Patient Investigation

ORTHOPTIC Assessment

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Orthoptic  Assessment
Code	PI1
Description	Trainees must understand the role of an orthoptic assessment, where appropriate, and interpret the findings.  They must understand the limitations of the investigation and the implications of positive or negative results.
Assessment	CbD portfolio/logbook and end of year review/COECSA exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.1.2 below

ORTHOPTIC Assessements Study Guide

Think:          

• ·An orthoptic assessment is essential for the proper diagnosis of ocular motility disorders
• ·What does an orthoptic report mean and how can I interpret it?
• ·What is a Hess chart/Lees screen and how do I interpret it?

Activity:

• ·Attend orthoptic clinics regularly
• ·Learn from the orthoptists how they perform a cover test and practice this with them watching you. Learn to talk to your patient, especially children and make them cooperate with your instructions
• ·Learn how to handle a prism bar effectively
• ·Read an orthoptic report and learn what the notation means
• ·Watch the orthoptist performing a Hess/Lees screen examination
• ·Interpret the results
• ·Become familiar with the Hess chart pattern of common oculomotor disorders

Resources:

• ·MRCOphth.com
• ·Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of Ophthalmology. Oxford; 1999
• ·Rowe F. Clinical Orthoptics. Blackwell; 2004.
• ·Fiona J. RoweClinical Orthoptics, 3rd EditionWiley-Blackwell  2012

Assessments:

• ·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give feedback.
• ·Case based discussions
• ·Part 1 COECSA
• ·Part 2 COECSA. OSCE

Corneal assessment

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Corneal assessment
Code	PI2
Description	Trainees must be able appropriately to select, perform and interpret investigations to assess the cornea.  They must understand the limitations of the investigation and the implications of a positive or negative test result. They must be aware of the possible discomfort to which the patient may be exposed during the test as well as the cost and resources involved.
Assessment	CbD,portfolio/logbook and end of year review/COECSA exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.2.2 below

Assessment of corneal shape, structure and thickness Study Guide

Think:

·Investigations for these parameters are very useful for determining refractive problems as well as managing glaucoma.

Activity:

• ·        Watch senior colleagues perform these investigations and then ask if they can watch you doing it. Try and practice on the two standard keratometers (Javal-Schiotz and Von Helmholtz)
• ·        Use a corneal topographer and pachymeter and interpret the printout obtained. Have the technique done on you to appreciate what the patient has to do.
• ·        Some instruments such as specular microscopy may not be available in your hospital. Make sure you know what the printout of such machines looks like and how you would interpret it.
• ·        Automated keratometry, UBM and OCT: Watch senior colleagues perform these investigations and then ask if they can watch you doing it.
• ·        Ensure you understand the K readings taken by the modern Biometers (eg IOL Master) and the indications for the use of a hand-held keratometer

Resources:

• ·        MRCOphth.com
• ·        Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of Ophthalmology. Oxford; 1999 Sinjab Mazen MCorneal Topography in Clinical Practice (Pentacam System)—Basics and Clinical Interpretation : ISBN: 9789350255759DOI: 10.5005/jp/books/11634 Edition:2/e2012    
• ·        Specific equipment User Guides

Assessment:

• ·        Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.
• ·        Case based discussions
• ·        Part 1 COECSA OSE
• ·        Part 2. COECSA OSCE

Ultrasonography

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Ultrasonography
Code	PI3
Description	Trainees must be able to appropriately select, order and interpret ocular and orbital ultrasound measurements and images. They must understand the limitations of the investigation and the implications of a positive or negative test result. They must be aware of the possible discomfort to which the patient may be exposed during the test as well as the cost and resources involved.
Assessment	CbD,portfolio/logbook and end of year review/COECSA exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide -3.3.3.2 below

Ultrasonography Study Guide

Think:

• ·        What structures are imaged by these techniques?
• ·        What is the difference between an A-scan and a B-scan?
• ·        What are the physical principles employed?
• ·        What are the newer techniques of ultrasound imaging?

