Ophthalmology

Opthalmology

Early developments

 
Sushruta
 
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. The Indian surgeon Sushruta has been described as the first cataract surgeon.
 
Pre-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 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. 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 roughly a correct but simplistic modern model of the eye, it contained errors. Yet 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, though he dissected the optic nerve, and saw it was solid, He mistakenly counted seven optical muscles, one too many. He also knew of the tear ducts.
 
Middle Eastern ophthalmology
 
Medieval Islamic physicians are considered founders of ophthalmology as an independent discipline. One of the pioneers of ophthalmology was the Persian physician Rhazes.
 
Ibn al-Haytham (Alhazen) wrote extensively on optics and the anatomy of the eye in his Book of Optics (1021). He was the first to hint at the retina being involved in the process of image formation.
 
Ibn al-Nafis, in The Polished Book on Experimental Ophthalmology, discovered that the muscle behind the eyeball does not support the ophthalmic nerve, and that the optic nerves transect but do not get in touch with each other. He also discovered new treatments for glaucoma and the weakness of vision in one eye when the other eye is affected by disease. Salah–ud-din bin Youssef al-Kalal bi Hama (i.e. the eye doctor of Hama) was a Syrian oculist who flourished in Hama in 1296. He wrote an elaborate treatise of ophthalmology entitled Nur al-Uyun wa Jami al-Funun (light of the eyes and collection of rules).
 
Seventeenth and eighteenth centuries
 
The seventeenth and eighteenth 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 though they were not properly discovered until Gottfried Reinhold Treviranus in 1834 by use of a microscope.
 
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, but the establishment of the first dedicated ophthalmic hospital in 1805; now called Moorfields Eye Hospital in London, England was a transforming event in modern ophthalmology. 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.
 
Professional requirements
 
Ophthalmologists are medical doctors (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 subspecialities. 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 30 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) or 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. Royal colleges of the United Kingdom, mainly Royal College of Surgeons of Edinburgh (RCSEd), Royal College of Ophthalmologists (RCOphth) and Royal College of Physicians and Surgeons of Glasgow (RCPSG) have conducted their fellowship and membership examinations since the mid-1990s and awarding fellowships and memberships to the successful candidates.
 
Pakistan
 
In Pakistan, after MBBS, a 4 year full time residency programme leads to an exit level FCPS examinations in Ophthalmology, held under the auspices of 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, Optics & Refraction Module; and a Dissertation writing on a research carried out under supervision is also assessed. Moreover, a two and a half years residency programme leads to MCPS while a 2 years training of DOMS is also being offered. For candidates in the Military, a stern 2 years Grading course, with quarterly assessments, is held under Armed Forces Post Graduate Medical Institute. Rawalpindi. M.S.(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 Punjab Institute of Preventive Ophthalmology (PIPO) Lahore and Pakistan Institute of Community Ophthalmology in Peshawar. Sub-specialty fellowships are also being offered in the fields of pediatric ophthalmology and vitreo-retinal ophthalmology. In Pakistan King Edward Medical university has launched 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) 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 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
 
Republic of 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; however most trainees take extra time to obtain MSc, MD or PhD degrees and to undertake clinical fellowships in the UK, Australia and the United States.
 
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) and are board-certified by the American Board of Ophthalmology. Some physicians that train in osteopathic medical schools may hold a Doctor of Osteopathy ("DO") degree rather than an MD. The same residency and certification requirements for ophthalmology training must be fulfilled by osteopathic physicians. Completing the requirements of continuing medical education is mandatory for continuing licensure and re-certification. Professional bodies like the AAO and ASCRS: The American Society of Cataract and Refractive Surgery organize conferences and help members through continuing medical education programs to maintain certification, in addition to 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
  • Cataract — 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.
  • 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
 
For a comprehensive list of surgeries performed by ophthalmologists, see eye surgery.
 
Notable ophthalmologists
 
This is an incomplete list, which may never be able to satisfy particular standards for completeness. You can help by expanding it with reliably sourced entries.
 
18th–19th centuries
 
  • 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.
  • 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 opthalmology clinic in Sicily in 1829 entirely as a philanthropic endeavor; later appointed as the first director of the opthalmology 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.
  • 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 his mother's both eyes for removal of a cataract.
20th–21st centuries
 
  • 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) Popularizer of radial keratotomy.
  • 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.
  • 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).
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