Ophthalmology

Ophthalmology

Eye examination with aid of a slit lamp.
System	Eye
Significant diseases	Blindness, Cataracts, Macular degeneration, Glaucoma
Significant tests	Visual field test, Ophthalmoscopy
Specialist	Ophthalmologist

Ophthalmology is the branch of medicine that deals with the anatomy, physiology and diseases of the eye.^[1] An ophthalmologist is a specialist in medical and surgical eye problems. Since ophthalmologists perform operations on eyes, they are both surgical and medical specialists.

Etymology

The word ophthalmology comes from the Greek roots ὀφθαλμός, ophthalmos, i.e. eye and -λoγία, -logia, i.e. "study of, discourse";^[2][3] ophthalmology literally means "the science of eyes". As a discipline, it applies to animal eyes also, since the differences from human practice are surprisingly minor and are related mainly to differences in anatomy or prevalence, not differences in disease processes.^{[citation needed]}

History

Ancient India

Statue of Sushruta (सुश्रुत) in Patanjali Yogpeeth, Haridwar

The Indian surgeon Sushruta wrote Sushruta Samhita in Sanskrit in about 800 BC which describes 76 ocular diseases (of these 51 surgical) as well as several ophthalmological surgical instruments and techniques.^[4][5] His description of cataract surgery was more akin to extracapsular lens extraction than to couching.^[6] He has been described as the first cataract surgeon.^[7][8]

Pre-Hippocrates

The pre-Hippocratics largely based their anatomical conceptions of the eye on speculation, rather than empiricism.^[9] They recognized the sclera and transparent cornea running flushly as the outer coating of the eye, with an inner layer with pupil, and a fluid at the centre. It was believed, by Alcamaeon and others, that this fluid was the medium of vision and flowed from the eye to the brain via a tube. Aristotle advanced such ideas with empiricism. He dissected the eyes of animals, and discovering three layers (not two), found that the fluid was of a constant consistency with the lens forming (or congealing) after death, and the surrounding layers were seen to be juxtaposed. He, and his contemporaries, further put forth the existence of three tubes leading from the eye, not one. One tube from each eye met within the skull.

Rufus

Rufus of Ephesus recognised a more modern eye, with conjunctiva, extending as a fourth epithelial layer over the eye.^[10] Rufus was the first to recognise a two chambered eye; with one chamber from cornea to lens (filled with water), the other from lens to retina (filled with an egg-white-like substance). The Greek physician Galen remedied some mistakes including the curvature of the cornea and lens, the nature of the optic nerve, and the existence of a posterior chamber.

Though this model was a roughly correct modern model of the eye, it contained errors. Still, it was not advanced upon again until after Vesalius. A ciliary body was then discovered and the sclera, retina, choroid and cornea were seen to meet at the same point. The two chambers were seen to hold the same fluid as well as the lens being attached to the choroid. Galen continued the notion of a central canal, but he dissected the optic nerve and saw that it was solid. He mistakenly counted seven optical muscles, one too many. He also knew of the tear ducts.

Middle Eastern ophthalmology

Medieval Islamic Arabic and Persian scientists (unlike their classical predecessors) considered it normal to combine theory and practice, including the crafting of precise instruments, and therefore found it natural to combine the study of the eye with the practical application of that knowledge.^[11]

Ibn al-Haytham (Alhazen) an Arab scientist with Islamic believes wrote extensively on optics and the anatomy of the eye in his Book of Optics (1021).

Ibn al-Nafis an Arabic native of Damascus wrote a large textbook, The Polished Book on Experimental Ophthalmology, divided into two parts, On the Theory of Ophthalmology and Simple and Compounded Ophthalmic Drugs.^[12]

17th and 18th centuries

François Pourfour du Petit

The 17th and 18th century saw the use of hand lenses (by Malpighi), microscopes (van Leeuwenhoek), preparations for fixing the eye for study (Ruysch) and later the freezing of the eye (Petit). This allowed for detailed study of the eye and an advanced model. Some mistakes persisted such as: why the pupil changed size (seen to be vessels of the iris filling with blood), the existence of the posterior chamber, and of course the nature of the retina. In 1722 Leeuwenhoek noted the existence of rods and cones^{[citation needed]} though they were not properly discovered until Gottfried Reinhold Treviranus in 1834 by use of a microscope.

