A friend referred a patient to me for treatment of a retinal detachment. I explained to him that my private practice is limited to cataract and refractive surgery and that I do not treat retinal disease. He was surprised and said, “The eyes are the size of walnuts—how can you not treat the whole eye?” In a big city like Los Angeles, I was able to send the patient to one of many local vitreoretinal specialists for successful treatment the very same day. But it got me thinking.
In the past, most ophthalmology residents went into practice after the completion of residency. Today, however, more and more of these newly minted ophthalmologists are seeking fellowship training to subspecialize. We divide up ophthalmology into multiple subfields and we tend to limit our expertise to a specific area. This allows us to have a deeper level of knowledge about a more limited spectrum of disease, but it may also mean that we’re unable to confidently treat a wide range of conditions.
More years of training can be a good thing for many ophthalmology residents, but the key is to retain a wide range of general ophthalmology knowledge even when choosing to subspecialize. This will make you more marketable when seeking your first job, but it will also prove beneficial in the treatment of your patients.
I admire the general ophthalmologists who treat everyone who walks in the door and all conditions that are eye related. While my private practice is limited in scope to cataract and refractive surgery, when I’m at our university-affiliated teaching hospital, I still treat a broad spectrum of conditions while assisting the residents in helping our at-risk population. A recent example is a patient who presented with neovascular glaucoma due to proliferative diabetic retinopathy. This patient had highly elevated intraocular pressure, a cataract, and neovascularization of both the anterior and posterior segments. The patient received an intravitreous injection of anti-VEGF medication and then was taken to the operating room. Cataract extraction with insertion of a posterior chamber intraocular lens was performed, indirect laser panretinal photocoagulation applied, and a glaucoma valve implanted, all in one sitting. In the postoperative period, the patient did well and we initiated intravitreous injection of anti-VEGF and retinal laser treatment in the fellow eye. If I only felt comfortable doing one part of the treatment, such as just the cataract surgery, then this patient would not have done as well. This is why it is critical for me to keep up my general ophthalmology skills.
In many parts of the United States, away from the large cities, there is a need for the general ophthalmologist to feel comfortable treating a wide range of patients and diseases. Access to subspecialists is not easy. To compound the issue, we only graduate about 450 new ophthalmologists in this country per year. There are general ophthalmologists who are able to treat newborns to geriatric patients, ocular surface disease to retrobulbar disease, and everything in between. It’s easy to admire the subspecialist who does an unusual surgical procedure to treat a rare disease, but the toughest job in ophthalmology may actually be that of the general ophthalmologist.