-minute presentation once a month to the Cornea Service on a recent article or a chapter from a Cornea text.

Research:

The Cornea and Refractive Surgery Faculty is involved with multiple clinical trials on an ongoing basis at the Eye Institute as well as the PCC Research Centre. The Fellow will be expected to be first author on at least one major research project. The Fellow is encouraged to present at a major Ophthalmology meeting (AAO, ASCRS, ESCRS, EuCornea, Asia Cornea, COS, etc.) and to submit a manuscript for publication in an ophthalmology journal. The Fellow will also present at the Department of Ophthalmology Annual Research Day. Access to the latest Ophthalmology journals will be available online.

Conference:

Conference leave may be taken if the Fellow is presenting at a meeting and must be approved by the Fellowship Director.

Call:

The Fellow is expected to carry a pager/cell phone at all times. Throughout the year, the Fellow is the first point of contact for residents and clinics wishing to discuss an urgent Cornea consult. The Fellow is also expected to be available for weekend/closure clinics, resident calls, and emergency procedures that take place when a supervisor is on call (about 8-9 weeks total). The Fellow will share first call duties with other clinical fellows when residents are not able to take call (mock orals, OKAP, etc.). Finally, the Fellow is expected to be available for weekend follow-ups of post-operative and complex Cornea patients.

Vacation:

Two weeks

Evaluations:

Formal evaluations of the Fellow’s progress in the fellowship will be performed by the Supervisors every four months.

Funding:

$60,000/year for a Fellow without funding support. Funding for research (including associated conference leave) is available on a competitive process through the University Medical Research Fund.

Contacts:

• Setareh Ziai, MD, FRCSC; Cornea Fellowship Director
  Email: [email protected]
• Ginette Snook, Departmental Education Program Coordinator
  University of Ottawa Eye Institute
  Email: [email protected]

Fellowship Objectives:

• To acquire experience beyond that of the normal residency in the diagnosis and treatment of medical and surgical retinal disorders by working closely with fellowship trained retinal surgeons at the University of Ottawa Eye Institute, the Riverside Eye Care Centre and the Children’s Hospital of Eastern Ontario.

• To become familiar with the use of diagnostic equipment for the diagnosis of retinal detachments, retinal tears and retinal disease including ultrasonography, fluorescein angiography, indocyanine green angiography and electrodiagnostics.
• To acquire experience reading computerized optical coherence tomography scans, ultrasonography scans, fluorescein and indocyanine green images and electrodiagnostic scans.
• To acquire experience in the surgical management of retinal tears and detachments, vitreous hemorrhage, macular disease, intraocular tumors, retinopathy of prematurity and traumatic ocular injury.
• To acquire experience in the management and treatment of macular degeneration.
• To become familiar with the management and operation of clinical trials related to retinal disease.
• Participate in at least one clinical or basic research project during the twenty-four months and present the data at a national or international meeting. Participate in writing several scientific reports or case reports during the fellowship year.
• Play a role in the teaching of medical students and residents.

This position is offered through the SF Match and uses its Central Application Service (CAS). Interested and qualified applicants should submit a personal statement, curriculum vitae, and three confidential reference letters through CAS. Non-CAS documents include medical school/residency transcripts and should be submitted to Ginette Snook. All Foreign Trainee applications to our program must go through the PGME office. Foreign Trainee candidates must apply on-line through the Fellowship application system. The application site for Foreign Trainees opens in July/August and the deadline for applications is September 30th for the next academic year. All Foreign Trainee candidates are expected to apply to both the SF Match and the PGME Foreign applications. Applications are due in the fall. Interview notifications will be made in October. Interviews will be held at the end of October/November. The Match takes place in December.

The objectives in Neuro-Ophthalmology are:

Clinical

• obtain direct hands-on clinical experience and training in the evaluation and management of afferent and efferent neuro-ophthalmic conditions.

• To be able to perform and master the art of a comprehensive neuro-ophthalmologic examination
• To develop and master a diagnostic and therapeutic approach to difficult neuro-ophthalmic case presentations.
• Develop facility and mastery in the evaluation and management of patients with optic neuropathies.
• Develop facility and mastery in the evaluation and management of patients with optic nerve head swelling including papilledema and pseudopapilledema
• Develop facility and mastery in the evaluation and management of patients with central nervous system disorders such as stroke, neuromuscular junction disease, and degenerative diseases (eg. Neuro-ophthalmic manifestations of Parkinson’s disease)
• Develop facility and mastery in the evaluation and management of patients with facial pain syndromes
• Develop facility and mastery in the evaluation and management of patients with orbital fissure, cavernous sinus, and chiasmal disorders
• Develop facility and mastery in the evaluation and management of patients with trigeminal pain syndromes, and migraine
• Develop facility and mastery in the evaluation and management of patients with visual field disturbances
• Develop facility and mastery in the evaluation and management of patients with neuro-ophthalmic features of multiple sclerosis
• Develop facility and mastery in the evaluation and management of patients with diplopia
• Develop facility and mastery in the evaluation and management of patients with anisocoria
• Develop facility and mastery in the evaluation and management of patients with cranial neuropathies

