Glaucoma and Advanced Anterior Segment Surgery (GAASS)

Supervisors
• Dr. Iqbal Ike K. Ahmed, Fellowship Director
• Dr. Devesh Varma
• Dr. Diamond Y. Tam
• Dr. Matthew Schlenker
• Dr. Thomas B. Klein

Contact Information

Daisy Huerto, Executive Assistant
2201 Bristol Circle, Suite #100
Oakville, Ontario L6H 0J8
Tel: 905-456-3937 x161
Fax: 905-820-0111
Email: daisy@prismeye.ca
(Please do not contact directly – see instructions in “Application Process” section.)

Locations
Clinical activities are primarily located at three state-of-the-art tertiary level clinics in the greater Toronto area (GTA). See www.prismeyeinstitute.com and https://www.kensingtonhealth.org/eye-clinic for more information.

Prism Eye Institute - Mississauga/Oakville
2201 Bristol Circle, Suite 100
Oakville, Ontario, L6H 0J8

Prism Eye Institute - Brampton
7700 Hurontario Street, Unit 605
Brampton, Ontario, L6Y 4M3

Kensington Eye Institute
340 College Street
Toronto, Ontario, M5T 3A9

Hospital Locations
Surgical services are primarily provided at the following hospitals:
• Credit Valley Hospital, Trillium Health Partners, Mississauga, Ontario
• Queensway Health Center, Trillium Health Partners, Mississauga, Ontario

• Brampton Civic Hospital, William Osler Health System, Brampton, Ontario
• Etobicoke General Hospital, William Osler Health System, Etobicoke, Ontario
• Toronto Western Hospital, University Health Network, Toronto, Ontario
• Kensington Eye Institute, Toronto, Ontario

The Fellow is expected to be present on clinic or operating room premises Monday to Friday, 7:30 a.m. to 5:30 p.m. regardless of scheduled clinical activities. There may be a need to be present during “off hours” for additional clinical volume and/or urgent cases.

Objectives
1. To develop subspecialty expertise in the clinical diagnostic subtleties of glaucoma and complex anterior segment disorders
2. To develop subspecialty expertise in the management of glaucomatous disorders through medical, laser, and surgical therapy. The primary focus is adult and juvenile glaucoma with some exposure to congenital/pediatric glaucoma
3. To develop subspecialty expertise in the management of routine and complex cataract cases and associated conditions including performing advanced anterior segment procedures involving cataract, IOL, iris, and angle anomalies.
4. To develop expertise and to participate in the design, implementation, and publication of clinical and/or basic science research in glaucoma and anterior segment disease
5. To gain insight and develop a working knowledge of practice management and to prepare for practice in a tertiary-level academic setting
6. To develop and refine skills needed to become an effective medical educator to train medical students, residents, as well as provide professional development for colleagues

Fellowship Description
We take 3 clinical Fellows per year. The GAASS Fellow spends 12 months on the Glaucoma Service at the Prism Eye Institute and Kensington Eye Institute. All clinics have robust medical informatics systems in place including integrated electronic medical records and diagnostic image management systems. The Glaucoma service also receives tertiary care referrals from an extended area within the province of Ontario, as well as from national and international sources. The GAASS Fellow will spend time with all of the preceptors throughout the year.

The GAASS Fellow will be exposed to and trained in current state-of-the-art advanced diagnostic, medical, laser, and surgical techniques in the management of anterior segment and glaucoma disorders, including access to novel and innovative diagnostic technologies

Laser modalities include a multi-wavelength laser, selective laser trabeculoplasty (SLT), micropulse laser trabeculoplasty (MLT), Nd:YAG laser, and 810nm diode laser for external and endoscopic cycloablation.

The primary objective of the fellowship is to provide the Fellow with exposure to and hands on training with the most advanced and complex glaucoma and anterior segment surgical problems. Surgical approaches are performed with the latest devices, technology, and techniques. The Fellow can expect to be in the operating room from one to three full days a week. Urgent cases may be performed “off-hours.” The Fellow is expected to be available to participate in these cases as well. Due to the high level of tertiary level surgical procedures, incoming fellows are expected to be proficient with routine phacoemulsification, and possess adequate surgical experience with such cases. The number of hands on cases will vary depending on the progression of surgical skills throughout the year.

