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Fellowship in Glaucoma - Massachusetts Eye and Ear Infirmary/Harvard Medical School

The Glaucoma Fellowship at the Massachusetts Eye and Ear Infirmary began under the tutelage of Drs. Chandler and Grant in the mid 1960’s. The glaucoma fellowship has graduated numerous professors of ophthalmology, glaucoma service directors, academic chairpersons, a dean of a medical school and a former president of the American Academy of Ophthalmology. In addition, many community-based glaucoma specialists are graduates of the glaucoma fellowship at Massachusetts Eye and Ear Infirmary. They serve to enrich the fellowship with their teaching contributions.

Our mission is to train fellows to manage the most difficult glaucoma cases while creating an atmosphere where one can explore career development through teaching and clinical research.

The fellowship is one year in length and is clinically intense. The fellow’s responsibilities include evaluating patients; taking call; providing consultation for inpatients at Massachusetts General Hospital; staffing the Mass Eye and Ear Emergency Room; responding to patient requests for information; being available for emergency and routine visits; preparing charts and patients for laser and incisional surgery; assisting during glaucoma laser and incisional surgery; preparing articles for journal club; teaching residents and other students who rotate through the service; and other tasks as deemed necessary by the glaucoma faculty.

Clinical Facilities and Organization

Facilities

The Glaucoma Service is located on the first floor of the Massachusetts Eye and Ear Infirmary. The current facility is fully equipped with examination lanes, procedure rooms, and diagnostic services. Diagnostic tools include 2 Humphrey visual field machines that run SITA, a Goldmann visual field machine, a Frequency Doubling Perimtery instrument, an ultrasound biomicroscope (housed on the 12th floor), A scan and B scan units (the B scan unit is also on the 12th floor) and a GDx ( an HRT is available on the Comprehensive Ophthalmology Service and an OCT is available on the Retina Service). A full range of photographic services is available, including slit photography, goniophotography and stereophotography for optic nerve documentation.

Preceptors

Teresa Chen, M.D. completed her residency at University of Illinois Eye and Ear Infirmary and a fellowship in glaucoma at Massachusetts Eye and Ear Infirmary. Dr. Chen’s research focuses on developing novel optic nerve imaging technology.

Cynthia Grosskreutz, MD, PhD completed her residency and fellowship in glaucoma at the Massachusetts Eye and Ear Infirmary. She also received a Ph.D. in pharmacology at the University of Iowa. She is Co-Director of the Glaucoma Service at Massachusetts Eye and Ear Infirmary. Her research interests in the mechanisms of retinal ganglion cell death in glaucoma is funded by the National Institutes of Health.

Louis R. Pasquale, MD completed his residency at Temple University Hospital and did a glaucoma fellowship at Johns Hopkins University Hospital. He is Co-Director of the Glaucoma Service at Massachusetts Eye and Ear Infirmary and Director of the Glaucoma Fellowship. His research interest involves detecting previously undiagnosed glaucoma using novel screening tools and understanding the pathogenesis of primary open-angle glaucoma. Dr. Pasquale has an NIH grant to study gene-environment interactions as putative risk factors for primary open-angle glaucoma.

Douglas Rhee, MD completed his residency at Wills Eye Hospital and fellowship in glaucoma at Bascom Palmer Eye Institute. After his fellowship he served as an attending ophthalmologist at Wills Eye Hospital. He will be joining the Glaucoma Serice at Massachusetts Eye and Ear Infirmary in September 2005. His research interest involve understanding the role matrix metalloproteinases play in trabecular meshwork function.

David S. Walton, MD is boarded in both Pediatrics and Ophthalmology. He completed his ophthalmic training at the Massachusetts Eye and Ear Infirmary. Currently he is Clinical Professor of Ophthalmology at Harvard Medical School. He has a unique practice that contains a high percentage of childhood glaucoma cases. His research interest is on the mechanisms of childhood glaucomas.

David S. Walton, MD is boarded in both Pediatrics and Ophthalmology. He completed his ophthalmic training at the Massachusetts Eye and Ear Infirmary. Currently he is Clinical Professor of Ophthalmology at Harvard Medical School. He has a unique practice that contains a high percentage of childhood glaucoma cases. His research interest is on the mechanisms of childhood glaucomas.

Fellow Responsibilities

Clinical Responsibilities

Approximately 80% of the fellow’s time is committed to direct patient care on the Glaucoma Service. The medical management of glaucoma cases as well as the pre- and postoperative care of surgical cases is considered an essential aspect of fellowship training. It is not critical that the fellow see every patient but it is very important that the fellow evaluate cases critically, formulating a tentative diagnosis or differential diagnosis as well a management plan. Fellows do not have to attend any external clinics but they are expected to serve in the Emergency Department one session a week for 6 months. A detailed schedule of clinical responsibilities will be provided when the fellow starts in July.