For more information on the Neuro-Ophthalmology fellowship program, please contact Ginette Snook at [email protected], Departmental Education Program Coordinator. All Foreign Trainee applications to our program must go through the PGME office. Foreign Trainee candidates must apply on-line through the Fellowship application system. The application site for Foreign Trainees opens in July/August and the deadline for applications is September 30th for the next academic year. All Foreign Trainee candidates are expected to apply to the PGME Foreign applications.

Surgical

• Develop an understanding of which clinical scenarios and presentations require or warrant surgical intervention.

• Develop an understanding of when optic nerve sheath fenestrations are warranted in the management of intracranial hypertension. The trainee should obtain the necessary skills and experience in the hands-on performance of optic nerve sheath fenestrations.
• Develop skills and strategies to independently plan and execute a variety of adult strabismus surgeries including but not limited to:
  • Adjustable suture techniques
  • Fixed suture techniques
  • Horizontal rectus muscles
  • Cyclovertical muscles
  • Sensory deviations
  • Thyroid-related dysmotility
  • Re-operations
  • Congenital or longstanding deviations
  • Congenital Nystagmus surgery
• Develop mastery of temporal artery biopsies
• To be able to assess the need for and independently perform suture tarsorrhaphies, ectropion and entropion repairs
• To develop an approach to the prevention (whenever possible) and management of peri-operative, intra-operative and post-operative complications.

For more information on the Neuro-Ophthalmology fellowship program, please contact Ginette Snook at [email protected], Departmental Education Program Coordinator. All Foreign Trainee applications to our program must go through the PGME office. Foreign Trainee candidates must apply on-line through the Fellowship application system. The application site for Foreign Trainees opens in July/August and the deadline for applications is September 30th for the next academic year. All Foreign Trainee candidates are expected to apply to the PGME Foreign applications.

Academic

• To develop a broad and in-depth fund of knowledge of neuro-ophthalmology and relevant aspects in related fields such as Neurology and Neurosurgery.

• To be able of teach clinical, academic, and surgical concepts to residents and medical students.
• To participate in on-going neuro-ophthalmology research projects, as well as take primary initiative on at least one project of particular interest to the trainee. This may lead to presentation of his/her work at a national or international conference, and/or to publication in a peer-reviewed academic journal.
• The trainee will be expected to provide guidance, leadership, and assistance to residents in their pursuit of academic proficiency in neuro-ophthalmology.

For more information on the Neuro-Ophthalmology fellowship program, please contact Ginette Snook at [email protected], Departmental Education Program Coordinator. All Foreign Trainee applications to our program must go through the PGME office. Foreign Trainee candidates must apply on-line through the Fellowship application system. The application site for Foreign Trainees opens in July/August and the deadline for applications is September 30th for the next academic year. All Foreign Trainee candidates are expected to apply to the PGME Foreign applications.

Fellowship in Pediatric Ophthalmology & Adult Strabismus

This fellowship is designed to promote subspecialty competence, confidence, and efficiency in managing the full range of medical and surgical cases in pediatric ophthalmology and adult strabismus. An innovative teaching environment with carefully graduated responsibility is a hallmark of this program. While competition between fellows and residents can be a concern in many fellowship programs, this program is designed to synergize learning for both the resident and fellow, maximizing the intensity and quality of the learning experience for each.

Interested and qualified applicants should submit a personal statement, curriculum vitae, medical school/residency transcripts, and three confidential reference letters through Ginette Snook at [email protected], Departmental Education Program Coordinator at the University of Ottawa Eye Institute. American/foreign medical graduates must contact Ginette Snook at [email protected] regarding the application process in advance of submitting an application, as the application process involves the Postgraduate Medical Education Office. Applications are due September 30th in the year preceding the fellowship, with candidates notified by December 1st regarding the success of their application.

Fellowship Director and Preceptor: Michael D. O'Connor, MD, FRCSC

Duration: One year fellowship starting July 1st.

