Emergency Department Ophthalmology – A Foundation Doctor Perspective

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Those interested in a career in ophthalmology should aim to maximise their exposure during the early years of their training, allowing the acquisition of important skills unique to this area of medicine. However, clinical exposure during medial school is often limited, with most undergraduate courses including 10 days or fewer of ophthalmology attachments and teaching [1]. Furthermore 56% of foundation doctors would have liked more ophthalmology exposure prior to starting their jobs [2]. This demonstrates a significant and common knowledge and skills gap upon graduation, that those with an interest in ophthalmology may need to address prior to specialty training.

Importantly, Foundation posts in ophthalmology are less common than those in many other specialties. Therefore, experience at Foundation level, and by extension, any experience prior to applications, can be difficult to achieve in the specialty, leaving many potential applicants without valuable clinical experience.As such it is important for those with an interest in ophthalmology to consider other options to maximise their exposure to ocular pathology throughout their foundation training.

Foundation posts in the emergency department are one way to address this problem, as they allow experience in management of acute ocular pathology outside of a specialist service.

Ophthalmology in the Emergency Department

Presentations with the acutely red eye account for around 4% of primary care consultations and are a common presenting complaint in the adult emergency department [3]. These cases often have a wide differential diagnosis initially and provide excellent experience and learning opportunities for those with an interest in ophthalmology. In addition, ocular and adnexal trauma represents a considerable proportion of presentations to the emergency department, and there are many such presentations to the Urgent Care Centre or Minors areas [4].

A comprehensive understanding of neuroanatomy and pathophysiology is of great value in the field of ophthalmology, and there is often considerable overlap between neurological and ophthalmological presentations to the emergency department. This again represents a great opportunity to investigate, diagnose and manage neuro-ophthalmological complaints, especially as neuro-ophthalmological diagnoses represent the 2nd most common sub-specialty in patients referred to an ophthalmology service, second only to corneal diagnoses [5].

As such, the emergency department can be an excellent setting for the refining of essential ophthalmological skills including ophthalmological history taking, fundoscopy and slit lamp examination and the use of topical medications.

Maximising the Emergency Department experience:

I was fortunate enough to have an excellent experience throughout my Emergency Department Foundation rotation. I was well supported by senior colleagues in furthering my ophthalmological experience and was exposed to a range of pathologies from corneal ulcers to canaliculitis to orbital fractures. This has given me confidence in the diagnosis and management of common ocular pathologies, which I look to build upon as my training progresses. Based on my own experience, the following advice will help to make the most of the emergency department rotation:

1. Seek out supportive supervisors or senior colleagues

Discussing your career goals and your aims for your emergency department rotation with your clinical or educational supervisor is an important step. They will be able to advise how to maximise your exposure and learning from ophthalmic presentations and may be able to direct you to further educational resources and members of staff with similar interests.

2.Ensure early familiarity with equipment

It is possible that many Foundation Emergency doctors have not used a slit lamp since learning to do so at medical school, as may be the case with other pieces of equipment. Early refreshing and practicing of technique with support fosters confidence to effectively examine patients. Seniors, both doctors and Emergency Nurse Practitioners, are an invaluable source of information and guidance in this.

3. Maximise Ophthalmology Shadowing opportunities

Emergency Department rotas can often be challenging in their variety of shift timings. However, one benefit this provides is the opportunity to shadow ophthalmology clinics, which can be hard to access in rotations in other specialties, and attendance at which can score portfolio points at interview [6]. Attending clinic allows exposure to more chronic ophthalmological conditions and may offer a supportive environment to practice clinical skills and become involved in research or audit work.

Conclusion

Many foundation doctors with an interest in ophthalmology will be unable to work in a dedicated ophthalmology rotation and feel that their clinical exposure to the specialty is less than desired. If approached correctly, an Emergency Medicine rotation can be the source of valuable learning opportunities in this field and should be strongly considered by all applicants.

References

  1. Sheth T, Thia B, Wong N. The state of ophthalmic education in medical schools: a UK perspective. MedEdPublish. 2018 May 31;7.
  2. Survey of current ophthalmology undergraduate teaching in the United Kingdom, EyeNews, 2019.https://www.eyenews.uk.com/features/ophthalmology/post/survey-of-current-undergraduate-ophthalmology-teaching-in-the-united-kingdom
  3. Dart JK. Eye disease at a community health centre. Br Med J (Clin Res Ed). 1986 Dec 6;293(6560):1477-80.
  4. Nash EA, Margo CE. Patterns of emergency department visits for disorders of the eye and ocular adnexa. Archives of ophthalmology. 1998 Sep 1;116(9):1222-6.
  5. Oh DJ, Kanu LN, Chen JL, Aref AA, Mieler WF, MacIntosh PW. Inpatient and Emergency Room Ophthalmology Consultations at a Tertiary Care Center. Journal of ophthalmology. 2019 Feb 14;2019.
  6. Severn Postgraduate Medical Education – Portfolio Review. Health Education England, NHS, 2019.
    http://www.severndeanery.nhs.uk/recruitment/vacancies/show/ophth-1-2020/portfolio-review-lib

Author

Dr James E Hazelwood FY2 Chelsea and Westminster Foundation Trust

Edited by EyeducationUK

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