Activity:

• ·        Watch senior colleagues perform these investigations. Ask them to take you through what they are doing and why. Ask them to watch you doing the same thing.
• ·        Use any opportunity to perform a B-scan - e.g. a vitreous hemorrhage
• ·        Perform the biometry. Be aware of the differing printouts of the machines and learn how to interpret them accurately.

Resources:

• ·        MRCOphth.com
• ·        Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of Ophthalmology. Oxford; 1999
• ·        Dr. Yale Fisher Essential Lectures in Ophthalmic Ultrasound Opthalmic Edge.org http://www.ophthalmicedge.org/essential-lectures-ophthalmic-ultrasound
• ·        Arun SinghBrandy HaydenUltrasonographyExpert Consult - Online and Print Elsevier 2011
• ·        Specific equipment User Guides

Assessment:

• ·        Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.
• ·        Case Based discussions
• ·        Part 1. COECSA OSE
• ·        Part 2 COECSA. OSCE

Fundus angiography

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Fundus angiography
Code	PI4
Description	Trainees must be able to understand the indications and possible risks associated to fundus angiography. They must be able to order, perform, & interpret positive and negative results & understand the implications of the results.
Assessment	CbD, portfolio/logbook and end of year review/COECSA exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.4.2 below

3.3.4.2 FUNDUS angiography Study Guide

Think:

• ·        What are the techniques involved and what structures are being imaged
• ·        What dyes are used in fundus angiography?
• ·        What are the alternative options for this type of investigation and the relative indications and risks of each, which might influence their choice
• ·        When may the options complement one another? - e.g. OCT, autofluorecscence and angiography or use of multiple dyes.

Activity:

• ·        Participate in as many Fluorescein angiography sessions as you can.
• ·        Be involved in taking the photographs and understand the techniques of the particular retinal camera used. Understand the nature of the filters used.
• ·        Become experienced in interpreting the images obtained.
• ·        Try and find out the indications for Indocyanine green angiography, its use and its limitations. Try and attend workshops and study days for angiography.

Resources:

• ·        MRCOphth.com
• ·        Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of Ophthalmology. Oxford; 1999
• ·        Web ,Text books
• ·        Specific equipment User Guides

Assessment:

• ·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.
• ·Case Based discussions
• ·Part 1 COECSA. OSE
• ·Part 2 COECSA OSCE

Retinal and optic nerve imaging

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Retinal and optic nerve imaging
Code	PI5
Description	All trainees must be able appropriately to perform order and interpret retinal and optic nerve investigations that require some form of imaging such as OCT. They must be aware of new techniques as they are developed. They must understand the limitations of the investigations and the implications of a positive or negative test result. They must be aware of the possible discomfort, distress and risks that the patient may be exposed to involved with the test as well as the cost and resources involved.
Assessment	Cbd, Portfolio/Logbook And End Of Year Review/COECSA Exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.5.2 below

 Retinal and optic nerve imaging techniques Study Guide

Think:

• ·These are common investigations done by all eye departments.
• ·What techniques are utilized and what structures are imaged by these methods?
• ·When can review of previous images be helpful?

Activity:

• ·Familiarize yourself with the various imaging modalities for retina and optic nerve.
• ·Participate in as many photographic imaging sessions as you can
• ·Attend a diabetic screening programme
• ·Try and use the instruments available yourself
• ·Gain experience in interpreting the pictures obtained
• ·Attend workshops and clinical forums when these topics are discussed
• ·Be aware that there are many instruments which may not be widely available in every eye unit. If this is the case try and find out as much as you can about those instruments you are unable to lay your hands on from sources such as manufacturer websites, visit sites that have them.

