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Salt Lake City VA Ophtho Medical Student Curriculum and Orientation

VA Ophthalmology Clinic
Medical Student Curriculum and Orientation

Download PDF version: 26811_Ophthalmology_Clinic_Expectations_and_Workflow_AW_SV

Introduction

Welcome to the VA ophthalmology service!

This is a great rotation where you will see a lot of pathology and have opportunities to learn a great deal about the eye.

You’ll primarily be working with the PGY-2 and PGY-3 residents, although you should feel free to bounce between the various residents and attendings on the floor.  You should be proactive in asking questions when appropriate and examining patients. Try to examine as many patients as you can without interrupting workflow while the resident looks up patient records and fills out documentation. Practice using the slit lamp and work on your fundus exam by examining patients with a direct ophthalmoscope. Ask to borrow your resident’s 90 diopter lens to try examining the fundus using the slit lamp or 20 diopter lens when using the indirect. If there is downtime, you can also observe what the techs do to work up patients. You will likely observe several procedures including lasers, injections, etc.

You are expected to take charge of your own learning, so feel free to look things up on your phone throughout the day during downtime. You can also look up topics in the Wills Eye Manual. Ask your resident, if you can borrow a copy in clinic. There will be a lot of new material and acronyms that may be unfamiliar to you, so you can carry the attached common acronyms list that was tailored for the VA rotation.

Remember than learning is more effective when it is effortful. Embrace the struggle.

 

Learning Objectives

  1. Understand the components of an ophthalmology history and physical exam to guide appropriate management and/or triage for the diseases listed in the “Schedule” section below.
  2. Work on the 8-point exam ophthalmology exam (https://www.aao.org/young-ophthalmologists/yo-info/article/how-to-conduct-eight-point-ophthalmology-exam). It takes time to learn the exam. An effective way of working on the exam is to focus on specific skills in specific clinics. See “Schedule” section below.
    1. Visual acuity
    2. Pupils
    3. Extraocular motility and alignment (Hirschberg)
    4. Intraocular pressures (by tonopen and palpation)
    5. Confrontation visual fields
    6. External exam
    7. Slit lamp exam
    8. Funduscopic exam
  3. Self-directed learning
    1. Your ophthalmology rotation has relatively short days from 7AM to 5PM. Work hard while you are in clinic, and spend 1.5 hours per day studying ophthalmology at home.
    2. Identify and acknowledge gaps in personal knowledge and develop efficient strategies for filling gaps.
    3. A list of resources is attached below in the appendix. Also, feel free to ask residents and attendings about their experiences and what resources they recommend.
    4. Be able to discuss at least two topics listed below in the schedule or your own topics of interest each day. Familiarize yourself with the attached acronyms and the topics listed under each day of the week.
  4. Conferences:
    1. Attend morning resident lectures held at the Moran Eye Center auditorium on the first floor starting at 0700 most weekday mornings. Ask Chandler Crane (crane@hsc.utah.edu) or Meghan Johnson (Meghan.johnson@hsc.utah.edu) to send you the resident lecture schedule for the week. We recommend briefly reviewing the lecture topic beforehand to get the most out of lecture. VA clinic starts at 0800 on Mondays, Tuesdays, Thursdays, and Fridays.
    2. Attend grand rounds on Wednesdays at 0800 in the Moran Eye Center auditorium on the first floor. There is no lecture on Wednesday mornings. VA clinic starts late at 0900.

 

Schedule

VA ophthalmology clinic is located on the 4th floor (south corridor: ophthalmology, north corridor: medical specialties, east corridor: GI/derm) and generally runs from 8am-5pm. While the location of the ophthalmology clinic does not change, the clinic rotates through various subspecialties throughout the week. For each day note the topics to learn and exam techniques to focus on. Work on visual acuity testing and slit lamp exam every day.

Monday:

Glaucoma AM

Retina PM

·  Primary open angle glaucoma

·  Secondary open angle glaucoma

·  Acute angle closure glaucoma

·  Chronic angle closure glaucoma

·  CRVO vs. BRVO

·  CRAO vs. BRAO

ü Red reflex testing

ü Direct/indirect/90D ophthalmoscopy

ü Cup:disc

Tuesday:

Retina all day

·  Age-related macular degeneration (wet vs. dry)

·  Diabetic retinopathy (non-proliferative vs. proliferative)

·  Hypertensive retinopathy findings

·  Applications of anti-VEGF intravitreal injections

·  Posterior vitreous detachment

ü Direct/indirect/90D ophthalmoscopy

ü Identify macula, fovea, and vessels

1st, 3rd, and 5th Wednesday of month:

Glaucoma AM

General PM

·   Visual Field Testing (University of Iowa website has a great resource for this)

