The ICO Subspecialty
Curricula provide aspects of modern curriculum design that complement the ICO
Residency Curriculum, which is a stratified content outline of cognitive and
technical skills. The comprehensive definition of a curriculum includes a content outline, the
resources required to adequately provide training (eg, faculty and facilities),
suggested numbers of procedures, teaching methods, and trainee and program
evaluations. We believe the incorporation of these crucial components produces
a valuable resource. The ICO Subspecialty Curricula are intended to be
modified, acknowledging differences across the globe due to available
resources, prevalence of disease, and geographic or demographic differences.
As an additional resource, you may also
want to refer to the Very Advanced Level Goals content outline for Glaucoma in the ICO Residency Curriculum.
[M]: Must
have/required
[S]: Should
have
I. INTRODUCTION
A. Definition
and Scope of Glaucoma Fellowship
Glaucoma subspecialists manage the entire spectrum of the disease, with
an ability to treat complex glaucoma in relation to underlying systemic and
ocular conditions. This may require collaboration with other medical and
ophthalmic specialty areas. Fellowship training is focused on additional
in-depth understanding and management of glaucoma beyond that obtained in
residency training. This training occurs during a continuous minimum period of 1
year and includes intense and focused training in developing and maintaining
knowledge, skills, scholarship, and professionalism.
B. Duration
and Scope of Education
1. The fellow must be able to fully comply with the clinical requirements of
the program and have completed an appropriate residency program for that
subspecialty fellowship. [M]
2. A minimum
of 12 months (not necessarily consecutive) of
clinical training is required, with vacation time and sick/personal leave at the
discretion of the program director and not necessarily equivalent to that
stipulated for residents at the same
training institute. Extension of the training period greater than 3 months, or an extended leave of absence, should have prior
approval. [M]
3. Prior to
entry into the
program, each fellow will be given an
orientation period for familiarization with the institute, the clinic, and the
basic examination skills. Each fellow is required to be notified of the required length of the program, policies for
vacation, duties, stipends, and other forms of support. [M]
II. INSTITUTIONAL
ORGANIZATION
A. Fellowship
programs in glaucoma are often in institutions that sponsor residency programs
in ophthalmology. Whenever possible, there should be coordination of the
fellowship and residency programs, so that both benefit. While affiliation of
the fellowship and residency programs may not be required, it is recommended. [S]
B. The institution committed to offering a glaucoma
fellowship program should have the capacity––and appropriate infrastructure––for
high quality, diverse exposure to complex glaucoma cases and their management.
Educational activities, including didactic lectures and grand rounds, are
necessary. Research activities, including presentations at meetings, are part
of the glaucoma fellowship program and fellows are encouraged to participate in
such activities. [S]
C. The number
of fellowship positions approved will depend on the adequacy of clinical
volume, number of faculty, and other resources, as determined by the fellowship
director with the support and approval of the departmental chair. [S]
The fellowship program should receive a letter of support from the
chairman and/or program director of the parent department of ophthalmology. The
fellowship program, as much as possible, should complement, support, and
enhance the residency program. The department chair, fellowship program
director, and residency program director should work together and periodically
meet to assure that the presence of the subspecialty fellowship does not unduly
draw cases, learning opportunities, or funding from the residency program. [S]
III. FACULTY
QUALIFICATIONS AND RESPONSIBILITIES
A. Fellowship
Program Director
There must be a single program director responsible for the fellowship program. [M]
1. Qualifications
of the fellowship program director:
a. Required to possess appropriate educational qualifications,
including certification in ophthalmology and glaucoma-fellowship training. [M]
b. Required to have at least 3 years of clinical experience in
glaucoma following his/her fellowship training.
[M]
i. In rare circumstances, in regions where there may not be a
fellowship-trained program director, a senior ophthalmologist may have 10 or
more years experience in substantial (greater than 50%) glaucoma practice,
including contribution to the literature in the way of clinical or basic
research. Such a clinician should be considered an appropriate primary
supervisor.
c. Should be engaged
in ongoing basic and/or clinical science research in the area of glaucoma, as
demonstrated by regular publications in peer-reviewed journals and/or
presentation of research material at national and international meetings.
[S]
d. Required to have a clinical practice with at least
50% of patients who have glaucoma and glaucoma-related disorders. [M]
e. Required to have an academic appointment on the
faculty of the affiliated ophthalmology-residency program or affiliated
institution. [M]
f. Required to be licensed to practice medicine in the
state or country where the institution that sponsors the program is located. [M]
2. Responsibilities
of the fellowship program director:
a. Required
to design and supervise the educational experience. [M]
b Required to prepare a written statement outlining the
educational goals of the program with respect to knowledge, skills and other
attributes, and educational goals for each major rotation or other program
assignments. [M]
c. Should promote awareness of the fellowship opportunity by
providing a job description and requesting applications via a public website. [S]
d. Required to develop and maintain documentation of institutional
or inter-institutional agreements, the fellowship selection process, patient-care
statistics, evaluations of faculty and the program, and assessment of the
fellows’ performance. [M]
e. Required to select fellows in accordance with institutional and
departmental policies and procedures.
