Ophthalmology/Introduction

Ophthalmology is the branch of medicine which deals with the diseases of the eye and their treatment. The word ophthalmology comes from the Greek roots ophthalmos meaning eye and logos meaning word; ophthalmology literally means "The science of eyes." As a discipline it applies to animal eyes also, since the differences from human practice are surprisingly minor and are related mainly to differences in anatomy or prevalence, not differences in disease processes. By convention, the term ophthalmologist is more restricted and implies a medically trained specialist. Since ophthalmologists perform operations on eyes, they are generally categorized as surgeons.

History of ophthalmology

The eye, including its structure and mechanism, has fascinated scientists and the public since ancient times. The discovery of the eye went through two cycles of limiting speculation and freeing observation, which led to a dark age between Galen and Vesalius.

Arab scientists are some of the earliest to have written about and drawn the anatomy of the eye—the earliest known diagram being in Hunain ibn Is-hâq's Book of the Ten Treatises on the Eye. Earlier manuscripts exist which refer to diagrams which are not known to have survived. Current knowledge of the Græco-Roman understanding of the eye is limited, as many manuscripts lacked diagrams. In fact, very few Græco-Roman diagrams of the eye are still in existence. Thus, it is not clear to which structures the texts refer, and what purpose they were thought to have.

The pre-Hippocratics largely based their anatomical conceptions of the eye on speculation, rather than empiricism. They recognised the sclera and transparent cornea running flashly as the outer coating of the eye, with an inner layer with pupil, and a fluid at the centre. It was believed, by Alcamaeon and others, that this fluid was the medium of vision and flowed from the eye to the brain via a tube. Aristotle advanced such ideas with empiricism. He dissected the eyes of animals, and discovering three layers (not two), found that the fluid was of a constant consistency with the lens forming (or congealing) after death, and the surrounding layers were seen to be juxtaposed. He, and his contemporaries, further put forth the existence of three tubes leading from the eye, not one. One tube from each eye met within the skull.

Alexandrian studies extensively contributed to knowledge of the eye. Aëtius tells us that Herophilus dedicated an entire study to the eye which no longer exists. In fact, no manuscripts from the region and time are known to have survived, leading us to rely on Celsius' account;which is seen as a confused account written by a man who did not know the subject matter. From Celsius it is known that the lens had been recognised, and they no longer saw a fluid flowing to the brain through some hollow tube, but likely a continuation of layers of tissue into the brain. Celsius failed to recognise the retina's role, and did not think it was the tissue that continued into the brain.

Rufus recognised a more modern eye, with conjunctiva, extending as a fourth epithelial layer over the eye. Rufus was the first to recognise a two chambered eye - with one chamber from cornea to lens (filled with water), the other from lens to retina (filled with an egg-white-like substance). Galen remedied some mistakes including the curvature of the cornea and lens, the nature of the optic nerve, and the existence of a posterior chamber. Though this model was roughly a correct but simplistic modern model of the eye, it contained errors. Yet it was not advanced upon again until after Vesalius. A ciliary body was then discovered and the sclera, retina, choroid and cornea were seen to meet at the same point. The two chambers were seen to hold the same fluid as well as the lens being attached to the choroid. Galen continued the notion of a central canal, though he dissected the optic nerve, and saw it was solid, He mistakenly counted seven optical muscles, one too many. He also knew of the tear ducts.

After Galen a period of speculation is again noted by Arab scientists - the lens modified Galen's model to place the lens in the middle of the eye, a notion which lasted until Versalius reversed the era of speculation. He, however, was not an ophthalmologist and taught that the eye was a more primitive notion than the notion of both Galen and the Arabian scientists - the cornea was not seen as being of greater curvature and the posterior side of the lens wasn't seen to be larger.

Understanding of the eye had been so slow to develop because for a long time the lens was perceived to be the seat of vision, not a tool of vision. This mistake was corrected when Fabricius and his successors correctly placed the lens and developed the modern notion of the structure of the eye. They removed the idea of Galen's seventh muscle (the retractor bulbi) and reinstated the correct curvatures of the lens and cornea, as well as stating the ciliary body as a connective structure between the lens and the choroid.

The seventeenth and eighteenth century saw the use of hand-lenses (by Malpighi), microscopes (van Leeuwenhoek), preparations for fixing the eye for study (Ruysch) and later the freezing of the eye (Petit). This allowed for detailed study of the eye and an advanced model. Some mistakes persisted such as: why the pupil changed size (seen to be vessels of the iris filling with blood), the existence of the posterior chamber, and of course the nature of the retina. In 1722 Leeuwenhoek noted the existence of rods and cones though they were not properly discovered until Treviranus in 1834 by use of a microscope.

The establishment of the first dedicated ophthalmic hospital in 1805 - now called Moorfields Eye Hospital in London, England was a transforming event in modern ophthalmology. Clinical developments at Moorfields and the founding of the Institute of Ophthalmology by Sir Stewart Duke-Elder established the site as the largest eye hospital in the world and a nexus for ophthalmic research.

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