Fee splitting and co-management are common practices in ophthalmology. These arrangements may conflict with the ethical principles governing the doctor-patient relationship, may constitute professional misconduct, and at times, may be illegal. Implications and perceptions of these practices may vary between different cultures. Full disclosure to the patient may minimize the adverse effects of conflicts of interest that arise from these practices, and may thereby allow these practices to be deemed acceptable by some cultural morays, professional guidelines, or by law. Disclosure does not necessarily relieve the physician from a potential ethical compromise. This review examines the practice of fee splitting in ophthalmology, its legal implications, the policies or guidelines governing such arrangements, and the possible ethical ramifications. A comparative view between 3 countries, Canada, the United States, and Oman, was conducted; illustrating that even in disparate cultures, there may be some universality to the application of ethical principles.