Topic outline

  • Perform a refractive assessment and provide an optical prescription

    • Think:

      • How does refracting children differ from refracting adults?

      Activity:

    • Ask your departmental or local optometrist to teach you to refract
    • Familiarise yourself with optical prescription documentation
    • Practice on colleagues, friends, secretarial staff and as many patients as you canGet a senior colleague to observe and give feedback
    • Consider going on a Refraction Course

    Resources:

    • Elkington AR, Frank HJ, Greaney MJ. Clinical Optics. 3rd ed. Blackwell Science; 1999: 165-215.
    • Theory and Practice of Optics And Refraction. A.K. Khurana. Elsevier. 2nd Edition. 2008.
    • Retinoscopy Video: http://www.rootatlas.com/wordpress/video/870/retinoscopy-workshop-video

    Self-Assessment:

    • Optics and Refraction section www.mrcophth.com
    • Basic Sciences in Ophthalmology: A self assessment Text byJohn Ferris,D.L. Easty
    • MCQS and OSCES in Optics and Refraction PDF Download at mrcophth.com

          • Administer periocular and intraocular drugs

            Think:

            • What clinical anatomy is relevant to the administration of periocular drugs?

            • What are the methods of action and pharmacokinetics of these drugs?

            • What side effects should I be prepared for in the specific context of periocular and intraocular administration?

            • How do you constitute and administer intravitreal antibiotics? Remember this is often performed in an emergency situation out of hours

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

            • Some more details on administering local anaesthesia

            • How do you constitute and administer intracameral drugs?

            Resources:

            • Kunimoto DY, Rapuano CJ, Friedberg MA, Maker M, Kanitkar KD. The Wills Eye Manual:Office and Emergency Room Diagnosis and Treatment of Eye Disease. 4th ed. Appendix 7. Technique for Sub-Tenons and subconjunctival injections. Lippincott Williams and Wilkins; 2004
            • Clinical Ocular Pharmacology. J.D. Bartlett, S.D. Jaanus. Butterworth Heinemann Elsevier. 5th Edition, 2008. Pg. 48-52
            • Duane's Ophthalmology DVD-ROM
            • British National Formulary

            • Use diathermy appropriately and safely

              Think:

              • What are the principles of diathermy?

              • What is the difference between monopolar and bipolar diathermy?

              • What are the possible dangers of diathermy?

              • What alternatives are there to diathermy for achieving haemostasis and for making incisions?

              • What settings do you start with on your diathermy machine for intraocular and extraocular procedures?

              Resources:

              • Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgeryedited by Daniel M Albert, Mark J Lucarelli 2nd Edition. Oxford University Atlas
              • Gonnering R S. Ch5. Physical Modalities and their Application. Monograph No 8 Surgery of the Eyelid, Orbit and Lacrimal System. American Academy of Ophthalmology; 1993

              • Use cryotherapy appropriately and safely

                Think?

                •                 What are the indications of cryotherapy in ophthalmology?

                Activities

                • Observe senior colleagues perform cryotheraoy procedures for retinal holes, retinal detachment surgery, intra-ocular tumours, scleral perforations, trichiasis, giant cobblestones etc
                • Learn how to set up the cryotherapy machines in your department.

                Resources

                • Find these: Medtube, Eyetube, AAO?
                • Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery edited by Daniel M Albert, Mark J Lucarelli 2nd Edition. Oxford University Atlas
                • Ophthalmic Surgical Procedures, PS. Hersh, BM Zagelbaum, SL Cremers. Thieme, 2ndEdition. 2011. Pg. 175-179 & 346 - 348.

                • Assess Tear Film

                  Think

                  • How do you determine if your patient has a tear film disorder?

                  Acivities

                  • What is the normal tear film structure?
                  • Which layer is likely to be deficient in the particular case at hand?
                  • What tests are appropriate for testing the suspected deficient layer?

                  Resources:

                  • AAO BCSC External Disease and Cornea Chapter 4 pg 61-70
                  • Anatomy and physiology of eye. A.K. Khurana, I. Khurana. CBS Publishers and Distributors. 2nd Edition. 2008. Pg. 390-393.
                  • Adler's Textbook of Ocular Physiology
                  • Dry Eye Disease: The Clinician's Guide to Diagnosis and Treatmentedited by Penny A. Asbell, Michael A. Lemp  Chapter 5

                  • Assess lacrimal function

                    Think:

                    • How would you examine a patient who complained of a watery eye?
                    • When should I and how do I know when to order and how to interpret relevant  investigations?

                    Activities

                    • Learn the various clinical and radiological tests that can be done to assess lacrimal function
                    • How and when do I do probing and syringing

                    Resources:

                    • Management of Epiphora. Focus. Royal College of Ophthalmologists. Spring 2000. Available on request
                    • www.emedicine.com/oph/topic465.htm
                    • Nguyen LK, Linberg JV: Evaluation of the lacrimal system. In: Surgery of the eyelid, orbit, and lacrimal system. American Academy of ophthalmology 1995; 3: 254-69
                    • Anatomy and physiology of eye. A.K. Khurana, I. Khurana. CBS Publishers and Distributors. 2nd Edition. 2008. Pg. 393-396.
                    • Principles and Practice of Lacrimal Surgeryedited by Mohammad Javed Ali Page 147

                    Self Assessment:

                    • www.djo.harvard.edu/site.php?url=/physicians/kr/731&page=KR_ QU

                    • Perform a corneal scrape

                      Think:

                      • When is a corneal scrape indicated?

                      • How should it be taken?