·   OCT RNLF interpretation

·   Pseudoexfoliation syndrome vs. pseudoexfoliation glaucoma

·   Gonioscopy

·   Dry eye syndrome

·   Cataracts (nuclear sclerotic cataract vs. cortical cataract vs. posterior subcapsular cataract)

ü Confrontation visual field testing

ü Pupil exam (RAPD)

ü Checking intraocular pressure (tonopen and by palpation)

ü Cup:disc

2nd and 4th Wednesday of month:

Oculoplastics all day

·   Blepharoptosis (AKA ptosis)

·   Dermatochalasis

·   Ectropion vs. Entropion

·   Trichiasis

·   Nasolacrimal duct obstruction

·   Blepharospasm vs. hemifacial spasm

ü Motility and alignment (Hirschberg)

ü External Exam including lid position in relation to pupil/iris/sclera

Thursday:

General AM,

Neuro-ophthalmology PM

·   Amblyopia

·   Diplopia

·   RAPD (relative afferent pupillary defect)

·   Eye pain differential diagnosis

·   Ocular manifestations/complications of thyroid eye disease

ü Confrontation visual field testing

ü Pupils (RAPD)

ü Motility and alignment (Hirschberg)

Friday:

General AM

Cornea PM

·   Keratoconus

·   Fuch’s corneal dystrophy

·   Corneal abrasion vs. corneal ulcer

·   Viral conjunctivitis vs. allergic conjunctivitis vs. bacterial conjunctivitis

ü External exam including ocular surface

ü Direct/indirect/90D ophthalmoscopy

 

 

 

Other topics to discuss/research during down time

Lippa LM. Ophthalmology in the medical school curriculum: reestablishing our value and effecting change. Ophthalmology. 2009;116:1235e1236. (https://www.aaojournal.org/article/S0161-6420(09)00039-6/pdf)

 

Clinic Workflow

Patients will be initially screened in the technicians’ rooms and then sent back to the front waiting area. Their charts will be placed in Jeannie’s, the lead technician’s, room on the desk to the left.  As you wrap up seeing a patient with the resident, you can go back to Jeannie’s room and grab the next patient’s chart to review and take back to your resident.

We use paper charts that are scanned into Vista Imaging Display. The front is filled out by the techs and has a lot of useful information regarding HPI and histories. The back is information filled out by the tech and resident for that day’s visit. To access Vista Imaging, log into CPRS, select your patient by typing in initial of last name and last 4 digits of their SSN. After selecting the patient, go to “Tools,” scroll down to “Vista Imaging Display.” In addition to previous chart notes, you will be able to see some scanned ancillary tests such as visual fields, OCT RNFL, OCT Macula, etc. These tests can also be viewed in more detail on the Zeiss app. (Login: md; Password: Password) Sometimes the patient may also have helpful notes in CPRS under “Eye Optometry.”

Your resident may have you examine a patient while he/she is looking up notes or filling out documentation. You may get comfortable enough with the ophthalmology lingo, exam, and diagnoses to even scribe for the resident. Scribing will allow you to reinforce what you are learning.

After a couple of days in clinic, if you feel comfortable, (and there is an extra exam room) you may start seeing patients on your own and presenting to either the resident or attending. If you see patients on your own, work out with the residents regarding who will be staffing and putting in orders for each patient. Unless there is an extra exam room that the residents or technicians are not using, you will likely not have access to your own computer at the VA.

 

Appendix I

Recommended Ophthalmology Resources for Medical Students

Websites

https://www.aafp.org/

 

Apps (Android and Apple Stores)

 

Books

 

