Ophthalmology

Etymology

The Greek roots of the word ophthalmology are ὀφθαλμό (ophthalmos, "eye") and -λoγία (-logia, "study, discourse"), i.e., "the study of eyes". The discipline applies to all animal eyes, whether human or not, since the practice and procedures are quite similar with respect to disease processes, while differences in anatomy or disease prevalence, whether subtle or substantial, may differentiate the two.

Ancient India

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. His description of cataract surgery was more akin to extracapsular lens extraction than to couching. He has been described as the first cataract surgeon.

Before Hippocrates

The pre-Hippocratics largely based their anatomical conceptions of the eye on speculation, rather than empiricism. 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 by 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. 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. Hunain ibn Ishaq, and others beginning with the medieval Arabic period, taught that the crystalline lens is in the exact center of the eye. This idea was propagated until the end of the 1500s.

Ibn al-Haytham (Alhazen), an Arab scientist with Islamic beliefs, 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.

17th and 18th centuries

In the 17th and 18th centuries, hand lenses were used by Malpighi, and microscopes by van Leeuwenhoek, preparations for fixing the eye for study by Ruysch, and later the freezing of the eye by 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, van Leeuwenhoek noted the existence of rods and cones, 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).

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. 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.

20th century

The prominent opticians of the late 19th and early 20th centuries 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.

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. 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. Ophthalmology training equips eye specialists to provide the full spectrum of eye care, including the prescription of glasses and contact lenses, medical treatment, and complex microsurgery. 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.

Bangladesh

In Bangladesh to be an ophthalmologist the basic degree is an MBBS. Then they have to obtain a postgraduate degree or diploma in specialty ophthalmology. In Bangladesh, these are Diploma in Ophthalmology, Diploma in Community Ophthalmology, Fellow or Member of the College of Physicians and Surgeons in ophthalmology, and Master of Science in ophthalmology.

Canada

In Canada, an ophthalmology residency after medical school is undertaken. The residency lasts a minimum of five years after the MD degree which culminates in fellowship of the Royal College of Surgeons of Canada (FRCSC). Subspecialty training is undertaken by about 30% of fellows (FRCSC) in a variety of fields from anterior segment, cornea, glaucoma, vision rehabilitation, uveitis, oculoplastics, medical and surgical retina, ocular oncology, ocular pathology, or neuro-ophthalmology. About 35 vacancies open per year for ophthalmology residency training in all of Canada. These numbers fluctuate per year, ranging from 30 to 37 spots. Of these, up to ten spots are at French-speaking universities in Quebec. At the end of the five years, the graduating ophthalmologist must pass the oral and written portions of the Royal College exam in either English or French.

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, postgraduate study in ophthalmology is required. The degrees are Doctor of Medicine, Master of Surgery, Diploma in Ophthalmic Medicine and Surgery, and Diplomate of National Board. 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 and various state-level ophthalmological societies hold regular conferences and actively promote continuing medical education.

Nepal

In Nepal, to become an ophthalmologist, three years postgraduate study is required after completing MBBS degree. The postgraduate degree in ophthalmology is called MD in Ophthalmology. This degree is currently provided by Tilganga Institute of Ophthalmology, Tilganga, Kathmandu, BPKLCO, Institute of Medicine, TU, Kathmandu, BP Koirala Institute of Health Sciences, Dharan, Kathmandu University, Dhulikhel and National Academy of Medical Science, Kathmandu. Few Nepalese citizen also study this subject in Bangladesh, China, India, Pakistan and other countries. All the graduates have to pass Nepal Medical Council Licensing Exam to become a registered Ophthalmology in Nepal. The concurrent residency training is in the form of a PG student (resident) at a medical college, eye hospital, or institution according to the degree providing university's rules and regulations. Nepal Ophthalmic Society holds 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 three 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, Waterford, 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 MBBS, a four-year full-time residency program leads to an exit-level FCPS examination in ophthalmology, held under the auspices of the College of Physicians and Surgeons, Pakistan. The tough examination is assessed by both highly qualified Pakistani and 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-year residency program leads to an MCPS while a two-year training of DOMS is also being offered. For candidates in the military, 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 programs. In addition to programs for doctors, various diplomas and degrees for allied eyecare personnel are also being offered to produce competent optometrists, orthoptists, ophthalmic nurses, ophthalmic technologists, and ophthalmic technicians in this field. These programs are being offered notably by the College of Ophthalmology and Allied Vision Sciences in Lahore and the Pakistan Institute of Community Ophthalmology in Peshawar. Subspecialty fellowships are also being offered in the fields of pediatric ophthalmology and vitreoretinal ophthalmology. King Edward Medical University, Al Shifa Trust Eye Hospital Rawalpindi, and Al- Ibrahim Eye Hospital Karachi have 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. There are two professional organizations in the country: the Philippine Academy of Ophthalmology (PAO) and the Philippine Academy of Medical Specialists, Discipline in Ophthalmology (PAMS Ophthalmology). Individually, they regulate ophthalmology residency programs and board certification through their respective accrediting agencies. To become a general ophthalmologist in the Philippines, a candidate must have completed a Doctor of Medicine degree (MD) or its equivalent (e.g. MBBS), have completed an internship in Medicine, have passed the physician licensure exam, and completed residency training at a hospital accredited by the Philippine Board of Ophthalmology (accrediting arm of PAO) or by the Philippine Academy of Medical Specialists, Discipline in Ophthalmology (PAMS Ophthalmology). Attainment of board certification in ophthalmology from either PBO or PAMS Ophthalmology is optional, but preferred, in acquiring privileges in most major health institutions. Graduates of residency programs can receive further training in ophthalmology subspecialties, such as neuro-ophthalmology, retina, etc. by completing a fellowship program which varies in length depending on each program's requirements.

United Kingdom

In the United Kingdom, three colleges grant postgraduate degrees in ophthalmology. The Royal College of Ophthalmologists (RCOphth) and the Royal College of Surgeons of Edinburgh grant MRCOphth/FRCOphth and MRCSEd/FRCSEd, (although membership is no longer a prerequisite for fellowship), the Royal College of Glasgow grants FRCS. Postgraduate work as a specialist registrar and one of these degrees is required for specialization in eye diseases. Such clinical work is within the NHS, with supplementary private work for some consultants. Only 2.3 ophthalmologists exist per 100,000 population in the UK – fewer pro rata than in any other nation in the European Union.

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 or the American Osteopathic Association 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 (DO) degree rather than an MD 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 to maintain licensure and for recertification. Professional bodies like the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery organize conferences, help physician members through continuing medical education programs for maintaining board certification, and provide political advocacy and peer support.

Subspecialties

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

18th–19th centuries

20th–21st centuries