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Oculoplastics: an Evolving Specialty

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Oculoplastics: an Evolving Specialty FEATURE Oculoplastics: an evolving specialty BY RAMAN MALHOTRA Consultant Ophthalmic and Oculoplastic Surgeon Raman Malhotra provides an insight into this increasingly popular subspecialty of ophthalmology. culoplastic surgery refers tailored approaches. Techniques in to such a question would be “To what to plastic, reconstructive aesthetic rejuvenation now cross level do you wish to learn?” and “What and aesthetic surgery of the over for therapeutic indications. are your career goals, interests and Oeyelids, the surrounding Rehabilitation for conditions such as personal commitments?” Simply put, facial areas, orbits and lacrimal thyroid eye disease and facial palsy there is no point seeking tertiary- system. Its scope has extended over are now aimed at restoring natural referral level orbital training if you wish the last two decades to the forehead appearance, with interventions at to pursue a career in ophthalmology and midface region, mainly due to thresholds now significantly lower in a geographical region where only the recognition that eyelids should than for sight-threatening indications. secondary care is provided. Conversely, be managed by specialists in this The management of periocular the pursuit of a tertiary-referral region and cannot always be treated malignancies has improved with a specialist practice as a long-term goal in isolation to the face. In fact, as deepening evidence-base. Some form of may prove difficult if you are unable to an aesthetic discipline it may be margin-controlled excision of tumours travel beyond your training region. It is thought of as oculo-facial surgery. in order to minimise the unacceptable always useful to speak to oculoplastic This transformation has resulted in occurrence of incomplete excision now consultants and fellows for advice. a subspecialty of ophthalmology to forms the mainstay of tumour removal. Do not be put off by the lack of jobs be now considered a specialty in its However, non-surgical modalities advertised at this point in time. The own right, certainly by those seeking are available either as adjuncts or situation regarding available consultant aesthetic treatment in the eyelid alternatives. The use of Mohs excision posts is incredibly fluid and ever- region. At the turn of this century, is another example of the cross- changing. If you enjoy your subject, then ophthalmic trainees considered simple speciality reach of oculoplastics. you should remain passionate towards ptosis surgery, dacryocystorhinostomy Nowadays, periorbital and oculo-facial maintaining the highest standards and correction of eyelid malposition to reconstruction can involve co- in your training. This in itself will be core competencies of ophthalmic management with ENT, maxillofacial, ensure your skills and achievements. specialty training. However, many plastic and even neuro-surgery. As a Competition for selection has been of these are now procedures only trainee, I still remember the words of tough, not only for medical school, but undertaken following fellowship one of my mentors: “I like oculoplastics, then for ophthalmology and beyond training in oculoplastics. Factors to because it gets you out the eye.” that, for a fellowship in oculoplastics. explain this include an evolution in our It then defies logic to opt for career understanding of orbito-facial diseases What are the best places choices based upon perceived lack of and the factors that need addressing in to learn reconstructive and competition for consultant posts. If a such disorders, as well as the expansion orbital surgery and which can career in oculoplastics interests you, of technique repertoire and complexity. be recommended to learn lid then go for it! The specialty has undergone a surgery? paradigm shift to include non-surgical Organising a trainee selected With planned changes to NHS modalities. Ophthalmology was the component (TSC) in oculoplastics funding and accreditation, will first specialty to use botulinum toxin (previously known as advanced specialist the spectrum of procedures as a therapeutic agent and hyaluronic training opportunity – ASTO) is always performed at district hospitals acid as a viscoelastic expander. a good start. This is a formalised period be limited to lid surgery (for Oculoplastics has embraced both of training vetted and monitored by the oculoplastic surgeons)? of these for both functional, as well Royal College of Ophthalmologists. It is certainly foreseeable that some of as aesthetic indications. Lacrimal A listing of available UK oculoplastic oculoplastics may be considered lower- surgery has evolved to include fellowships may be found at http://www. priority and accordingly be affected by endoscopic endonasal