Although the eye and its surrounding structures would seem to provide an ideal anatomical and functional basis for specialisation, ophthalmol- ogy can no longer regard itself as a specialty on its own but more the heading for a group of sub- specialties. There are those who know all about the pigment epithelium of the retina and yet bow to those who have a special knowledge of the bipolar cells in the retina. Over the past 100 years the science has advanced at an unbeliev- able rate and with the increase in our knowledge has come the development of treatments and cures, which have had a great impact on our everyday lives.
The importance of the eye and its function is sometimes underrated, but a consideration of the part played by vision in our consciousness makes us soon realise its value. If we think of dreams, memories, photographs and almost anything in our daily existence, it is difficult to express them without visual references. After a little careful consideration of the meaning of blindness, it is easy to sense the rational and irrational fears that our patients present to us in the clinic. Nevertheless, in a modern European community the effects of blindness are not so apparent as in former years, and blind people tapping their way about the street or begging for food are less in evidence to remind us of the deprivation that they suffer. This is due to the effective application of preventive medicine and the efficacy of modern surgical techniques.
However, in the western world we have a new and increasing problem related to the increasing
number of elderly people in the population. The problem is that of sensory deprivation owing to degenerative disease. Degenerative changes in the eye are now a major cause of blindness and although support services are being developed there is still no effective cure.
The broad and detailed scientific interest in the eye and vision is witnessed by the large number of journals, conferences and meetings that now exist, possibly more than in any other specialty. There are several hundred ophthal- mological journals all contributing to the scientific literature on the subject and many are now accessible through the internet or on CD- ROM. As an organ of clinical specialisation, the eye does have a special advantage; it can be seen. Using the slit-lamp microscope it is possible to examine living nerves, including nervous system tissues and blood vessels, in a manner that is not possible in other parts of the body without endoscopy or biopsy. So much are the component parts of the eye on display to the clinician that when a patient presents to a casualty department with symptoms, the explanation of the symptoms should be made evident by careful examination. Compare this with the vague aches and pains that present to the gastroenterologist or the neurologist, symptoms that might ultimately resolve with- out any cause being found for them. The student or newly qualified doctor must be warned that if the patient presents with eye symptoms and no abnormality can be found after examination, then he or she must look
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The Scope of Ophthalmology
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4 Common Eye Diseases and their Management
again, because it is likely that something has been missed.
Most of the work of the ophthalmologist is necessarily centred on the globe of the eye it- self, and there are a number of conditions that are limited to this region without there being any apparent involvement of the rest of the body. Ophthalmology is usually classified as a surgical specialty but it provides a bridge between surgery and medicine. Most of the surgery is performed under the microscope and here the application of engineering principles in the design of finer and finer instruments has played an important part. There is overlap with the fields of the plastic surgeons and the neuro- surgeons. On the medical side, the ophthal- mologist has links with the physicians and particularly the diabetic specialists and cardiologists, not to mention paediatricians and dermatologists.
Historical Background
In 1847, the English mathematician and inven- tor Charles Babbage showed a distinguished ophthalmologist his device for examining the inside of the eye, but unfortunately this was never exploited and it was not until 1851 that Hermann von Helmholtz published his classic description of his instrument, the ophthalmo- scope. He developed the idea from his knowl- edge of optics and the fact that he had previously demonstrated the “red reflex” to medical students with a not dissimilar instru- ment. In principle, he had, for the purposes of his demonstration, looked through a hole in a small mirror, which reflected light from a lamp into the subject’s eye. This produced the red reflex in the pupil well known to photographers and night drivers and no doubt this fascinated medical students at that time. Von Helmholtz worked out that a similar device could be used to inspect the inside of the eye. According to correspondence of the time, it took him about a week to learn the technique of examining in detail the structures within the eye and he wrote a letter to his father telling him that he had made a discovery that was “of the utmost importance to ophthalmology”. Soon after this, a mass of descriptive information on the optic fundus appeared in the scientific literature and modern clinical ophthalmology was born. The changes
in the eye associated with systemic diseases such as hypertension and anaemia became recognised. Several blinding conditions limited to the eye itself, such as glaucoma and macula degeneration, were also described at this time.