Glaucoma surgical procedures include:
• standard trabeculectomy with and without antimetabolites
• tube-shunt procedures using the Ahmed and Baerveldt drainage devices
• MIGS procedures, including Schlemm’s canal, suprachorodial, and subconjunctival micro-stents, as well as investigational procedures
• goniotomy and trabeculotomy
• bleb needling and resurrection strategies with the use of antimetabolites
• bleb repair and revision surgery

Although the emphasis of this fellowship is on glaucoma, there is exposure and opportunity for involvement in the assessment and management of other related complex anterior segment problems.
Advanced anterior segment procedures include:
• phacoemulsification/IOL implantation
• surgical management of pediatric cataracts
• surgical management of dislocated cataracts, including the use of (sutured-in) capsular tension devices
• surgical management of aphakia, including iris, scleral sutured and intrascleral haptic fixation of foldable IOLs
• surgical management of IOL complications, including IOL subluxation, dysphotopsia, etc, with IOL repositioning and/or IOL exchange
• iris reconstruction including iris suturing techniques and the use of aniridic/iris prosthetic implants
• vitrectomy, via limbal and pars plana approaches
• exposure to femtosecond assisted cataract surgery and refractive laser vision correction

Exposure to the use of new and innovative IOL technologies is highlighted. Current IOLs being used and studied include aspheric, toric, multifocal, accommodative and iris-enclavated IOLs.
Special emphasis will be placed on the latest innovations in glaucoma surgery; in particular new lasers in glaucoma, developments in micro-invasive glaucoma surgery, new drainage devices, and tube shunt surgery. There is also a particular interest in the management of iris abnormalities, dislocated cataracts/loose zonules and intraocular lenses.

Clinical Duties
Approximately 90% of the time will be spent on clinical responsibilities. This includes all aspects of adult and juvenile glaucoma care including glaucoma diagnostic workup, medical management, laser and surgical procedures. These activities will be done under the supervision of a preceptor.

The Fellow will spend a variable amount of time with each preceptor concurrently throughout the year in both the clinic and the operating room.

It is expected that the Fellow carries a mobile phone (with a local GTA phone number) and pager at all times. The Fellow must notify the fellowship supervisors and coordinator of requests for his/her absence for holidays well in advance.

The Fellow will be responsible for first call during some weekdays and evenings as well as 4 to 5 weekends for the year. On call is not onerous for the Fellow.

The Fellow is expected to be available as needed to see patients for weekend clinical evaluations, post-operative case management, and for complicated glaucoma patients. Sufficient pre-clinic review of charts is critical to ensure smooth clinic flow. Completion of charts, preoperative planning, operative notes and dictations, and miscellaneous forms is expected on a timely basis. It is expected that the Fellow review clinic electronic messages and respond at least daily. All clinic time not occupied by patient responsibilities must be used to further academic pursuits such as research and teaching. As mentioned above, all absences during the workweek must be approved well in advance.

Research
Approximately 10% of the Fellow’s time will be spent in clinical and/or basic science research. Currently, the Glaucoma service is involved in numerous clinical trials at various levels, encompassing a diverse range of areas. The Fellow will be expected to be first author on at least one major research project, in coordination with our Research Scientist on site. The Fellow will present a research paper at the Department of Ophthalmology Annual Research Day, usually in May, as well as at a major national or international Ophthalmology meeting. It is also expected that a manuscript be submitted to these meetings and for publication in a major Ophthalmology journal. Furthermore, the development of critical appraisal of published research is encouraged.

The Fellow will be responsible for occasional resident and/or medical student formal and informal teaching. Organization and presenting at regular academic rounds is expected. Furthermore, the Fellow is recommended to attend Visiting Professors' Rounds, which are held on certain Fridays during the academic year from 7:00 - 8:00am. Approximately 2-3 times per year, when the grand rounds topic is on glaucoma, participation in cases for presentation is expected. The Fellow is also expected to attend departmental research rounds, which are held 3-4 times per year.

