September 25, 2025
10 min read
Key takeaways:
- From cornea to retina and glaucoma, ophthalmology offers a number of subspecialties with their own pros and cons.
- Medical students should consider their own interests and strengths before selecting a niche.
Like all physicians, ophthalmologists undergo extensive training.
After years of learning skills as an undergraduate, in medical school and continuing into residency, they then have a choice to make: begin their career or continue their training in a subspecialty fellowship.
Image: Courtesy of Emily M. Schehlein, MD
Ophthalmology offers trainees a range of options when it comes to subspecialties. From cornea to retina, neuro-ophthalmology to oculoplastics, eye care physicians can find a focus that fits their interests.
Healio | OSN Technology Board Member Sumitra S. Khandelwal, MD, professor at Cullen Eye Institute, Baylor College of Medicine, said ophthalmologists are exposed to different subspecialities through their years of residency training. In Khandelwal’s case, a focus started to develop in her PGY3 year.
“You start spending a little bit more time on private rotations within academic centers,” she said. “You start to realize, ‘This is something I really want to work toward.’”
Sumitra S. Khandelwal
The application process for fellowships begins the summer before the fourth year of residency, so Khandelwal said it is best to decide on a direction a few months before that. It is also reasonable to feel undecided during that time, especially between comprehensive vs. subspecialty or between two subspecialties.
“There’s no harm in not knowing what you’re going to do until the end of that year,” she said. “We’ve had plenty of residents who have done their whole senior year and then decided that they wanted to do a fellowship. There are definitely paths to changing your mind, but in general, most will figure out what their plan is going to be in the summer before their senior year.”
Khandelwal said every trainee learns about core procedures through Accreditation Council for Graduate Medical Education (ACGME) requirements. From there, they can pick their interests in the wide variety of procedures they observe.
“There are certain procedures that the ACGME board feels are important for residency training to incorporate that a comprehensive ophthalmologist should know,” Khandelwal said. “Most programs get fair exposure. There are programs that get a little more retina or cornea, for example, but part of the decision-making includes talking to attendings in those fields to see how they decided their specialty.”
After gaining experience in ophthalmology’s subspecialties, Khandelwal said trainees should have some understanding of what their careers will look like in those fields. If they are torn between options, she asks them to think about the worst cases that they could field at 5 p.m. on a Friday.
“Whatever seems palatable to you at 5 on a Friday, that’s the subspecialty you should go into,” she said. “If you don’t mind a corneal perforation, go into cornea. If you don’t mind high pressure/low pressure, glaucoma is for you. If you don’t mind a retinal detachment, then that might be for you. Part of it is just realizing the things you don’t mind doing even when it’s not convenient.”
On the other hand, Khandelwal said residents should also think about the less emergent or complicated parts of a subspecialty.
“I always ask residents to take the most boring part of a specialty and ask themselves if they could do it every day,” she said. “Could you check for floaters every day? Could you do glaucoma suspects all day long? Those two things can help make residents aware of what they want to do. You certainly don’t want to do a subspecialty where you don’t like the bread-and-butter boring stuff. If you don’t like emergencies, then that’s just not the subspecialty for you, and maybe comprehensive is a better option.”
When Khandelwal was choosing a subspecialty during her training, she was leaning toward cornea and ready to take on the everyday tasks.
“For me, it was dry eye,” she said. “I don’t mind doing dry eye. It’s not everyone’s favorite thing in the world, but I don’t mind it. That ends up taking up a lot of your practice, especially when you’re building up.”
She also liked that a cornea practice allowed her to be flexible.
“I decided, at the end of the day, that I wanted to do cornea, cataract and refractive,” Khandelwal said. “In a subspecialty like this, you can do a great fellowship, and then you can decide if you want to do less cataract and more cornea. Every day is a little different, and your practice can pivot quite a bit within the subspecialty compared with some of the other areas like glaucoma or retina, which are great but a little more specific.”
Cornea
Healio | OSN Cornea/External Disease Section Editor Preeya K. Gupta, MD, echoed those feelings about the variety of options available in a cornea career pathway.
“What I loved about cornea was the breadth of surgery,” she said. “You could be doing corneal transplant, performing LASIK or cataract surgery, or taking care of complex medical disease.”
