The Challenge of Oculoplastic Training in Europe

Up until the late 1960s, European ophthalmological training programs were not structured for proper fellowship attachments. It was the foundation of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) in 1969, and 12 years later the European Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS), that galvanized interest in ophthalmic plastic surgery as a subspecialty. Since that time oculoplastic surgery has rapidly evolved, with progressively more structured and recognized training programs globally. In our current climate, cadaveric dissection courses, international meetings with attendees from all over the world, masterclasses with live surgery, and webinars are now offered on a regular basis.

However, European oculoplastic teaching programs are still regarded as somehow difficult to come by. We start our training with a residency, and then – to go above and beyond in training, experience, and research – we need a fellowship. We know that in the US, a two-year oculoplastic fellowship provides a specialized full spectrum training in eyelid, orbit, lacrimal, and facial aesthetic and reconstructive surgery.  And in the UK there are structured fellowships, varying in length from six months to two years. But what happens in the rest of Europe?

In some European countries, such as Italy and France, only very few ophthalmology departments will guarantee regular oculoplastic services, and although there are some fellowship programs available, access to these is difficult, posts are limited, and there is no official, recognized title for these programs.

With the aim of creating a European recognition that would help to homogenize the various types of training throughout the continent, the European Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS) launched its EBO-ESOPRS exam in 2023 (1). The examination is primarily aimed at trainees starting their independent practice, who have recently completed a minimum one-year full-time fellowship, or else have documented equivalent training in countries where official fellowships are not available.

But what can we do to improve oculoplastics training further? How can we get young colleagues to sit for the exam? And how might oculoplastic surgery be made more widely recognizable as an ophthalmic subspecialty?

There is indeed an argument to be made for the case of bringing oculoplastics into the ophthalmic spotlight: current projections indicate that ophthalmology, by 2035, will experience the second most severe shortage among all medical specialties (2). There are also well-known geographic disparities in oculoplastic surgeons’ distribution throughout Europe. Moreover, core aspects of oculoplastics – such as lacrimal and orbital pathology – appear to be unfamiliar to both the public and, more worryingly, to other physicians (3).

If one examines this lack of knowledge around the subject at face value, it would appear that most medical students tend to ignore the existence of oculoplastic surgery altogether, with no interest in pursuing a career in the field. But, on the contrary, the spread of social media has recently increased awareness of ophthalmic plastic surgeons as the main experts in cosmetic surgery and aesthetics of the periocular district. Rather ironically, this increased recognition of oculoplastics runs parallel to an increased prevalence in reported cases of body dysmorphic disorder (BDD), again thought to be correlated with the mass popularity of social media apps.

So, how might we improve oculoplastics training where facilities are lacking, or where private practice makes hands-on training more difficult for students? Virtual reality (VR) could be one solution. It’s a still emerging technology with wide potential applications. For example, orbital surgery can be extremely difficult, with surgeons operating in very small areas containing a high density of delicate and complex anatomical structures. In this scenario, VR offers aspiring surgeons a chance to practice in a safe environment, mitigating the shortage of oculoplastic surgeons by accelerating ophthalmology trainees’ journey to surgical proficiency.

I also believe that it is essential to improve our teaching in aesthetics – teaching that should be rooted in science and evidence-based – as well as training all oculoplastic fellows in endoscopic surgery. This will define the next generation of surgeons: endoscopic surgery is now mainly performed collaborating with other specialists, but a broadened teaching experience where fellows learn to operate an endoscope efficiently and accurately would likely translate into safer surgical outcomes in the management of many orbital pathologies.

In tandem with VR, artificial intelligence (AI) is also making a huge impact on the ways in which healthcare is delivered. Our intelligence is, of course, what makes us human, but I believe that AI should be viewed as an extension of that quality. It is more objective than manual methods, it can help in clinical decision-making, and I believe that in the future it will play a broader role in the assessment of eyelid and orbital disorders.

Why does the future of oculoplastic teaching in Europe remain challenging? There is an urgent need for established European training requirements to ensure standardization of patient care. We have to increase awareness of our subspecialty among medical students, physicians, and the general public. With the predicted shortages in ophthalmology, necessity is growing and we must be ready. We also need to establish officially recognized European centres for training, and define areas of potential growth (e.g., opening more clinical practices in underserved regions).

Although AI will inevitably play an increasingly significant role in our lives, connecting the global community and transforming healthcare as an industry, we still require leaders with a passion for teaching and research, who can take the helm when it comes to leading the next generation of oculoplastic surgeons. And while VR should never be considered a replacement for hands-on surgical experience in fellowship training, it should be used as a supplementary training aid for enabling trainees to make that daunting transition into real-life surgery.

Embracing these fledgling technologies, we must believe in the future while continuing to respect the legacy of the past. We need to embrace our mentors’ embedded culture of cross-discipline learning and continuous mentorship, all while acknowledging what benefits might be gleaned from incorporating such technology into our oculoplastic procedures. My profound belief now is that oculoplastic surgery is ready to be transformed into a surgical speciality in its own right. As I wrote in my ESOPRS 2024 Mustardé Lecture: “the future is the door, the past is the key.” (3)