Topic outline

  • CA1 Conduct a Consultation/History

    Patient's history

    Think:

    • Many of your communication skills will have been acquired in your foundation training. How do these skills apply to an ophthalmic patient?

    • How should I proceed when there is conflict between the history from the patient and that from relatives and careers?

    • In what situations may it be helpful to revisit the history with the patient?

    • What aids to history-taking can be used? (e.g. Questionnaires etc.?)

    • How can I be sure that I have accurately identified the patient's concerns?

    • What special considerations apply to an individual patient, taking into account the nature of their problem and its potential management?

    • If there is bad news to be broken, how can I do so in the optimal way?

    • How much should I involve the patient in their management decisions, and in particular how can I identify how much they wish to be involved?

    • To what sources of further information and support can I refer the patient?

    • How should I draw the consultation to a close?

    • If I were the patient or relative, how would I want the doctor to handle the consultation? (NB remember that all patients are different) 

    Activity:

    • Observe senior colleagues and ask them to observe you

    • With the patient's consent, video-record your consultation and discuss your performance with your trainer

    Resources:

    • Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco. American Academy of Ophthalmology. 2005

    Self Assessment:

    • Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback

  • CA2 Assess vision

    Think:

    • What is meant by 'visual acuity'?
    • How do you assess vision in children or people with learning or communication difficulties?
    • How do you assess vision away from the eye clinic?
    • How can colour vision be assessed?
    • When is it appropriate to test colour vision?
    • Which test is best used for the different causes of impaired colour vision?
    Knowledge:
    • Understanding the underlying principles, benefits and pitfalls of visual acuity assessment methods including Snellen, logMAR Sheridan-Gardner etc.
    Activity:
    • Ask your orthoptist if you can participate in an orthoptist clinic assessing childrens vision
    Resources:

    • ·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco.  American Academy of Ophthalmology. 2005
    • ·Leat SJ, Shute RH, Westall CA. Assessing Children's Vision: A Hand Book. Oxford. Butterworth Heinemann. 1999

  • CA3 External Eye Examination

    Think:

    • What neuroanatomical sites give rise to detectable field defects on clinical examination?

    Resources:

    • Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco.  American Academy of Ophthalmology. 2005

    Self Assessment:

    • Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.

  • CA4 Examination Of The Pupils And Perform Diagnostic Pharmacological Tests

    Think:

    • What are the pupillary pathways?

    Resources:

    • ·Foroozan R, Bhatti MT, Falardeau j, Gordon LK, Lee MS, Subramanian PS et al. Section 5; NeuroOphthalmology. In Skutta GL, Cantor LB, Cioffi GA. Basic and Clinical Science Course. 2013 - 2014. San Francisco. American Academy of Ophthalmology. 2013. Pages 245 - 257
    • ·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco.  American Academy of Ophthalmology. 2005

    Self Assessment:

    • Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback

  • CA5 Perform A Cover Test And Assess Ocular Motility

    Think:

    • What are the actions of the extraocular muscles?
    • This is an examination technique that requires a lot of practice
    • What are the implications of the different types of nystagmus?

    Activity:

    • Spend time with your orthoptist and ask to participate in their clinics

    Resources:

    • Rowe F. Clinical Orthoptics.London. Blackwell Science; 2004.
    • Pratt-Johnson J, Tillson G. Management of Strabismus and Amblyopia. 2nd Edition. New York. Thieme. 2001
    • Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco.  American Academy of Ophthalmology. 2005

    Self Assessment:

    • Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.

  • CA6 Measure Intraocular Pressure Using Applanation Tonometry

    Think:

    • How would I feel if I were the patient having applanation done for the first time, and how can I help them to relax appropriately?
    • What can make the measurement of IOP less accurate? - how can I ensure the most accurate result possible?
    • What factors should influence my interpretation of the result?
    • In what situations should I be wary of performing applanation?
    • What damage could applanation cause to the patient?

    Activity: 

    • Watch senior colleagues and discuss the nuances of their technique

    Resources:

    • Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco.American Academy of Ophthalmology. 2005

  • CA7 Perform Slit Lamp Biomicroscopy Of The Anterior Segment Using Appropriate Illumination Techniques And Stains, And Diagnostic Contact Lenses

    Think:

    • It is important to know exactly how the slit lamp and its accessories work

    Activity:

    • Make sure that you can use a hand held slit lamp
    • Ask a senior to observe and confirm your gonioscopic technique and findings
    • Get a senior colleague to show you and the instruction manuals are a useful resource!

    Resources:

    • Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco.  American Academy of Ophthalmology. 2005

  • CA8Examine The Fundus Using Appropriate Techniques

    Think:

    • Is pupil dilation necessary to achieve adequate examination?
    • Scleral indentation is a skill that takes a lot of practice
    • When is it appropriate to use the different types of lenses that are available for fundus examination? How do all the techniques differ in magnification, orientation of the retinal image and field of view?

    Activity:

    • Take as many opportunities as you can to practise
    • Watch senior colleagues and discuss the nuances of their technique, then practise again

    Resources:

    • Hilton GF, McLean EB, Brinton DA, editors. Retinal Detachment. 2nd Edition. San Francisco: American Academy of Ophthalmology. 1995
    • Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5th Edition. San Francisco.  American Academy of Ophthalmology. 2005

    Self Assessment:

    • Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback

  • CA9 Perform A Focused General Medical Examination Taking Into Account The Associations Between Systemic And Ophthalmic Diseases

    Think:
    • Many of your general medical examination skills will have been developed during your foundation years. Which ophthalmological problems would prompt you to use these skills as an ophthalmologist?
    • When should I request a chaperone?

    Activity:

    • Offer to help a medical trainee with eye examination skills for postgraduate examinations if they will help you with your general medical examination skills (record this in your portfolio)

    Resources:

    • Swash M. Hutchinson's Clinical Methods. 21st Edition. Edinburgh. Saunders. 2002
    • Douglas G, Nicol F, Robertson C. MacLeod's Clinical Examination. 11th  Edition.2005.


  • CA10 Perform A Basic Paediatric And Developmental Examination Taking Into Account The Associations Between Systemic And Ophthalmic Diseases

    Think:

    • What developmental milestones would you expect a two year old to be capabable of?

    Activity: 

    • Offer to help a paediatric trainee with eye examination skills for postgraduate examinations if they will help you with your paediatric examination skills (record this in your portfolio)

    Resources:

    • Douglas G, Nicol F, Robertson C. MacLeod's Clinical Examination. 11th  Edition.2005.
    • Swash M. Hutchinson's Clinical Methods. 21st Edition. Edinburgh. Saunders. 2002

  • CA11 Perform A Focused Neurological Examination Taking Into Account The Associations Between Systemic And Ophthalmic Diseases

    Think:

    • Many neurological problems present to the ophthalmologist and a competent neurological assessment of patients is required

    Activity:

    • Arrange sessions with your local neurology/neurosurgical department in their clinics or ward rounds to develop your examination skills
    • Offer to help a medical trainee with eye examination skills for postgraduate examinations if they will help you with your neurological examination skills (record this in your portfolio)

    Resources:

    • Swash M. Hutchinson's Clinical Methods. 21st Edition. Edinburgh. Saunders. 2002

  • CA12 Formulate A Differential Diagnosis

    Think:

    • What developmental milestones would you expect a two year old to be capabable of?

    Resources:

    • Hamptom Roy F. Ocular Differential Diagnosis. 6th Edition. Baltimore. Williams and Wilkins. 1997

    Activity:

    • Make it routine at the end of a consultation to document a differential diagnosis.
    • Make sure that you discuss your differential diagnosis during CbD