Georg Joseph Beer (1763–1821) was an Austrian ophthalmologist and leader of the First Viennese School of Medicine. He introduced a flap operation for treatment of cataracts (Beer's operation), as well as popularizing the instrument used to perform the surgery (Beer's knife).^[13]

Ophthalmic surgery in Great Britain

The first ophthalmic surgeon in Great Britain was John Freke, appointed to the position by the Governors of St Bartholomew's Hospital in 1727. A major breakthrough came with the appointment of Baron Michael Johann Baptist de Wenzel (1724–90), a German who became oculist to King George III of England in 1772. His skill at removing cataracts legitimized the field.^[14] The first dedicated ophthalmic hospital opened in 1805 in London; it is now called Moorfields Eye Hospital. Clinical developments at Moorfields and the founding of the Institute of Ophthalmology (now part of the University College London) by Sir Stewart Duke Elder established the site as the largest eye hospital in the world and a nexus for ophthalmic research.^[15]

20th century

The prominent opticians of the late 19th and early 20th century included Ernst Abbe (1840–1905), a co-owner of at the Zeiss Jena factories in Germany where he developed numerous optical instruments. Hermann von Helmholtz (1821-1894) was a polymath who made contributions to many fields of science and invented the ophthalmoscope in 1851. They both made theoretical calculations on image formation in optical systems and had also studied the optics of the eye.

Central Europe

Numerous ophthalmologists fled Germany after 1933 as the Nazis began to persecute those of Jewish descent. A representative leader was Joseph Igersheimer (1879–1965), best known for his discoveries with arsphenamine for the treatment of syphilis. He fled to Turkey in 1933. As one of eight emigrant directors in the Faculty of Medicine at the University of Istanbul, he built a modern clinic and trained students. In 1939 he went to the United States, becoming a professor at Tufts University.^[16]

Polish ophthalmology dates to the 13th century. The Polish Ophthalmological Society was founded in 1911. A representative leader was Adam Zamenhof (1888–1940), who introduced certain diagnostic, surgical and nonsurgical eye-care procedures and was shot by the Nazis in 1940.^[17] Zofia Falkowska (1915–93) head of the Faculty and Clinic of Ophthalmology in Warsaw from 1963 to 1976, was the first to use lasers in her practice.

Professional requirements

Ophthalmologists are physicians (MD/MBBS or D.O., not OD or BOptom) who have completed a college degree, medical school, and residency in ophthalmology. In many countries, ophthalmologists also undergo additional specialized training in one of the many subspecialties. Ophthalmology was the first branch of medicine to offer board certification, now a standard practice among all specialties.

Australia and New Zealand

In Australia and New Zealand, the FRACO/FRANZCO is the equivalent postgraduate specialist qualification. It is a very competitive speciality to enter training and has a closely monitored and structured training system in place over the five years of postgraduate training. Overseas-trained ophthalmologists are assessed using the pathway published on the RANZCO website. Those who have completed their formal training in the UK and have the CCST/CCT are usually deemed to be comparable.

Canada

In Canada, an ophthalmology residency after medical school is undertaken. The residency lasts a minimum of five years after the MD degree although subspecialty training is undertaken by about 30% of fellows (FRCSC). There are about 35 vacancies per year for ophthalmology training in all of Canada.

Finland

In Finland, physicians willing to become ophthalmologists must undergo a five year specialization which includes practical training and theoretical studies.

India

In India, after completing MBBS degree, post-graduation in ophthalmology is required. The degrees are Doctor of Medicine (MD), Master of Surgery (MS), Diploma in Ophthalmic Medicine and Surgery (DOMS), and Diplomate of National Board (DNB). The concurrent training and work experience is in the form of a junior residency at a medical college, eye hospital or institution under the supervision of experienced faculty. Further work experience in form of fellowship, registrar or senior resident refines the skills of these eye surgeons. All India Ophthalmological Society (AIOS) and various state level ophthalmological societies (like DOS) hold regular conferences and actively promote continuing medical education.

Ireland

In Ireland, the Royal College of Surgeons of Ireland grants Membership (MRCSI (Ophth)) and Fellowship (FRCSI (Ophth)) qualifications in conjunction with the Irish College of Ophthalmologists. Total postgraduate training involves an intern year, a minimum of 3 years of Basic Surgical Training and a further 4.5 years of Higher Surgical Training. Clinical training takes place within public, Health Service Executive-funded hospitals in Dublin, Sligo, Limerick, Galway, and Cork. A minimum of 8.5 years of training is required before eligibility to work in consultant posts. Some trainees take extra time to obtain MSc, MD or PhD degrees and to undertake clinical fellowships in the UK, Australia and the United States.

