Bnar Massraf
Foundation Year 2 Doctor, East of England
Introduction
My idea of an ophthalmology rotation as a foundation doctor was quite limited, mostly consisting of sitting in with emergency clinics and theatre lists akin to medical students. My experience in a busy tertiary centre has been quite different. This article describes what my experience has involved, to give you a better understanding of the role and responsibilities before starting your own rotations, if fortunate enough to get them.
The large part of my week consists of vitreoretinal (VR) pre-operative assessment, working closely with the specialist nurses. It is broad medical work that draws heavily on the skills and knowledge you have developed as a foundation doctor so far. I make the argument that this rotation has also been valuable general medical training as well as an amazing insight into a specialty that is often glossed over in medical school.
The medical complexities behind eye surgery
In my own hospital, general anaesthetic (GA) is frequently used in ophthalmic surgeries, particularly VR. These patients require careful pre-operative assessment because of this. Most of the time, these are patients that are older with many comorbidities that need to be assessed/optimised before their surgeries. Of course, VR surgery is time-sensitive in terms of giving patients the best visual outcome and this pre-operative assessment can be the first time patients have been examined systematically. This clinic might seem like a routine task at first glance however it often reveals findings such as undiagnosed cardiac murmurs, poorly controlled diabetes, or suspected obstructive sleep apnoea (OSA) which all need investigation and optimisation.
The pre-operative anaesthetic (POA) team provide a comprehensive framework for my role. This is to take a full history, examine the patient, and identify those who require further investigation or optimisation for the sake of patient safety before proceeding with a procedure under GA. An ejection systolic murmur heard on examination should prompt questions relating to symptoms that could indicate aortic stenosis and requesting an echocardiogram. This can subsequently lead to an official diagnosis of aortic stenosis, at which point the POA team can review and assess their fitness for surgery. Another example would be a patient with a high BMI, prompting questions to screen for sleep apnoea, making use of the STOP-BANG questionnaire (1), to flag to the POA team who would then arrange for sleep studies. The decision regarding fitness for GA lies with the POA team, and my role is to recognise potential problems and refer appropriately.
This can be demanding due to the complexity of some patient’s medical backgrounds and acting on incidental findings you might pick up on your own history or examination. However, this has been rewarding, as it has given me responsibility that is rare for a foundation doctor: recognising signs on assessment and ordering investigations within POA guidelines, which sometimes leads to a formal diagnosis.
When the clinic turns into A&E
As mentioned previously, many patients I see have complex medical histories and might not have had a thorough assessment in a while. As a result, the pre-operative clinic can bring unexpected acute issues that need urgent action, and occasionally a transfer to A&E. Markedly high blood pressure during assessment is a common example. Finding a systolic reading of over 200 mmHg is not something you’d expect to see as an FY2 in an outpatient eye clinic. In these situations, careful history and examination are needed to establish whether this would be a hypertensive urgency or hypertensive emergency, depending on evidence of end-organ damage (2).
It goes without saying, senior input from the medical team is also needed in situations such as this alongside the Ophthalmology registrars and consultants. It can be daunting being the first doctor to identify a problem like this but decisions such as these are never made alone or without proper escalation.
Ward work
Another surprising part of the job is caring for patients that have been unexpectedly admitted, often for social reasons related to their frailty. I review these patients daily, request investigations and discuss management with the ophthalmology team and medics as needed. At times this can lead to a mini general medicine ward round however this scenario is quite rare but one I have found myself doing.
Spinning plates
Much of the work is quite ‘admin heavy’ and outside of consultations. Notes from other hospitals need chasing up, outstanding investigations need following up, and POA requests need doing such as better diabetic control. Often, you will find yourself writing letters to the GP in terms of achieving this while the patient is in the community. Letters are also needed to update their GPs regarding new diagnoses or elevated blood pressure for the sake of the patient’s continuity of care beyond their surgery. This can be overwhelming at times, especially in a tertiary centre with many patients in and out of the door every day.
Opportunities beyond the clinic
All that being said, this post offers a great deal of freedom outside these responsibilities to shape your own learning. My slit lamp and fundus examination skills have benefitted greatly on this rotation. I practise on patients whose findings have already been established by seniors, which allows me to develop my ability to spot signs. There are also many opportunities to sit in with your supervisors and other seniors during clinics and theatre lists. If you are interested in Ophthalmology as a career, then this rotation provides many opportunities for projects to build your portfolios. It also gives an insight into what the day-to-day work of an ST trainee could look like. Few foundation posts give this much freedom to direct your own learning, so it is what you make it.
Conclusion
An Ophthalmology FY2 rotation is not a break from general medicine. Pre-operative assessment requires examination skills, risk assessment, targeted investigation, communication with GPs and other teams, and knowing when to escalate. These are skills which need to be developed during our foundation years, and Ophthalmology certainly does that. For the foundation doctors considering Ophthalmology as a rotation, I highly recommend it, as it offers both a special insight into the field and a platform to build general medical skills. Along with the freedom it gives you to direct your own learning, I find that all of this makes the rotation invaluable.
References
- Pivetta B, Chen L, Nagappa M, Saripella A, Waseem R, Englesakis M, et al. Use and Performance of the STOP-Bang Questionnaire for Obstructive Sleep Apnea Screening Across Geographic Regions: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2021;4(3):e211009.
- National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management (NG136) [Internet]. London: NICE; 2019 [updated 2026 Feb 26; cited 2026 Oct 21]. Available from: https://www.nice.org.uk/guidance/ng136