Ophthalmology and Optometry

The distinction between ophthalmology and optometry is a frequent source of confusion. In addition to the fact that both are concerned with eye care, several other factors contribute to this misunderstanding. One source of confusion stems from the fact that optometrists are often referred to as “eye doctors” although, unlike ophthalmologists, they do not have medical degrees.
In addition, as a result of recent legislation state-by-state, organized optometry has been able to expand the powers of various state optometry boards, who then license optometrists to prescribe and administer diagnostic and therapeutic pharmaceutical agents. As a result, organized optometry has politically self-defined an optometrist to be a “primary eye care provider.”

An optometrist receives a Doctor of Optometry (OD) degree and is licensed to practice optometry, not medicine. The practice of optometry traditionally involves examining the eye for the purpose of prescribing and dispensing corrective lenses, and screening vision to detect certain eye abnormalities. In comparison, the scope of an ophthalmologist’s practice is much broader. An ophthalmologist is a medical doctor (M.D.) who specializes in all aspects of eye care including diagnosis, management, and surgery of ocular diseases and disorders. Ophthalmologists also routinely carry out many of the same tasks as optometrists and, although there are almost twice as many practicing optometrists as ophthalmologists, about 1/4 of the nation’s refractions and eye examinations are performed by ophthalmologists.

The difference between the training of an optometrist and that of an ophthalmologist underscores the difference in the range of practice. An optometrist may have only 7 years of post-high school training, consisting of 3 to 4 years of college and 4 years in an optometric college. An ophthalmologist receives a minimum of 12 years of education, which typically includes 4 years of college, 4 years of medical school, 1 or more years of general clinical training, and 3 or more years in a hospital-based eye residency program, often followed by 1 or more years of subspecialty fellowship.

Beyond refractive errors, optometrists have limited exposure in training to patients with eye disorders or health problems. Didactic training in medical, pharmaceutical and ocular subjects averages approximately one year. In contrast, ophthalmologists have a full medical education, followed by extensive clinical and surgical training in ophthalmology, with thousands of hours devoted to care and treatment of sick patients.

The History of Ophthalmology

An Egyptian papyrus (circa 1600 BC) discloses that ophthalmology, in comparison with other medical specialties of the time, was relatively advanced. Many ocular conditions – blepharitis, chalazion, iritis, cataract, trachoma, ophthalmoplegia – were already recognized entities. On the other hand, available treatments were far less sophisticated, including the use of crocodile dung and lizard blood.

In the second century AD, Galen wrote several ophthalmic texts that described the eye as the most divine organ. He theorized that rays proceed from the brain through the optic nerve, retina, lens, and cornea, continuing in straight lines toward the object of regard. These rays would then return in exactly the same path to the lens, where vision was mysteriously manufactured and retransmitted to the brain.

Although the surgeon Susruta performed cataract surgery in India over 2,000 years ago, it was not until the mid-nineteenth century in western Europe that a solid scientific base for the specialty was first established. Significant scientific and medical advances of the period included the development of the ophthalmoscope, an increased understanding of refractive errors and their correction, and a more sophisticated knowledge of visual physiology. The current practice of ophthalmology remains based on a firm foundation of scientific research.

As a consequence of its long history, ophthalmology has witnessed many firsts. In 1864, the American Ophthalmological Society was established as the first medical specialty organization in the United States, and in 1917, ophthalmology became the first branch of medicine to develop specialty board examinations.

A number of medical breakthroughs have been made as a result of research in ophthalmology. For example, the first successful use of antiviral agents was for the treatment of eye disease. In the area of surgery, corneal transplants were the first successful homotransplants.

Other surgical innovations include the development of laser photocoagulation, microsurgery, and the development of techniques for micromanipulation and laser photocoagulation from within the vitreous cavity itself. Modern diagnostic advances range from the use of ultrasound and fluorescein angiography to sophisticated electrophysiology and visual function studies.

These new advances continue to add challenge and excitement to the field, giving every indication that the future of ophthalmology will be as dynamic as its history.

Information Statement: Unique Competence of the Ophthalmologist

Qualified ophthalmologists possess general and unique competence. This competence renders the ophthalmologist capable to diagnose and treat disorders of the eye, adnexae, and visual system, as well as to recognize and appropriately manage their association with systemic disease. Currently approved training for ophthalmologists consists of undergraduate education in science and humanities, graduation from an accredited four year medical school, and a minimum of four post-graduate years of training, at least one year of which is applied to general medical disciplines. Three or more of these years are spent in specialized training in the art and science ophthalmology – a specialized discipline of caring for the eyes and the visual system based on medical principles. Comprehensive medical training and experience permit and foster recognition of the spectrum of normal physical variation, understanding of normal physiologic and pathophysiologic reactions (including cause/effect relationships), knowledge of the boundaries of medical science, judgment to apply accumulated wisdom appropriately, and humanity to attend with honesty and empathy.

Medical conditions affecting the eye require a comprehensive understanding of medical diagnostic and therapeutic principles. Systemic diseases of particular concern include those revealed by the eye, those whose management and course may affect the eye, and conversely, those potentially affected by management of ocular disease. The former relationship is exemplified by two conditions: hypertension and diabetes mellitus. These conditions may be observed in the eye and the eye affected by their treatment. Specifically, hypertensive retinal vascular changes require monitoring and appropriate and timely diagnostic evaluations, and laser treatments and other surgical intervention may be required to preserve sight in those suffering from diabetes mellitus. Glaucoma management illustrates the systemic effects of treatment of ocular disease. Various medications are used in the treatment of glaucoma including beta-blocking agents; carbonic anhydrase inhibitors, and strong miotics (echothiophate). Among the many systemic effects of these agents are respiratory depression, cardiac failure, impotence, blood electrolyte imbalance, profound anemia, kidney stones, psychic and emotional changes, severe fatigue, risks with anesthesia and death.

The spectrum of ophthalmologic disease includes such complex medical conditions as uveitis, glaucoma, degenerative retinal disease, infectious disease, ocular and adnexal tumors, neuro-ophthalmic syndromes including strabismus, central nervous system tumors and vascular disease (stroke), congenital anomalies and disorders, and genetic syndromes. While others may observe signs of complicated medical ophthalmic disease, only the qualified ophthalmologist will comprehensively evaluate, promptly diagnose and appropriately manage these conditions.

Surgical ophthalmic conditions require special competence. Ophthalmic surgical procedures alter, remove, replace, and/or reshape ocular and adnexal tissue for beneficial therapeutic effect by the use of instruments and applied physical forces. Through education and experience, qualified ophthalmologists apply to surgical endeavors comprehensive understanding of ophthalmic and systemic disease and trauma. Through examination, appropriate diagnostic testing and interpretation, surgical judgment (including avoidance of unnecessary procedures and complications), and understanding of the natural history of disease, potential risks, and treatment options are subsumed. Further, the ophthalmologist possesses surgical skill, understands the evolution of the healing process, and diagnoses, monitors and manages complications in an appropriate and timely manner. Ophthalmologists’ operative care encompasses the preoperative and postoperative periods, those times when the patient is at risk from all aspects of the procedure. These attributes set a standard for special competence in ophthalmic surgery.

The unique competence of ophthalmologists is broadly based in medical knowledge and is consistently applied through ophthalmologic medical and surgical skill. This competence is amplified by elevated medical standards, continuity of caring, comprehensive and continuing education, and humanitarian concern for patient welfare. The qualified ophthalmologist brings singular expertise to bear on disease by fusion of comprehensive medical and ophthalmologic capacity, i.e., unique competence