[M]
f. Required to designate and supervise the faculty through explicit
descriptions of supervisory lines of responsibility for the care of patients. [M]
g. Required to ensure the implementation of fair procedures and due
process regarding academic discipline and fellow complaints or grievances, as
established by the sponsoring institution.
[M]
h. Required to keep open lines
of communication with their fellows and be sensitive to issues of professional
and personal stress, which may interfere with the fellows’ interaction with
patients and colleagues, medical and non-medical. The fellowship program
director should be aware of issues that would interfere with the professional
development of their fellows and be willing to facilitate timely provision of confidential counseling and
psychological support services to fellows by professionals. Training situations
that consistently produce undesirable stress on fellows must be evaluated and
modified. [M]
i. Required to ensure that accurate statistical and narrative
descriptions of the program are developed and maintained. [M]
3. Any
change in the fellowship director position is to be communicated within 90
days. [M]
B. Faculty in
Glaucoma
It is required that there be at least 1 faculty member who is the
fellowship program director. [M] Additional
supervising faculty for each approved fellowship position is desirable. [S]
Faculty members are required to:
1. Be highly
qualified and possess appropriate clinical and teaching skills. [M]
2. Devote
adequate time to the education of fellows.
[M]
3. Demonstrate
a strong interest in the education of fellows, have sound clinical and teaching
abilities, support the goals and objectives of the program, and be committed to
their own continuing medical education and participation in scholarly
activities. [M]
4. Maintain
regularly scheduled, documented meetings in order to review the program’s goals
and objectives, as well as the program’s effectiveness in achieving goals and
objectives. [M]
5. Periodically
evaluate the utilization of resources available to the program, the
contribution of each institution participating in the program, the program’s
financial and administrative support, the volume and variety of patients
available for educational purposes, the performance of faculty members, and the
quality of supervision of fellows. [M]
6. Periodically
evaluate outcomes of the research activities of the fellows. [M]
7. Evaluate
curriculum and career development of the fellows.
[M]
8. Each
faculty member must have glaucoma subspecialty fellowship training or
equivalent training and be a member of the faculty of the sponsoring
institution. In addition, research faculty and scientists may be involved with
the clinical fellowship program and are encouraged to interact with the
fellows. [M]
C. Other
Program Personnel
Programs must be provided with the additional professional, technical,
and clerical personnel needed to support the administrative and educational
activities of the program. [M]
IV. FACILITIES
AND RESOURCES
A. Clinic
The outpatient area of each participating institution must have a
minimum number of of fully equipped examination lanes for each fellow in the
clinic. There must be access to current diagnostic equipment. [M]
B. Operating
Facilities
There
must be adequate operating facilities, including an operating microscope to
perform and teach surgeries. [M]
C. Inpatient
Facilities
There
must be inpatient facilities with access to sufficient space and beds for good
patient care. [M]
D. Library
Fellows
must have ready access to a major medical library and facilities for electronic
retrieval of information from medical databases.
[M]
V. EDUCATIONAL
PROGRAM
The program director is responsible for the structure and content of the
educational program and must provide a statement of objectives, methods of
implementation, and procedures for assessment of the program by the faculty and
the fellows. (See
section III-A Fellowship Program Director.) [M]
A. Clinical
Components
1. History
Taking
The
fellow must have in-depth knowledge to inquire about common and rare clinical
conditions that may be associated with worsening disease, covering glaucomatous
and nonglaucomatous causes of vision loss.
[M]
2. Clinical Examination
Skills
The
fellowship must be organized to provide training that will equip the fellows to
regularly perform evaluations and consultations, including history and
examination, which involve the techniques of ophthalmology specific to glaucoma
and related ocular and systemic conditions.
[M]
3. Technical
Clinical Examinations
The
fellow should become proficient in the indications for and interpretation of
results of specialized diagnostic testing appropriate to the subspecialty of
glaucoma, including but not limited to the following:
a. Tests of
visual function, including evaluation of visual disability using standard
automated perimetry and Goldmann perimetry.
[M]
b. Tests of
optic nerve and retinal nerve fiber layer structure, including examination of
the optic nerve, disc photography, and familiarity with optical imaging
techniques, such as optical coherence tomography (OCT) and Heidelberg retinal
tomography (HRT). [M]
c. Assessment
of intraocular pressure. [M]
d. Evaluation
of the anterior chamber angle with gonioscopy and available anterior segment
imaging techniques such as [AS-OCT] and ultrasound biomicroscopy [UBM]). [M]
e. Assessment
of other risk factors, such as corneal thickness.