Resources:

• ·MRCOphth.com
• ·Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of Ophthalmology. Oxford; 1999
• ·Optical Coherence Tomography: A Colour Atlas of Retinal Images. D.A. Landry. Bryson Taylor Publishing, 2013.
• ·Fluoresceine and ICG Angiography: Textbook and Atlas. G. Richard. 2^nd Edition. Thieme. 1998.
• ·Diagnostic and Imaging Techniques in Ophthamlology. A. Agarwal, S. Boyd, RC Andrews. Jaypee Medical. 2011.
• ·Sankara Nethralaya Atlas of Imaging in Ophthalmology. A. Selvakumar, V. Noronha, PM Sundaram. Jaypee Medical 2014.
• ·The ABCs of OCT. J. Sherman, D. Epshtein. Review of Optometry,
• ·Online journal: http://www.reviewofoptometry.com/content/d/technology/c/36644/

Assessment:

• ·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.
• ·Case based discussions
• ·Part 1 COECSA. OSE
• ·Part 2 FCOECSA. OSCE

                     

Radiology and Neuro-imaging

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Radiology and Neuro-imaging
Code	PI6
Description	Trainees must be able to appropriately select order and interpret radiological and related investigations; to understand the limitations of the investigations and the relative risks to the patient; to take into consideration the cost and resources involved.
Assessment	Cbd, Portfolio/Logbook And End Of Year Review/COECSA Exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.6.2 below

Radiology and other Neuro- imaging Study Guide

Think:

• ·What are the structures identified in X-rays, CT scans and MRI scans?
• ·What are the differences between the techniques?
• ·Be aware of the physical principles of the investigations.
• ·What contrast media are used to enhance the images obtained?
• ·What are the newer investigations that are coming into common practice e.g. PET scans?
• ·When may MRA and angiography be useful?

Activity:

• ·Observe as many images as you can and read the associated report. Ask a senior colleague to go through the findings with you.
• ·Try and visit the radiology department and ask questions of the clinicians and technicians there.
• ·Try and attend seminars and workshops of relevant radiology.

Resources:

• ·MRCOphth.com
• ·Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of Ophthalmology. Oxford; 1999
• ·Sankara Nethralaya Atlas of Imaging in Ophthalmology. A. Selvakumar, V. Noronha, PM Sundaram. Jaypee Medical 2014.

Assessment:

• ·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.
• ·Case Based discussions
• ·Part 1 COECSA. OSE
• ·Part 2 COECSA. OSCE

Electrodiagnostics

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Electro-diagnostics
Code	PI7
Description	Trainees must be able to appropriately select order & interpret appropriate electro-diagnostic tests. They must understand the limitations of investigations and implications of negative and positive tests. They must be aware of possible discomfort and distress and risks to which the patient may be exposed as well as the cost and resources involved.
Assessment	Cbd, Portfolio/Logbook And End Of Year Review/COECSA Exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.7.2 below

ELECTRO-DIAGNOSTIC TESTS STUDY GUIDE

Think:          

• ·What are the types of electro-diagnostic tests
• ·Why are these techniques useful?
• ·What are the principles involved?
• ·Which investigation is appropriate for what ocular pathology?

Activity:

• ·Many hospitals do not have direct access to these techniques and rely on a larger department for them. If you can gain access to a neurophysiology department go and observe the techniques in action. Otherwise read the principles involved and make yourself aware of the various printouts and parameters of each technique.
• ·If you see a patient in the clinic who needs electrodiagnostic tests try and accompany them to the investigation.

Resources:

• ·MRCOphth.com
• ·Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of Ophthalmology. Oxford;
• ·Adler. Physiology of the Eye, Clinical Application. Mosby 1999
• ·Sankara Nethralaya Atlas of Imaging in Ophthalmology. A. Selvakumar, V. Noronha, PM Sundaram. Jaypee Medical 2014.
• ·Grant T. Liu, Nicholas J. Volpe, and Steven L. Galetta. Neuro-Ophthalmology: Diagnosis and Management illustrated. Philadelphia, W.B. Saunders, 2001

Assessment:

• ·Case Based discussions
• ·Part 1 COECSA OSE
• ·Part 2 COECSA. OSCE

Laboratory investigations

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Laboratory investigations
Code	PI8
Description	Trainees must be able to appropriately select order and interpret appropriate laboratory investigations and recognize when further action is required.  They should understand the limitations of each investigation and implications of positive or negative test results. They should be aware of possible discomfort and distress and risks to which patient may be exposed as well as the costs and resources involved.
Assessment	CbD, portfolio/logbook and end of year review/COECSA exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.8.2 below

Laboratory investigations Study Guide

·

Think: 

• What are the haematological, microbiological/parasitological, biochemical and immunological processes involved in ophthalmic conditions?
• What investigations can be performed by ophthalmologists in the clinic?

