Topic outline

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    • To formulate and agree with the patient a management plan based upon clinical assessment and investigations, with reference to established protocols and guidelines

      Think:

      • How can I best develop my personal patient management skills?

      • What are the gaps in my knowledge and competencies which I need to address? - and in particular which will I attempt to fill in the next 6 months?

      • Can I organise my thoughts appropriately, or do I need to improve my powers of logic and decision-making?

      • Am I aware of published guidelines to help me take an evidence-based approach?

      • Can I communicate my suggested management plan clearly and be sure I have correctly interpreted my patients' understanding, motivation and ability to carry out the management plan?

      • Do I ensure my patients feel comfortable to discuss or question my management plan without anxiety of compromising their future care?

      • Can I improve my patients' ability to administer treatment with advice, devices or referral to other staff or agencies?

      • How can I best involve and support the patient in the management of their condition ("self-care") and help their family, friends and carers to assist them?

      • What are the risks and benefits of the management options and how can I best communicate these to the patient?

      Activity:

      • Ensure that your Programme Director and local trainer have planned your timetable to provide wide exposure to range of cases in a supportive, supervised environment

      • Observe senior colleagues as they formulate management plans, and ask questions - even "stupid" ones!

      • Ask senior colleagues to discuss your management plans for your patients and criticise constructively

      • Take time to present cases (particularly new or difficult cases) both in the clinic situation and in meetings ("Case-based Discussions")

      Resources:

      • Case based discussions, Ophthalmology Fact Fixer (MCQ revision) CN Chua, Voon and Goel Radcliffe medical Press 2002

      • Royal College Ophthalmologists guidelines on common problems: e.g. management of glaucoma, retinal vein occlusion, cataract, diabetic retinopathy (http://www.rcophth.ac.uk/clinicalguidelines)

      • The Wills Eye Manual : Office and Emergency Room Diagnosis and treatment of Eye Disease. Kunimoto et al. Lippincott Williams and Wilkins (2004)

      • Oxford Textbook of Ophthalmology. Easty and Sparrow. Oxford Medical Publications (1999)

      • National Institute for Health and Clinical Excellence guidelines http://guidance.nice.org.uk

      • The Cochrane Collaboration including Cochrane reviews and links to other databases offering online medical evidence (eg TRIP database) http://www.cochrane.org/about-us/evidence-based-health-care/webliography/databases

      • Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association

      • Clinical Ophthalmology, 7th ed. Kanski, J.

      • Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

      • To make appropriate use of triage and prioritise or refer patients when indicated

        Think:

        • How do I decide which is the most urgent case?

        • Which patient has a condition which will respond to rapid intervention?

        Activity:

        • Participate in weekly casualty sessions

        • Participate in on call sessions

        • Get involved in accepting acute referrals from GPs and A and E Departments

        • Develop an algorithm for priorities : preserve life, preserve sight, relieve pain

        • Maintain life support skills annually

        Resources:

        • Access to above with correctly equipped eye exam room, working alongside nurse practitioners and with access at all times to more senior opinion

        • Wills Eye Manual

        • Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)

        • Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association

        • Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)

        • Clinical Ophthalmology, 7th ed. Kanski, J.

        • Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

        • Prescribe and administer appropriate local and systemic therapy

          Think:
          • When should I be wary of dilating the pupil?

          • What is the anatomy of eye/ orbit?

          • What needle should I use?

          • What are the actions, side effects and interactions of drugs my patient is receiving and what monitoring may be necessary?

          • What special considerations should be taken when prescribing in pregnancy and lactation?

          • What are the maximum doses? E.g. local anaesthetics

          • In what situations may a dose adjustment be required?

          • How can I best minimize use of drugs?

          • How often should a drug regime be reviewed?

          • What do I need to tell my patient/carer about the drugs?

          • How can I monitor and improve concordance with treatment?

          • Has the drug been stored properly and is it within its expiry date?

          Activity:

          • Administration of :

              • topical drops

              • subconjunctival injections

              • intraocular injections (AC & vitreous) (see also PS3)

              • oral medications

              • intravenous medications including steroids

              • acetazolamide and other agents

              • antibiotics 

          Resources:

          • Sessions in casualty and in operating theatre so techniques can be learned under supervision

          • Access to and use of hospital pharmacy advice, BNF, Drug company information

          • Education on short and long term effects of steroids and other immunosuppressives (e.g. from rheumatologist)

          • Wills Eye Manual

          • Clinical Ophthalmologyl, 6th ed. Kanski, J.

          • The Pharmacological Basis of Therapeutics, 9th ed. Goodman and Gilman. McGraw Hill (1996)

          • Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association

          • Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)

          • Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.


          • Select appropriate cases for surgery

            Think:

            • What is the purpose of consent?

            • Where written consent is taken, which form is most appropriate for my patient?

            Activity:

            • Attendance at clinics where decisions to offer surgery are made e.g. one stop cataract clinics, cyst clinics

            • Observation and training in taking informed consent

            • Pre-operative rounds with senior colleagues

            • Observation and practical experience in surgical procedures and post operative management

            • Video analysis of taking informed consent

            • Case based discussions with trainers

            Resources:

            • Time for training in above issues

            • Written information leaflets on specific procedures

            • GMC guidelines on informed consent, consent taking for children and those patients with reduced capacity to give consent

            • Royal College Ophthalmologists information on consent, eg information and consent document on cataract surgery

            • Local Trust and departmental guidance on consent, forms to be used etc

            • Essential ophthalmic surgery Foss, A. Butterworth (2000)

            • To recognise and manage local and systemic complications of treatment

              Think:

              • What are potential benefits and side effects from the treatment I am recommending?