[M]
4. Therapeutics
The fellow must become familiar with the indications for and limitations of
pharmacological, laser, and surgical therapies that may be recommended for
patients with glaucoma and related conditions.
[M]
5. Clinical
Experience
The
fellow should become proficient in the diagnosis and management of glaucoma.
This should be based on differential diagnostic skills development, knowledge
of test indications and interpretations, in addition to individualized care
based on indications and limitations of pharmacological, laser, and surgical
therapies in any patient.
The fellow should be exposed to as broad a variety as possible of
conditions falling within the scope of glaucoma. Patients seen/procedures
performed must cover:
a. Subspecialty
examinations (new and follow-up patient examinations) over 12 months; [M]
b. Subspecialty
new patient examinations over 12 months;
[M]
c. The following subspecialty diagnostic examinations should be
performed on a sufficient number of patients to allow the fellow to achieve
competence in the indications, interpretation, and limitations of these
diagnostic modalities:
i. Computerized visual field examination, optic
nerve and retinal nerve fiber layer imaging, optic disc photography, and other
adjunctive studies. [M]
d. Subspecialty
surgical procedures performed: [M]
Recommended Minimum Numbers of Glaucoma
Procedures for Fellows
It is recommended that fellows perform a sufficient number of
glaucoma procedures to achieve competence. Individual programs utilizing these
guidelines should determine minimum numbers based on local need and available resources.
Class I (Fellow as Primary Surgeon) and Class II (Fellow as First
Assistant)
Operative Procedures
|
Class I
|
Class II
|
Complex cataract* or combined
procedures
Filtering procedures, including
use of antimetabolites
Aqueous shunts (valved and
non-valved)
Argon and selective laser trabeculoplasty
Laser iridotomy
Laser suture lysis
Needling of failing/encysted
filtering blebs
Repair of leaking blebs
Management/reformation of
shallow anterior chamber
Management of hypotony and
choroidals
Laser cyclophotocoagulation
Goniotomy/trabeculotomy for
primary congenital glaucoma
Examination under anesthesia
for congenital glaucoma
Peripheral iridoplasty
YAG capsulotomy
Anti-VEGF injections/panretinal
photocoagulation
|
* Complex cataract includes small pupil, posterior synechiae,
pseudoexfoliation, loose zonules, and other appropriate cases.
To provide a minimum experience in the management of patients with refractory glaucoma and acknowledge variations in practice patterns, fellows should perform a variety of glaucoma procedures and not be limited to just a single approach. It is recommended that fellows
perform and become proficient in trabeculectomy with
antimetabolites, tube shunts, and cyclodestructive procedures. It is
recommended that fellows perform a sufficient number of glaucoma procedures
to achieve competence (eg, 20 glaucoma procedures as primary surgeon and
40 glaucoma procedures as assistant surgeon). Fellows should become proficient
with laser trabeculoplasty, iridotomy, and iridoplasty procedures. They should
also perform postsurgical follow up, including suture lysis and be able to
manage complications, including malignant glaucoma, failing or leaking blebs,
hypotony, and choroidal detachments and hemorrhages.
B. Didactic
Components
Fellows
should participate in clinical conferences and didactic lectures in glaucoma and
related topics that are separate from patient-care activities within the parent
institution, including presenting cases and lectures, and participating in
grand rounds and other departmental conferences. Fellows are expected to
participate in 30 hours of such time per year. [S]
Fellows
should have basic knowledge of statistics for interpretation of published
literature and conducting their own research. [S]
Fellowship
preceptors must emphasize the principles of ethical and humane treatment of
patients in accordance with the International Council of Ophthalmology Code of
Ethics (http://www.icoph.org/downloads/icoethicalcode.pdf). Preceptors and faculty should
communicate these principles in both didactic and clinical aspects of the
fellowship training. [M]
C. Supervision
Fellows
must be appropriately supervised in patient care services by qualified faculty.
The program director must ensure, direct, and document appropriate supervision
of fellows. Attending physicians who supervise fellows must be available to the
fellows and have sufficient experience with the severity and complexity of
patient conditions. Fellows who supervise residents that treat glaucoma
patients should have an attending physician readily available. Patient interactions
may be later reviewed with the fellow for appropriateness of care, including
review of prepared consultation letters.
