When veterinary ophthalmologists enter academia, they assume a
vaguely-defined
responsibility for which they may be incompletely prepared. The majority
of
undergraduate veterinary students will enter the profession as
generalists, theoretically
requiring the most basic ophthalmology education. The ophthalmologist is
usually not
told what to teach, only how many lecture and laboratory hours are
available. Due to
increasing demands by other specialties, these hours are diminishing. With
the increasing
depth of knowledge in all clinical fields, decisions about what to teach
or what not to
teach in the core curriculum are difficult. The purpose of this paper is
to propose a
general philosophy for teaching ophthalmology to undergraduate veterinary
students, and
to offer guidelines for the clinical educator to make the task easier.
The veterinary profession recognizes that every student needs a basic
knowledge of
ophthalmology because ocular problems are common in most areas of clinical
veterinary
medicine. For practical purposes, the emphasis should be on the dog, cat,
and horse.
The students' basic knowledge about these companion animals can be applied
to other
species of interest to them.
Veterinary students and their clinical instructors are often at odds when
defining which
information is worthy of being taught. Students are quick to object if
they think they are
being given material that is too detailed, but may also resent being
informed that some
material will not be covered because it is too specialized.
Early in their training, students should be educated about the mutually
beneficial
relationship between the general practitioner and clinical specialists,
such as the
ophthalmologist. Students should recognize that the two work together to
the advantage
of their clients and patients, as well as themselves. The generalist is
typically the first
veterinarian to evaluate ocular cases, most of which will be external in
nature, such as
conjunctivitis, corneal abrasions/scratches, and eyelid abnormalities. An
interested and
competent general practitioner can usually manage the majority of these
cases
successfully, referring the more complex problems to an ophthalmologist.
In the public
sector, deciding which cases are referred depends both on the generalist's
interest and
skills in diagnosing and treating ocular problems, combined with the
accessibility of a
specialist. The role of the academic clinician is to help students acquire
sufficient
knowledge to know which cases should be referred, and how to diagnose and
treat routine
problems themselves.
The Basic Sciences
The eye is unique in that the majority of problems involving the globes
and their adnexa
can be observed. Ocular structure and function are relatively simple to
evaluate, if the
observer has basic knowledge of anatomy and physiology. The clinical
instructor in
ophthalmology often has a greater appreciation for the value of these
basic sciences than
those actually teaching them in the curriculum. Often, the organs of
special senses are
inserted at the end of anatomy and physiology courses when both time and
patience are
short. Although the ophthalmologist may be the best teacher of ocular
anatomy,
physiology and response to disease, time constraints, and
interdepartmental boundaries
may dictate otherwise.
The following list is not purported to be complete. It is intended to
identic some topics
worthy of inclusion in the basic ophthalmology course work for the
veterinary student.
- Major components of the eye and its adnexa, including their anatomical
relationship to each other.
- Four layers of the cornea, and how this structure maintains its clarity
and heals
itself when injured.
- Basic structure and function of the anterior uvea, including the formation
and
movement of aqueous fluid.
- The lens, its structure, nutrition, how it changes with age, and how it
responds
to injury.
- Major layers of the retina, how they work together for vision, and their
relationship to the optic nerve.
- Anatomy of the eyelids, and what happens during a blink.
- Composition, importance, and critical quantity of the tear film.
- Maintenance of a normal intraocular pressure - and why this is important.
- Ocular embryology.
- Ocular pharmacology.
- The different nerves supplying the eye and the muscles they stimulate, to
understand:
- Maintenance of tear secretion
- Movement of the globe
- Movement of the eyelids
- Movement of the pupil
- Vision
- How the different parts of the eye respond to inflammation.
- Major intraocular and periocular neoplasms.
The Clinical Sciences
Clinical ophthalmology within the professional curriculum should be taught
by a boarded
ophthalmologist. Such a person is best qualified to train the student to
recognize those
problems treatable by the general practitioner, and how to manage them.
The instructor
should be able to explain specialized diagnostic and therapeutic
procedures and equipment
so students comprehend what will be available to their clients. The
generalist needs to
know why he/she is referring a patient.
At the heart of the clinical ophthalmology curriculum, is teaching the
students to perform
adequate ophthalmic examinations. A general practitioner must be able to
do a "fairly"
complete ophthalmic exam in order to assess whether they are capable of
managing a case
independently. Their training should at least include:
A suitable environment for an ocular exam
Effective diagnostic lights
Topical anesthesia
Fluorescein staining
Manipulation of the globe and eyelids
Evaluation of tear secretion
Simple magnification (such as loupes)
Evaluation of intraocular pressure
Evaluate patency of nasolacrimal ducts
The ocular neurologic exam
Evaluation of vision
Some method of ophthalmoscopy
In many schools, in the developing "modern" curriculum, not all students
will complete
an ophthalmology clinical rotation. When this is the case, training in the
"ophthalmic
examination" should be done in a laboratory setting in the core
curriculum. When all
students rotate through ophthalmology, examination techniques can be
discussed and skills
acquired as "on the job" training.
Not all specialists will agree on what should be referred and what not,
and as stated
earlier, a great deal will depend upon the knowledge and skill of the
general practitioner.
In the academic setting, not all clinical teachers will agree on what
should or should not
be taught. The curriculum for any specialty evolves through a combination
of academic
freedom and the time available. Regardless, a basic core of knowledge (or
material) will
emerge, a core that can be added to by an interested/enthusiastic student,
but cannot be
lessened by even the most unappreciative.
A reasonable premise for teaching clinical ophthalmology is that a
competent veterinary
practitioner should be prepared to manage the majority of all
ophthalmology cases. If
such a premise is accepted, then it is the responsibility of the academic
clinician to:
Teach examination techniques to facilitate problem recognition.
Teach which problems fall into each category.
Emphasize therapeutic approaches for those cases they will be
treating.
The following is a list of problems or situations in which the average
general practitioner
should consider offering the client referral to a veterinary
ophthalmologist.
Early evidence of cataracts
Any suspicion of glaucoma
Deep or non-healing comeal ulcers
Any blindness, partial or complete
Anything involving intraocular surgery
Any confusing or nonresponsive ocular or orbital problem
Anytime they lack the appropriate instruments, either for diagnosis or
surgery
Conclusion
As technological advancements have expanded the depth and breadth of our
understanding
of veterinary medicine, the concept of the Renaissance man - or woman -
has become
obsolete. No one can know, or do, everything. Increasingly, academic
programs in
veterinary colleges are faced with the dilemma of which specialty
materials should be left
out or deleted from the curriculum to allow students to graduate within a
realistic period
of time, with knowledge of the basics (but potentially limited skills in
the specialties), and
at a reasonable cost.
Competent, enthusiastic instructors, paired with conscientious, interested
students, remain
the critical, unquantifiable elements in successful education programs.
Ophthalmology is
a significant part of most general practices, so a task of clinical
academicians is to
communicate the importance of the field to the students who will one day
apply it, and
to the administrators and other faculty who determine the number of hours
allotted to its
teaching.