A 38 year old white male patient presented to his community optometrist complaining of a four day history of painless blurred vision in the right eye that he described as “like looking through a glazed-bathroom window”. He had noted one similar episode two weeks previously that self-resolved within 2 hours. The patient was otherwise well and symptom free; he denied any pain or antecedent trauma and there was no history of recent surgery, travel or illness.

Foundation Year (FY) placements are there for you to primarily fulfil the competencies of a Foundation Year Doctor (FYD). They are there for you to develop into a well-rounded Doctor. However, with a competition ratio of almost 10:1 many who plan to apply to Ophthalmology will undoubtedly need to keep an eye on the prize also (1). Here we will focus on the benefits of certain foundation year rotations and how you can maximise your time in each specialty towards your application.

There was a great deal of upset in my year group when it came to electives. I was not in the year group where the idea of going abroad was completely out the question. Instead, for us it was a touch and go situation, dependent on country policies and the ever-fluctuating situation of the COVID pandemic. Many of those who did plan to go abroad had to cancel their electives and opt for a local department, few managed to fulfil placements abroad at the time. In a time of great uncertainty, I opted to arrange an elective with my local department through my university. Here I explain how staying local benefitted me.

Keratoconus is a bilateral asymmetric chronic disease process characterised by progressive corneal thinning that results in irregular astigmatism and decreased visual acuity. The pathophysiology of keratoconus begins with a reduction in collagen lamellae within Bowman’s membrane (the second outermost of the five corneal layers, between the outer corneal epithelium and middle stromal layers). Progression of disease then affects the deepest corneal endothelial layer, distorting the morphology and tessellation of normal hexagonal shaped corneal endothelial cells (reduced pleomorphism), increasing the variation in cell size (polymegathism), but without affecting the overall number of corneal endothelial cells. In the UK, keratoconus has been shown to have a marked ethnicity split, with incidence in Caucasian British populations (3.3-4.5/100,000 population/year) significantly lower than in British Asian populations (19.6-25/100,000 population/year). Its onset and progression is usually in the second and third decades of life, with subsequent stabilisation thereafter, although progression may also occur in older affected individuals. Keratoconus management is usually conservative through monitoring and refractive correction, with complications such as corneal hydrops dealt with separately, and surgical treatment such as corneal collagen cross-linking, deep anterior lamellar keratoplasty (DALK), and penetrating keratoplasty (PK) usually reserved for those with more severe disease.

Many factors can induce anxiety in patients before and during an eye examination. It is important to take into consideration that many patients did not have a previous ocular assessment and thus remain unfamiliar with the procedural aspects. Among these patients, some are in a lot of pain around or inside the eye or have an episode of sudden loss of vision or their disease progresses and they are gradually losing their vision. These patients are usually anxious and concerned about the pronouncements that the ophthalmologist would make regarding their ocular condition and visual acuity. Additional sources of anxiety may arise from pre-existing mental health issues, exacerbating patients’ stress in clinical and crowded settings. Moreover, language barriers impair effective communication between patients and their healthcare providers triggering their anxiety. They will feel the pressure to provide precise information while simultaneously worrying about their ability to understand the doctor’s instructions after the consultation.

Bietti’s crystalline corneoretinal dystrophy (BCCD) is a rare heritable disease first described in a case-series of three patients in 1937. Since then, BCCD has been reported worldwide in a range of ethnic groups, although it is known to be particularly prevalent in the Japanese and Chinese populations. In its early stages BCCD is often asymptomatic, and may only be picked up as an incidental finding in patients that have undergone slit-lamp fundoscopy. The disease typically becomes symptomatic at 20 to 40 years of age, with affected patients reporting impaired night-vision, constriction of the visual-fields, and a decline in visual acuity, sometimes with colour-vision impairment. Both eyes are typically affected, although often asymmetrically.

Acute macular neuroretinopathy (AMN) is a condition that was first described in a four- patient case-series by Bos and Deutman in 1975. It is commonly classed as one of the white-dot syndromes, a group of inflammatory chorioretinopathies characterised by multiple focal chorioretinal lesions seen on slit-lamp fundoscopy. AMN is an uncommon condition known to generally affect young healthy Caucasian females 20-40 years old and is associated with a spectrum from transient to longer-term visual disturbance. The commonest presentation of AMN is one or more wedge-shaped paracentral scotomas of acute to subacute onset, developing over days to weeks, with patients also known to variably report a decline in visual acuity, metamorphopsia, and floaters. One or both eyes may be affected.

Ocular immune-privilege (IP) is a reduced or altered immune response to an immunogen in the eye. It is believed that ocular IP is essential to prevent collateral damage from inflammatory responses and retain the clarity of the visual axis through the cornea and retina. IP is achieved through two mechanisms: unique anatomical structure and the immunosuppressive microenvironment of the eye. Anatomical structure that supports IP includes a limited lymphatic system, non-fenestrated endothelium with supportive cells such as pericytes, astrocytes, Müller cells and perivascular macrophages, and tight junctions formed by retinal pigment epithelial cells. The immunosuppressive microenvironment within the eye is created by soluble factors (e.g. α-MSH, TGF-β2) in the aqueous humour and membranous molecules (e.g. FasL, PD-L1, CD200) of cells in the intraocular compartment. In addition, tolerogenic Antigen Presenting Cells (APC) and homeostatic microbiome-induced regulatory T cells (Treg) also contribute to the immunosuppressive microenvironment. However, such IP is always threatened by physiological changes and pathological processes within the body. This short article will discuss common mechanisms which disrupt our ocular IP.

Endophthalmitis is a rare but devastating, sight-threatening complication of intraocular surgery and intravitreal injections (IVIs). The visual outcome of postoperative endophthalmitis is poor. High volumes of cataract surgery are performed worldwide, and the incidence of postoperative endophthalmitis is relatively low. This relatively very low incidence of endophthalmitis can be attributed to two factors. It is a well-established fact that pre-operative cleaning of the conjunctival sac and the eyelids with povidone-iodine (PI) for up to three minutes has contributed to the reduction of endophthalmitis. The second factor contributing to the decrease in endophthalmitis is the administration of intra-cameral antibiotics at the end of surgery.

Ophthalmology is the busiest outpatient specialty. Currently there is significant pressure on NHS ophthalmology services, exacerbated by a backlog of over 600,000 patients and workforce shortages. Efforts to improve the efficiency of ophthalmology services is vital. In our hospital, eye emergencies are initially assessed by emergency department (ED) clinicians, as there is no walk-in eye casualty service. It has been consistently demonstrated that junior doctors have low confidence in the assessment and management of eye emergencies, and it is likely a high proportion of cases presenting to the ED are referred to the emergency eye clinic (EEC). Given the challenges facing ophthalmology services, there is an urgent need to optimise referral pathways, to facilitate effective triage of eye emergencies.