But we must not belittle the developments that had occurred before the invention of the ophthalmoscope. In the eighteenth century, con- siderable advances had been made in the tech- nique and instrumentation of cataract surgery, and the science of optics was being developed to enable the better correction of refractive errors in the eye. If we go back to the seven- teenth century, the existing ophthalmological services were definitely limited, as is revealed in the writings of the famous diarist, Samuel Pepys. Although we have no record of his eye condition other than his own, he did consult an oculist at the time and unfortunately received little comfort or effective treatment. His failing eyesight brought his diary to an abrupt end in spite of the use of “special glasses” and the medicaments, which caused him great pain.
Although records of eye surgical techniques go back as far as 3000 years, modern eye surgery was largely developed thanks to the introduc- tion of cocaine and then of general anaesthesia at the end of the nineteenth century. The use of eserine eye drops to reduce the intraocular pres- sure in glaucoma was introduced at the same time, this being the forerunner of a number of different medical treatments that are now avail- able. Cataract surgery saw great advances at the beginning of the twentieth century, with the introduction of the intracapsular cataract extraction. In the 1920s, successful attempts were being made to replace the detached retina, which had previously been an irreversible cause of blindness. Such early surgical techniques have now been developed to produce some of the most dramatic means of restoring sight. As a spin-off from the last war came a revolution- ary idea of “spare-part” surgery in the eye. The observation that crashed fighter pilots were able to tolerate small pieces of perspex in their eyes led to the use of acrylic intraocular implants, the lens of the eye being replaced by an artificial one. Such spare-part surgery has now become commonplace, as will be seen in Chapter 11. The operating microscope was introduced in the 1960s, and with it came the development of fine suture materials and the use of instruments too small for manipulation with the naked eye. This
The Scope of Ophthalmology 5
in turn has led to small incision techniques and sutureless surgery, which has made the day-case cataract operation a routine. Forty years ago, the vitreous was a surgical no-man’s land, but instruments have now been developed that can cut, aspirate and inject fluid simultaneously, all these procedures being carried out through fine-bore needles. Membranes, blood or foreign bodies can now be removed from the vitreous as a routine. Much important eye disease is inherited and it is not surprising that very important advances have occurred recently in the field of ophthalmic genetics. The gene con- trolling the development of the eye has now been identified and perhaps the answer to the tragic problem of inherited degenerative retinal disease is on the horizon.
In the early days of the development of the specialty, a number of specialised hospitals were built throughout the UK. The first of these was Moorfields Eye Hospital, founded largely to combat the epidemic of trachoma, which was prevalent in London at the time. Subsequently other eye hospitals appeared in the main cities of this country, often the result of pressures of local needs such as the treatment of industrial accidents. In recent years, there has been a ten- dency for eye departments to become incorpo- rated within the larger district general hospitals, although individual eye hospitals remain and are still being built.
Making a Career in Ophthalmology
Ophthalmology is a popular specialty and so the aspiring eye surgeon can expect considerable competition. There are certain essential require- ments. First, an initial interest in physics and
optics is helpful and most important is a considerable degree of manual dexterity. Good binocular vision goes along with the manual dexterity demanded by microscopic surgery.
That is to say, the future surgeon should see well out of each eye and should be able to use the eyes together to give proper stereoscopic vision.
In many cases, an interest in the subject is aroused in medical school by a mentor or a good teacher. By and large, those who see ophthal- mology as a soft option are not happy in their career. Those who, as most doctors do, set out to improve the lot of the patient, find the specialty very rewarding because it is undoubtedly extremely effective in this respect.
In the UK, medically qualified graduates can start their eye training with a senior house officer (SHO) job and thence look for a special- ist registrar post in one of the training centres.
A question sometimes asked is what jobs as an SHO, other than ophthalmology, are best suited to an eventual career in ophthalmology.
Obvious ones are in plastic surgery, neurology or neurosurgery but sometimes a seemingly unrelated one can prove to be good experience.
The membership part of the FRCOphth qualification is needed at this point and once on the training ladder there is an exit examination before training is completed. The rules about training arrangements can vary from time to time and advice on this can be provided by the Royal College of Ophthalmologists. A handbook for trainees is supplied by the college on appli- cation. When the doctor is fully trained, he or she can decide whether to start applying for consultant posts or whether to gain a fellowship in a subspecialty and perhaps obtain a higher degree. At the present time consultant posts are often advertised as requiring some special expertise, such as paediatric ophthalmology or retina surgery.
