In reflecting on my journey through medical school, I have realized how essential the core clerkship rotations are for aspiring ophthalmologists. The versatility of each of these rotations provides medical students with the opportunity to grow through diverse challenges and valuable learning experiences. It is important to maximize every clinical opportunity, especially in the absence of an ophthalmology elective during third year. This article explores how third-year medical students can make the most of their clerkship experiences to become well-rounded physicians and build a strong foundation for a future career in ophthalmology.
FAMILY MEDICINE
During a family medicine rotation, medical students encounter a wide array of patients, some of whom present with ocular health concerns. These often include common eye problems such as conjunctivitis, hordeolum, or visual changes. During one such visit, I encountered a 13-year-old boy who expressed difficulty seeing the classroom board. This was confirmed when I assessed his visual acuity. The physician and I identified signs of refractive error, which prompted a referral and conversation about the importance of routine eye exams.
My greatest takeaway from my family medicine rotation was its emphasis on preventive care, particularly in terms of referrals for comprehensive eye exams. When primary care physicians who actively engage in recommending and referring patients to eye care services, it significantly increases the likelihood of patients using these services.1 For instance, a patient with diabetes presenting for a wellness exam may be advised to receive annual eye exams for early detection of complications like diabetic retinopathy and diabetic macular edema. This highlights the importance of collaboration between primary care physicians and ophthalmologists to ensure early interventions and preventive strategies for optimal eye health.
NEUROLOGY
A neurology rotation provides an incredible learning experience as it affords the opportunity to encounter neurologic conditions that manifest with ocular symptoms. Undoubtedly, the most rewarding aspect of this rotation is the hands-on experience it offers. Medical students may perform multiple exams daily, assessing patients’ neurologic function with tools like a reflex hammer, penlight, and direct ophthalmoscope. Due to the close link between neurology and ophthalmology, medical students can gain a better understanding of how neurologic disorders affect the visual pathway, especially if they are able to rotate on a neuro-ophthalmology service.
During a neurologic exam, students examine the cranial nerves, including the optic nerve, by conducting visual acuity and visual field testing. They also assess the oculomotor, trochlear, and abducens nerves by testing the extraocular muscle movements. Students examine eyelid movements, which are controlled by the oculomotor and facial nerves, and assess sensation to the eyelids and face, mediated by the branches of the trigeminal nerve. Additionally, students assess the pupillary light reflex, measure pupil size and symmetry, and visualize the optic disc using a direct ophthalmoscope. By assessing a patient's symptoms with a neurologic exam, it is possible to identify the location of a lesion as well as detect conditions like intracranial hypertension. To distinguish these symptoms from other causes of acute vision loss, it is important to consider whether the issue lies within the eye or along the visual pathway.
A neurology rotation provides exposure to a variety of patient cases that serve as valuable learning opportunities for future ophthalmologists. For example, encountering a patient with visual field deficits following a stroke or signs of Horner syndrome can teach students the neurologic basis of these ocular manifestations and how to manage them. During this rotation, my role in identifying a case of amaurosis fugax and arranging a carotid duplex ultrasound with my team resulted in a patient undergoing carotid revascularization. This experience highlighted the impact medical students can have on patient care when they actively participate in clinical decision-making. Such cases also provide medical students with the opportunity to learn how to recognize neuro-ophthalmic emergencies and understand the interventions required.
PSYCHIATRY
During a psychiatry rotation, medical students become familiar with different medications, including antipsychotics and antidepressants. As an aspiring ophthalmologist, the primary lessons I learned from this rotation center on the potential ocular side effects associated with these medications.
Conducting a thorough medication review should remain a priority as you move forward in your medical career. For example, prescribing a tricyclic antidepressant such as amitriptyline to a patient with a history of acute angle-closure glaucoma is likely not recommended. These medications have anticholinergic effects, which lead to pupil dilation and possible blurry vision. Although a majority of these medications commonly cause blurred vision, dry eyes, or cataracts, some have unique ocular side effects.2 Chlorpromazine can result in pigmented corneal deposits, and thioridazine can cause retinal toxicity.3 Typical antipsychotics, tricyclic antidepressants, lithium, benzodiazepines, carbamazepine, and selective serotonin reuptake inhibitors are responsible for a majority of documented ocular side effects.3 Overall, counseling patients about these adverse effects is essential to ensure that they are well informed about potential risks to their eye health.
