Ophthalmology is the specialty concerned with all aspects of vision: the eyes, their adnexa (supporting structures) and the visual apparatus in the brain.
This is one of medicine’s most popular career choices. The patients are of both sexes and of all ages from premature babies to the very elderly. The effect of ophthalmic surgical procedures on patients’ lives are most gratifying. To emphasise this, the WHO recently recognised cataract surgery as one of the most cost-effective of all health interventions (1). There is a high emphasis on postgraduate education and clinical research, which add to the popularity of the specialty.
The specialty is often in the public eye due to media attention, but there is much professional and lay confusion surrounding the scope of ophthalmology, which is compounded by the involvement of the eye in a panoply of medical conditions, the large variety of paramedical staff operating within this area of interest and the vast technological advances which have occurred in the last decade (2). Within the medical profession, there is widespread ignorance of eye conditions. A recent survey highlighted the fact that most doctors view their undergraduate education in ophthalmology as inadequate (3), despite the fact that eye conditions account for some 4% of the patients presenting to GP’s (4).
It is my aim in this two-part article to provide an account of the speciality which is relevant to the legal professional, and to answer the following questions:
• What are the major subspecialties of ophthalmology? • Who are the main players? • How does it relate to primary care and the other medical specialties? • What should the legal professional look for in an ophthalmological negligence case? • What should the legal professional look for in obtaining an ophthalmological opinion?
What are the major subspecialties of ophthalmology?
Ophthalmology has traditionally been forward-looking in its promotion of subspecialisation. For many years, trainee ophthalmologists have been encouraged to spend one to two years following their general training in developing expertise in a specific area of knowledge.
The main areas of subspecialty training are:
Cornea and external eye disease (including refractive surgery) This includes allergic disorders and infections of the ocular surface, failure of the tear film, and diseases causing opacification of the cornea. Surgical procedures include corneal transplantation, and refractive surgery, which increasingly is being carried out using the excimer laser. Public awareness of the use of lasers in ophthalmology has reached saturation due to advertising campaigns, often disguised as popular science programmes, but unfortunately this has not been reflected very accurately, so that patients are nowadays often bitterly disappointed to discover that the use of a laser is not required in their treatment. (It has been said that the acronym laser, which formerly stood for Light Amplification by Stimulated Emission of Radiation, now stands for Latest Attempt to Secure Extra Revenue !)
Glaucoma This refers to a group of conditions characterised by raised pressure in the eye and sudden or, more often, gradual loss of vision. Because these conditions are often without symptoms, their detection depends on a thorough examination being carried out by an optometrist when the patient attends to have their sight tested for glasses. The glaucomatologist treats these conditions with eye drops and monitors for deterioration in vision. If the eye drops do not halt the visual reduction then surgery may be necessary to enhance the drainage of fluid from the eye. One of the major changes which has occurred in the specialty recently is the acceptance of the idea that surgery should be carried out early in the disease, and not left until it is a last-ditch attempt to prevent total blindness in advanced disease.
Uveitis and medical ophthalmology This involves a variety of inflammatory conditions within the eye, which are often the result of auto-immune processes. One of the best known negligence cases in medicine (5) concerned one type of uveitis. These may have to be treated with steroids or immunosuppressant drugs, which carry powerful side-effects. Medical ophthalmology also involves the use of lasers in treating the complications of diabetes in the eye. There are some trainees who specialise purely in medical ophthalmology, but these are rare in this country and most exponents of medical ophthalmology also carry out eye surgery.
Vitreoretinal disease This is one of the most technically demanding areas of ophthalmology. Surgery is carried out within the eye and treats a variety of conditions which threaten to separate the retina from the back of the eye. A lot of high-tech equipment is required, with skilled support from technicians and theatre nurses; the procedures are often long, complicated and expensive and, because disease processes are often aggressive, the visual results are often less dramatic than simpler procedures such as cataract surgery. The aim may sometimes be only to preserve what little vision the patient has on presentation, albeit that this limited vision is very precious to the patient.