Pakistan

In Pakistan, after an MBBS, a four-year full-time residency programme leads to an exit level FCPS examinations in ophthalmology, held under the auspices of the College of Physicians & Surgeons, Pakistan. The tough examination is assessed by both highly qualified Pakistani & eminent international ophthalmic consultants. As a prerequisite to the final examinations, an intermediate module, an optics and refraction module, and a dissertation written on a research project carried out under supervision is also assessed. Moreover, a two and a half years residency programme leads to MCPS while a two-year training of DOMS is also being offered.^[18] For candidates in the, ilitary, a stringent two-year graded course, with quarterly assessments, is held under Armed Forces Post Graduate Medical Institute in Rawalpindi. The M.S. in ophthalmology is also one of the specialty programmes. In addition to programmes for doctors, various diplomas and degrees for opticians are also being offered to produce competent optic technicians in this field. These programmes are being offered notably by the Punjab Institute of Preventive Ophthalmology (PIPO) in Lahore and the Pakistan Institute of Community Ophthalmology in Peshawar.^[19] Sub-specialty fellowships are also being offered in the fields of pediatric ophthalmology and vitreo-retinal ophthalmology. King Edward Medical University, Al Shifa trust eye hospital Rawalpindi & Al- Ibrahim eye hospital Karachi has also started a degree program in this field.

Philippines

Ophthalmology is a considered a medical specialty that uses medicine and surgery to treat diseases of the eye. To become a general ophthalmologist, a candidate must have completed a Doctor of Medicine degree or its equivalent (e.g. MBBS), have passed the physician licensure exam, completed an internship in medicine, and completed residency at any Philippine Academy of Ophthalmology (PAO)^[20] accredited program. Attainment of board certification in ophthalmology from PBO is optional, but is preferred and required to gain privileges in most major health institutions. Graduates of residency programs can receive further training in subspecialties of ophthalmology such as neuro-ophthalmology, etc. by completing a fellowship program which varies in length depending on each program's requirements. The leading professional organization in the country is the Philippine Academy of Ophthalmology^[21] which also regulates ophthalmology residency programs and board certification through its accrediting agency, the Philippine Board of Ophthalmology.

United Kingdom

In the United Kingdom, there are three colleges that grant postgraduate degrees in ophthalmology. The Royal College of Ophthalmologists (RCOphth) grants MRCOphth and FRCOphth (postgraduate exams), the Royal College of Edinburgh grants MRCSEd, the Royal College of Glasgow grants FRCS. Postgraduate work as a specialist registrar and one of these degrees is required for specialisation in eye diseases. Such clinical work is within the NHS. There are only 2.3 ophthalmologists per 100,000 population in the UK – fewer pro rata than in any other nation in the European Union.^[22]

United States

In the United States, four years of residency training after medical school are required, with the first year being an internship in surgery, internal medicine, pediatrics, or a general transition year. Optional fellowships in advanced topics may be pursued for several years after residency. Most currently practicing ophthalmologists train in medical residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) and are board-certified by the American Board of Ophthalmology or the American Osteopathic Board of Ophthalmology and Otolaryngology. United States physicians who train in osteopathic medical schools hold the Doctor of Osteopathic Medicine (D.O.) degree rather than an M.D. degree. The same residency and certification requirements for ophthalmology training must be fulfilled by osteopathic physicians.

Physicians must complete the requirements of continuing medical education in order to maintain licensure and for re-certification. Professional bodies like the AAO and ASCRS: The American Society of Cataract and Refractive Surgery organizes conferences, helps physician members through continuing medical education programs for maintaining board certification, and provides political advocacy and peer support.

Sub-specialities

Ophthalmology includes sub-specialities which deal either with certain diseases or diseases of certain parts of the eye. Some of them are:

• Anterior segment surgery
• Retinal ophthalmology, which emphasizes such things as laser treatment of the retina and actual retinal surgery.
• Cataracts — not usually considered a subspecialty per se, since most general ophthalmologists perform cataract surgery
• Cornea, ocular surface, and external disease
• Glaucoma
• Medical retina, deals with treatment of retinal problems through non-surgical means.
• Neuro-ophthalmology
• Ocular oncology
• Oculoplastics & Orbit surgery
• Ophthalmic pathology
• Pediatric ophthalmology/Strabismus (mis-alignment of the eyes)
• Refractive surgery
• Uveitis
• Immunology
• Veterinary Formal specialty training programs in veterinary ophthalmology now exist in some countries.^[23][24]
• Vitreo-retinal surgery, deals with surgical management of retinal and posterior segment diseases and disorders. Medical retina and vitreo-retinal surgery sometimes together called posterior segment subspecialisation.

Ophthalmic surgery

Notable ophthalmologists

18th–19th centuries

Joseph Forlenze

• Theodor Leber Discovered Leber's congenital amaurosis, Leber's hereditary optic neuropathy, Leber's miliary aneurysm, and Leber's Stellate Neuroretinitis.
• Sir William Adams (UK) Founder of Exeter's West of England Eye Infirmary.
• Carl Ferdinand von Arlt (1812–1887), the elder (Austrian) proved that myopia is largely due to an excessive axial length, published influential textbooks on eye disease, and ran annual eye clinics in needy areas long before the concept of volunteer eye camps became popular. His name is still attached to some disease signs, e.g., von Arlt's line in trachoma. His son Ferdinand Ritter von Arlt, the younger, was also an ophthalmologist.
• Jacques Daviel (France) claimed to be the 'father' of modern cataract surgery in that he performed extracapsular extraction instead of needling the cataract or pushing it back into the vitreous. It is said that he carried out the technique on 206 patients in 1752–3, out of which 182 were reported to be successful. These figures are not very credible, given the total lack of both anaesthesia and aseptic technique at that time.
• Frans Cornelis Donders (1818–1889) (Dutch) published pioneering analyses of ocular biomechanics, intraocular pressure, glaucoma, and physiological optics. Made possible the prescribing of combinations of spherical and cylindrical lenses to treat astigmatism.
• Joseph Forlenze (1757-1833) (Italy), specialist in cataract surgery, became popular during the First French Empire, healing, among many, personalities such as the minister Jean-Étienne-Marie Portalis and the poet Ponce Denis Lebrun. He was nominated by Napoleon "chirurgien oculiste of the lycees, the civil hospices and all the charitable institutions of the departments of the Empire".^[25] He was known also for his free interventions, mainly in favour of poor people.

Allvar Gullstrand

• John Frederick France (1817-1900) In 1847, he succeeded the late Mr John Morgan as lecturer on Ophthalmic Surgery at the school. In 1855 he was elected a Fellow of the Royal College of Surgeons; he was also a Fellow of the Society of Antiquaries France edited, with notes, the second edition of Morgan's work on Lectures on Diseases of the Eye (1848) and was a voluminous writer himself on Ophthalmic subjects. To the ‘Guys Hospital Reports’ he contributed 17 papers between 1848 and 1861, and numerous other papers appeared in various periodical publications. He was one of the authors who supported the theory of causal connection between diabetes and cataract, which at that time was still questioned by many physicians and he used, for fixation of the eyeball, a simple artery forceps (without spring lock) in 27 patients and had success in all of them. France also published clinical observations about eye injuries, paralysis of the pupil and ptosis. and in the same journal (October 1845) he reported about the successful extraction of a traumatic calcified cataract from the anterior chamber. (Lancet 1850,1,14)
• Albrecht von Graefe (1828–1870) (Germany) Along with Helmholtz and Donders, one of the 'founding fathers' of ophthalmology as a specialty. A brilliant clinician and charismatic teacher who had an international influence on the development of ophthalmology. A pioneer in mapping visual field defects and diagnosis and treatment of glaucoma. Introduced a cataract extraction technique that remained the standard for over 100 years, and many other important surgical techniques such as iridectomy. Rationalised the use of many ophthalmically important drugs, including mydriatics & miotics. The founder of one of the earliest ophthalmic societies (German Ophthalmological Society, 1857) and one of the earliest ophthalmic journals (Graefe's Archives of Ophthalmology). The most important ophthalmologist of the nineteenth century.
• Allvar Gullstrand (Sweden), Nobel Prize winner in 1911 for his research on the eye as a light-refracting apparatus. Described the schematic eye a mathematical model of the human eye based on his measurements known as the optical constants of the eye. His measurements are still used today.
• Hermann von Helmholtz, great German polymath, invented the ophthalmoscope (1851) and published important work on physiological optics, including colour vision (1850s).
• Socrate Polara (1800–1860) (Italy), founded the first dedicated ophthalmology clinic in Sicily in 1829 entirely as a philanthropic endeavor; later appointed as the first director of the ophthalmology department at the Grand Hospital of Palermo, Sicily (Italy) in 1831 after the Sicilian government became convinced of the importance of state support for the specialization.^[26]
• Hermann Snellen (Netherlands) introduced the Snellen chart to study visual acuity.
• Sir Arthur Conan Doyle (United Kingdom). English writer, primarily of the Sherlock Holmes stories. Trained in but apparently never practiced Ophthalmology.
• Jose Rizal (Philippines). The Philippines' national hero was an ophthalmologist. One of his works was an operation of both his mother's eyes for removal of a cataract.