                      • How should the specimen(s) be treated (plating-out etc), labeled and transported?

                      • What does the laboratory need to know and how is this best communicated?


                      Activity:

                      • Contact your local microbiology department to find out what the plating procedures are in your hospital and what other specific requirements need to be addressed including for sample preparation, documentation and transportation .

                      • Follow up your patient

                      • Ensure that youreceive the result promptly, or at least ensure that someone knows you have delegated this to them

                      • Ensure you know the significance of the result (eg changing or maintaining medication), and discuss this with colleagues/trainers if necessary

                      Resources:

                      • Remove ocular surface foreign bodies

                        Think:

                        • How does the nature and location of a foreign body affect your management plan?
                        Activity:

                        • This is a very common procedure in casualty clinics. Take advantage of opportunities very early in your training to performing this under supervision, as it is a skill you are likely to need soon
                        • Familiarize yourself with the different types of topical anaesthetic you may need.
                        • Familiarize yourself with the different instruments you may need to remove a foreign body.
                        • What medications would you use after removing the foreign body.

                        Reference:


                        • AAO BCSC External Disease and Cornea Chapter 19 page 404-406
                        • Frederick S. BrightbillCorneal Surgery: Theory, Technique and Tissue 4th Edition - 2009 - Page 136
                        • Harwood-Nuss' Clinical Practice of Emergency Medicine edited by Allan B. Wolfson, Gregory W. Hendey, Louis J. Ling, Carlo L. Rosen 2009 Section 5 Chapter 57

                        • Remove sutures from eye and adnexae

                          Think:

                          • Can you identify the different types of suture material?

                          • When may it be appropriate to prescribe topical treatment following suture removal?

                          • When is the best time to remove different sutures?

                          Activities

                          • Preparation of appropriate instruments and anaesthetic agents
                          • Preparation of appropriate anaesthetic agents
                          • Observe senior colleagues perform the procedure`with and without a slit lamp as appropriate.

                          Resources

                          • Watch Removalof Five ReleasableSuturesin Trabeculectomy at .https://www.youtube.com/watch?v=0lssWhoKdKY and Suture removalat slit lamp in uncooperative patient

                          • Fit a bandage contact lens

                            Think:

                            • How would you determine which size of bandage contact lens to use?

                            • Do you know where to access a bandage contact lens?

                            Activities.

                            • Familiarize with indications for BCL

                            • Observe senior colleagues perform the procedures for inserting and removing a BCL

                            Familiarize with what instructions to give patients after inserting BCL.

                            Resources:

                            • Apply corneal glue

                              Think:

                              • When might glueing be necessary?

                              • When might I have to do it myself in an emergency?

                              • How can I ensure my competence, as it is needed only rarely?


                              Activity:

                              • Observe senior colleagues perfrom this procedure
                              • Practice corneal glue application in wetlab
                              • Perform glue application


                              Resources:

                              • Coster DJ. Procedures. Cornea. BMJ. (2002) (Some good tips here)

                              • Brightbill, FS, McDonnell PJ, McGhee CNJ. Corneal surgery: theory, technique and tissue. Mosby (2009)

                              • WatchOcular News Video Bandage Contact Lenses: Review of Indications and Innovations for Treatment of Ocular Surface Disease at http://video.healio.com/video/Bandage-Contact-Lenses-Review-o

                              • Perform forced duction tests

                                Think: 

                                • This patient has a squint - could there be any mechanical restriction?

                                Activity:

                                • Take appropriate opportunities in theatre during squint lists to observe and perform forced duction tests and also on awake patients if possible

                                Resources:

                                • Manual of Strabismus Surgery. 1st ed. MacEwen CJ, Gregson RMC. Butterworth Heinemann. (2001)

                                • The Wills Eye Manual:Office and Emergency Room Diagnosis and Treatment of Eye Disease. 4th ed. Appendix 5. Forced Duction Test. Kunimoto DY, Rapuano CJ, Friedberg MA, Maker M, Kanitkar KD. Lippincott Williams and Wilkins. (2004)

                                • Wills Eye Video Atlas of Ocular SurgeryDVD-ROM2006byDerek Y. Kunimoto MD(Editor),William Tasman MD(Editor),

                                • Biometry

                                  Think

                                  What intraocular lens do I implant after cataract surgery?

                                  Activities

                                  • Familiarize yourself with the various formulae used in calculating IOL power.
                                  • Familiarize yourself with the A scan ultrasound and Keratometer (whether manual or automated) in your eye department.
                                  • Match Biometry reading to appropriate A constants for the different lenses.
                                  • Do several tests and assess your consistency.
                                  • Assess surgical outcome for targeted refractive error and actual outcome and asses for consistency between the 2.
                                  • Familiarize yourself with the automated biometry machines ef IOL Master, Biograph, etc.

                                  Resources.

                                  • AAO BCSC Lens and Cataract Chapter 7 and 8
                                  • Community Eye Health. How to avoid mistakes in biometry, Nick Astbury and Balasubramanya Ramamurthy2006; 19(60): 70-71.

                                  • Perform the correct hand hygiene technique

                                    Think:

                                    • Do you disinfect your hands before and after every patient, after contact with bodily fluids and patient surroundings and before carrying out an aseptic procedure?

                                    • Do you know the correct procedure for gowning and gloving prior to surgical procedures?

                                    Activities

                                    • Observe theatre and clinic staff to learn correct technique for hand washing and scrubbing.

                                    • Familiarize with the different hand-cleaning solutions.

                                    • Familiarize with the correct gowning and de-gowning technique prior to performing surgical procedures

                                    Resources: