Sara Sarhadi

Undergraduate education department in Queen Elizabeth Hospital Birmingham

Introduction

From personal experience, I have observed that many students don’t feel confident in eye examinations especially fundoscopy. They often express they do not get to practice this in their clinical placements which contributes to their lack of confidence on the matter. In one session, despite having learnt ophthalmoscopy before, students expressed they are not sure what they are looking for or proceeded to hold the ophthalmoscope like a pen as they would do in otoscopy. As a clinical teaching fellow, this has prompted me to investigate educational failures on this matter and explore them further.

Problem

Literature has identified duration of ophthalmology placement has declined in both United Kingdom and United States (1). I personally had one week of ophthalmology placement and looking back I realise a longer placement would have most definitely been useful. In addition to reduced exposure to the specialty, one literature review identified despite guidelines from International Council of Ophthalmology (ICO), many medical schools do not follow these (2). This highlights inconsistent standards amongst medical schools for teaching eye exams which in turn can contribute to varying skills presented by students and even newly graduated doctors. Evidence identified SHOs often expressed low confidence in managing eye emergencies, ophthalmoscopy and slit lamp examination (3). In high pressure environments with limited senior support this can pose serious patient safety concerns.

Solution

Standardisation of ophthalmology education amongst medical schools would be a big step that ensures core competencies are met during medical school. In addition to this, the same literature suggests ophthalmology department would have to be in close communication with medical education to aid incorporating standards that meet actual practice expectancies (2). In addition, use of technology and multimedia has shown to reduce cognitive load in students and increase their interest in the specialty (2). From personal experience, students often express they find case-based teaching very useful. However, given the niche nature of the specialty and limited ward experience available, most of the exposure falls onto clinic experience which is very consultant lead.

Many medical students finish medical school feeling unsure about how to examine the eye, particularly when it comes to direct ophthalmoscopy. In teaching sessions, students often tell me that they have had very few opportunities to practise this skill during their placements. Unsurprisingly, the lack of repetition undermines their confidence. In one recent session, despite having been taught ophthalmoscopy before, several students held the ophthalmoscope as though it were an otoscope, while others admitted they were not entirely sure what they were supposed to be looking for. These moments are not about ability; they are about exposure. As a clinical teaching fellow, I have found myself reflecting on why ophthalmology feels so inaccessible for students, and what might realistically be done to support them.

Part of the challenge is structural. The duration of ophthalmology placements has declined over time in both the United Kingdom and the United States (1). My own undergraduate ophthalmology placement lasted one week, which seemed perfectly normal at the time. Looking back, it is hard to imagine developing confidence in any clinical skill within such a limited window. Many students report that their ophthalmology teaching is confined to brief tutorials or lecture-based content, with little hands-on practice. A UK survey found that fewer than half of medical students had opportunities to practise basic eye examinations, and very few had meaningful exposure to slit-lamp examination or fundoscopy (4). This uneven distribution of clinical experience means that students are often asked to master a skill with no realistic chance to refine it.

Curriculum inconsistency compounds the problem. A recent scoping review highlighted that despite clear guidance from the International Council of Ophthalmology (ICO), many medical schools do not follow the recommended curriculum for undergraduate ophthalmic teaching (2). As a result, there is substantial variation in what students learn and the skills they graduate with. Another systematic review identified a global decline in ophthalmology teaching hours and wide variability in clinical content, with students reporting low confidence in both knowledge and examination skills (5). These gaps do not disappear after graduation. Newly qualified doctors and even senior house officers report low confidence in managing eye emergencies, performing ophthalmoscopy, and using the slit lamp; skills that can be crucial in acute settings where senior support is limited (3).

From the student perspective, the issue is not a lack of interest; if anything, ophthalmology often sparks curiosity because it feels different from other specialties. Students frequently tell me that case-based learning helps them make sense of the specialty, it gives them a narrative, a context, and a clear link between symptoms and findings. Yet this format is not always used consistently, often because ophthalmology teaching has to compete with numerous other curriculum priorities. With most ophthalmology care delivered in outpatient clinics, where time is tight and patient flow is crucial, students may be present but not actively involved. Understandably, clinic time remains centred on patient care, meaning students often observe rather than participate.