Another psychiatric concept relevant to ophthalmology is the biopsychosocial model for formulating an assessment and plan. By applying the biopsychosocial model, medical students can practice approaching patients from a holistic perspective to ensure that their mental, social, biological, and visual health needs are all considered and addressed.
OBSTETRICS AND GYNECOLOGY
During an obstetrics and gynecology rotation, medical students learn about women's reproductive care, pregnancy, childbirth, and disorders of the female reproductive system. This rotation offers a unique perspective on how certain conditions or treatments can impact a woman's eye health: For example, preeclampsia can cause blurred vision or retinopathy, while hormonal contraceptives can result in retinal vein occlusions and dry eye symptoms.4,5 Understanding the connections between reproductive health and eye health is important for providing comprehensive care to female patients. Within this rotation, an emphasis is placed on communication and patient education skills, which are invaluable for discussing reproductive health conditions that may affect eye health.
PEDIATRICS
A pediatrics rotation offers opportunities to identify and manage ophthalmic conditions unique to children. From routine vision screenings such as checking the red reflex to the identification of conditions such as amblyopia, strabismus, and retinopathy of prematurity, this rotation covers essential knowledge for recognizing and treating pediatric eye conditions. Specifically, medical students learn about the risk factors, screening guidelines, and developmental milestones related to vision. Through this rotation, medical students are taught how to integrate pediatric and eye knowledge to ensure optimal visual health outcomes for children.
SURGERY
Although the focus may not always be on eye conditions, a surgery rotation instills skills such as attention to detail, hand-eye coordination, and teamwork, all of which are essential to ophthalmic surgery. Medical students can also learn about a variety of surgical interventions across specialties and their implications on patients’ eye health. For example, for perioperative management, it is important to consider the effects of anesthesia on IOP.
In this rotation, students may encounter situations that test their clinical skills. I vividly recall when, during one night shift, a patient was brought to the trauma bay following a motor vehicle accident. As part of the trauma team, I immediately jumped into action to assess the patient's neurologic status using the Glasgow Coma Scale. This experience highlighted the importance of attentiveness and teamwork, especially in a specialized field like ophthalmology, as well as the value of neuro-ophthalmic findings in trauma. Integrating these surgical skills with ophthalmology creates a solid foundation for those pursuing a career in ophthalmic surgery.
INTERNAL MEDICINE
An internal medicine rotation represents the culmination of the third-year learning journey and a fundamental step toward a career in ophthalmology. It shows how well-connected ophthalmology is with other medical specialties and provides a comprehensive foundation for understanding a variety of systemic diseases with ocular manifestations, such as diabetes and hypertension.
During my internal medicine rotation, I had the opportunity to consult the ophthalmology service on several occasions. One memorable experience occurred when I cared for a patient on the nephrology floor who showed symptoms of periorbital cellulitis. In this case, I consulted ophthalmology, participated in the physical exam, and contributed to the treatment plan. The internal medicine rotation offers a comprehensive experience built on interdisciplinary collaboration.
CONCLUSION
Establishing a solid foundation in ophthalmology during medical school relies heavily on optimizing the core clerkship rotations. It is especially important for medical students to maximize opportunities at their base hospital, particularly if they have an ophthalmology program. This allows them to benefit from tailored experiences, supportive mentorships, and unique learning opportunities that can significantly enhance their preparation for a career in ophthalmology. I was fortunate to be in a hospital system with an ophthalmology program, which provided me with ample opportunities for learning and growth during these rotations. By actively engaging in third-year core clerkships, medical students can gain diverse clinical skills, deepen their understanding of eye conditions and treatments, and cultivate a holistic approach to patient care.
1. Goyal A, Richards C, Patel V, et al. The Vision Detroit Project: visual burden, barriers, and access to eye care in an urban setting. Ophthalmic Epidemiol. 2022;29(1):13-24.
2. Constable PA, Al-Dasooqi D, Bruce R, Prem-Senthil M. A review of ocular complications associated with medications used for anxiety, depression, and stress. Clin Optom (Auckl). 2022;14:13-25.
3. Richa S, Yazbek JC. Ocular adverse effects of common psychotropic agents: a review. CNS Drugs. 2010;24(6):501-526.
4. Abu Samra K. The eye and visual system in the preeclampsia/eclampsia syndrome: what to expect? Saudi J Ophthalmol. 2013;27(1):51-53.
5. Vessey MP, Hannaford P, Mant J, Painter R, Frith P, Chappel D. Oral contraception and eye disease: findings in two large cohort studies. Br J Ophthalmol. 1998;82(5):538–542.
