CLINICAL ASSESSMENT (CA)

Patient’s history

Learning outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	Patient’s history
Code	CA1
Description	Trainees must be able to gather focussed information from patients or patient caretaker in an organised way and document the clinical situation based on the individual patient’s needs.
Assessment	CRS1,portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1  and 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide - 3.2.1.2 below

Patient’s history Study Guide

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?

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. 5^th 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

Vision assessment

Learning outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	Vision assessment
Code	CA2
Description	Trainees must be able: To assess visual acuity for both distance and near; to assess and interpret colour vision; to know the principles of contrast sensitivity assessment; to assess visual acuity in children and adults with barriers to communication; to assess vision outside the OPD environment and to perform and interpret confrontation visual fields.
Assessment	CRS2, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide  3.2.2.2 below

Vision assessment STUDY GUIDE

Think:

·        What is meant by 'visual acuity'?

·        What are the various related tests done in assessment of vision?

·        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 children’s vision

Resources:

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

External eye examination

Learning outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	External eye examination
Code	CA3
Description	Trainees must be able to perform an examination of the external eye – (sclera & cornea), ocular adnexae, eyelids, and orbits and face using appropriate equipment/instruments. They must be able to carry out further examination utilizing other techniques as indicated.
Assessment	CRS3, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12

External eye examination STUDY GUIDE

Resources:

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th 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.

PUPIL EXAMINATION

­ LEARNING outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	Examine the pupil and perform appropriate diagnostic pharmacological tests
Code	CA4
Description	Trainees must be able to assess the pupil for abnormalities of shape, size and reactions and interpret their findings. They must know how to perform and interpret appropriate pharmacological tests for specific pupil abnormalities.
Assessment	CRS4, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.4.2 below

Examination of the pupils and perform diagnostic pharmacological tests STUDY GUIDE

Think:

• ·What are the pupillary pathways?
• ·What does a normal pupil look like?
• ·What are the causes of an abnormal pupil?

Resources:

• ·Kline LB, Bajandas FJ. The Pupil. Neuro-ophthalmology Review Manual. 5th ed. 2004
• ·American Academy of Ophthalmology. Pupil. Neuro-ophthalmology. 1997.
• ·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th 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

Ocular Motility

Learning outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	Ocular Motility
Code	CA5
Description	Trainees must be able: to perform and interpret cover tests; to assess and interpret ocular movements; to perform prism cover tests and to describe nystagmus if present.
Assessment	CRS5, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.5.2 below

Perform a cover test and assess ocular motility STUDY GUIDE

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 or the strabismus clinics.

Resources:

·Rowe F. Clinical Orthoptics. Blackwell; 2004.

·MacEwen CJ, Gregson RMC. Manual of Strabismus Surgery. 1st ed. Butterworth Heinemann; 2001.

·http://www.mrcophth.com/videosonclinicalexamination

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th 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.

Learning outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	IOP measurement using various Tonometers
Code	CA6
Description	Trainees must be able to measure IOP accurately using a variety of tonometers and understand the limitations of each. They must be able to check the calibration of the tonometer.
Assessment	CRS6, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12

Measure intraocular pressure using applanation tonometry STUDY GUIDE

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:

·http://www.opt.indiana.edu/riley/HomePage/new_Goldmann_tonometry/2Goldmann_Tonometry.html

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

Slit lamp examination

Learning outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	Slit Lamp Examination
Code	CA7
Description	Trainees must be able to examine the eye and adnexae using the slit lamp and interpret their findings. They must know the indications for and uses of different kinds of illumination and filters. They must know the proper care and economical use of the instrument.
Assessment	CRS7, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.7.2 below

Slit lamp biomicroscopy EXAMINATION STUDY GUIDE

Think:

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

Activity:

·Make sure that you can use the  hand held and the table-mounted slit lamp microscope

·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. 5^th Edition. San Francisco. American Academy of Ophthalmology. 2005

3.2.8 Fundoscopy

3.2.8.1 Learning outcome

CLINICAL ASSESSMENT­
Learning Outcome	Fundoscopy
Code	CA8
Description	Trainees must be able to examine the fundus using a direct and indirect ophthalmoscope, and slit lamp biomicroscopy (with contact and non-contact lenses).  They must understand the optics of the techniques and the resulting images.  They must be able to examine the peripheral retina with indentation
Assessment	CRS8a CRS8b CRS8c CRS8d   end of year exams, COECSA Exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.8.2 below

3.2.8.2 FUNDOSCOPY STUDY GUIDE

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 practice

·Watch senior colleagues and discuss the nuances of their technique, then practice again

Resources:

·Rosenthal ML. The Technique of Binocular Indirect Ophthalmoscopy. In: Hilton GF, McLean EB, Chuang EL, editors. Retinal Detachment. 5th ed. San Francisco: American Academy of Ophthalmology; 1989: 160-203.