20th–21st centuries

William Bates and his assistant

• William Horatio Bates (1860–1931) (United States) Creator of the unorthodox Bates Method, credited for being the founder of the Natural Vision Improvement movement.
• Vladimir Petrovich Filatov (1875–1956) (Ukraine) His contributions to the medical world include the tube flap grafting method, corneal transplantation and preservation of grafts from cadaver eyes and tissue therapy. He founded The Filatov Institute of Eye Diseases & Tissue Therapy, Odessa, one of the leading eye care institutes in the world.
• Ignacio Barraquer (1884–1965) (Spain) In 1917, invented the first motorized vacuum instrument (erisophake) for intracapsular cataract extraction. Founded of the Barraquer Clinic in 1941 and the Barraquer Institute in 1947 in Barcelona, Spain.
• Tsutomu Sato (Japan) Pioneer in incisional refractive surgery, including techniques for astigmatism and the invention of radial keratotomy for myopia.
• Jules Gonin (1870–1935) (Switzerland) "Father of retinal detachment surgery".
• Sir Harold Ridley (United Kingdom) In 1949, may have been the first to successfully implant an artificial intraocular lens after observing that plastic fragments in the eyes of wartime pilots were well tolerated. He fought for decades against strong reactionary opinions to have the concept accepted as feasible and useful.
• Charles Schepens (Belgium) "Father of modern retinal surgery". Developer of the Schepens indirect binocular ophthalmoscope whilst at Moorfields Eye Hospital. Founder of the Schepens Eye Research Institute in Boston, Massachusetts. This premier research institute is associated with Harvard Medical School and Massachusetts Eye & Ear Infirmary.
• Marshall M. Parks "Father of pediatric ophthalmology".
• José Ignacio Barraquer (1916–1998) (Spain) "Father of modern refractive surgery". In the 1960s, developed lamellar techniques including keratomileusis and keratophakia, as well as the first microkeratome and corneal microlathe.
• Tadeusz Krwawicz (Poland) In 1961, developed the first cryoprobe for intracapsular cataract extraction.
• Svyatoslav Fyodorov (Russia) "Father of ophthalmic microsurgery". Improved and popularized the radial keratotomy, invented a surgical cure for cataract and developed the scleroplasty.
• Charles Kelman (United States) Developed the ultrasound and mechanized irrigation and aspiration system for phacoemulsification, first allowing cataract extraction through a small incision.
• Ioannis Pallikaris (Greece) Performed the first laser-assisted intrastromal keratomileusis or LASIK surgery.
• Fred Hollows (New Zealand/Australia) Pioneered programs in Nepal, Eritrea, and Vietnam, and among Australian aborigines, including the establishment of cheap laboratory production of intraocular lenses in Nepal and Eritrea.
• Marco Abbondanza (Italy) Developed the Mini Asymmetric Radial Keratotomy (M.A.R.K.) for keratoconus and astigmatism, popularized the cross-linking.
• Ian Constable (Australia) Founded the Lions Eye Institute in Perth, Western Australia, the largest eye research institute in the southern hemisphere and home to ten ophthalmologists.
• Rand Paul (United States) is a current member of The United States Senate from Kentucky. His father is U.S. Representative Ron Paul.
• L. L. Zamenhof (Poland) Creator of the Esperanto language.
• Bashar al-Assad (Syria) The President of Syria. He did his ophthalmology residency in a hospital in London.
• Syed Modasser Ali (Bangladesh) An ophthalmic surgeon who used to be the Director-General of Health Services for the government of Bangladesh. He wrote the first book on community ophthalmology (public eye health).
• Dr Albrecht Hennig (Germany) Pioneered the "fish-hook" technique enabling his team to complete more than 48,000 cataract operations in Nepal in 2004. He was nominated as cbm's 'Eye Health Hero', at the International Agency for the Prevention of Blindness (IAPB) 9th General Assembly (9GA) in September 2012.
• Dr. Paul T. Finger (United States) Pioneered the use of palladium-103 plaque radiation to treat choroidal melanoma and 3D and high-frequency ultrasound to image intraocular tumors.

See also

• Optometry
• Orthoptics
• Eye care professional
• Eyeglasses
• Prentice position
• Eye color
• Copiale cipher
• Book of the Ten Treatises of the Eye

References

External links

Wikimedia Commons has media related to Ophthalmology.

• Directory of Open Access Ophthalmology Journals
• The Royal College of Ophthalmologists
• The David G. Cogan Ophthalmic Pathology Collection
• Dictionary of ophthalmic terms
• EyeWiki
• Multilingual illustrated Dictionary of Ophthalmology