Fellowship in Glaucoma, Royal Victorian Eye and Ear Hospital, Melbourne

Report of Jonathan Goodfellow

In January 2013 I arrived in Melbourne to undertake a one year glaucoma fellowship at the Royal Victorian Eye and Ear Hospital (RVEEH), Victoria’s leading ophthalmic hospital and, as I was to find out, one that deals with plenty of complex glaucoma.

During my training in the UK, I had met several Australian ophthalmologists and had picked up on a recurring theme of the strength of the RVEEH in Australia and furthermore, a strong glaucoma department led by Professor Jonathan Crowston. I therefore set about trying to organise a fellowship at the RVEEH a couple of years in advance and whilst colleagues complained of ‘radio silence’ when attempting to contact leading ophthalmologists elsewhere in the world, Prof Crowston in typical fashion could not have been more helpful and responsive when I contacted him. After managing to meet up face-to-face, subsequent interviews, endless Australian paperwork, and formal completion of my UK training, I was finally all set to head down under.

 

The Royal Victorian Eye and Ear Hospital

The RVEEH was celebrating its 150th year when I arrived in Melbourne and having started as an infirmary with one bed in 1863, it had expanded to a hospital now seeing over 250,000 patients every year. Within the glaucoma department alone, there were 11 consultants and I was one of 2 glaucoma fellows. One of the striking differences with the NHS system I was so familiar with was the difference in the consultants’ work patterns: in Australia, a much greater proportion of healthcare is provided through the private rather than the public sector and as a result, many of the consultants only attended the RVEEH for one or 2 sessions a week.  Consequently as fellows, we were key cogs in the department, providing continuity of care for many of our patients, and prioritising and managing our glaucoma operating lists as we felt appropriate. 

My weekly timetable was almost exclusively glaucoma-related. Many of the more straightforward glaucoma patients never made it as far as the glaucoma clinic and were managed by ophthalmologists in general clinics at the RVEEH, whilst the dedicated glaucoma clinics attracted the most complex cases. Compared to my experience in the UK, patients’ vision was frequently in a much more precarious situation – a large proportion of the patients had end stage visual field loss from their glaucoma or were already blind in one eye. The eyes we were faced with also rarely seemed to be unoperated ‘virgin’ eyes. This was probably due to a combination of receiving normal tertiary centre referrals, but also a consequence of the unavoidable logistical challenges of providing ophthalmic care in rural Australia. As a result of many patients living hundreds of miles from a major city, ophthalmic care is often provided more locally by a general ophthalmologist who will undertake primary trabeculectomies for glaucoma and only if these fail will the patient be referred on to Melbourne for further care. As a result, I gained excellent surgical experience in both redo and revision trabeculectomies and glaucoma drainage implants. Equally, complications arising from trabeculectomies elsewhere were often referred in to the RVEEH for further management as patients strayed from the comfort zone of general ophthalmologists. This all made for fantastic learning opportunities as a fellow.

I usually attended two glaucoma theatre lists each week and was struck by the difference in the emphasis of these lists compared with the UK: in the UK, theatre lists retain a strong emphasis towards service provision, with training provided by enthusiastic consultants as best they are able. In RVEEH, training was paramount and consultants displayed the attitude that their time at the RVEEH was their time to teach.  As a result, I gained excellent surgical experience, performing around forty trabeculectomies/ revision trabeculectomies, twenty bleb needlings, drainage of choroidal effusions, over fifty cataract operations, as well as both assisting in and supervising many more operations. However, the operation I was most keen to learn during my fellowship at RVEEH was glaucoma drainage implant (or tube) surgery. Glaucoma drainage implant surgery is usually reserved for higher risk patients in whom trabeculectomy surgery is either likely to, or already has failed, but falls outside the skill-set of many glaucoma surgeons. During my training in the UK, I had completed an internal glaucoma fellowship year and during this year, I had been able to assist in three of these procedures and performed one. I remember my supervising consultant in these operations telling me had not been able to perform any during his fellowship. In Melbourne, I completed eighteen of these and assisted in many more. This was fantastic experience and I finished the fellowship with absolute confidence in performing this surgery. The acquisition of this skill has enabled me to return to the UK with a full armamentarium of glaucoma surgical skills to run a comprehensive glaucoma service, without needing to refer patients on to distant units with all of the accompanying inconvenience that this involves for patients.

Outside of the clinical work, I was involved in several research projects running in the department. These included studies investigating the use of electrodiagnostic testing to assess treatment effect in glaucoma, and also recruitment and treatment of newly referred glaucoma patients in a trial comparing initial selective laser trabeculoplasty to conventional medical treatment. I authored a book chapter on the Molteno glaucoma drainage device and co-authored a chapter on trabeculectomy bleb management.

Even further beyond clinical work, I enjoyed being able to use time off from work to explore the beautiful state of Victoria with my family. Melbourne is well placed to travel down The Great Ocean Road in one direction, or explore the coast and the vineyards of the Mornington peninsula in the other. Both sides of our family viewed our time in Australia as an excuse to come and enjoy some sunshine themselves, so they too visited and we were able to make the most of their visit by flying south to enjoy the spectacular beauty of Tasmania.

One of many Tasmanian beaches that we had to ourselves

Having now returned to the UK, I have taken up a consultant position in the southwest and lead the glaucoma service in the department. Whilst starting a new consultant post has the potential to be a daunting prospect, one less thing for me to worry about has been my ability to manage my patients, both clinically and surgically. My fellowship training in Melbourne has given me great confidence in feeling equipped to deal with all glaucoma patients, with the surgical skills to manage them in our region, rather than needing to refer complex patients elsewhere, particularly for glaucoma drainage implant surgery. Glaucoma is a potentially blinding disease and as a result of my fellowship training in Melbourne, I hope I will be able to minimise patients’ sight loss who suffer from this disease, as well as teaching the techniques that I have learnt to our trainees so that they too will possess these skills in the future. I am enormously grateful to the HCA International Foundation for their support in helping make this possible.

Sunset at St Kilda Pier – one of my favourite spots for an evening stroll after work