Ophthalmology

Basic Specialist Training (BST) in Ophthalmology will be for 3 years, with trainees taking the Associated Fellowship of the Royal College of Surgeons in Ireland (Ophthalmology) AFRCSI Ophth after a minimum of 18 months training.

Entry Requirements

Prior to their entry into BST, doctors must have completed both a pre-registration year and a period of post-registration general professional training, preferable in specialties relevant to ophthalmology, such as neurology, is desirable.

Basic Specialist Training will be undertaken by those at Senior House Officer level. The training will consist of 3 years in recognised training posts in the following units.

• Dublin South Hospitals - RVEEH, Crumlin, St. Vincent’s
• Dublin North Hospitals - Mater, Beaumont, Temple Street
• Cork Regional Hospital
• Galway Regional Hospital
• Limerick Regional Hospital
• Waterford Regional Hospital

There are 24 SHO training posts available in Ireland. Acceptance for appointment will be by competition.

Basic Specialist Training will be for a minimum of 3 years. All trainees (SHOs) working in Ophthalmology in recognised units will be issued with a logbook by the Irish College of Ophthalmologists. All trainees will have an in-house assessment every six months.

Trainees will be interviewed during their third year by a panel consisting of the officers of the Irish College of Ophthalmologist, the Chairman of the Manpower, Education and Research Committee and the Chairman of the Medical Eye Specialist Group. Those wishing to pursue a career in Ophthalmology will be assigned specific modules to include medical retina, paediatric ophthalmology, anterior segment, neuro-ophthalmology and medical ophthalmology. The modules assigned to a particular trainee will be linked to their previous experience. Specialist registration will be at a minimum of 4 years. The AFRCSI must be obtained before applying for registration. The EBOD (European Board of Ophthalmology Diploma) is recommended.

Ophthalmic Surgery

Trainees who wish to enter Higher Surgical Training will be eligible to apply after a minimum of 2 years of Basic Specialist Training (Royal College of Ophthalmologists).

Entry Requirements for Higher Surgical Training (HST)

1. AFRCSI or equivalent
2. Microsurgical skills course
3. Documented evidence of surgical procedures
   (a) 50 intraocular procedures
   (b) 50 miscellaneous
   (c) 50 Laser procedures
   See enclosed list

Basic Specialist Training Programmes in Ireland

• Mater Hospital Dublin and University Hospital Galway
• Cork University Hospital, Limerick Regional Hospital and Waterford Regional Hospital
• Royal Victoria Eye and Ear Hospital Dublin, St. Vincent’s Hospital Dublin and it is proposed that Sligo General Hospital will link with this group.

Basic Specialist Training in Ophthalmology
Surgical Procedures

N.B Intraocular procedures and strabismus surgery for Higher Surgical Training only (3 and 4).

Postgraduate Training in Ophthalmology in Ireland

It is the policy that Fellowships should be taken the last 6 months and not during modular training.
Trainees who wish to stay a further 6 months may complete 5 years as a Specialist Registrar.

N.B. Academic appointments can be recognised for Higher Training as long as educationally approved.

Educational Objectives for Ophthalmic Senior House Officers

To obtain a comprehensive training in the knowledge of ophthalmology, including the basic sciences and management of common diseases affecting the eyes.

To attend the participate in the Teaching Programme.

To develop communications skills and a sympathetic and caring approach to patients and their relatives.

To develop skills in clinical assessment and become competent in:

• History taking
• Examination of the eyes and surrounding structures
• The use of diagnostic instruments including the direct and indirect ophthalmoscope, retinoscope, slit-lamp, tonometer and diagnostic fundus and contact lenses.

To learn the concepts and principles of refraction.

To received training in orthoptics and the examination of children with eye disorders.

To be familiar with a number of practical procedures including syringing tear ducts, removal of corneal foreign bodies and minor lid procedures.

To gain experience in ophthalmic surgery and be introduced to microsurgical techniques.

To become familiar with the use of laser in ophthlamology.

To be able to carry out investigative techniques including visual field assessment, ocular biometry and keratometry.

To receive guidance in the counseling of patients who are partially sighted or blind and be aware of the support services available.

