Careers in ophthalmology

Don't be put off by memories of fumbling with an ophthalmoscope. Amar Alwitry discusses what is involved in this expanding specialty

Due to the enormous medical curriculum and the pressures on time in undergraduate training, ophthalmology teaching at medical schools tends to be quite a shortlived affair, with only about two weeks being dedicated to this vast subject. Subsequently, when medical students graduate and begin to decide on their future career, few have had a true taste of ophthalmology. The occasional clinic session spent fumbling with the ophthalmoscope, confidently saying you can see the disc margins clearly while being focused on an eyelash, may give a false and slightly offputting impression of this rewarding career.

What is ophthalmology?

Ophthalmology is the study of the eye and the visual system. It encompasses the skin around the eyes, the globe and orbit, and the nervous connections in the brain all the way back to the visual cortex. Pathology in this system and the management of systemic diseases that affect the eye are in the remit of the ophthalmologist.

The eye is the window to the soul

Ophthalmology combines surgical skills with medical skills. There are few medical conditions that are not related to or may manifest as eye signs. Numerous rheumatological, neurological, vascular, and cardiovascular conditions have ocular features, and these features may be the primary presentation of systemic disease.

Ophthalmologists deal with a healthy, elderly population. Patients walk in and out of a clinic under their own steam and are extremely grateful for anything you do for them. Often patients are followed up for an extremely long period of time, which allows for the building of a true rapport. On the flip side these innumerable follow up appointments may be draining on the doctor. Most operations are undertaken on a day case basis and under local anaesthesia, which means few ward inpatients and thus minimal ward based work.

Surgical skills

Ideally, ophthalmologists will be involved in both the medical and the surgical side of ophthalmology, but if you are averse to operating it is possible to specialise in medical ophthalmology. Ophthalmologists undertake delicate periocular and lid surgery (oculoplastics), fine microsurgery using the operating microscope, and intraocular surgery at the front (anterior segment and cornea) or at the back (vitreoretinal surgery) of the eye.

Lasers

Laser usage is an inherent part of an ophthalmologist's practice. Lasers are used for retinal treatment in a variety of conditions (but most frequently for patients with diabetes) and also used for treatment to the iris or to eyes that have had cataract surgery. Laser treatment is an exciting and continually progressing branch of ophthalmology.

Subspecialties

Although at first sight (excuse the pun) the eye does not seem big enough to support subspecialties, ophthalmology is divided into numerous fields. In the future, few posts will be available for true generalists.

Oculoplastics--The management of skin and lid position abnormalities. Oculoplastic surgeons operate on the lids and the periocular skin. This subspecialty requires very delicate surgical skills much akin to those of plastic surgeons.

Cornea--The cornea, although only 1Ž2 mm thick, suffers from a plethora of pathology. The management of corneal dystrophies, corneal infections, and other causes of corneal opacification causing visual loss are the remit of the cornea specialist. Corneal surgeons often undertake corneal grafts, replacing the whole cornea with donor
tissue, and may enter the field of refractive surgery.

Orbit--Orbital surgeons specialise in disorders of the orbit, varying from orbital cellulitis and thyroid eye disease to orbital tumours.

Vitreoretinal--This branch of ophthalmology is probably the most technically challenging from a surgical perspective. These surgeons deal with retinal detachments and numerous other retinal disorders.

Paediatrics--Paediatric ophthalmology covers all the other subspecialties applied to children. It requires a very generalist approach and good rapport with children.

Cataract--Nearly all eye surgeons undertake cataract surgery, and, with the ever increasing demand for this service, ophthalmologists will inevitably be undertaking some cataract surgery whatever they specialise in.

Glaucoma--Glaucoma specialists manage patients with glaucoma either medically or surgically.

Strabismus--Squint surgeons deal with paediatric or adult disorders of ocular alignment.

Medical--Pure medical ophthalmologists do not perform surgery. They deal with endocrinology, vascular disease of the eye, inflammatory disorders (both local and
systemic), HIV, genetics, and neuro-
ophthalmology. At present, part of higher specialist training in medical ophthalmology requires the trainee to undertake surgical training.

Refractive surgery--This involves using lasers or precise incisions into the cornea to change the focusing power of the eye and thus negate the need for wearing spectacles. The technology and skills are advancing rapidly, as is demand, for this exciting and highly lucrative subspecialty.

The ophthalmoscope

Although the ability to use an ophthalmoscope remains an essential skill for ophthalmologists, most of their clinical practice involves using a slit lamp and a lens to obtain a beautiful three dimensional view of the retina and optical disc. This image is wider than that seen by the direct ophthalmoscope, allowing much greater visualisation and appreciation of the structures at the back of the eye.

More exams

As with many specialties there are numerous exams which are undoubtedly hard.

