Ophthalmology
A Pathways Through Medicine Article by Justin Koh
Introduction:
Almost anyone would agree that our sense of vision offers the most useful information about our world. In the second century AD, Galen once referred to the eye as “the most divine organ” – after all, despite the eye’s drastic importance in our everyday lives, ophthalmology as a science is only about 200 years old and many of today’s standard surgical methods were only developed within the past 5-10 years (The History of Ophthalmology). With a unique blending of both medical and surgical techniques in their art, ophthalmologists enjoy a world of clean, efficient microscale surgeries and medical interventions in one of the most exciting sectors of modern medicine.
Ophthalmology Today:
Modern ophthalmology encompasses a wide range of conditions and their respective treatments, including glaucoma, cataracts, diabetic retinopathy, retinal detachment, macular degeneration and refractive conditions – the extent of treatable conditions and treatment plans is growing dramatically. As previously mentioned, the treatments for these conditions include both medical and surgical means, making an ophthalmologist’s treatment repertoire remarkably broad. Dr. Christopher Andreoli of The Massachusetts Eye and Ear Infirmary noted that the scope of treatable disease is continually advancing and that many of these conditions were not considered surgical diseases 5-10 years ago.
Surgery:
I had the opportunity to observe Dr. Andreoli during a surgery to correct an elderly patient’s diabetic retinopathy and retinal detachment. The surgery was performed in a darkened operating room – the patient lay on the table completely draped except for her affected eye. The surgical site had been given local anesthetic and the patient was awake as the surgery progressed.
The operation itself was conducted under a powerful microscope with 3 viewports – one for the physician, one for the resident working with him, and a vacant port through which I was able to observe. This surgery involved accessing the vitreous chamber of the eye via a series of canulae less than 2 millimeters in diameter, through which the physician was able to insert a light source, infusion tube and a series of tools, ranging from an ablating tip, to a combined suction/cutting instrument, to a microscale laser tip for sealing the damaged areas during the retinal reattachment. Like laparoscopic surgery, the procedure caused minimal external trauma relative to the extensive work done within the vitreous region. In the end, sealing the wound simply required a few microscopic sutures – with the smaller canula size, the wounds are frequently self-sealing. The entire surgery was remarkably clean and despite the considerable damage her eye had sustained, the patient would regain partial vision and keep the eye.
Dr. Jennifer Sun of the Beetham Eye Institute at the Joslin Center for Diabetes noted that “Everything is getting miniaturized – smaller instruments create smaller incisions and wounds. Much of the surgery, because of miniaturization, involves less manipulation of the eye. Patients recover much more quickly, both anatomically as well as functionally.” Dr. Sun also noted recent advances in surgery site visualization, including brighter light sources that can be inserted into canulae, such as the source utilized in Dr. Andreoli’s procedure above. Such improvements allow hands-free operation, while new lenses allow better wide-field visualization inside the eye to improve surgeons’ mechanical ability to perform surgery while minimizing patient trauma and discomfort from surgery.
Medicine:
Meanwhile, medical interventions for eye conditions are becoming increasingly popular. Dr. Joan Miller, the department chair of Ophthalmology at Harvard Medical School pioneered a photodynamic therapy for the treatment of macular degeneration – a debilitating and blinding condition that used to render patients “untouchable” by ophthalmologists.
Additionally, diabetic retinopathies are now treatable by medical means, with the development of drugs that block the production of Vascular Endothelial Growth Factors (VEGF). VEGF is associated with the formation of new blood vessels, including the extraneous vessels that develop in diabetic patients whose bodies are responding to lacking nutrients to eye tissue. However, the presence of these vessels can disrupt a patient’s vision, and this diabetic retinopathy was previously an entirely surgical concern. With new anti-VEFG medications, however, ophthalmologists need only inject these medications and can observe these extraneous vessels’ degeneration soon after.