              • What was last serious clinical incident in the department and how was it handled?

              Activity:

              • Look up side effects of any treatment you are proposing, whether pharmacological, surgical or other intervention

              • Look up average complication rates of procedures and be alert for these being exceeded

              • Take every opportunity to examine patients pre and post intervention and follow their progress

              • Take time to discuss progress with senior colleagues and modify management in light of response or complications

              • Observe and seek practical experience of the recognition and management of complications of treatment

              • Seek training at induction and later in what constitutes a serious clinical incident and how it is reported

              • Observe the management of clusters of infectious incidents and how these are reported and managed

              • Participate in clinical audit and governance at local, regional and national levels

              Resources:

              • Clinical Ophthalmology, 7th ed. Kanski, J.
              • Wills Eye Manual
              • Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
              • Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)
              • ·Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

              • To apply emergency management of medical problems and first aid

                Think:

                • What are vital signs and can I assess deterioration in these signs?

                Activity:

                • Attendance in Accident and Emergency Department or on acute Medical Firm

                • Practice BLS on mannekins

                Resources:



                • To Involve, And Make Appropriate Referrals To, Medical And Non-Medical Colleagues

                  Think:

                  • Do I know the criteria for registration of partial and severe visual impairment?

                  • Do I know about local and national organisations which support visually impaired people?

                  • Patients involved in a support group can contribute to helping others as well as benefiting themselves.

                  Activity:

                  • Take part in the completion of the CVI form (Certificate of Visual Impairment)

                  • Attend Low Visual Aid and Visual Rehabilitation clinics

                  • Practice the assessment of low visual aids appropriate to the condition

                  • Go out with a social services support worker on the home assessment of a person with vision problems

                  • Go out with an educational support officer working with visually impaired children

                  Resources:

                  •  To involve, and make appropriate referrals to, medical and non-medical colleagues

                    Think:

                    • Do I know about systemic conditions caused by or linked to ophthalmic problems?

                    • When can another professional help or add to the management of a patient?

                    • Do I know the urgency with which onwards referrals should be made to other professionals?

                    • Are there any local guidelines or protocols for referrals?

                    Activity:

                    • Attend general practice, medical, neurological and genetics clinics

                    • Ask to work with allied medical professions (dieticians, orthoptists, optometrists, social services staff) to develop an appreciation of their roles

                    • Observe those involved in providing visual support services

                    • Get feedback on the appropriateness of your referrals. Reflect on the response letter; did you miss anything?

                    • Keep a note of your referrals and check what happened to the patient

                    • Make a referral the subject of a CbD

                    Resources:

                    • Clinical Ophthalmology, 6th Ed. Kanski J

                    • http://www.rnib.org/

                    • Local Social services for visual impairment

                    • NICE.org.uk for clinical guidelines on various conditions

                    • To recognise and act upon ocular findings and treatments that have implications for the general health and well-being of patients

                      Think:

                      • Do I know, and can I recognise, the associations between ophthalmic conditions and systemic diseases?

                      • Do I understand to when and to whom it is appropriate to refer a patient for further investigation or management of systemic problem?

                      • Are there any guidelines or protocols that I can use to estimate the risk of systemic disease e.g. Transient monocular visual loss and stroke risk? Xanthelasmata and vascular disease

                      Activity:

                      • Attend joint/special clinics e.g relating to diabetes, neurology, rheumatology, paediatric and genetic clinics

                      • Ensure that you routinely assess the whole patient rather than their ophthalmic problem alone

                      Resources:

                      • MRCOphth.com CN Chua website

                      • Clinical Ophthalmology, 6th Ed. Kanski J.

                      • Eye in Systemic Disease Kanski J, et al Butterworth Heinemann

                      • Wills Eye Manual

                      • Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association

                      • Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)

                      • Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

                      • To use spectacle lenses and prisms when indicated

                        Think:
                        • In what situations should I advise correction of a refractive error, and when should it be left uncorrected?

                        • What are the different forms of spectacle lens, and what are their advantages and disadvantages?

                        • What forms of prism correction are available and when should I advise their use?

                        • How do patients with refractive errors present to the eye department?

                        • When is a refractive error caused by other ocular or systemic disease e.g. cataract, diabetes, keratoconus?

                        • How will a refractive error influence the management of eye disease e.g. cataract surgery

                        Activity:

                        • Read up on the optics of refractive correction

                        • Talk to a local optometrist about the spectacle correction of refractive errors

                        • Arrange to sit in with an optometrist and a dispensing optician for one or two sessions

                        Resources:

                        • Basic Clinical Science Course: Section 3; American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
                        • Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)
                        • Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

                        • Clinical Optics, Elkington AR, Frank HJ and Greaney MJ. 1999

                        • To use contact lenses when indicated

                          Think:

                          • Do I understand the optics of contact lenses?

                          • Do I understand the basic principles of fitting of hard and soft lenses?

                          • What are the indications for refractive and therapeutic uses of contact lenses?

                          • What rules and procedures should a practitioner and a patient follow for safe contact lens wear?

                          • What complications can arise and how do they present?

                          • How should I manage contact lens complications?

                          Activity:

                          • Read up on the necessary basic sciences (optics, microbiology, properties of the various lens materials and care solutions)

                          • Attend contact lens clinics, discuss cases with the practitioner and observe practice

                          • Ask to be involved in inserting and removing bandage contact lenses

                          • Get involved in recognising and managing acute complications as they present to the ophthalmic department

                          Resources:

                          • Clinical Optics, Elkington AR, Frank HJ and Greaney MJ. 1999

                          • American Academy Ophthalmology BCSC section on contact lenses

                          • Topic 12

                            • Topic 13

                              • Topic 14