Appendix II

                             List of Ophthalmology Acronyms

AC
ACIOL
APD, RAPD
ARMD, AMD
AT, PFAT
Anterior chamber
Anterior chamber intraocular lens
(Relative) Afferent pupillary defect
Age-related macular degeneration
Artificial tears, Preservative free artificial tears
BAT
BCVA
BRAO
BRVO
BULB
Brightness acuity test
Best corrected visual acuity
Branch retinal artery occlusion
Branch retinal vein occlusion
Bilateral upper lid blepharoplasty
cc
CCT
C:D
CE/IOL
CF
C
3F8
CL, CTL
CME
CNV, CNVM
CPC
CRAO
CRVO
CSME
CSR, CSCR
With correction
Central corneal thickness (ave is 550um)
Cup to disc
Cataract extraction with intraocular lens implant
Counting fingers (vision)
Perfluoropropane (gas)
Contact lens
Cystoid macular edema
Choroidal neovascularization (neovascular membrane)
Cyclophotocoagulation
Central retinal artery occlusion
Central retinal vein occlusion
Clinically significant macular edema
Central serous (chorio) retinopathy
DCR
DES
DFE
DME
DR
DSAEK
DMEK
Dacryocystorhinostomy
Dry eye syndrome
Dilated fundus exam
Diabetic macular edema
Diabetic retinopathy
Descemet stripping automated endothelial keratoplasty
Descemet..endothelial keratoplasty
E
EL
EOM
ERM
ET
Esophoria
Endolaser
Extraocular muscles (or extraocular movements)
Epiretinal membrane
Esotropia
FTMH Full thickness macular hole
GATT
Glx
GVF
Gonioscopy assisted transluminal trabeculotomy
Glaucoma
Goldmann visual field
HM
HSV
HVF
HZO
Hand motions
Herpes simplex virus
Humphrey visual field
Herpes zoster ophthalmicus
IOL
IOP
IRF
IRMA
IVA
IVE
IVT
Intraocular lens
Intraocular pressure
Intra-retinal fluid
Intraretinal microvascular abnormality
Intravitreal Avastin
Intravitreal Eylea
Intravitreal Triessence (AKA triamcinolone)
K
KCN
KP
Cornea
Keratoconus
Keratic precipitates
LASIK
LH
LHT
LP
LPI
Laser in situ keratomileusis
Left hyperphoria
Left hypertropia
Light perception
Laser peripheral iridotomy
MA
MAC
MGD
MH
MP
MR, MRX
MRD1
MRD2
Microaneurysm
Macula
Meibomian gland dysfunction
Macular hole
Membrane peeling or macular pucker
Manifest refraction
Margin to reflex distance 1 (measured from upper lid margin to corneal light reflex)
Margin to reflex distance 2 (measured from lower lid margin to corneal light reflex)
NAION
NLP
NPDR
NS
NVA
NVD
NVE
NVG
NVI
Non-arteritic anterior ischemic optic neuropathy
No light perception
Nonproliferative diabetic retinopathy
Nuclear sclerosis
Neovascularization of the angle
Neovascularization of the disc
Neovascularization elsewhere
Neovascular glaucoma
Neovascularization of iris (rubeosis iridis)
OCT
OD
ON
OS
OU
Optical coherence tomography
Oculus dexter (right eye)
Optic nerve
Oculus sinister (left eye)
Oculus uterque (both eyes)

PACG
PAM
PAS
PC
PCIOL
PCO
PDR
PED
PEE
PERRL(A)
PF
PFAT
PH
PI
PK, PKP
POAG
PPA
PPV
PRK
PRP
PS
PSC
PTK
PVD
PVR
PUK
PXE
PXG
PXS
Primary angle-closure glaucoma
Potential acuity meter
Peripheral anterior synechiae (iris attached to cornea at angle)
Posterior chamber
Posterior chamber intraocular lens
Posterior capsule opacity
Proliferative diabetic retinopathy
Pigment epithelial detachment
Punctate epithelial erosion
Pupils equal, round, reactive to light and accommodation
Preservative free
Preservative free artificial tears
Pinhole
Peripheral iridotomy
Penetrating keratoplasty
Primary open-angle glaucoma
Peripapillary atrophy
Pars plana vitrectomy
Photorefractive keratectomy
Panretinal photocoagulation
Posterior synechiae (pupil attached to lens capsule)
Posterior subcapsular cataract
Phototherapeutic keratectomy
Posterior vitreous detachment
Proliferative vitreoretinopathy
Peripheral ulcerative keratitis
Pseudoexfoliation
Pseudoexfoliation glaucoma
Pseudoexfoliation syndrome
RAPD
RD
RH
RHT
RK
ROP
RNFL
RP
RPE
RRD
Relative afferent pupillary defect
Retinal detachment
Right hyperphoria
Right hypertropia
Radial keratotomy
Retinopathy of prematurity
Retinal nerve fiber layer
Retinitis pigmentosa
Retinal pigment epithelium
Rhegmatogenous retinal detachment
SB
sc
SF
6
SLE
SLT
SO, SiO
SPK
SRF
Scleral buckle
Without correction
Sulfur hexafluoride (gas)
Slit-lamp examination
Selective laser trabeculoplasty
Silicone oil
Superficial punctate keratopathy
Subretinal fluid
TA
TID
Tp
TBUT
TRD
Tonometry by applanation
Transillumination defect
Tonometry by tonopen
Tear breakup time
Tractional retinal detachment
Ung Ointment
VA
VEGF
VF
VH
VZV
Visual acuity
Vascular endothelial growth factor
Visual field
Vitreous hemorrhage
Herpes zoster
X
XT
Exophoria
Exotropia
YAG Yttrium-aluminum-garnet laser used in posterior capsule opacity; also referred to as a neodymium (Nd):YAG laser

 

Faculty Approval by: Griffin Jardine, MD
Identifier: Moran_CORE_26811
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