[M]
D. Duty Hours
and Conditions of Work
Duty
hours and night and weekend call for fellows must reflect the concept of
responsibility for patients and provide for adequate patient care. Fellows must
not be required to regularly perform excessively difficult or prolonged duties. [M]
E. Scholarly
Activity
The
fellowship must take place in a scholarly atmosphere where resources are
available that allow the fellows to participate in scholarly activities, such
as research. Fellows should participate in the development of new knowledge and
evaluate research findings. The responsibility for establishing and maintaining
an environment of inquiry and scholarship rests with the faculty. While not all
members of the faculty must be investigators, the staff as a whole must
demonstrate broad involvement in scholarly activity. Faculty activity should
include: [M]
1. Active
participation in clinical discussions, rounds, and conferences in a manner that
promotes a spirit of inquiry and scholarship. Scholarship implies an in-depth
understanding of basic mechanisms of normal and abnormal states and the
application of current knowledge to practice.
[M]
2. Participation
in journal clubs and research conferences.
[M]
3. Active
participation in regional, national, or international professional and
scientific societies, particularly through presentations at meetings and
publications in peer-reviewed journals. [S]
4. Participation
in research, particularly in projects that are funded following peer review
and/or result in publications or presentations at regional, national, or
international scientific meetings. [S]
5. Guidance
and technical support (eg, research design, statistical analysis) for fellows
involved in research. [M]
6. Provision
of support for fellows participation in scholarly activities.
7. Adherence
to the Declaration of Helsinki on the Rights of Research Human Subjects and to
the Association for Research in Vision and Ophthalmology Guidelines for Use of
Research Animals. [M]
F. Fellow
Research Activities
Fellows should be exposed to opportunities to develop research skills by
planning and executing at least 1 research project with set milestones. A
specific block of time may be set aside for clinical or laboratory research,
which may require that the fellowship be extended beyond 12 months. [S]
VI. EVALUATION
A. Program
and Faculty Evaluation
The
educational effectiveness of the fellowship program must be evaluated annually in
a systematic manner. In particular, the quality of the curriculum and the
extent to which the fellows have met the educational goals must be assessed.
Teaching faculty must be evaluated on a regular basis. Faculty members who serve
as clinician, scientist, and professional role models should be evaluated. Evaluation
of faculty should include teaching ability, commitment, and clinical knowledge.
There must be a formal mechanism by which fellows participate in this
evaluation. Written evaluations by fellows, through mechanisms that promote
candor and maintain confidentiality as much as possible, should be utilized in
the evaluation of both the program and faculty.
[M]
B. Fellow
Evaluation
There
must be regular evaluation of the fellow’s knowledge, skills, and overall
performance, including the development of professional attitudes consistent
with being a physician. [M]
The
program director, with the participation of members of the faculty, shall:
1. At least
semi-annually evaluate the knowledge, skills, professional growth, and
curriculum development for each fellow using appropriate criteria and
procedures. [M]
2. Communicate
each evaluation to the fellow in a timely manner.
[M]
3. Advance
fellows to positions of higher responsibility on the basis of evidence of their
progressive development of knowledge, skills, and professionalism. [M]
4. Maintain
a permanent record of evaluation for each fellow and have it accessible to the
fellow and other authorized personnel.
[M]
5. Keep
tracking information of the former fellows’ curriculum and career development
and include this information in the record of each former fellow. [M]
C. The
program director must provide a written, final evaluation for each fellow who
completes the program. The evaluation must include a review of the fellow’s
performance during the period of training and should verify that the fellow has
demonstrated sufficient professional ability to practice competently and
independently. This final evaluation should be part of the fellow’s permanent
record maintained by the institution.
[M]
VII. POST-FELLOWSHIP RECOMMENDATIONS TO HELP
ENSURE SUCCESS
A. In certain circumstances, especially regarding
fellows in or from developing countries, it may be necessary to maintain an
affiliation with the fellow’s home institution in order to assist in creating
an infrastructure and capacity development to ensure the fellow practices in an
enabling environment upon return to their home institution. [S]
ICO Subspecialty Curricula
Development Project
Andrew G. Lee, MD, Chair, United States
ICO Glaucoma Subspecialty
Curriculum Development Committee:
Neeru Gupta, MD, PhD, MBA, Chair, Canada
Tanuj Dada, MD, India
Daniel Kiage, MBChB, MMed,
FEACO, Kenya
Robert Ritch, MD, United
States
Fotis Topouzis, MD, Greece
Glaucoma Curriculum
Reviewers:
Steven J. Gedde MD, United
States
Ivan Goldberg, MBBS,
FRANZCO, FRACS Australia
David S. Greenfield, MD,
United States
Tarek Shaarawy, MD, MSc,
Switzerland
Remo Susanna Jr., MD,
Brazil
Tetsuya Yamamoto, MD, PhD,
Japan
- The final document is posted here.
- Comments on the draft were collected 15 November 2014, for potential incorporation into the final document.
- Any further feedback will be considered, but possibly not incorporated until the next edition. Please see the homepage for directions on commenting.
- The published document is available for download from the ICO website as a MS Word document, a PDF, and a Google Doc.
If you need help or have further comments, please contact curricula@icoph.org.