Activity:

• ·  Study any haematological, microbiological/parasitological, biochemical and immunological form that arises from your clinical management.
• ·  Learn the relevance of any variance from the normal values.
• ·  Be aware of allergy testing such as the patch test.
• ·  Be aware of the use of immunological tests in patients on immunosuppressive treatment
• ·  Talk to a senior colleague about the relevance of each parameter.

Resources:

·  The Eye: Basic Sciences and Practice. Forrester JV, Dick AD,McMenamin P, Lee WR, WB Saunders Ltd, London

Assessment:

• ·  Case based discussion
• ·  Part 1 COECSA exam

Biometry

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Biometry
Code	PI9
Description	Trainees must be able to perform and interpret appropriate biometry investigation, particularly in relation into
Assessment	CbD, portfolio/logbook and end of year review/COECSA exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.9.2 below

Biometry Study Guide

Think:

• ·  A cause of patient dissatisfaction in ophthalmology is the implantation of an incorrect power intraocular lens. How do you accurately assess the power of an intraocular lens?

Activity:

• ·  Attend the pre-operative assessment clinic, often run by nurse practitioners. Become familiar with the biometry apparatus in your department including ultrasound A-scans and partial coherence interferometers. Know what the printout looks like and the relevance of the A-constants of each individual implant/surgeon.
• ·  Always predict a particular power for the intraocular lens and then compare your estimate with the surgeon who is in charge of the patient.
• ·  Perform a continuous audit of the refractive outcome of your cataract surgery to refine your own A-constant.

Resources:

• ·  Cataract Guidelines pp25 - 30: Royal College of Ophthalmologists 2004
• · Ophthalmic Ultrasonography by Arun Singh Brandy Lorek 2011

·Assessment:

• ·  Case Based discussions
• ·  Part 1 COECSA exams
• ·  Part 2 COECSA OSCE/Viva exams

Visual fields

Learning outcome Overview

PATIENT INVESTIGATION (PI)
Learning Outcome	Visual fields
Code	PI10
Description	Trainees must be able to perform confrontation, manual and automated visual field tests.  They must understand the limitations of visual field tests.  They must be able to interpret visual field test results. They must understand the clinical correlates of visual field defects
Assessment	CbD,portfolio/logbook and end of year review/COECSA exams
Target Year of Achievement	Year 2
Related Learning Outcomes	PI 1 – P10
Other Links	Study Guide  3.3.10.2 below

Visual fields Study Guide

Think:

• ·  Visual field analysis is a vital part of an ophthalmic examination.
• ·  What instruments are available to analyze the visual field?
• ·  How do they function?
• ·  What are their limitations?
• ·  What are the different programmes and which one should be chosen for what condition?

Activity:

• All eye units should have an automated visual field analyzer. Ensure you observe a technician performing such a test.
• Have a test performed on you to appreciate the problems that patients may have whilst doing the test.
•  Learn how to set up the instrument properly including the provision of the refractive error in the eyepieces.
• ·  Find out about the fixation monitoring protocols and the meaning of the reliability indices.
• ·  Know which programme to select for glaucoma monitoring, neurological assessment and driving standards.
• ·  If there is a Goldmann perimeter in the department, take the opportunity to watch a field analysis being done using this instrument. Know the differing nomenclature for the spot size, illumination of the target etc.

Resources:

• ·Automated visual field analysis - J Sowka. 2005
• ·http://www.nova.edu/~jsowka/Course_Notes/Glaucoma%20Visual %20Fields.doc
• ·Visual Fields Examination and Interpretation. American Academy of Ophthalmology; 1990.

Assessment:

• ·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.
• ·Case Based Discussions
• ·Part 1 COECSA Exams
• ·Part 2 COECSA OSCE/Viva exams