Topic outline

  • PI1 Assessment of corneal shape, structure and thickness

    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 andinterpret the printout obtained. Have the technique done on yourself 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

    • 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

    • PI2 Orthoptic Assessment

      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.

      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

      • PI3 Retinal and optic nerve imaging techniques

        Think:

        • These are common investigations done by all eye departments.

        • What techniques are utilised 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

        • Current Books on OCT, FLA, HRT, GDX

        • Online: review of optometry ABCs of OCT

        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

        • PI4 Ocular angiography

          Think:

          • What are the techniques involved and what structures are being imaged

          • 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? - eg 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

          • PI5 Ultrasonography

            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 - eg. a vitreous haemorrhage

            • 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

            • 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

            • PI6 Radiology and other neuro- imaging

              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-check for newer edition of same or similar book.

              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

              • PI7 Ocular and Neuro-electrophysiology

                Think:

                • 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; 1999-newer version?

                • Adler. Physiology of the Eye, Clinical Application. Mosby 1999

                Assessment:

                • Case Based discussions

                • Part 1 COECSA . OSE

                • Part 2 COECSA . OSCE

                • PI8 ┬áLaboratory Investigations

                  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



                  • PI9 Biometry

                    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

                    • Need to add another commonly used books on biometry in the region

                    Assessment:

                    • Case Based discussions

                    • Part 1 COECSA exams

                    • Part 2 COECSA OSCE/Viva exams 

                    • PI10 Visual Fields

                      Think:

                      • Visual field analysis is a vital part of an ophthalmic examination.

                      • What instruments are available to analyse 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 analyser. Ensure you observe a technician performing such a test.

                      • Have a test performed on yourself 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:

                      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

                      • PI11 Microbiology

                        Think:

                        • Infection is a common problem in ophthalmology. What organisms are responsible for ocular infections? How are they isolated and identified?
                        Activity:
                        • Make yourself aware of the various methods to collect microbiological specimens.
                        • Become familiar with the techniques to obtain swabs and scrapes of the ocular tissues.
                        • Learn which transport medium is required for optimal isolation of the organism.
                        • Learn how to perform a Gram stain out of hours in order to get a preliminary diagnosis and to initiate treatment of a severe ocular infection.
                        Resources:
                        • Coster DJ. Procedures. Cornea. BMJ; 2002.
                        • Ocular Pathology: A Text and Atlas. Yanoff M, Fine BS. JB Lippincott Co, Philadelphia The Eye:
                        • Basic Sciences and Practice. Forrester JV, Dick AD,McMenamin P, Lee WR, WB Saunders Ltd, London
                        Assessments:
                        • Case based discussions
                        • Part 1 FRCOphth. CRQ
                        • Part 2 FRCOphth. CRQ
                        • PI12 Biometry

                          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
                          Assessment:
                          • Case Based discussions
                          • Part 1 FRCOphth. OSE
                          • Part 2 FRCOphth. OSCE