extracapsular

Ophthalmology

[of-thuhl-mol-uh-jee, -thuh-, -thal-, op-]

Ophthalmology is the branch of medicine which deals with the diseases and surgery of the visual pathways, including the eye, brain, and areas surrounding the eye, such as the lacrimal system and eyelids. By convention the term ophthalmologist is more restricted and implies a medically trained surgical specialist. Since ophthalmologists perform operations on eyes, they are generally categorized as surgeons.

The word ophthalmology comes from the Greek roots ophthalmos meaning eye and logos meaning word, thought or discourse; 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. However, veterinary medicine is regulated separately in many countries and states/provinces resulting in few ophthalmologists treating both humans and animals.

History

The eye, including its structure and mechanism, has fascinated scientists and the public in general since ancient times. The majority of all input to the brain comes from vision. Many of the expressions in the English language that mean to understand are equivalent vision terms. "I see", to mean I understand.

Many patients when told that they may have an eye problem will be more concerned about diseases that affect vision than other, more lethal diseases. Being deprived of sight can have a devastating effect on the psyche, as well as economic and social effects, as many blind individuals require significant assistance with activities of daily living and are often unable to continue gainful employment previously held while seeing.

The maintenance of ocular health and correction of eye problems that decrease vision contribute greatly to the ability to appreciate the longer lifespan that all of medicine continues to allow. Given the importance of vision to quality of life, many ophthalmologists consider their job to be rewarding, as they are often able to restore or improve a patient's sight. As detailed below, advances in diagnosis and treatment of disease, and improved surgical techniques have extended our abilities to restore vision like never before.

Sushruta

Sushruta wrote Sushruta Samhita in about fifth Century BCE in India. He described about 72 ocular diseases as well as several ophthalmological surgical instruments and techniques. Sushruta has been described as the first Indian cataract surgeon.

Arab scientists are some of the earliest to have written about and drawn the anatomy of the eye—the earliest known diagram being in Hunain ibn Is-hâq's Book of the Ten Treatises on the Eye. Earlier manuscripts exist which refer to diagrams which are not known to have survived. Current knowledge of the Græco-Roman understanding of the eye is limited, as many manuscripts lacked diagrams. In fact, there are very few Græco-Roman diagrams of the eye still in existence. Thus, it is not clear to which structures the texts refer, and what purpose they were thought to have.

Pre-Hippocrates (pre-Ahad Fazalat)

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.

Alexandrian studies

Alexandrian studies extensively contributed to knowledge of the eye. Aëtius tells us that Herophilus dedicated an entire study to the eye which no longer exists. In fact, no manuscripts from the region and time are known to have survived, leading us to rely on Celsius' account—which is seen as a confused account written by a man who did not know the subject matter. From Celsius it is known that the lens had been recognised, and they no longer saw a fluid flowing to the brain through some hollow tube, but likely a continuation of layers of tissue into the brain. Celsius failed to recognise the retina's role, and did not think it was the tissue that continued into the brain.

Rufus

Rufus 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). 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.

After Galen

After Galen a period of speculation is again noted by Arab scientists - the lens modified Galen's model to place the lens in the middle of the eye, a notion which lasted until Vesalius reversed the era of speculation. However, Vesalius was not an ophthalmologist and taught that the eye was a more primitive notion than the notion of both Galen and the Arabian scientists - the cornea was not seen as being of greater curvature and the posterior side of the lens wasn't seen to be larger.

Understanding of the eye had been so slow to develop because for a long time the lens was perceived to be the seat of vision, not as part of the pathway for vision. This mistake was corrected when Fabricius and his successors correctly placed the lens and developed the modern notion of the structure of the eye. They removed the idea of Galen's seventh muscle (the retractor bulbi) and reinstated the correct curvatures of the lens and cornea, as well as stating the ciliary body as a connective structure between the lens and the choroid.

Muslim ophthalmology

Of all the branches of Islamic medicine, ophthalmology was considered one of the foremost. The specialized instruments used in their operations ran into scores. Innovations such as the “injection syringe”, invented by the Iraqi physician Ammar ibn Ali of Mosul, which was used for the extraction by suction of soft cataracts, were quite common. In cataract surgery, Ammar ibn Ali attempted the earliest extraction of cataracts using suction. He introduced a hollow metallic syringe hypodermic needle through the sclerotic and successfully extracted the cataracts through suction.