Part I (no ophthalmology experience needed to sit)

Part I covers the basic sciences. A detailed understanding of ocular anatomy, ocular physiology, and ocular pharmacology is required, along with general systemic physiology and pharmacology. This part may be taken before starting any ophthalmology training, but this is usually difficult as all the concepts are completely new. If you can do it, it is an excellent boost to your chances of obtaining a first job as a senior house officer in ophthalmology.

Part II (1 year of experience as a senior house officer in ophthalmology needed before sitting)

Part II covers optics and refraction. Recently, an assessment of general ophthalmological clinical skills has been incorporated. It concentrates on the refractive physiology of the eye (the focusing of light on the retina), spectacles, and lenses. An appreciable amount of physics is involved, and so an A level understanding of the properties of light may be a distinct benefit. Practical refraction skills are essential as in the exam you have to prescribe the correct spectacle prescription of a real, live patient.

Part III (18 months of experience as a senior house officer in ophthalmology needed before sitting)

Part III has to be completed before starting higher specialist training. It is the hardest section of the eye exams. There are two true and false examinations, a pathology and microbiology viva voce examination where candidates may be faced with histological photomicrographs, an ophthalmology clinical examination, and a medical and neurology clinical examination. The medical clinical examination is the usual stumbling block for the part III candidate as it requires an in depth understanding of the numerous medical and neurological conditions that may affect the eye and a high degree of clinical competence in examination skills.

You can sit the Royal College of Ophthalmologists examinations (MRCOphth) or the Royal College of Surgeons of Edinburgh examinations (MRCSEd), and once you have completed part II and part III you may undertake work in a dispensing opticians as a valuable boost to your income.

Basic specialist training

At least two years must be spent as a senior houe officer in a recognised ophthalmology post. During basic specialist training, trainees should acquire the general clinical skills of an ophthalmologist and gain a basic knowledge of the conditions covered by the specialty. There are numerous clinics and theatre sessions where trainees may get first hand experience of extraocular procedures. Once you gain more experience, you can undertake supervised intraocular surgery. Basic ophthalmology trainees must have attended the Royal College of Ophthalmologists' course in basic microsurgical skills before attempting intraocular surgery.

Higher specialist training

Higher specialist training takes four and a half years, during which time you rotate through each segment of the required curriculum spending on average six months in each specialty. In order to enter this training you must have obtained a certificate of eligibility for higher specialist training from the Royal College of Ophthalmologists. Requirements are having passed the MCROphth or equivalent and having spent two years in a recognised ophthalmology post as a senior house officer. At the end of this time it is common to undertake a fellowship in your chosen subspecialty before taking up a consultant post.

Advanced subspecialist training in ophthalmology

Higher specialist training in ophthalmology has included the opportunity to undertake subspecialty training in a chosen field. This training period of up to one year can count towards training. It may be undertaken anywhere--for example, in Australia or New Zealand. It is usually taken in the fourth or fifth year of higher specialist training.

Non-career grade ophthalmologists

There are numerous opportunities for non-career grade doctors (clinical assistants, staff grades, associate specialists, etc) with varying clinical commitments. Usually you are required to complete basic specialist training in ophthalmology before entering these posts, but examinations are not always required.

How to get into ophthalmology

After obtaining full registration, two options are available. You may attempt to obtain a job as a senior house officer in ophthalmology directly or undertake a post as a senior house officer in another specialty such as medicine, emergency medicine, plastic surgery, or neurosurgery. Wider experience of hospital specialties (particularly those that may be allied to ophthalmology) will improve your chances of securing a first job as a senior house officer. Taken further, a higher degree such as MRCP or MRCS will greatly improve your chances of not only obtaining jobs as a senior house officer but also making the jump to higher specialist training. Most trainees begin in an eye unit in a district general hospital and then, after completing the part I examination, move to a teaching hospital. Generally a trainee in eyes will spend approximately two to three years as a senior house officer.

Career prospects

With the ageing population and the higher and higher demands for ophthalmology services (particularly cataract services) there will always be job opportunities for ophthalmologists, and there are plans for future expansion of the numbers of consultants.

My experience

Having completed my preregistration year I entered a general surgical training rotation. After doing two years of jobs (casualty, general surgery, orthopaedics, and cardiothoracics) I obtained my MRCS examination. I then started ophthalmology training. Having sat all my exams I have now completed my basic specialist training and am ready to start higher specialist training. I can honestly say that I have never looked back. The surgical, medical, and cerebral skills required for a career in ophthalmology keep me enthusiastic and stimulated in all aspects of my day to day work.

Ophthalmology continues to need bright, intelligent, and enthusiastic people. Give it a chance, come and sit in on a few clinics, and see what we are really about.