Gupta’s practice at Triangle Eye Consultants in Raleigh, North Carolina, mirrors what she studied in fellowship. She focuses on cataract refractive surgery, LASIK, dry eye, ocular surface disease and corneal transplantation.
Preeya K. Gupta
“I love having variety in my day,” she said. “Each of those disease types has different demographics, so it’s not only a variety of surgery but a variety of patient types.”
Gupta said one of the most important skills to learn in cornea training is transplantation.
“It’s a big part of doing a corneal fellowship,” she said. “You need to learn how to suture, whether by working in the wet lab or even suturing your cataract incisions just to get used to working with corneal tissue. Developing that skill set is important not only to do a good job with corneal transplantation but also learning how to do it efficiently.”
Successful cornea fellows will have good attention to detail, an important attribute that will help with clinical exam, diagnosis as well as interpretation of topography and tomography images, Gupta said.
Subspecialty training can be a difficult decision, Gupta said, because it means another year before physicians can start their practice in earnest. However, subspecialty training can make physicians more enticing job candidates once they finish fellowship.
“We have a rapidly aging population, and the need for ophthalmologists is greater and greater,” she said. “That is particularly true for people who have specialty training. We need more specialists all across the country. You might think that it sets you back yet another year training, but I think it make you more competitive as an applicant for various job positions.”
Gupta said doing a fellowship allows someone to retain flexibility. For example, one can choose between having a general practice with a touch of subspecialty work or focusing on primarily a subspecialty practice.
“It gives you a lot of options,” she said. “Especially in the competitive job market arena, it gives you a leg up.”
Glaucoma
When she was in training, Emily M. Schehlein, MD, of Brighton Vision Center in Brighton, Michigan, was interested in cornea, pediatrics and even comprehensive ophthalmology. Her decision came down to how she felt during her glaucoma rotation.
“They say when you get married, ‘When you know, you know,’ and I think it’s similar for choosing your subspecialty in ophthalmology,” she said. “I heard a lot of criticisms about glaucoma — you’re just poking holes in eyes, and patients are rapidly losing vision — but when I actually went on that rotation, I got to see for myself. I saw surgeries that were changing patients’ lives. I saw innovations and patients who needed a doctor to walk with them over decades of care. I thought that could be me.”
Schehlein has always been drawn to innovation in glaucoma, not just during her time in training but also in practice.
“Glaucoma is one of the fastest moving fields in ophthalmology,” she said. “Even 10 years ago, the surgical options we had were nothing like we have today. That pace of innovation just keeps accelerating. When I was looking to choose a subspecialty, I wanted to choose something where I was constantly learning and adapting to new technology, and I felt like glaucoma was the place to be.”
The patient-physician relationship in glaucoma, in which physicians often work with patients for years to manage their disease, is another aspect that Schehlein enjoys.
“You become part of their lives,” she said. “You get to know them, their kids, their family members and their pets.”
Glaucoma offers opportunities to be more surgically focused and to comanage patients with optometrists and comprehensive ophthalmologists, Schehlein said.
“There’s flexibility within glaucoma to build the practice that you want,” she said. “I have patients who have more severe glaucoma who see me and only me. I also have patients in whom I’m able to make an impact on their lives, and then they go back to their own communities where they may not have a glaucoma specialist. Both of these relationships are special and something that I enjoy.”
Glaucoma is complex and provides a certain mental challenge.
“It’s not always straightforward,” Schehlein said. “Pressures can be normal. OCTs can be confusing. Visual fields can look like something else entirely. It’s a subspecialty where you have to look at context clues, synthesize those clues and think critically. I get to see cases that are surgically and medically complex. That feels like detective work, and there is an intellectual challenge.”
Schehlein said glaucoma has one of the broadest surgical palettes in all of ophthalmology and includes everything from in-office procedures to lasers, minimally invasive glaucoma surgery and traditional incisional surgery. It also integrates with cataract care.
“I love cataract surgery, but with glaucoma, you can do as much or as little cataract surgery as you want,” she said. “Many times, especially in angle closure, cataract surgery is the procedure that you need to do. It’s actually going to solve the problem. With glaucoma, if you love cataract surgery, great, you can do as much as you want. If you want to be doing a lot more glaucoma surgery alone, you can do that as well. The sky’s the limit. You have a lot of choice.”