Ibn al-Haytham (Alhazen), the "father of optics", studied the anatomy of the eye extensively. He made important contributions to ophthalmology and eye surgery and posited the first correct explanations of the process of sight and visual perception in his Book of Optics (1021). He was also 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, that they do not get in contact with it, and that the optic nerves transect but do not get in touch with each other. He also discovered many 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 for his son a very elaborate treatise of ophthalmology entitled Nur al-Uyun wa Jami al-Funun (light of the eyes and collection of rules).

Seventeenth and eighteenth century

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 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 (M.D.) or Doctors of Osteopathic Medicine (D.O.). who have completed a college degree, medical school, and an additional four years of post-graduate training in ophthalmology in many countries. Many 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.

United States

In the United States, 4 to 5 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. 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 train in osteopathic medical schools may hold a Doctor of Osteopathy degree denoted as DO rather than MD. The same residency and certification requirements for ophthalmology training must be fulfilled by osteopathic physicians (DO degree). Completing the requirements of continuing medical education is mandatory for continuing licensure and re-certification. Professional bodies like the AAO and ASCRS organize conferences and help members through CME programs to maintain certification, in addition to political advocacy and peer support.

United Kingdom

In the United Kingdom, there are four colleges that grant postgraduate degrees in ophthalmology. The Royal College of Ophthalmologists grants MRCOphth and FRCOphth (postgraduate exams), the Royal College of Edinburgh grants MRCSEd, the Royal College of Glasgow grants FRCS and Royal College of Ireland grants FRCSI. Work experience as a specialist registrar and one of these degrees is required for specialisation in eye diseases.

Australia and New Zealand

In Australia and New Zealand, the FRACO/FRANZCO is the equivalent postgraduate specialist qualification. 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.

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) are conducting their fellowship and membership examinations since mid 1990s and awarding fellowships and memberships to the successful candidates.

Pakistan

In Pakistan, there is a structured residency program leading into FCPS. Further detail is at http://cpsp.edu.pk/

Canada

In Canada, an Ophthalmology residency after medical school is undertaken. The residency lasts a minimum of 5 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 5 year specialization which includes practical training and theoretical studies.

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 considered a subspecialty per se, since most general ophthalmologists do surgery for this.
Cornea, ocular surface, and external disease

Glaucoma
Neuro-ophthalmology
Ocular oncology
Oculoplastics & Orbit surgery
Ophthalmic pathology
Pediatric ophthalmology/Strabismus (squint)
Refractive surgery
Medical retina, deals with treatment of retinal problems conservatively.
Vitreoretinal Surgery, deals with surgical management of retinal and posterio segment diseases and disorders. Medical retina and vitreoretinal surgery sometimes together called posterior segment subspecialisation.
Uveitis/Immunology
Veterinary" Formal specialty training programs in veterinary ophthalmology now exist in some countries

Ophthalmic surgery

Notable ophthalmologists

Pre-18th century

Marie Colinet, wife of Wilhelm Fabry, employs a magnet for removing a foreign body from the eye, 1627.

18th-19th century

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, eg, 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 the 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).
Hermann Snellen (Netherlands) introduced the Snellen chart to study visual acuity.

20th-21st century

William Horatio Bates (1860-1931) (USA) Creator of the unorthodox Bates Method, credited for being the founder of the Natural Vision Improvement movement.
Vladimir Petrovich Filatov (Ukraine) (1875-1956) 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 (Spain, 1884-1965),invented in 1917 the first motorized vacuum instrument (erisophake) for intracapsular cataract extraction. Founder of the Barraquer Clinic (1941) and the Barraquer Institute (1947) in Barcelona, Spain.
Tsutomu Sato (Japan), pioneer in incisional refractive surgery, including techniques for astigmatism and the invention of radial keratotomyfor myopia.
Jules Gonin (Switzerland)"father of retinal detachment surgery"
Sir Harold Ridley (UK) may have been the first to successfully implant an artificial intraocular lens 1949, 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, Boston, USA. 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 (Spain, 1916-1998), "father of modern refractive surgery", developed in the 1960s lamellar techniques including keratomileusis and keratophakia, as well as the first microkeratome and corneal microlathe.
Tadeusz Krwawicz (Poland), developed in 1961 the first cryoprobe for intracapsular cataract extraction.
Svyatoslav Fyodorov (Russia) popularizer of radial keratotomy
Charles Kelman (United States) developed the ultrasound and mechanized irrigation/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 10 ophthalmologists.
L. L. Zamenhof, Poland - Creator of the language Esperanto.
Bashar al-Assad is the Syrian President. He did his ophthalmology residency in a London hospital.
Syed Modasser Ali is an ophthalmic surgeon from Bangladesh who used to be the Director-General of Health Services for the Bangladesh government. He is the authour of the first book on Community Ophthalmology (public eye health).