• What to Expect: The Practice of Ophthalmology

  • Most ophthalmologists practice a mixture of medicine and surgery, ranging from lens prescription and standard medical treatment to the most delicate and precise surgical manipulations. The average American general ophthalmologist spends approximately four days per week in the office performing primarily medical ophthalmic functions and one day in the operating room. In a typical workweek, the ophthalmologist will see more than 100 patients and perform three or more major surgical procedures. Cataract removal is the most commonly performed ophthalmic surgical operation.

    In addition to managing local ocular disease, the ophthalmologist interacts with other physicians. Many systemic diseases have ocular manifestations, and the ophthalmologist may be prominently involved in both the diagnosis and management of these conditions.

    A prospective ophthalmologist should keep in mind that a typical ophthalmic practice involves the treatment of patients with vision-threatening diseases. These patients often believe (correctly or incorrectly) that they are going blind. Dealing with the prospect of vision reduction or loss presents a unique challenge that can be highly stressful and frustrating for both physician and patient. The ophthalmologist must be prepared to offer the patient compassion and understanding as well as clinical expertise.

    Those considering the field should also be aware that certain visual and motor abilities are necessary for effective clinical and surgical practice. Ideally, an ophthalmologist will have good fine motor skills, depth perception and color vision. Impairment of these abilities may interfere with the effective use of essential ophthalmic instruments, such as the indirect ophthalmoscope and the operating microscope.

    Like many other specialties, ophthalmology has undergone considerable subspecialization. At first glance, the proliferation of subspecialties dealing with such a small sensory organ may seem excessive. However, the development of many highly sophisticated methods of diagnosis and therapy has resulted in the establishment of important discrete areas of interest. Although most ophthalmologists choose to practice general ophthalmology, many decide to pursue a subspecialty area. Many residents who are interested in working in an academic center choose to take additional post residency training (i.e., a fellowship) in a subspecialty area. Others choose to do so either because it fits with the community needs where they hope to practice, or purely out of a passion for the subspecialty field.

    The Job Market

    Future demand for ophthalmology, as for the other specialties, will depend on the advances of medicine and how fast new procedures and techniques can be made available to meet the needs of the public. Ophthalmology has enjoyed more than its share of scientific and technological breakthroughs in medicine. As such, there are locations throughout the country with relative shortages and others with relative surpluses of comprehensive (general) ophthalmologists and ophthalmologic subspecialists.  Overall, from a manpower perspective, ophthalmology continues to be an attractive field of medicine with great opportunities.

    Ophthalmic Subspecialties

    Ophthalmologists can choose from several different areas of specialty. Those who choose comprehensive ophthalmology treat a range of conditions and patients. Many ophthalmologists choose to focus on one of several subspecialties, however.

    Cornea and External Disease

    This subspecialty involves the diagnosis and management of diseases of the cornea, sclera, conjunctiva and eyelids, including corneal dystrophies, microbial infections, conjunctival and corneal tumors, inflammatory processes and anterior ocular manifestations of systemic diseases. Training in this area frequently includes corneal transplant surgery and corneal refractive surgery to correct refractive errors. 

    Cataract and Refractive Surgery

    A relatively new subspecialty within ophthalmology, this field involves the surgical management of refractive errors in the human eye. Training in this specialty is sometimes included in corneal and external disease fellowships and uses some of the most recent technological advances within the field of ophthalmology.

    Glaucoma

    This subspecialty includes the treatment of glaucoma and other disorders that may cause specific types of ophthalmic damage, usually associated with increased intraocular pressure and ultimately manifesting typical optic nerve changes. This area involves the medical and surgical care of both pediatric and adult patients, including new laser applications and implantation of drainage devices.

    Uveitis and Ocular Immunology

    The term “uveitis” describes inflammation of the middle layer of the eye, which consists of the iris, the ciliary body and the choroid. This subspecialty involves the medical diagnosis and management of immune-mediated conditions of the eye. A subspecialist in this field has advanced training in ocular immunomodulatory therapy and frequently works closely with rheumatology and immunology specialists.

    Vitreoretinal Diseases

    This subspecialty involves both the medical and surgical treatment of retinal and vitreoretinal disease. The types of diseases treated include manifestations of local, systemic and genetic diseases as they affect the retina and vitreous. Diagnosis involves the use and interpretation of ultrasound, fluorescein angiography and electrophysiology. Treatment methods include laser therapy, cryotherapy, retinal detachment surgery and vitrectomy (removal of the vitreous).

    Ophthalmic Plastic Surgery

    The practice of ophthalmic plastic surgery includes orbital surgery, cosmetic lid surgery and lid and upper facial reconstructive procedures following trauma and tumors. Oculoplastic surgeons combine ophthalmic surgery with plastic surgery and are trained in the use of radiotherapy, chemotherapy and chemosurgery to treat ocular and orbital disease. 

    Pediatric Ophthalmology

    The bulk of pediatric ophthalmic practice involves the medical and surgical management of strabismus, amblyopia, genetic and developmental abnormalities and a wide range of inflammatory, traumatic and neoplastic conditions occurring in the first two decades of life. This subspecialty also deals with the ocular manifestations of certain systemic disorders. Pediatric ophthalmologists frequently treat adult ocular motility disorders as well.

    Neuro-Ophthalmology

    Involving the relationship between neurologic and ophthalmic diseases, neuro-ophthalmology also deals with local pathology affecting the optic nerve and visual pathways. Over 50 percent of all intracranial lesions involve the visual or oculomotor pathways. Neuro-ophthalmology is generally practiced as a nonsurgical subspecialty but can be combined with surgery of the eye and orbit.

    Ophthalmic Pathology

    The ophthalmic pathologist has training in both ophthalmology and pathology, typically in that order. Because of the unique combination of skills involved in this subspecialty, it is usually the ophthalmic pathologist (rather than the general pathologist) who examines tissue specimens from the eye and adnexa.