Minimum educational and clinical requirements

1. A degree of medical doctor (MD) or equivalent from an approved medical school.

2. Successful completion of an approved ophthalmology post-graduate residency training program or equivalent prior to starting the fellowship.
3. Documented experience in the following areas:
   a. Clinical examination, diagnosis, and formulation of a. treatment plan of pediatric ophthalmology patients.
   b. Clinical examination, diagnosis, and formulation of a treatment plan of adult ophthalmology patients.
   c. Horizontal muscle strabismus surgery as the primary surgeon in first operation cases.
4. Priority will be given to graduates of Canadian residency programs who plan to practice in Canada following completion of the fellowship. Additional priority will be given to those who are planning a career in academic medicine. Special consideration will also be given to international candidates who will be practicing in regions that are lacking in pediatric ophthalmology resources.

Training sites

1. CHEO is the primary training centre for the fellowship, which is centred around paediatric ophthalmology.

2. iCare Surgical and Optical Centre for adult strabismus and comprehensive ophthalmology.
3. The Ottawa Hospital (The University of Ottawa Eye Institute at the Ottawa Hospital – General Campus) for adult on-call duties and ophthalmic ultrasound.
4. Off-site observerships at other designated sites (for example, CNIB). Funding $60,000/year for an applicant without external funding support. Funding for research (including associated conference leave) is available on a competitive process through the University Medical Research Fund. Qualifications obtained in training Candidates who successfully complete the training program will be awarded a certificate at the end of the fellowship.

Fellowship Goals

This fellowship is intended to prepare candidates for a career as a comprehensive ophthalmologist with a strong emphasis on pediatric ophthalmology and strabismus, and for candidates who envision a career as a full-time pediatric ophthalmologist and strabismus surgeon, in an academic or community setting.

1. Clinical
   a. Appropriately evaluate, diagnose, and treat pediatric and adult in patients in an adult and pediatric ophthalmology outpatient setting.

2. Surgical
   a. Appropriately evaluate, diagnose, and treat the spectrum of pediatric surgical eye conditions, particularly strabismus, pediatric cataract, and glaucoma, and obtain subspecialty-level skill in the management of adult strabismus.
3. Education
   a. Develop a more organized, effective, and efficient approach to the basic clinical training of medical students and residents in the clinic and operating theatre.
   b. Become a more effective oral and visual communicator in a didactic teaching setting, including medical student and resident teaching sessions, as well as Department of Ophthalmology Grand Rounds.
4. Scholarship
   a. Develop an appreciation for pursuit of knowledge and advancement of medicine and surgery through scientific enquiry, including clinical research project design and completion, along with publication and presentation.
5. Personal Development
   a. Employ techniques to maximize personal growth and career and life satisfaction.
   b. Incorporate volunteerism into a life plan.

Specific objectives

At the end of the fellowship, the successful candidate will be able to perform the following:

1. Pediatric ophthalmology and adult strabismus

   1. Medical expert

      1. Effectively triage consultations.

      2. Evaluate, diagnose, and manage the following conditions:

         1. Congenital eye abnormalities

         2. Retinopathy of prematurity

         3. Pediatric cataracts

         4. Retinoblastoma

         5. Nystagmus

         6. Hemangioma

         7. Hyphema

         8. Cellulitis

         9. Uveitis

         10. Amblyopia

         11. Strabismus

         12. Abnormal head position

   2. Medical skills

      1. Perform visual acuity testing confidently and reliably in the appropriate scenarios using the following techniques

         1. Bruckner test

         2. Central/steady/maintained fixation testing

         3. Age-appropriate optotypes

         4. Fixation preference with Teller/Cardiff cards

         5. Special techniques for the visually impaired child

         6. Special techniques for the child with functional visual loss

      2. Perform ocular motility and sensory testing confidently and reliably in the appropriate scenarios using the following techniques

         1.  Worth four dot

         2. Stereo tests (including Lang, Randot, and Frisby)

         3. Cover testing for phorias, tropias

      3. Identify the following on examination

         1. Common patterns of childhood strabismus

         2. Monofixation syndromes/microtropias

         3. Paralytic strabismus and secondary deviations

         4. Oblique muscle dysfunction

         5. Monocular elevation deficiency

         6. Incomitancy

      4. Perform refractions confidently and reliably in the appropriate scenarios using the following techniques

         1. Loose lens refractions

         2. Manifest and cycloplegic refractions

         3. Aphakic refractions

         4. ​Over-refractions

         5. Bifocal assessment

2. Comprehensive adult ophthalmology

   1. Appropriately diagnose, manage, and treat adult patients with

      1. Glaucoma and suspicion of glaucoma

      2. Cataract, including performing a pre-operative assessment

      3. Uveitis

      4. Refractive error

      5. Macular degeneration

      6. Urgent complaints in an emergency outpatient ophthalmology clinic setting

3. Pediatric and comprehensive ophthalmology

   1. Surgical skills

      1. Understand the indications, create a surgical plan, anticipate surgical complication, and perform surgery safely and independently for surgical correction of