Another major component of fellowship experience involves assisting in the operating room. Fellows are expected to be in the OR long before the attending and ensure, to the best if their ability, that surgical plans are implemented. A surgical schedule will be provided but there will always be add-on cases and fellows are expected to assist on these cases at the discretion of the attending and the call schedule.

Glaucoma fellows will take call for the Glaucoma Service approximately one week each month. The on-call fellow is responsible for all emergency medical and surgical admissions to the Glaucoma Service during weeknights and weekends. An assigned attending will be on call at all times and available for immediate backup of complicated cases, admissions or surgical procedures. Any changes to the on-call schedule must be processed through the manager of the Glaucoma Service. If the fellow is unable to provide on-call coverage on any given pre-assigned week, then they must find coverage from amongst the other housestaff in the call rotation.

Educational Responsibilities

Glaucoma lectures are held Friday mornings (dates and times will be posted). These lectures will be didactic in nature and cover all the glaucomas and their treatments. Glaucoma journal club will take place on the first Monday of every month. All faculty and fellows are expected to attend. Faculty and fellows will take turns presenting an interesting and important recent paper of their choice. Grand Rounds is held on Wednesday morning at 8:00AM. All fellows must attend Grand Rounds. Once or twice per year, the fellow will be responsible for presenting a case at Grand Rounds. Each year there is a Fellows Course. Each fellow is expected to write a review paper and make a 10-minute presentation. The theme of the Fellows Course dictates the choice of a distinguished visiting faculty and the topic for the paper.

Research Responsibilities

There are many opportunities to do clinical research at MEEI and the fellow is encouraged to pursue a research project. In order to successfully complete a project a fellow is encouraged to conceive and plan their work before they arrive in Boston. The faculty will be happy to provide resources and assistance in this regard. While research is not mandatory, preference will be given to applicants who demonstrate strong clinical capabilities and a proclivity to research endeavors. Fellows who have strong academic inclinations should be aware that MEEI holds a career development grant allowing the institution to extend a K-12 award to a fellowship-trained ophthalmologist. While competition for this award is typically fierce, MEEI fellows who demonstrate strong research potential will be given careful consideration for this award. K-12 awards give a graduating fellow junior faculty status with 80% protected time for research.

Selected Faculty Publications

Listed below are selected recent publications of the faculty. The purpose of this listing is to give the applicant an idea of the scope of glaucoma research interests at MEEI:

1. Wiggs JL et al. A genomewide scan identifies novel early-onset primary open-angle glaucoma loci on 9q2 and 20p12. Am J Hum Genet 2004;74:1314-20
2. Wigg JL et al. Lack of association of mutations in optineurin with disease in patients with adult-onset primary open angle glaucoma. Arch Ophthalmol 2003;121:1181-1183
3. Sena DF, Finzi S, Rodgers K, Del Bono E, Haines JL, Wiggs JL. Founder mutations of CY1B1 gene in patients with congenital glaucoma from the United States and Brazil. J Med Genet 2004;41:e6
4. Allingham RR, Wiggs JL Hauser J et al. Early Adult-Onset POAG Linked to 15q11-13 Using Ordered Subset Analysis. Invest Ophthal Vis Sci 2005;46:2002-5
5. Nassif N, Cense B, Park BH, Yun SH, Chen TC et al. In vivo human retinal imaging by ultra high-speed spectral domain optical coherence tomography. Opt Lett 2004;29:480-2
6. Cense B, Chen TC et al. In vivo birefringence and thickness measurements of the human retinal nerve fiber layer using polarization-sensitive optical coherence tomography J Biomed Opt 2004;9:121-5
7. Chen TC, Bhatia LS, Walton DS. Complications of pediatric lensectomy in 193 eyes. Ophthal Surg Lasers Imaging 2005;36:6-13
8. Chen TC, Walton DS, Bhatia LS. Aphakic glaucoma after congenital cataract surgery. Arch Ophthalmol 2004;122:1819-25
9. Adelman RA, Brauner SC, Afshari NA, Grosskreutz CL. Cataract formation after initial trabeculectomy in young patients. Ophthalmology 2003;110:625-9
10. Hanninen VA, Pantcheva MD, Freeman EE, Poulin NR, Grosskreutz CL. Activation of caspase 9 in a rat model of experimental glaucoma. Curr Eye Res 2002;25:389-95
11. Grosskreutz CL et al.. FK506 blocks activation of the intrinsic caspase cascade after optic nerve crush. Exp Eye Resi 2005;80:681-6
12. Kang JH, Pasquale LR et al. Prospective study of cigarette smoking and the risk of primary open-angle glaucoma. Arch Ophthalmol 2003;121:1762-8
13. Kang JH, Pasquale LR et al. Antioxidant intake and primary open-angle glaucoma: a prospective study. Am J Epidemiol 2003;158:337-46
14. Kang JH, Pasquale LR, Rosner B, Willet W, Faberowski N, Hankinson SE. Dietary fat consumption and primary open-angle glaucoma in two cohorts. Am J Clin Nutr., 2004;79:755-64
15. Zhao JC, Zacks DN, Gragoudas ES, Pasquale LR. Pupil-sparing excision of an atypical iris melanocytoma induces remission of secondary glaucoma. Br J Ophthalmol, 2004;88:842-3
16. Ho CL, Walton DS. Primary megalocornea: clinical features for differentiation from infantile glaucoma. J Pediatr Ophthalmol Strabismus 2004;41:11-7; quiz 46-7
17. Smith PV, Walton DS. Prevention of vomiting after general anesthesia for pediatric ophthalmic surgery. AANA J 2001;69:39-43
18. Gupta NK, Simon JW, Walton DS, Augsburger JJ. Bilateral ectopia lentis as a presenting feature of medulloepithelioma. J AAPOS 2001;5:255-7
19. Walton DS, et al. Glaucoma with the oculocerebral syndrome of Lowe. J Glaucoma 2005;14:181-5
20. Rhee DJ et al. Donor corneascleral buttons: a new source of trabecular meshwork for research. Exp Eye Res 2003;77:749-756
21. Rhee DJ, et al. The matricellular protein SPARC is expressed in human trabecular meshwork. Exp Eye Res 2003;77:601-607
22. Farjo AA, Rhee DJ et al. Iris-sutured posterior chamber intraocular lens implantation during penetration keratoplasty. Cornea 2004;23:18-28