approaches, bopss.co.uk/fellowship-listings/ The NHS funding. It behoves us to continue both for children and adults. Orbital exposure to orbital surgery is indicated clinical audit and evaluation with decompression surgery as been honed for each fellowship. QoL and PROMs to demonstrate the to minimally-invasive and individually- In some respects, my first response functional benefit of procedures. Many eye news | AUGUST/SEPTEMBER 2015 | VOL 22 NO 2 | www.eyenews.uk.com FEATURE eyelid, orbital and lacrimal disorders will Is it worth considering history and evolution of each topic. Also have sight-threatening potential and we fellowship abroad? familiarise yourself with seminal papers need to ensure the design and quality Yes, for life experience. A particular on each topic. Lastly, obtain one or two of NHS research in oculoplastics helps centre overseas may provide additional good textbooks, but consider this a basic establish and / or reinforce the need for specialist expertise that may be limited knowledge. Do not rely upon this as your treatment of these disorders. This is a or unavailable in the UK. core basis of knowledge. This is merely crucial question that needs to be asked an introduction and within a few years from the outset when embarking upon a How would you design the will no longer be sufficient even as a research project in oculoplastics. perfect ASTO? Would you reference source. involve other specialties? What affected your career The perfect ASTO should not just How do you think the choice? be considered an introduction to a subspecialty is likely to change My priorities for a desirable ophthalmic sub-specialty. It can be a phenomenal over the next 10 years? sub-subspecialty included: opportunity for an intense period of Oculoplastics will continue to evolve • Need for a good breadth of surgical enhanced training. Clear achievable into a speciality in its own right, within repertoire. aims and objectives should be set at the the discipline of ophthalmology. Areas • Crossover with neuro-ophthalmology, outset and both parties should be held such as periocular tumour management, ocular surface and strabismus. accountable for its delivery. A curriculum thyroid orbitopathy and, to a degree, • Involvement of systemic health and should be set out and minimum facial palsy management already have a disease. standards to achieve established. The multidisciplinary team approach in order • Ability to undertake both adult and case mix should be broad and involve to optimise outcomes. This will continue paediatric care. direct supervision during outpatients to develop and become established. • The ability to apply a creative and theatre. Oculoplastics will increasingly approach to my work. In outpatients, trainees should present dominate aesthetic medicine as a new cases as long cases and be prepared specialty to manage the eyelid region; What is the best way to get a to justify plans of management. In the however, this requires continued fellowship? What makes the operating theatre, a trainee should come enthusiasm and skill from within our perfect candidate? prepared, knowing how to carry out a current generation of peers. Lastly, In my opinion, fellowship training procedure even if they have not seen one oculoplastics will always remain the begins the day you decide to pursue a before. In the era of internet, Youtube, ideal linchpin for an individual wishing subspecialty interest in oculoplastics. At electronic media etc. it is hard to justify to combine ophthalmology, paediatrics, that moment, trainees should read all the absence of literature available to plastic surgery, neuro-ophthalmology, oculoplastic papers that appear in the facilitate this. Having such a proactive strabismus, ocular surface care and main ophthalmic journals. Concentrate approach will fast track your learning. general medicine. on the discussion, not just the abstract! Trainers should also supervise surgery This provides valuable insight into the to ensure basic surgical techniques, background and controversies of each including tissue handling, identifying Acknowledgement Questions posed by Katarzyna Klodnicka, topic. Knowledge is the foundation of tissue planes and anatomy etc. is Manchester Royal Eye Hospital. your learning and does not begin the excellent. day you commence your first fellowship, it is cemented at that stage. Aim to What oculoplastic courses familiarise yourself with every procedure and other resources can you you are exposed to during your basic recommend? ophthalmic training. Make notes the Attend all RCOphth seminars and same evening with specific attention symposia in oculoplastics and consider to steps, how instruments were held, attending the American Academy specific equipment used, pitfalls and of Ophthalmology annual meeting, difficulties highlighted or encountered.
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