         1. Strabismus, including vertical muscles, oblique muscles, reoperations, and adjustable sutures

         2. Nystagmus

         3. Nasolacrimal duct obstruction

         4. Pediatric cataract

         5. Pediatric glaucoma

         6. Hemangioma

         7. Hyphema

         8. Retinopathy of prematurity

         9. Examination under anaesthesia

   2. Communicator

      1. Establish therapeutic relationships with patients

      2. Establish therapeutic relationships with families

   3. Collaborator

      1. Establish effective working relationships with other members of the patient’s circle of care

   4. Manager

      1. Utilize the resources of the clinic effectively

   5. Scholar

      1. Perform independent study with respect to clinical cases

   6. Health Advocate

      1. Facilitate patient access to hospital and community resources appropriately

   7. Health Professional

      1. Exhibit exemplary interpersonal interactions with colleagues and co-workers

      2. Demonstrate empathy, compassion, and honesty in dealing with patients and families

Expectations and minimum requirements for completion

1. The Department of Ophthalmology Administrative Assistant will make the Clinic and Operating Theatre schedules available at least one month in advance.

2. Unless other clinical duties have been specified, the Fellow will work in clinic and in the operating theatre with Dr. O’Connor on weekdays. Typical workday hours are 0730-1730.
3. The Fellow will participate in weekly retinopathy of prematurity screening at the neonatal intensive care unit with Dr. O’Connor.
4. The Fellow will supervise the resident(s) covering daytime emergencies and inpatient consults at CHEO, under the guidance of Dr. O’Connor.
5. The Fellow will make regular presentations/small group teaching sessions to the residents and will participate in Department Grand Rounds and Journal Club.
6. The Fellow will spend dedicated time each week on reading for personal learning.
7. The Fellow will spend dedicated time in the Ophthalmic Surgical Skills Centre, including with the cataract surgical simulator (EyeSi).
8. Participation in research project(s) during the fellowship is encouraged but not mandatory.
9. A minimum of one half-day should be spent observing strabismus surgery by other surgeons in the Department. Ideally this will be arranged on a day when no other clinical duties are scheduled.
10. If possible, a minimum of one half-day will be spent at each of the following:
    1. CNIB Ottawa
    2. The OCTC Low Vision Early Intervention Program
    3. The Ottawa Public School Board Itinerant Low Vision Teachers
    4. The “i-screen” Kindergarten Vision Screening Program
    5. The electrophysiology lab at the Eye Institute
    6. Other learning opportunities of this nature can be discussed upon request.

Performance evaluation

Formal performance evaluations will be completed at 3-month intervals. Informal feedback will be provided on a day-to-day basis. Evaluations will be based on performance in clinic, operating theatre, teaching sessions and rounds, and from feedback from other members of the health care team.

On-Call Duties

1. In the event that the resident assigned to CHEO is unavailable (for example in the event of a vacation or conference leave), the Fellow will take first call for CHEO outpatient and inpatient consults from 0800-1700 hrs, excluding weekends and holidays.

2. The Fellow will cover on-call responsibilities when the residents are relieved of their on-call duties, for example the night before the Oral Exams and OKAP Examination. This responsibility will be shared between the Fellows, and the call schedule will be organized in conjunction with the Fellowship Preceptor and Program Director.
3. The Fellow will be responsible for and will attend to weekend and evening clinical responsibilities as per Dr. O’Connor’s staff on-call schedule and as clinical responsibilities demand. The Fellow is expected to be available, unless otherwise planned, to receive telephone queries from surgical patients.

Vacation and Education Leave

Provided in compliance with PARO guidelines.

Reading requirements

At a minimum during the Fellowship, the Fellow should complete reading of the following during the fellowship:
1. Pediatric Ophthalmology and Strabismus by Hoyt and Taylor
2. Color Atlas of Strabismus Surgery by Kenneth Wright
3. Crucial Conversations by Kerry Patterson et al.

Contacts:

• Michael D. O’Connor, Fellowship Director and Preceptor
  Department of Ophthalmology
  Children's Hospital of Eastern Ontario​​​​​​​
  Email: [email protected]

• Ginette Snook, Departmental Education Program Coordinator
  Department of Ophthalmology
  The Ottawa Hospital
  ​​​​​​​Email: [email protected]