Maximizing Cornea Fellowship

Dr. Prerna Ahuja, MBBS, MS, FICO (UK), FCRS (NN), FCED (RGUHS)

Dr. Prerna Ahuja successfully completed her long term Fellowship in Cornea, Ocular Surface & Refractive Surgery from Narayana Nethralaya, Bengaluru and Fellowship in Cornea and External Eye diseases ( RGUHS, Karnataka).
She completed her MS Ophthalmology from Maharashtra University of Health Sciences and is an alumnus of KEM Hospital and Seth G S Medical College. She holds an MBBS degree from the Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai.
Her fields of interest include lamellar corneal surgeries and ocular surface procedures.

Interview

Q1. Why did you choose Refractive Surgery as your Superspeciality of interest?

A1. I did my MS ophthalmology at KEM Hospital: a high-volume government hospital in Mumbai. We had a tremendous number of patients who required intensive management to save sight.

What impressed upon me was that unlike several other ocular conditions – when treated at the right time and with a patient & meticulous plan of management, a myriad of corneal lesions can be reversed. To me, this was very important personally as a doctor. While there are often plenty of ophthalmologists, who approach corneal lesions with gusto and good intent, without the right tools or knowledge, there may often be unfavorable results rendering essentially treatable lesions with unnecessarily poor outcomes. I was especially impressed upon by the need for good, ethical cornea specialists to treat what can be potentially a reversible cause of blindness. But that is what draws me to Cornea as a passion.

From a more practical point of view – to survive in today’s current scenario of private practice you not only need to be up-to-date with upcoming research but also need to have a speciality that your colleagues can refer patients to you for. This is important for practice building – to have a unique skill set thus leading to a productive symbiotic relationship.

Evaluate thoroughly your options prior to applying for a fellowship – choose your fellowship to match your 5-year goal plans, your intended city/country of practice, your affinity for government vs private setup and your potential for financial investment.

Q2. Why did you choose Narayana Nethralaya for your fellowship?

A2. Once I had decided to pursue a fellowship in cornea and refractive surgery, I started doing my research on the best institutes to do it. Few things were important to me;

An equal balance between the training of cornea and refractive surgery.
A lot of institutes provide exceptional cornea training, Narayana Nethralaya was definitely one of them. But the quality of refractive training was attractive and unparalleled. There was a lot of exposure promised to a multitude of screening equipment under one roof as well as performing all types of surgeries including lamellar corneal surgeries and refractive surgeries like Femto LASIK and SMILE. There was also tremendous exposure to all modalities of treatment for keratoconus, a subject of keen interest to me since my postgraduate days.
A high quality Cornea training.
Once again, NN provided ample opportunities to not only perform full-thickness keratoplasties; but also lamellar surgeries (DALK, DSEK, DMEK), ocular surface procedures as well as keratoprosthesis procedures. Very rare centers in the country offer the kind of extensive exposure that could be achieved here. The OPD volume ensured that you would care for patients with all types of corneal disorders. Independence while treating was encouraged, it was yet highly supervised by prolific and experienced surgeons– this ensured a high quality of medical and surgical management whilst giving you time to clarify any doubts that may arise. Towards the end of my fellowship, I was given the opportunity to run an independent Corneal clinic without supervision – this emboldened my acumen and skills.
Tremendous exposure to participate in Research, Publications, and Presentation.
I trained initially in a very resource-limited setup. We had every type of case but no resources to pursue a better understanding of unusual ones. NN provided me the opportunity to delve deeper until every why and how was answered. The chance to present at national and international platforms was an honor in itself, but the chance to meet people from all over the country and world – to engage in discussions and healthy arguments opened up my mind to the sheer possibilities and advancements in Ophthalmic Science. It inculcated in me a drive to question everything I know and to never accept without explanation – to put evidence over eminence.

Q3. What were your areas of interest?

A3. My particular areas of interest were lamellar corneal surgeries and Ocular surface procedures.

Q4. Is it mandatory to have had some surgical experience before joining Cornea / Refractive Fellowship?

A4.