To work towards and be encouraged to sit the Royal College of Ophthalmology examination leading up to the Final Fellowship.

To develop future career plans.

To participate in medical audit meetings.

To understand the principles and practice of medical research.

To acquire a knowledge of the process of management

The Affiliated Fellowship in Ophthalmology ExaminatIon

The AFRCSI Ophth. Examination comprises of:

• Part I - Basic Science
  
  The new Part 1 examination will be very similar to the present FRCSI Section A in Ophthalmology examination and will assess a wide range of knowledge in basic science.
  The examination content will include anatomy and embryology of the head and neck, including the central nervous system and, in particular, the visual system. Knowledge of the general principles of physiology will be required, with an emphasis on their relation to the visual system.
  In addition to this, a basic understanding of the physics of light (including optics) will be required as well as knowledge of genetics, molecular biology, pharmacology, immunology and pathology. Questions on basic statistical methods may also be included.
  
  
• Part 2 - Clinic Methods
  
  An understanding of the theoretical aspects of refraction and the practical ability to perform this are essential for all ophthalmologists, and optics and refraction will form half of the Part 2 examination.
  In the practice of clinical medicine, it is imperative that the patient be correctly assessed from both the point of view of taking a history and performing an examination. In addition, it is important that investigations can be accurately assessed. For this reason, the second half of the Part 2 examination will consist of clinical methods. There will be a written part to this examination and the practical part of the examination will be conducted as an objectively structured clinical examination (OSCE). Following successful completion of the second part of the Associated Fellowship, the trainee will be thoroughly competent to assess any patient presenting with an ophthalmic problem.
  
  
• Part 3 - Clinical
  
  The Part 3 examination will replace the former final fellowship examination. This part of the examination will be mainly clinical but will include an oral examination in ocular pathology.
  After the successful completion of all three parts of the examination, the trainee will be considered to have reached a high standard of ophthalmic practice and will then be eligible to complete for a place in Higher Surgical Training.
  

Limits on attempts: Candidates must successfully complete the examination within two years of first attempting Part 3.

Curriculum of Basic Specialist Training in Ophthalmology

1. Accident and Emergency Ophthalmology
2. Disorders of the lids, lacrimal drainage apparatus, adnexae and orbit
3. External eye disease, sclera, cornea and anterior uvea
4. Disorders of refraction, the crystalline lens and zonules
5. Disorders of aqueous production and drainage
6. Vitreoretinal disorders
7. Medical retinal and choroidal disorders
8. Disorders of the optic disc and visual pathway
9. Ocular motility, strabismus, amblyopia and diplopia
10. Disorders of the eye and visual system affecting children

1. Accident and Emergency Ophthalmology

Essential topics/experience
To have become familiar with the following:

• Superficial ocular trauma: including assessment and treatment of foreign bodies, abrasions and minor lid lacerations
• Severe blunt ocular injury: management of hyphaema - recognition and initial management of more severe injury.
• Severe orbital injury: recognition and initial care of corneal and scleral wounds; recognition of acqueous leakage and tissue prolapse.
• Retained intraocular foreign body; anticipation from history, confirmation of X-ray and CT scan.
• Sudden painless loss of vision; recognition of retinal arterial occlusion, central retinal vein occlusion, acute ischaemic optic neuropathy, optic neuritis, urgency of treatment.
• Severe intraocular infection; recognition and initial investigation and management of hypopyon.
• Acute angle closure glaucoma; recognition and acute reduction of intraocular pressure.
• Liaison with Radiological department, Microbiologist, ENT and Faciomaxillary surgeons.

Practical Skills
To have undertaken (under supervision until proficient) the following:

• Removal of superficial foreign bodies
• Corneal epithelial debridement
• Repair of minor conjunctival/lid lacerations
• YAG iridotomy

Background theory/principles
To have gained an awareness of the following:

• Eye protection and prevention of injury
• Lateral canthotomy and inferior cantholysis for retrobulbar haemorrhage
• Chemical/alkali burns of the conjunctiva and cornea
• · Drug penetration into the eye and vitreous
• Use of intravitreal antibiotics, including dosage and potential complications

2. Disorders of the lids, lacrimal drainage apparatus, adnexae and orbit

Essential topics/experience
To have become familiar with the following:

• Abnormal lid position; including assessment of ectropion, entropion, ptosis, trichiasis, lagophthalmos and exposure.
• Abnormal lid swelling, including chalazion, stye, retention cysts, papilloma and basal cell carcinoma.
• The watering eye, including the distinction between excessive lacrimation and epiphora, blepharitis, recognition and investigation of nasolacrimal obstruction.
• Orbital swelling, including dysthyroid eye disease, distinguishing intraconal from extraconal space-occupying lesions, orbital cellulitis, recognition of compressive optic neuropathy.
• Liaison with Neurosurgeons, ENT, Endocrinologists and prosthetic service.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Use of exophthalmometer
• Syringing and probing
• Incision and curettage for chalazion
• Wedge biopsy and removal of papilloma, etc.
• Tarsorrhaphy
• Electrolysis/cryotherapy for trichiasis
• Surgery to involutional ectropion/entropion

Background theory/principles
To have gained an awareness of the following:

• Sebaceous carcinoma of lid and squamous cell carcinoma
• Cicatricial malposition of the lids
• Management of ptosis and blepharospasm
• Canaliculus repair
• Dacryocystorhinostomy
• Orbital and lacrimal tumours and their treatment
• Inflammatory orbital and lacrimal diseases and their treatment
• Paranasal sinus disease
• Use of radiographs, MRI, CT scan
• Enucleation, evisceration and fitting of prosthesis
• Excenteration

3. External eye disease, sclera, cornea and anterior area

Essential topics/experience
To have become familiar with the following

• Infectious external disease, including viral, bacterial and chlamydial conjunctivitis.
• The dry eye, including symptoms, assessment of reduced tear production and tear film stability and treatment.
• Allergic and atopic eye disease recognition and management.
• Corneal ulceration from viral and bacterial disease, marginal keratitis.
• Complications of contact lens wear.
• Corneal oedema, opacity and ectasia, indications for corneal transplantation, standards of care in donor eye procurement, signs of corneal graft rejection and other complications.
• Epislceritis, recognition and management.
• Anterior uveitis, including classification, differential diagnosis, systemic associations, investigations and treatment.
• Liaison with microbiology, immunology.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Conjunctival sampling and corneal scraping for microbiological investigations.
• Pachometry for corneal thickness.
• Keratometry and Placido’s disc.
• Removal of corneal sutures.
• Retrieval of donor eyes for transplantation (5)

Background theory/principles
To have gained an awareness of the following:

• Acanthamoeba keratitis and fungal keratitis
• Cicatricial conjunctival disease.
• Punctal occlusion
• Corneal topography and specular microscopy
• Corneal stromal dystrophies, interstitial keratitis.
• Corneal biopsy, indications.
• Chemical injury of the cornea and conjunctiva.
• Therapeutic contact lenses and their complications.
• Corneal transplantation, immunology of rejection.
• Limbal stem cell transplantation.
• Autoimmune corneal and scleral disease including peripheral ulcerative keratitis.
• Use of immunosuppressive therapies.
• Management of pterygium.
• Conjunctival and uveal tumours.
• Aniridia and other dysgenesis.
• Fuch’s heterochromic cyclitis.

4. Disorders of refraction, the crystalline lens and zonules

Essential topics/experience
To have become familiar with the following:

• Ametropia, including hypermetropia, myopia, astigmatism and their complications.
• Accommodation problems, including spasm and presbyopia.
• Lens opacifications, including types of cataract, relationship of opacity to symptoms, contribution to visual loss in co-morbidities, systemic associations, cataract surgery and its complications.
• Pseudoexfoliation of the lens capsule, including its recognition and significance.
• Calculation of intraocular lens power, according to the patient’s needs.
• Liaison with contact lens service.

Practical Skills
To have undertaken (under supervision until proficient) the following:

• Retinoscopy with trial lenses and subjective refraction.
• Correction of refractive error by spherical, cylindrical and multi-focal lenses.
• Lens neutralisation and use of focimeter.
• Biometry and keratometry for intraocular lens calculation.
• Surgery for routine cataract, including extracapsular extraction and phacoemulsification with intraocular lens insertion, management of intra-operative complications (50 cataracts or other intraocular procedures).
• YAG laser posterior capsulotomy (20).