Fellow Funding and Benefits

1. SALARY: Currently $35,000/year.
2. MALPRACTICE: Malpractice premiums are fully paid by the Glaucoma Service.
3. HEALTH INSURANCE: Family health insurance will be provided through the benefits program of Massachusetts Eye and Ear Associates. Depending upon the plan selected, all or a large portion of the premiums is included in the benefits package.
4. VACATION AND SICK LEAVE: Each fellow is allowed 3 weeks (15 work days) per year. All time out must be pre-approved by the Glaucoma Service Manager and by the attendings affected by the fellow’s absence. The vacation may not be taken at the beginning or end of the fellowship.
5. PROFESSIONAL MEETINGS: Attendance and participation at appropriate meetings is encouraged. Fellows will be allowed one week (5 work days) to attend meetings but coverage for missed clinics and call must be arranged. Fellows will be reimbursed for travel to meetings (AAO, ASCRS, ARVO, AGS, etc) up to a maximum of $1500 per academic year if they present at the meeting they attend.

Tentative Fellow Schedule

Monday	Tuesday	Wednesday	Thursday	Friday
Fellow #1 (July – September in 3 month alternating blocks with Fellow #2)
OR with CG or Glaucoma Clinic	CG postops then OR with TC/DR	Clinic with TC	free *ER	Clinic CG AM Clinic DR PM
Fellow #2, (July – September in 3 month alternating blocks with Fellow #1)
Glaucoma clinic DR AM JW PM	OR with DW or LRP Glaucoma Clinic	OR/lasers LRP	Clinic with LRP am Clinic with DR	free
Key for acronyms above:	OR= Operating Room GES=General Eye Service TC=Teresa Chen, M.D. CG= Cynthia Grosskreutz M.D., Ph.D. LRP=Louis R. Pasquale, M.D. DR=Douglas Rhee, MD DW=David Walton, M.D. JW=Janey Wiggs, M.D., Ph.D.
*ER is only required one half session for 6 months out of the year. The 3-month alternating blocks of time apply to Glaucoma Service obligations only.
The fellow on Dr. Pasquale’s block will be expected to attend Saturday clinics. Saturday clinics run from September to June

Miscellaneous

Audiovisual

You should use electronic media rather than 35 mm kodachromes for most of your audiovisual needs. If you have to prepare a poster for a meeting presentation, Massachusetts General Hospital has a service for generating the poster from a powerpoint or word file. We will reimburse your expenses for this.

Mail

An in-box for your mail and / or important messages is located in an area immediately behind the front desk of the Glaucoma Service. You should check your mailbox frequently for messages, patient-related matters, and other correspondence.

Paging

You are supplied with a pager that you must wear during business hours and also at all times when on-call. Please respond to your pages promptly. If you change the status of your beeper for any reason (in surgery, not available), please make sure you promptly reverse the status on your return to clinical duty.

Contact

Requests for applications should be directed to:

Glaucoma Consultation Service
Massachusetts Eye and Ear Infirmary
243 Charles Street
Boston, MA 02114

Only completed applications will be considered for interview. A completed application consists of a completed application form, CV, personal statement and 3 letters of reference. Generally the deadline for receipt of completed applications is mid October. Interviews will take place at MEEI usually on the 3 rd Wednesday of November. Any questions regarding the fellowship can be directed to Dr. Louis R. Pasquale at the same address or via email (Louis_Pasquale@meei.harvard.edu).

page updated:11/10/06