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Chronic Visual Loss

(What’s an Ophthalmologist?)

Wade Graham MD
Assistant Professor TTUHSC
Residency Program Director
Wade’s Top 10 List
Reasons to study Ophthalmology or
consider it as a career
You’re too smart to be an Orthopedic
You can set your alarm clock at 8am
Doing rectal exams is not as much fun as
you might think
Free leftover Botox
Chicks dig Nerds
Intimidate others with obscure
We can’t even spell malpraktise
Hard work ain’t good for you, but money is
You’re already ugly—you might as well be
To pass an upcoming exam
Lecture Outline
We will cover age related macular
degeneration, cataract, and “what it’s
like to be an Ophthalmologist”.
Age related Macular Degeneration is the #1
cause of irreversible blindness in patients
over 50 in the United States
Affects 10% of patients over 65
Affects 28% of patients over 75
By definition, ARMD affects patients over
age 50
There is no gender bias
Whites are affected more than blacks, with
hispanics somewhere in between
ARMD is in essence an age related
deterioration of the neurosensory retina
Find atrophy of the RPE
Get photoreceptor loss
See deposition of “drusen”
Drusen are the hallmark finding in ARMD
These are yellow deposits on Bruch’s
They represent accumulated photoreceptor
breakdown products
Occur primarily in the macula
May also find subretinal bleeding,
pigmentary changes, retinal scarring, retinal
edema, and retinal detachments
Based on physical exam findings, ARMD is
2 major subdivisions of ARMD exist
The “wet” form is one in which new blood
vessel growth occurs in and under the retina
The “dry” form is more of an atrophic
process of degeneration
Also called neovascular vs non-neovascular
“Wet” form with worse prognosis
In area where drusen form, Bruch’s
membrane becomes thickened. If a break in
this membrane occurs, new blood vessel
can grow in from the vascular
choriocapillaris beneath
While a patient with the “dry” form will
lose vision slowly, the “wet” form causes
rapid visual decline
Unclear what actually causes the disease
Risk factors include age (over 50), systemic
vascular disease, and sunlight exposure
over many years
There is a racial predisposition—fair
skinned whites of Scandinavian ancestry
most at risk
Presents as a painless slow loss of vision in
most cases (faster in “wet” form)
May get metamorphopsia (distortion) and
central scotomas (blind spots)
Peripheral vision intact
Asymmetric disease between the eyes
Only about 10% of patients with ARMD
have the “wet” form
Conversion from “dry” to “wet” can occur
at any time
Using IVFA (intravenous flourescein
angiography), dye injected into an arm vein
is photographed at specific time intervals,
using specific filters, to map out the normal
and abnormal retinal and choroidal
Treatment options are fairly limited
Guided by IVFA, laser ablation of the new
blood vessels can be performed
Laser therapy is rarely a restorative
procedure, but done more to retard
Light activated intravenous medications are
also being used with some success—termed
“Photodynamic Therapy”
Various other more drastic surgical
procedures have also been tried with limited
New modalities being FDA approved as we
Much emphasis has been placed on
Study published in last 4 years showed that
in advanced ARMD, specific multivitamin
formulations do slow progression
Avoiding UV exposure and using a good
multivitamin with antioxidants and
carotenoids may help (and should not hurt)
#1 cause of blindness in the world
Responsible for about 10% of the blindness
in the United States
Readily reversible ($$$$)
Affects 90% of patients by age 80
The natural lens is optically transparent
This property is due to its orderly
arrangement of its lens proteins, its total
lack of vascularity, and its relative state of
dehydration (compared to other body
The lens continues to grow throughout life
In youth, it is composed of soluble proteins
With age, the solubility of the proteins
decreases, and the lens opacifies
Various other changes occurs with age and
disease process to alter the hydration of the
lens, as well as the orderly arrangement of
the lens fibers
The opacification of the natural lens is
termed a “cataract”
It is not a growth of new tissue, but rather a
change in the optical clarity of a pre-
existing tissue
Risk factors include age, diabetes, trauma,
steroid use (topical or systemic), sun
exposure, diet, and smoking
The biggest risk factors outside age are
diabetes and steroids—each increasing the
risk by 3-4 fold
Symptoms (what the patient complains of)
include glare from lights, halos around
lights, difficulty with night vision, and
progressive changes in refractive error
Later in the progression, the patient will
experience decreased vision not correctable
with a glasses adjustment
The main sign (what the doc finds on exam)
is the loss of clarity of the lens
This can be a white, yellow, or brown,
discoloration, or could be more of an
irregular distortion of the light path due to
alteration of the normal lens microscopic
architecture (ie a smudge of grease on your
spectacle lens)
Cataract can be classified by anatomic
The lens resides inside a true capsule
The cataract can form adjacent to this
capsule (anterior subcapsular, posterior
subcapsular), or can be more of a uniform
change throughout the lens (nuclear
Some varieties of cataract involve triangle
shaped peripheral spokes (cortical cataracts)
An end stage cataract in which much of lens
has liquified, and a dense residual kernal of
lens material floats in a milk filled capsular
bag, is termed a morgagnian cataract
Although much research has been done
towards prevention, no clear measures have
proven useful
Sun protection, limited steroid use, blood
sugar control, smoking cessation, and
antioxidants are all thought to offer some
Tx is surgical extraction--“Heal with steel”
What it’s like to be an
MD degree (or rarely DO)
One year of internship in field of your
choice (most often a designated transitional
year, a year of internal medicine, or a year
of general surgery)
3 additional years of Ophthalmology (a few
programs are 4, may all be 4 soon)
What we are!
Primary care doctors for the eyes
The busiest surgeons in any field
What we aren’t!
The guys in the mall
Ophthalmology ranks in the top 2-3 fields
in terms of competitive residencies
Many people who apply for interviews will
not get invitations (44 out of 307 in our
program last year)
About 20% of applicants who actually get
interviews won’t match
Most programs have a 4 year program, a
year of internship in “something else”, and
3 years of Ophthalmology
You are trained (and tested) in the various
subspecialties--which includes geometrical
Both surgical and clinical instruction is
Several fellowships exist in Ophthalmology
(Refractive surgery, Cornea, Retina, Neuro,
Plastics, Pediatrics, Glaucoma, Pathology,
Oncology, Uveitis)
About 20-25% of residents enter
Board Certification
You must pass a 3 hour written examination---
about 30% of first time takers fail
After passing the written, you take a 3 hour oral
examination---about 20% of first time takers fail
After these 2, you are board Certified, but must re-
certify in 10 years—including a written test and
chart reviews from your clinic patients
Practicing Ophthalmologist
Most Ophthalmologists are in small group
They are in clinic 3-4 days per week, and
are in surgery ½ to 2 days per week
The top 2 surgeries performed in the U.S.
are ours (Phaco and refractive)
We don’t rely on trauma or acute illness for
the majority or our revenue—so call is
generally comparatively light—remember,
we are solar powered
Hourly workweek varies, but is generally
between 40-60
Bling Bling
The average salary for a non-fellowship
trained Ophthalmologist in private practice
in 2003 was $253,629
This is more yearly than primary care
(Internists, Family Medicine, Pediatricians),
emergency room docs, and OB/GYN
Very similar to General Surgery, ENT,
Urology, and Anesthesia
We have a significant shortage of several of
the subspecialties within Ophthalmology
Our residents do not have trouble getting
jobs in every conceivable part of the
Last year, our graduates found jobs in
California, Arizona, and South Carolina
Cataract surgery video