Vacation
2 weeks vacation per year.

Conference
Conference time may be taken if the fellow is presenting at the meeting, upon approval by the fellowship director.

Evaluation
An evaluation after one month of the fellowship will be held to determine performance and to validate the educational license. A mid-term evaluation will be held with the Fellow to evaluate his or her performance and to give feedback regarding his/her activities. Fellows are encouraged to provide feedback and express their comments on how their fellowship is progressing.

Duration
1 or 2 years, as negotiated.

Salary
$55,000 CAD/year.

Application Process

For United States based applicants who are in a residency or practising in the US, please apply to this fellowship through the SF-Match service (sfmatch.org). For NON-US applicants, please apply directly to our program by completing the GAASS application package.  Click here (309.45 KB) to download GAASS Application Package. Application instructions are included in the GAASS Application Package. US applicants do not need to complete the GAASS application package, although it is recommended.

Fellowships begin in July, August or September and run for a minimum of 1 year. A two-year combined research and clinical fellowship is also available. Applications are due by August 31 of the year prior to beginning the fellowship but are preferred earlier.

Due to the high volume of applicants, once all applications are reviewed, only a selection of individuals will be contacted for an interview. As part of the interview process, these candidates may be invited to visit for an observership. Final selection of fellows generally takes place 6 to 9 months prior to the start date.

Information on submitting your application is included in your GAASS application package. Once your completed application has been received, you will receive a confirmation email from our office. To help manage the high volume of inquiries, we ask that once you have submitted your application that you wait to be contacted by our offices.

What do we look for in an applicant?

Being a GAASS fellow is likely to be something that you have never experienced – something that is likely best described to you by former fellows. The year will be the busiest year of your training and will push you to your limits – and ideally beyond. You will be pressed to think beyond "textbook training." There is a philosophical mantra in this fellowship – one of discovery and critical analysis. We respectfully question the norm, challenge the "conventional way" and seek out better ways to care for our patients. Questions are expected and curiosity is encouraged. We love to ask "why." We firmly believe in the concept of evidence-based medicine, but also realize that discretionary personalized and individualized care is always needed. Clinical trials and research are a major part of our program, and a key aspect of discovery. This means inquisitiveness, open-mindedness, mental fortitude, discipline, and plain old hard work are key traits of a successful fellow. Fellows should expect to work quite independently as well to integrate well within a team of clinical staff and surgical nurses. Our preceptors attempt to foster an environment conducive and supportive for learning. We look at this experience as more of an apprenticeship.

Clinical and surgical competency is a key performance indicator, and it is expected fellows are functioning at a very high level when they start their year. Competency is not just technical skill, but includes appropriate judgment, wisdom, and consideration.

We also value the sanctity of the profession. We strive to be patient advocates and caring physicians. This fellowship is not just about surgery but about better understanding the sacred trust our patients place in us. We place high value in the moral and ethical practice of medicine. Humility is a key attribute of being a physician. Although we challenge the norm, we must do so in a respectful and thoughtful way.

Superior communication skills are a valued asset. Excellent patient communication is critical, and our fellows are expected to have full command of the English language. Fellows are expected to be compassionate physicians who are able to provide in-depth discussions with patients and their families. Excellent "bedside manner" is highly rated. Furthermore, our fellows are expected to be excellent team players who will be working within small and large teams.

We look for that special applicant who is a critical thinker, demands the highest level of quality, is able to have the discipline and focus to reach beyond their limits, and is willing to venture onto the path much less traveled.

We are looking for applicants that display an enthusiasm to learn and a willingness to push themselves beyond standard expectations. They need to be a team player who can produce independently when required, a fast learner, have extremely strong problem-solving skills, and the ability to think quickly on their feet. Most importantly, we are looking for good people. We expect our fellows to commit to the highest standards for their patients – not only in the treatment they provide but also in the care they give.