Background theory/principles
To have gained an awareness of the following:

• Basis of spectacle intolerance from poor dispensing or defective prescription.
• Use of logMAR charts in assessment of acuity.
• Alternatives to capsular IOL fixation.
• Combined cataract and glaucoma/corneal transplantion surgery.
• Ectropia lentis and Marfan’s syndrome.
• Contact lenses and refractive surgery.
• Therapeutic contact lenses.
• Fluidics and ultrasonics.
• Intraocular lens design and biomaterials.

5. Disorders of aqueous production and drainage

Essential topics/experience
To have become familiar with the following:

• Glaucomatous optic neuropathy, recognition and investigation.
• Glaucoma suspects, including ocular hypertension.
• Rubeotic glaucoma recognition, differential diagnosis and management.
• Hypotensive agents, topical and systemic drugs affecting intraocular pressure and their complications.
• Glaucoma drainage surgery, indications, complications and their treatment.
• Hypotony, including its causes and consequences.
• Liaison with glaucoma shared care schemes.

Practical Skills
To have undertaken (under supervision until proficient) the following:

• Applanation tonometry
• Assessment of peripheral and central anterior chamber depth, including pachometry.
• Assessment of irido-corneal angle structures by gonioscopy.
• Methods of optic disc cup measurement.
• Visual field testing, including Goldmann/kinetic perimetry and automated static perimetry.

Background theory/principles
To have gained an awareness of the following:

• Risk factors for primary open-angle and normal-tension glaucoma
• Other secondary glaucomas, including phacolytic, pigmentary, erythroclastic, pseudo-exfoliative and silicone-oil glaucomas.
• Posner Schlossman syndrome.
• Chronic closed angle glaucoma.
• Malignant glaucoma
• Tonopen, Perkins and non-contact tonometry.
• Scanning laser ophthalmoscopy and nerve fibre layer analysis
• Argon laser trabeculoplasty
• Prevention of glaucoma bleb failure e.g. using anti-metabolites
• Drainage tubes and stents.
• Cycloablation.

6. Vitreoretinal disorders

Essential topics/experience
To have become familiar with the following:

• Flashes and floaters, complications of posterior vitreous detachment and recognition of retinal tears.
• Vitreous haemorrhage, from retinal tears or neovascularization – initial management.
• Retinal detachment, classification, predisposition, recognition and urgency of treatment, recognition of proliferative vitreoretinopathy.
• Senile/acquired retinoschisis, - recognition.
• Liaison, with Low Vision services.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Scleral indentation with indirect ophthalmoscopy.
• Retinal drawing
• Cryopexy and laser (via slit-lamp and indirect ophthalmoscope delivery systems) for retinal tear.

Background theory/principles
To have gained an awareness of the following:

• B-Scan ultrasound for opaque media.
• Vitreoretinal surgery, including closed intraocular microsurgery, scleral buckling and internal tamponade.
• Intraocular foreign body, complications and management.
• Other vasoproliferative vitreoretinopathies including sickle cell retinopathy, retinopathy of prematurity, Eales’ disease.
• Genetic vitreoretinal disease – Stickler syndrome, X-linked retinoschisis.
• Asteroid hyalosis
• Choroido-retinal coloboma

7. Medical Retinal and Choroidal disorders

Essential topics/experience
To have become familiar with the following:

• Diabetic retinopathy, classification, screening strategies, management.
• Hypertensive and arteriosclerotic retinopathy, including macroaneurysms and branch retinal vein occlusion.
• Retinal vascular occlusions, recognition of ischaemic and exudative responses, rubeosis.
• Macular diseases, including recognition of age-related maculopathy, subretinal neovascularization, cystoid macular oedema, macular hole, related symptomatology and urgency of treatment.
• Fluorescein angiography, indications, complications and interpretation.
• Liaison with diabetologists, vascular surgeons and low vision services.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Assessment of macular function (Amsler Chart, Watske Allen slit beam test)
• Scatter laser photocoagulation of the peripheral retina (20)

Background theory/principles
To have gained awareness of the following:

• Fundus imaging including scanning laser ophthalmoscopy.
• Indocyanine green angiography.
• Electrodiagnostic tests and dark adaptation.
• Genetic retinal disease, retinal dystrophies, retinoblastoma.
• Differential diagnosis and treatment of malignant melanoma.
• Macular laser photocoagulation, principles and laser safety.
• Toxic maculopathy and central serous retinopathy.
• Intraocular lymphoma.
• Intermediate and posterior uveitis, toxoplasmosis, toxocara and sympathetic ophthalmia, retinal vasculitis.
• Coats’ disease, other telangiectasis and the retinal phakomatoses.
• AIDS-related opportunistic infections and anti-AIDS treatment.
• Low vision aids, including optic principles and fitting.

8. Disorders of the optic disc and visual pathways

Essential topics/experience
To have become familiar with the following:

• Swollen optic disc, differential diagnosis, recognition and evaluation of papilloedema, ischaemic optic neuropathy (arteritic and non-arteritic), acute optic neuritis and congenital optic disc anomalies.
• The atrophic optic disc, recognition and differential diagnosis, clinical evaluation of optic nerve function.
• Visual pathway disorders, identification of site and nature of lesion from history, examination and investigations, transient ischaemic attacks.
• Liaison with neurologists, neurosurgeons, endocrinologists and vascular surgeons.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Goldmann visual fields
• Examination of the cranial nerves
• Temporal artery biopsy

Background theory/principles
To have gained an awareness of the following:

• Benign intracranial hypertension
• Compressive optic neuropathy
• Optic nerve glioma
• Chiasmal lesions
• Visual evoked responses
• Neuro-imaging including CT, MRI and carotid doppler
• Carotid endarterectomy
• Multiple sclerosis and its ophthalmic manifestations
• Higher cortical dysfunction, including the visual agnosias.

9. Ocular Motility, Strabismus, Amblyopia and Diplopia

Essential topics/experience
To have become familiar with the following:

• Concomitant strabismus, screening strategies, epicanthus, accommodative aspects, interpretations of orthoptic report, indications for surgery.
• Amblyopia, anisometropic, stimulus-deprivation, strabismic prevention and treatment using occlusions.
• Incomitant strabismus, cranial nerve palsies including diabetic mononeuropathies, significance of painful third nerve palsy and of pupil sparing, prediction of post-operative diplopia.
• Liaison with neurologists, orthoptists.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Eye movement evaluations
• Cover test (including alternate and prism)
• Stereo tests
• Cycloplegic refraction
• Horizontal muscle surgery

Background theory/principles
To have gained an awareness of the following:

• Nystagmus
• Ocular motility syndromes (Duane’s, Brown’s)
• Use of botulinum toxin
• Ocular myopathies and the neuromuscular junction
• Supranuclear eye movement disorders
• Fresnel prisms
• Oblique muscle, vertical muscle and adjustable suture surgery
• Electromyography.

10. Disorders of the Eye and Visual System affecting children

Essential topics/experiences
To have become familiar with the following:

• The approach to infants, children and their parents.
• Ophthalmia neonatorum, diagnosis and management.
• Congenital nasolacrimal obstruction: recognition and management
• Ametropia in children, significance and treatment
• The apparently blind infant, normal and delayed visual maturation
• Liaison with paediatricians, geneticists.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Assessment of vision in children, fixation, preferential looking, single and linear optotype tests.
• Cycloplegic refraction and prescribing for children.
• Fundoscopy in children.

Background theory/principles
To have gained an awareness of the following:

• Congenital nystagmus
• Ocular albinism
• Congenital glaucoma, diagnosis and management.
• Congenital cataract, diagnosis and management including prevention of amblyopia.
• Leucocoria, differential diagnosis including retinoblastoma.
• Retinopathy of prematurity, screening and treatment.
• Genetic and developmental disorders, Leber’s amaurosis, X-linked schisis, Coats’ disease.
• Paediatric neurological diseases.
• Presentation of raised intracranial pressure in infancy and childhood.
• Ophthalmic signs of child abuse
• Orbital cellulitis presenting in children.
• Orbital tumours in children, including rhabdomyosarcoma.
• Services for the rehabilitation of the visually disabled child.