These and other breakthroughs have radically changed the landscape of ophthalmology, and this fine balance between surgery and medicine creates unique working conditions for the field. The vibrant energy of this rapidly advancing field has created unique opportunities for practitioners – according to Dr. Nicole Benitah, a senior resident at Massachusetts Eye and Ear Infirmary, the field presents many opportunities for research, while also allowing for international work – “(you) can do a lot of good by going to other countries and performing cataract surgeries, essentially curing blindness for people who would otherwise go blind.”
Challenges and Rewards:
Ophthalmology does present its own challenges and rewards. The primary concern, noted by Dr. Andreoli and Dr. Sun, is that despite the amazing capabilities of modern surgery, many patients may eventually go blind, losing the ability to drive or take care of themselves. Dr. Benitah also noted the difficulty for other doctors in properly diagnosing conditions, given their inexperience with the eye and its physiology. Dr. Miller expressed her academic concerns for the future of research and the education of residents and fellows in today’s questionable economic climate.
However, the field presents numerous rewards for its practitioners. Every doctor interviewed mentioned the unique combination of medical and surgical techniques in their work, while also enjoying the ability to work with patients for the long term, sometimes following patients for as long as 15 to 25 years. Moreover, despite the discouraging occasions of patients losing their vision, the opposite segment of patients show the incredible lengths that ophthalmology has come; the happiness of patients who can see when the eyepatch is removed post-surgery carries its own tremendous rewards.
The Future:
The unique climate for ophthalmology creates an exciting future for the field. In an interview, Dr. Miller noted, “as we understand genetic pathways better, we see other useful targets for these diseases. Specific gene therapies may be difficult to apply to many people, but insights from genetics will lead to therapies that can be applied broadly.” The field is growing with leaps and bounds in both surgical and medical techniques, creating a richly diverse landscape for patient care, all the while presenting a tremendously rewarding opportunity to impact patients’ lives while working with them in long-term doctor-patient relationships.
Words to the Wise:
For the current premedical student:
“Keep your mind open and go into medical school with an interest in anything; Have no preconceived notions and try anything that comes your way – you may be surprised at what you like!”
-Dr. Christopher Andreoli
“Make sure you’re interested in medicine for the right reasons! Make sure it’s something you’re passionate about. It’s not as financially rewarding as it once was, and if you go into it without wanting to work hard and without a real desire to take care of people, you’ll constantly feel tired and overworked. If you enjoy taking care of people, it doesn’t seem like much work.”
-Dr. Nicole Benitah
“There’s much ‘doom and gloom’ about the medical field and people worry about change. Medicine encompasses patient care and the ability to improve function and save lives – there aren’t many fields that allow you to do that. Along the way, there are many pieces that can be added to a practice – research, teaching, working in pharmaceutical companies to develop new pathways. It’s a great career path!”
-Dr. Joan Miller
“Pursue other interests in addition to premed studies that you are passionate about because those are the things you can build into your career that are going to make life fun, worthwhile, and exciting.”
-Dr. Jenifer Sun
Justin Koh is an Editor for the Next Generation and a member of the Harvard Class of 2012
Christopher M. Andreoli, M.D. is a Clinical Instructor of Ophthalmology at Harvard Medical School and is an Active Staff Member of Massachusetts Eye and Ear Infirmary
Nicole Benitah, M.D. is a Senior Resident at Massachusetts Eye and Ear Infirmary
Joan Miller, M.D. is the Henry Willard Williams Professor of Ophthalmology & Chair of the Department of Ophthalmology at Harvard Medical School and is Chief of Ophthalmology at Massachusetts Eye and Ear Infirmary.
Jennifer Sun, M.D. is Chief of the Center for Clinical Eye Research and Trials at the Beetham Eye Institute & Eye Research Section, Joslin Diabetes Center and is an Instructor at Harvard Medical School
References:
“The History of Ophthalmology.” American Academy of Ophthalmomlogy. 30 July 2009. http://www.aao.org/careers/envision/history.cfm?RenderForPrint=1&