When I initially started writing an article on the present state of comprehensive ophthalmology in the United States, I thought I would sort of look in the mirror, take my own pulse and come up with something brilliant based on my 30+ years of experience in practice. But, to be on the safe side, I decided to reach out to some of my colleagues around the country to make sure that my life in what we used to call “general ophthalmology” matched the arc of their careers.

BZZZZZTT! Wrong. Johnny, tell Dr. White about our lovely parting gifts.

In this 25th Anniversary issue of Ophthalmology Management, we have heard from a plethora of pioneers discussing not only the significant macro trends of the last quarter century but also about some very particular technical innovations that have made it into the market. With the exception of instrumentation geared toward the most sub-specialty driven procedures (eg, micro instruments to peel epiretinal membranes), the bulk of these innovations can be accessed and utilized by pretty much any ophthalmologist. MIGS, anti-VEGF injections, point-of-care testing in the office and other technologies are all within the purview of the comprehensive ophthalmologist.

What I discovered — both in the mirror and on the phone — is a kind of “two nations” situation. During the last 25 years, comprehensive ophthalmology practices have diverged along two major pathways: a little bit more of everything, or more and more of less and less. Another apt label for the first group would be “all things for all patients”: no matter what a patient may require, the comprehensive ophthalmologist in this category would provide it, the only exception being the most specialized of the subspecialized. Doctors who purposely shifted the emphasis of their personal practice to a much more narrow sliver of primarily anterior segment care comprise the second group.

PATHWAY ONE: A BIT OF EVERYTHING

My first instinct upon seeing our list of key innovations (see page 32) was that the majority of comprehensive ophthalmologists were practicing in a manner similar to my practice in the ‘80s through the early 2000s. “A little more of whatever you need” would be a good way to describe how the majority of us saw our practices develop. I guess you would call this “classic” comprehensive ophthalmology. Everyone in this group does cataract surgery, of course, and other classic anterior segment disease categories are almost entirety covered. Glaucoma, for example, is not just a medically treated (or laser-treated) disease. The “classic” comprehensive ophthalmologist continues to expand as they provide a full suite of surgical options; they perform incisional glaucoma surgery, if necessary, and have added a suite of MIGS options as well.

Without meaning to blaspheme, the introduction of anti-VEGF intravitreal treatments for “wet” AMD is as close to a miracle as anything anywhere in medicine. Where once the arrival of sub-retinal neovascularization meant we were trying to end up with the smallest blind spot possible, now we have a very high “cure” rate. Here, too, the “classic” comprehensive ophthalmologist is utilizing new technology, in this case OCT, to identify and then treat these patients without referral to a subspecialist. These ophthalmologists do anti-VEGF injections themselves; they are certainly as qualified as the residents, fellows and physician assistants that do injections in large academic and other referral settings. They treat wet macular degeneration.

PATHWAY TWO: DOING MORE OF LESS

When I began practicing some 30+ years ago, anyone who was a comprehensive ophthalmologist could be described as providing most things for all patients. In less populous areas of the country, one still sees this ever-expanding role for the comprehensive ophthalmologist. These docs laser every horseshoe tear they diagnose. In our cities, inner and outer-ring suburbs, the rapid (and ravenous) growth of large referral institutions has changed this dynamic. I practice in an outer-ring suburb in a city that has not one, not two, but three large academic institutions. Each of them is populated with multiple doctors in each of the subspecialties. There are large subspecialty groups, too. My comprehensive colleagues in similar situations have mostly followed the same path that I did: we do more and more of less and less.

In effect, the presence of subspecialists in metro areas has led to a contraction of the services offered by comprehensive ophthalmologists. Where once we added to the breadth of diagnostic and therapeutic services across the anterior and posterior segment as soon as they became available, we now increase the depth of our commitment to a small slice of the anterior segment pie. Most of us do cataract surgery. Expanding our role means going deeper into the different advanced IOLs to treat astigmatism and presbyopia. Some, like me, will treat two or three other conditions and do so in a similar “deep dive” manner. In my office, that condition would be dry eye; we offer a menu of diagnostic and treatment options that goes well beyond basic care. However, in contrast to the early years of my comprehensive career, I no longer do pediatric care, lid surgeries or surgical glaucoma. It’s been 20 years since I lasered a horseshoe tear.

CONCLUSION

What effects have all of the advances highlighted in this 25th Anniversary issue had on the role of the comprehensive ophthalmologist? It’s complicated! Two roads have been taken, each determined in large part by where your “test subject” lives. We still have “classic” comprehensive ophthalmologists who offer almost everything to everyone, with better technology making those offerings possible. In suburban and urban America, the comprehensive ophthalmologist is more likely to be described as an anterior segment specialist. We expand the depth of our dive into a smaller piece of the clinical pie, with other types of care “shared” with the subspecialists at post-Affordable Care Act mega-institutions.

It seems that we now have two, distinct species of what was once known as the general ophthalmologist. OM

Darrell E. White, MD, is an anterior segment surgeon and founder of SkyVision Centers in Westlake, Ohio.