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th 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.

3.2.9 General Medical examination

3.2.9.1 Learning outcome OVERVIEW

CLINICAL ASSESSMENT­
Learning Outcome	General Medical examination
Code	CA9
Description	Trainees must be able to perform a basic medical examination relevant to ophthalmic disease and understand the importance of their findings so as to be able to know when a patient requires appropriate referral.
Assessment	Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.9.2 below

3.2.9.2 general medical examination STUDY GUIDE

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:

·MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005. Editors: Douglas,G. Nicol,F. Robertson,C.

3.2.10 Paediatric developmental examINATION

3.2.10.1 Learning outcome Overview

CLINICAL ASSESSMENT­
Learning Outcome	Paediatric developmental exam
Code	CA10
Description	The trainee should be able to perform an appropriate assessment of a child’s developmental milestones, understand the associations between systemic and ophthalmic diseases and recognise when it is appropriate to seek a paediatric opinion.
Assessment	Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 / Year 3-4
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.10.2 below

3.2.10.2 paediatric and developmental examination STUDY GUIDE

Think:

·What developmental milestones would you expect a two year old have?

·What key areas should be examined in a child concerning their development?

·when should a paediatric specialist’s opinion be sought

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:

·MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005. Editors: Douglas,G. Nicol,F. Robertson,C.

3.2.11 neurological examination

3.2.11.1 Learning outcome Overview

CLINICAL ASSESSMENT­
Learning Outcome	Perform a focused neurological examination taking into account the associations between systemic and ophthalmic diseases
Code	CA11
Description	Trainees must be able to perform a basic neurological assessment with particular emphasis on the cranial nerves and conditions relevant to ophthalmic disease. They must be able to recognise when serious neurological problems are present that require the opinion of a neurologist. They must be able to recognise neurological emergencies.
Assessment	Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.11.2 below

3.2.11.2 Perform a focused neurological examination STUDY GUIDE  

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:

·MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005. Editors: Douglas,G. Nicol,F. Robertson,C.

3.2.12 differential diagnosis

3.2.12.1 Learning outcome Overview

CLINICAL ASSESSMENT­
Learning Outcome	Formulate a differential diagnosis
Code	CA12
Description	Trainees must be able to formulate and justify an appropriate differential diagnosis for a patient as part of the management plan.  They must be able to identify the most likely diagnosis and initiate management.  They must consider the common conditions as well as the rare but important ones in the differential diagnosis.
Assessment	CbD, Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.12.2 below

3.2.12.2 DIFFERENTIAL DIAGNOSIS STUDY GUIDE

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

Resources:

• 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)

Assessments:

·Case based discussions

·Part 1 COECSA

·Part 2 COECSA. OSCE

3.2.13 Gonioscopy

3.2.13.1 Learning outcome OVERVIEW

CLINICAL ASSESSMENT
Learning Outcome	Gonioscopy
Code	CA13
Description	Trainees must be able to perform gonioscopy with an indirect gonioscopy lens, identify anterior chamber angle anatomy and interpret the clinical significance of their findings.  They should be able to use the major angle grading systems clinically.
Assessment	CRS13, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1 - CA12
Other Links	Study Guide -3.2.13.2 below

3.2.13.2 Gonioscopy Study Guide  

Think:

·Why is gonioscopy physically required to see the angle and why is it needed clinically?

·How would I feel if I were the patient having gonioscopy done for the first time, and how can I help them to relax appropriately?

·What are the major classes of gonioscopy lenses and how do their uses differ?

·What are the anatomic landmarks of the angle?

·What landmark can be identified using the corneal light wedge technique?

·How can one distinguish an open angle from a closed angle?

·What is dynamic gonioscopy and when does it help you assess the angle?

·What are the major grading systems used in evaluating/reporting the angle?

·In what situations should I be wary of performing gonioscopy?

·What damage could gonioscopy cause to the patient?

Activity:

·Watch senior colleagues and discuss the nuances of their technique.

·Perform gonioscopy on all glaucoma patients.

·Perform the corneal light wedge technique to identify Schwalbe’s line.

·Perform dynamic gonioscopy with an indirect Posner, Sussman or Zeiss style lens.

Resources:

·Alward, W. L. M. (2007) Atlas of Gonioscopy. gonioscopy.org

·eyewiki.aao.org/Gonioscopy

·American Academy of Ophthalmology, Glaucoma, Section 10. Basic and Clinical Science Course. San Francisco: American Academy of Ophthalmology; 2014:38-42.