Maximizing Vitreoretina Fellowship

Dr. Saurabh Deshmukh, MBBS, DNB, FVRS, MNAMS
  • Dr. Saurabh Deshmukh completed his ophthalmology residency program and Vitreoretinal surgery fellowship from Sri Sankaradeva Nethralaya, Guwahati, India (Centre of Excellence in Eye care). He holds an MBBS degree from the Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai.
  • He discovered a new clinical sign in Ophthalmology – Triangle Sign 
  • He has published 50+ research articles in International and National journals.
  • He has delivered invited talks, presented numerous papers and won multiple awards at various International and National conferences.

Interview

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

A1. I completed my DNB Ophthalmology from Sri Sankaradeva Nethralaya, Guwahati, a centre of excellence in eyecare. It is a referral centre for all ophthalmic diseases and emergencies in the Northeast India. As a result, during my residency I had adequate exposure to all the super specialities in the field of Ophthalmology.

During my residency I still remember if a patient developed TASS on the first post-operative day after cataract surgery, it leads to a lot of stress considering the grave differential diagnosis of endophthalmitis. Also, post-operative endophthalmitis is the worst nightmare ophthalmologist can ever face. It can lead to the loss of vision of the patient and also irreparable damage to the credibility of treating ophthalmologist. In my residency I came across many referred cases of post-operative endophthalmitis who are meticulously managed and treated by our Vitreoretinal surgeons and many of these patients retained good visual acuities.

As a resident while learning small incision cataract surgery and phacoemulsification we all at one point of time have faced the complications like posterior capsular rupture, nucleus drop and IOL drop. Whenever these complications occurred we all felt helpless and also felt bad for the patient as he or she might have to be left aphakic. These complications can be managed skilfully by the Vitreoretinal surgeons.

When I was posted in the comprehensive OPD I realised that there was a gradual and steady increase in the number of patients losing sight due to lifestyle diseases like diabetes and hypertension. These patients were investigated and managed (either with intravitreal injections or surgical intervention) by Vitreoretinal surgeons.

So, considering all these factors, that is, management of post-operative complications (endophthalmitis and PCR, nucleus and IOL drop) and also management of lifestyle diseases affecting the eye, and my love for ophthalmic imaging, I decided to pursue Vitreoretina as my superspeciality of interest.

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

A2. I believe that a few key factors should be considered before selecting an institute for fellowship. These are;

  1. Optimum balance between medical and surgical retina training.
    • Medical retina and investigations – At Sri Sankaradeva Nethralaya (SSDN) the VR fellowship program is very well structured. During the initial months of training I was posted in the medical retina department and the investigations department. During this time I learned the perfect technique of performing indirect ophthalmoscopy with scleral indentation and also learnt the basics of fundus drawing. Simultaneously, I was also trained in performing retina lasers including Panretinal photocoagulation (PASCAL + LIO), barrage lasers, focal and grid lasers. I also learnt the basics of TTT and PDT as well. In the investigations posting, I was trained in performing all retinal investigations like fundus photography, fundus autofluorescence, OCT, OCTA, FFA, ICGA, VEP, ERG and EOG. I was also trained extensively in performing ultrasound B-scan and UBM.
    • After finishing few months of medical retina and investigations posting, the surgical retina posting was initiated. The surgical retina posting was also very structured starting in a very step-by-step manner. Each and every step, starting from draping to the creation of sclerotomies was taught in detail. Also, what all complications can occur in which steps and how we can prevent them was also taught simultaneously. Gradually as I progressed through my surgical training, I was allowed to operate independently on cases of retinal detachment, diabetic vitrectomies and scleral buckling. I was also trained to manage complications of cataract surgeries including endophthalmitis, dropped nucleus, dropped IOL, fixation of Iris claw lens and SFIOL. At the completion of fellowship I was confident enough to perform all the surgeries independently.
  2. Academic and research – At SSDN, I was constantly encouraged to get involved in academic and research activities. We undertook research into various vitreoretinal diseases and published multiple good research papers in high index peer reviewed national and international journals. At SSDN, I was also motivated to present my work at national and international platforms like AIOC, AAO etc.
  3. Others – The dedicated ROP and retinoblastoma/ocular oncology OPDs helped me develop additional skills for the management of these sight and life threatening diseases.
Q3. What were your areas of interest?

A3. My particular areas of interest were management of diabetic retinopathies and retinal detachments.

Q4. Is it mandatory to have had some surgical experience before joining Vitreoretina Fellowship?

A4. I feel that it is not mandatory to have surgical experience before joining VR Fellowship but it does you an advantage if you have performed basic surgeries like SICS and phacoemulsification during residency. Also, the training program at SSDN is made in such a way that you get ample number of surgeries to hone your surgical skills.

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

A5. It is an important part of VR training. Wetlab is a place where you can learn the mechanics and holding pattern of instruments. Suturing is a vital part of VR surgeries like scleral buckling and closure of leaking sclerotomies, this can be practised in the wetlab. At SSDN we had a well-equipped wetlab.

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

A6. A mentor will not only teach you during your fellowship but also guide you throughout your career as an ophthalmologist and VR surgeon. The best way to build a rapport with your mentor is to be true to duties and well read. During a busy OPD it may not be possible for the mentor to teach you everything but if you are well read he may give you small practical tips which are not available in the textbooks and this is the knowledge that matters in the clinical practice. Also, discussing difficult to diagnose cases at the end of the day with your mentor can be quite helpful.

Q7. How important is the support of your colleagues?

A7. I believe it is quite essential. Your colleagues are the people who work shoulder to shoulder with you during your fellowship and faces the same hardships as you do. Reading, discussing and sharing surgical experiences with colleagues makes your fellowship training period a breeze.

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

A8. At SSDN most of the work could be finished during the hospital working hours, and very rarely I had to work overtime.

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.

Take time to destress daily, priorities your health – physical, mental & emotional. Be honest with yourself, if you feel you are close to burnout take a few days off. If you share an honest relationship with your colleagues and mentor – they would not begrudge you the time you need.  Remember that when you don’t take care of yourself, your quality of work and ultimately your patient care is hampered.

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

A9. The best textbooks for VR fellows are;

  • Ryan provides an excellent understanding of the retinal physiology and diseases.
  • Peyman for basics of vitrectomy and scleral buckling.
  • Book by Steve Charles is excellent for learning techniques of small gauge vitrectomy

To keep at pace with recent advances it is important to follow high impact journals like RETINA, Ophthalmology Retina. 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.

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