There are, however, realistic and achievable ways to improve the situation. Standardising the core undergraduate ophthalmology curriculum would be a meaningful step forward. Ensuring that every medical student learns a small set of essential skills such as visual acuity assessment, pupil examination, confrontation fields, and basic fundoscopy, could reduce the variation seen across medical schools and give students a foundation to build on (2). Close collaboration between ophthalmology departments and medical education teams would help ensure that what is taught aligns with what doctors actually need to know in practice.

Technology also offers opportunities. Multimedia tools, instructional videos, and digital simulations have been shown to reduce cognitive load and improve student engagement in ophthalmology teaching (2). Some studies suggest that simulation-based teaching can significantly enhance confidence in ophthalmoscopy, particularly when real-patient exposure is limited (6). These resources cannot replace clinical time, but they can supplement it effectively, especially when students may not have the chance to examine many real fundi during their short placements.

Small changes can make a difference. Incorporating short, structured case-based discussions into clinical teaching, even for five or ten minutes, can help demystify the specialty. Allowing students to handle equipment under guidance or giving them simple tasks such as leading a visual acuity test, can make the clinic feel less intimidating. Even brief exposure to seeing normal and abnormal retinal images can help them understand what they are aiming to identify. These are small interventions that fit within existing constraints.

Ultimately, the issue is not that students are disengaged or uninterested. It is that ophthalmology remains a small, compressed component of an already overflowing curriculum. Students want to learn this skill, and they recognise its relevance across almost every branch of medicine. By making ophthalmology teaching more accessible, structured, and context-driven, we can help students feel more confident and better prepared for the realities of clinical practice.

Better ophthalmology teaching does not require a complete overhaul but thoughtful, achievable changes that meet students where they are. These small shifts could meaningfully improve confidence, competence, and ultimately patient safety.

References

1. Yusuf, I., Salmon, J. & Patel, C. Direct ophthalmoscopy should be taught to undergraduate medical students—yes. Eye 29, 987–989 (2015). Available at: https://doi.org/10.1038/eye.2015.90. Accessed: 4th November 2025.
2. Liao, J., Wright, R. R., & Vora, G. K. (2024). The Decline of Basic Ophthalmology in General Medical Education: A Scoping Review and Recommended Potential Solutions. Journal of Medical Education and Curricular Development, 11. Available at: https://doi.org/10.1177/23821205241245635. Accessed: 5^th November 2025.
3. Mendall, J., Tolley, A., Parisi, V. et al. Confidence of Emergency Department doctors in managing ophthalmic emergencies: a systematic review. Eye 38, 2751–2760 (2024). Available at: https://doi.org/10.1038/s41433-024-03115-z. Accessed: 4^th November.
4. Cobbs, L., Tsui, E., Haberman, I.D., Kim, E., Sperber, L., Wu, M. & Schuman, J.S. (2018) Student perceptions of the ophthalmology curriculum in medical school, Journal of Academic Ophthalmology, 10(1), e79–e82. Available at: https://doi.org/10.1055/s-0038-1653974. Accessed: 5^th November.
5. Spencer, S.K.R., Ireland, P.A., Braden, J., Hepschke, J.L., Lin, M., Zhang, H., Channell, J., Razavi, H., Turner, A.W., Coroneo, M.T., Shulruf, B. and Agar, A. (2024) ‘A systematic review of ophthalmology education in medical schools: The global decline’, Ophthalmology, 131(7), pp. 855–863. Available at: https://doi.org/10.1016/j.ophtha.2024.01.005. Accessed: 5^th November 2025.
6. Shih, K.C., Chan, J.C.H., Chen, J.Y. and Lai, J.S.M. (2020) ‘Ophthalmic clinical skills teaching in the time of COVID-19: A crisis and opportunity’, Medical Education, 54(7), pp. 663–664. Available at: https://doi.org/10.1111/medu.14189. Accessed: 5^th November 2025.