In my opinion, being trained to perform Cataract surgeries would definitely be beneficial.
A corneal surgeon must know how to perform a variety of complicated cataract surgeries and being trained in the basics is an added advantage.
It is of course beneficial to perform and assist in as many surgical procedures as possible – of every ophthalmic super-specialty. Every case differs in finer nuances and assisting different surgeons teaches you a variety of approaches and techniques.
Observing different surgeries teaches you of the different instruments that could be useful to you and also to be resourceful in terms of techniques. After all, as a surgeon, there could be a multitude of things that would not go according to our textbooks, and lateral thinking on your feet while remaining calm is mandatory.
In my opinion, being trained to perform Cataract surgeries would definitely be beneficial. A corneal surgeon must know how to perform a variety of complicated cataract surgeries and being trained in the basics is an added advantage.

Q5. How important is wet lab training according to you?

A5.

It is extremely important in my opinion. Unlike other branches, Corneal surgeons are blessed to have a medium to perform procedures on unutilized corneal donor tissue – take full advantage of this. As my professors at Narayana Nethralaya always said – you must perform a step 100 times in your mind before doing it once on a patient.
If your institute has the facility, you can practice suturing, lamellar dissection, trephining, graft harvesting and insertion, etc. Watch videos prior to wetlab, and perform intensive wetlab training (preferably under the supervision of a senior) before taking up an actual case. In fact, most conferences have Wetlab training at interactive booths – once again a great way to capitalize on learning new techniques from the experienced surgeon and discuss one on one of your personal difficulties. It is also a great way to learn new techniques once you have finished your fellowship and may no longer have access to institutional wetlabs.

Q6. How to build a good rapport with your mentor?

A6.

A good mentor will guide through your fellowship; a great mentor will teach you throughout your career. To develop that type of rapport, you need to show your sincerity – often going beyond the call of duty.
The fellowship is often the final learning phase of a long medical education – maximize your time.
Study the basics, take every chance to see different and challenging cases, read up articles to enhance your knowledge – your mentor being busier will appreciate if you can bring to his notice good articles that enhance the institute practice and research.
Don’t be afraid to ask questions or discuss new concepts. Trust is always a two-way relationship and building a good rapport means earning the trust and respect of your mentor first. It will open up a free channel of communication enhancing your knowledge and allowing you to ask doubts as well communicate.
You have to keep an open, receptive mind to truly train under someone – you may not get the exact same opportunities as a colleague but it’s important to have faith in your teacher.

Q7. How important is the support of your colleagues?

A7. Beyond the mundane aspects such as helping you in your work and duties; your colleagues will form a support system for you at your work place, be a sounding board for ideas. They will go through a similar life trajectory as you and it is always beneficial to have someone to discuss your difficult cases as well as professional paths with. A healthy competition between contemporaries can often push you to work beyond what you assume are your limits. A happy work environment ensures productivity for everyone involved. Try to avoid unhealthy comparisons that lead to unnecessary toxicity – remember you can always find something to learn from each person you come across. It’s your own attitude that will make all the difference in how you approach people who could be lifelong friends.

Q8. How to cope up with the stress and not let it reflect in your work?

A8. The pressure of being in the final stage of your education, finding the right balance between personal and professional obligations and facing the eventuality of entering the rat race sooner than later – can make fellowship a period of stress.

My advice would be to find activities that relax you – be it meditation, reading, a favorite show, exercise or spending time with your family. But find time to create a work free zone.

Avoid workaholic tendencies in an effort to gain most out of your time – remind yourself that for doctors learning is a continued process. You will continue learning in your practice later and that what a fellowship should mean is to equip yourself with the skills and mindset to face any challenge.

Q9. Quick checklist for young aspiring Cornea fellows to follow during their fellowship.

A9. As far as textbooks go;

Krachmer provides an excellent understanding of the corneal physiology and diseases.
Brightbill for Surgical methods.
Dmitri Azar for basics of Refractive surgery.

However, our textbooks only form the basis of our understanding – it is necessary to follow high impact journals to keep up to date with advancements. It helped me greatly to develop an understanding of statistics – it also helps you critique and appreciate the papers you read. There are lots of Surgical technique videos available on YouTube – make sure to follow them regularly. I tried to follow a simple rule during my fellowship – “try not to go to bed without having watched a surgical video and having read something new for the day”. I would make it a point to read about any unusual case I came across the same day – try to read thoroughly from textbook, learn the surgical manoeuvres as well as do a PubMed search to make sure my knowledge was up to date.