Paediatrics. The treatment of childhood eye disease is often different from that in the adult because the disease behaves differently. A specialist in paediatric ophthalmology will see a large number of premature babies, children with physical or mental developmental disorders and some children with congenital cataracts or glaucoma. Because the neurological connections between eye and brain are established in early childhood, there is a fairly narrow interval during which these diseases must be detected and treated, and for this reason, general paediatric examinations must pay attention to the eyes. Pre-school screening programmmes aim to detect treatable eye disorders before it is too late to treat them, and also identify children whose visual impairment may necessitate special educational provision. There has been a recent controversy in the management of amblyopia (2); critics have pointed to the lack of evidence for the effectiveness of treatment by patching the favoured eye, and the occurrence of adverse effects in the normal eye in children so treated.
Neuro-ophthalmology A variety of diseases of the central nervous system manifest themselves in the eye, particularly in the coordinated movement of the eyes. A neuro-ophthalmologist will most often be found working in a larger centre along with neurologists and neurosurgeons in the multi-disciplinary care of patients with neurological problems.
Ocular motility This interfaces with paediatrics and with neuro-ophthalmology and involves the teatment of strabismus, or squint, where the eyes are not aligned with one another. The treatment may be orthoptic (orthoptics is discussed in more detail in Part 2) or surgical. More recently, the use of botulinum toxin injections has come in to prominence, particularly in adult squints.
Orbital, plastics and lacrimal disease Also known as adnexal disease, this involves the treatment of the structures around the eyes such as the bony orbit, the tear glands, the tear ducts and the eyelids. Common examples include droopy eyelid, eyelid tumours, thyroid eye disease and restorative surgery in patients with artificial eyes. Potential difficulties arise in these areas because of territorial disputes. For many years in the UK diseases in these regions have been successfully treated by general plastic surgeons and neurosurgeons, whereas elsewhere in the continent and in the USA there is a longer history of oculoplastic surgery. This is another area of emergence of interdisciplinary care within “head and neck” teams involving general plastic surgeon, neurosurgeon, ENT surgeon, maxillofacial surgeon and oculoplastic surgeon (6).
Advantages of subspecialisation It has been suggested that subspecialisation positively influences the delivery of a high standard of care. The restriction of the area of expertise makes it more practicable for the practicioner to stay academically current in his area of expertise, to maintain fluency in the treatment of large numbers of patients with relevant disorders, and to carry out meaningful clinical research and audit. Subspecialisation thus provides one of the most appropriate ways of developing, promoting and expanding a field (7).
Disadvantages of subspecialisation Obtaining subspecialist training is expensive. The training costs are often borne by the individual undergoing the training, who may reqire to spend a period overseas for exposure to the cutting edge of the subspecialty. Scholarships are available from some sources, and the more responsible trusts may identify areas of need within their own services and send suitably qualified individuals for training while keeping their posts open or preserving their salaries. The limited number of appropriately trained subspecialists has implications for clinical governance and revalidation; it is unlikely that a paediatric ophthalmologist, for example, will be able to objectively revalidate a glaucoma specialist. The decline of the generalist clinician carries the risks of inappropriate diagnosis and referral (7), and makes the task of finding an expert more difficult for the legal professional.
The period of training in the UK system formerly lasted eight to ten years, but has now been superceded by the Calman Report (8), based on European specialist training programmes, which compresses surgical training into a period of four years. This means that ophthalmologists coming through the system nowadays have, relatively speaking, more subspecialised knowledge and less general knowledge of the specialty than ever before. This enhances the difficulty facing the legal professional in finding an expert with practical knowledge in the subspecialty field of the case.
References (1) Global initiative for the elimination of avoidable blindness. WHO Information Factsheet No. 215, 1999. (2) Fielder AR, Bentley C. Recent advances: Ophthalmology. Br Med J 1999: 318; 717-720. (3) Shuttleworth GN, Marsh GW. How effective is undergraduate and postgraduate teaching in ophthalmology? Eye 1997; 11: 744-750. (4) Sheldrick JH, Wilson AD, Vernon SA, Sheldrick CM. Management of ophthalmic disease in general practice. Br J Gen Pract 1993; 43: 459-462. (5) Rogers v Whitaker (1992) 109 ALR 625 at 633, [1993] 4 Med LR 79 at 83 (High Court of Australia), per Mason CJ et al. (6) Jones N. Craniofacial trauma. Oxford University Press, 1997. (7) Lumley JS. Subspecialisation in medicine. Ann Acad Med Singapore 1993; 22: 927-933. (8) Working group on specialist medical training. Hospital doctors: training for the future. NHS Executive. May 1995.