For individuals just starting their careers, Schehlein said glaucoma provides security.
“Glaucoma is the second leading cause of blindness in the world,” she said. “With an aging population, especially in the United States, and with our looming shortage of ophthalmologists, especially glaucoma-trained ophthalmologists, there is most certainly job security. You will have the ability to be flexible in your location and your practice style.”
Pediatric ophthalmology
Pediatric ophthalmologist Olivia J. Killeen, MD, MS, of Park Nicollet Eye Care in St. Louis Park, Minnesota, came to her subspecialty later than most. She practiced comprehensive ophthalmology for 2 years while working part time to get her master’s degree to improve her research skills, but she became frustrated. Her days were too routine, and she was not stimulated. She wanted to make a change.
“I was thinking back to my time in residency about the things that made me excited, and I started thinking about pediatrics,” she said. “I love operating, but the clinic day was a whole lot more fun and dynamic in pediatrics.”
Killeen’s focus on research helped her land the perfect spot in pediatric ophthalmology.
“I’m interested in public health interventions to prevent vision loss,” she said. “In kids, if you can prevent vision loss, you’ve totally changed their life and their life trajectory. So many of the diseases we see in pediatrics are treatable, so everything aligned for me.”
During her fellowship, Killeen started to understand just how surgically dynamic pediatric ophthalmology is. Strabismus surgery takes center stage, she said, but pediatric eyes experience a lot of the same issues as adult eyes.
“Kids get cataracts, and pediatric cataracts are surgically a lot harder to deal with than adult cataracts,” she said. “Kids get glaucoma, and glaucoma surgery in kids is challenging because their eyes are smaller, and the causes of glaucoma can be more complex. Kids can experience everything that adults experience. But in adult ophthalmology where the glaucoma surgeon does glaucoma, the cataract surgeon does the cataract and the oculoplastic surgeon lifts a droopy eyelid, in kids, as a pediatric ophthalmologist, you do everything.”
As for the job market, Killeen applied all over the country and received offers nationwide. Pediatric ophthalmologists are so in demand that Killeen was essentially able to pick her type of practice and how much she wanted to work.
“Research and advocacy are important to me, and I have a family who I want to spend time with,” she said. “I chose to be clinical only 3 days a week, and in pediatric ophthalmology, this is acceptable because there’s a shortage of specialists. You are calling the shots as a pediatric ophthalmologist. It’s not the employer or the health system or the practice telling you what to do because you are a hot commodity.”
The prospect of doing eye exams in uncooperative children can be daunting and even discouraging for some people, Killeen said. Although it can take time, it is a skill that can be learned just like any other in ophthalmology.
“Just like you learned how to see the retina, you will learn how to examine kids just fine,” she said. “I wouldn’t let feelings of anxiety as a first-year resident dissuade people from going into pediatrics because you learn how to examine kids just like you learn any other skill.”
Killeen said the No. 1 reason to go into pediatric ophthalmology is that it is a lot of fun.
“You get to be wacky,” she said. “You get to play all day. I think there’s a lot of joy in pediatric ophthalmology that you don’t necessarily feel in other fields of ophthalmology. We legitimately have a lot of fun all day long.”
If someone is having trouble choosing between specialties, Gupta said mentorship and exposure to the work can have a big impact.
“Shadow people within the same specialty,” she said. “Everybody does things a little bit differently, and it’s nice to see how different physicians practice in different styles. By doing that, you can find someone that you resonate with and have a mentor to emulate your career after. That can be a great resource for you as you go along in training but also as you think about how you want to create your practice going forward.”
For more information:
Preeya K. Gupta, MD, of Triangle Eye Consultants in Raleigh, North Carolina, can be reached at preeyakgupta@gmail.com.
Sumitra S. Khandelwal, MD, of Baylor College of Medicine in Houston, can be reached at sumitra.khandelwal@bcm.edu.
Olivia J. Killeen, MD, MS, of Park Nicollet Eye Care in St. Louis Park, Minnesota, can be reached at olivia.killeen@gmail.com.
Emily M. Schehlein, MD, of Brighton Vision Center in Brighton, Michigan, can be reached at emschehlein@gmail.com.
Sources/Disclosures
Source:
Healio Interviews
Disclosures:
No products or companies that would require financial disclosure are mentioned in this article.
