Essential Medical Ophthalmology
By John D Ferris
Butterworth & Heinemann, Oxford, UK, 2001
Paperback / 290 pages / Colour photographs
ISBN: 0-7506-4937-2 / $79.95

Ophthalmologists are doctors - not only eye doctors

Essential Medical Ophthalmology
By John D Ferris

It is the biggest danger of specialisation and sub-specialisation: to loose the skill of seeing the patient as a whole and eventually make an avoidable mistake.

It is not common to actually cause harm in this way, but it is not uncommon to find cases in which an ophthalmologist has failed to diagnose a systemic disease in a patient who may have benefited greatly from earlier diagnosis and treatment.

Essential Medical Ophthalmology is a complete manual for anyone who wants to minimise that possibility. It is a highly practical textbook that systematically highlights the ocular conditions associated with common systemic diseases.

It is a heavy book for a paperback, but it is well-produced and beautifully illustrated. The illustrations range from colour photographs to X-rays, electro-diagnosis and lab results. All illustrations have practical use, not to make points clearer, but to serve as practical case examples for the diseases being explored.

The author is John D Ferris, FRCOphth, a Consultant Ophthalmologist at the Gloucestershire Eye Unit in Cheltenham, UK. This is his second ophthalmology textbook. He has also published sparse clinical papers over the past decade in ophthalmology journals, mainly in the UK. Most of the clinical material used in the book comes from Addenbooke's Hospital in Cambridge.

The full book is UK-based. The publisher's blurb on the back page makes the point very clearly when it says that the book is aimed at "trainee ophthalmologists studying for the MRCOphth and for physicians studying for the MRCP" exams. The biochemical printouts unashamedly come from Addenbooke's NHS Trust. The guidelines for oral corticosteroid use are those of the UK's National Osteoporosis Society.

The mix of patient ethnic backgrounds reflects those more likely to be found in England than anywhere else. Nevertheless, this is a valid approach that in no way belittles the well-presented contents and practical advice that the book provides. When referring to key clinical papers and sources of evidence-based practice, there are no geographic barriers. The best, most relevant and more recent studies and clinical trials are mentioned.

Essential Medical Ophthalmology is a collection of 109 clinical cases. The author presents a piece of clinical evidence: a fundus photograph, the face of a patient, a biochemistry department printout, a radiograph or an electrocardiogram. And, of course, a few relevant details of the patient.
Some questions follow, the first of which nearly always asks the reader to describe and to identify possible aetiology. Each case follows approximately this pattern: identification of the key issues, differential diagnosis, ophthalmologic involvement, correct management and therapy implications. A few differential diagnosis tables and occasional simple line diagrams complete the didactic approach.

To maximise the teaching value of the approach, each case is headed by its section and case number, without a title. It allows you to try to guess diagnosis and relevant ophthalmic issues, without immediately linking the photograph to the header.

The approach is surprisingly effective. The clear answers encourage you to read further, and the impeccable clinical logic of the next question leaves you with a "black and white" didactic approach to systemic diseases with eye involvement. Of course, clinical practice is hardly ever black and white, but, as a method of putting ideas in your mind, the approach is very effective.

For those not concerned with passing exams, the excellent table of contents and index make retrieving information extremely easy. The main difference between this book and a traditional textbook is that all of its chapters are written in "practical case" form. Such a style makes the information more easily related to daily clinical practice.

Most of the case examples that make up the book have a brief "further reading" section at the end, with anywhere from one to five references. The references include clinical trials, key studies, reviews, papers and texts addressing the issue under review. All references are well chosen.

Although Mr Ferris acknowledges the help of a few colleagues in the preface, the extremely consistent use of language and structure within each case gives a unity to the book that only a single writer can provide. Technical vocabulary is widespread; Mr Ferris makes no attempt to make the text available to anyone other than ophthalmologists or general practitioners with a good working knowledge of ophthalmologic terminology. The result is precise and clear text.

The cases are grouped in sections, according to location within the eye or other part of the body. In practice, this results in association by diagnostic tools used. The first two sections are retinal photographs. Section one deals with fundi. Section two deals with optic discs. All types of diabetic alterations, retinal vein pathologies, infectious diseases, blood disorders and drug reactions are there, one-by-one, with management and treatment suggestions.

Section three presents ocular motility alterations and lid disorders. Case presentation is based mainly on photographs of the patient's face, with several stills of eye movements in several directions.

Section four is devoted to visual fields (yes, by giving you visual field exploration results). And Section five presents systemic diseases which can have distinct face features, such as acromegaly, Grave's disease and myotonic dystrophy.

The following two sections take the same approach with hands and skin. Rheumatic hands and Kaposi's sarcoma are two examples of the author's comprehensive approach. The book's last three sections take their starting points from biochemistry and haematological laboratory tests results, radiographies (including CT scans and MRI) and electrodiagnosic results (ECG, nerve stimulation, nystagmus waveform).

The sum is a complete overview of common and uncommon systemic diseases. Most of them are related to old age, but can have repercussions on any aspect of eye function. That includes many currently used therapies: some are ophthalmic treatments with actions in other parts of the body, such as beta-blockers affecting respiratory function in elderly glaucoma patients.

Others include systemic therapies that have repercussions in the eye or interfere with eye therapies. For instance, the author describes how warfarin interferes with coagulation processes in cataract operations. In all, the book provides essential stuff to be comfortable with, but provides few excuses not to be.

Although the style of presentation of the information may make the book particularly appropriate for the student or trainee, it is also an extremely useful book for a wider audience.
For instance, general ophthalmologists dealing with an aged population should be aware of the many forms and shapes that geriatric diseases take - this book is full of pointers to consider.

General practitioners can also learn from the book. It can help them determine whether an ophthalmic sign or symptom may be reflecting a systemic disease, or if a systemic condition requires an eye check to detect sub-clinical eye damage.

Fully specialised ophthalmologists can benefit from the book, too, because they must always remember that <the patient attached to those eyes may have clues, needs and treatment interactions coming from all corners of the body. > And as a fully qualified doctor, the specialised ophthalmologist is expected to identify and sometimes manage eye therapy in the context of systemic conditions. With increasing numbers of patients living longer, this can only become more important. The time when you could pass over to another hospital department your patient for "outside-the-eye" events is probably over.

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