Overview

COURSE OBJECTIVES AND OUTLINE

During the Ophthalmology block, students are exposed to a variety of ambulatory ophthalmology patients by attending eye clinics for a large portion of the rotation. The rotation will also include a clinical skills review (orientation session), a pediatric ophthalmology seminar and time in the operating room.

In the clinic, students will be responsible for examining patients, which may involve taking an ophthalmic history and performing a relevant ocular examination, as well as formulating a differential diagnosis and plan of management. All patients seen in the clinic will be reviewed by an ophthalmology staff, fellow or resident. Students will be expected to research each assigned patient's disease using appropriate texts and journals.

The clinical skills review (orientation session) will take place on the first morning of each week (Tuesday morning if Monday is a holiday). This session will be scheduled at the Kensington Eye Institute (KEI). The location of the clinical skills review sessions may be subject to change.

The pediatric ophthalmology seminar will take place on the first and third Friday morning of the ANES/OPT/ENT/EM rotation at the Hospital for Sick Children (HSC). Videoconferencing will be set up so that the seminars are available to students at the Mississauga Academy of Medicine (MAM). The pediatric ophthalmology seminar is meant to enhance the material presented in the course syllabus.

Friday afternoons are to be reserved for the pediatric Otolaryngology seminar or self-study depending on the week of the rotation.

On the fourth Friday of each block, students will sit for separate written examinations in Ophthalmology, Otolaryngology, and Anesthesia. There are no seminars during the fourth week of the rotation.

Students will be expected to independently review the course material found in the course syllabus on the course portal. Sections to be reviewed under course material include:

• Cornea and anterior segment (the red eye)
• Lens and optics
• Glaucoma
• Retina
• Uveitis and Systemic Diseases
• Neuro-ophthalmology
• Oculoplastics and orbital disease
• Pediatric ophthalmology and strabismus
• Ocular emergencies and trauma

TOTAL DURATION

The Department of Ophthalmology and Vision Sciences offers a one week rotation during the core Clerkship as part of the Anesthesia/Otolaryngology-Head and Neck Surgery/Ophthalmology/Emergency Medicine (ANES/OPT/ENT/EM) block.

PREPARATION

As your clerkship time is very limited, your Ophthalmology teaching will be very concentrated.  Below are some suggested resources in addition to the course syllabus.  Reviewing this material BEFORE your rotation begins will greatly improve your educational experience in Ophthalmology.

1. Begin studying the clerkship guide found under Handbook/Syllabus. Please note that there is a pdf version as well as a mobile compatible version of this ibook (iphone, android).
2. Review relevant lectures/sessions from your preclerkship years (ex: “vision week” lectures, ICE sessions).
3. A useful resource is a text published by the American Academy of Ophthalmology "Basic Ophthalmology for Medical Students and Primary Care Residents, 8th ed" by C. Bradford, 2004.
4. Supplementary material including ocular anatomy and clinical skills videos can be found under the resources tab on the portal. This material is meant to be a resource to enhance what is covered in the course syllabus.
5. If you have access to your own ophthalmoscope, please bring it with you to your clinical placements.

This course adheres to all relevant policies, statements, and guidelines of the Undergraduate Medical Education Program, the Faculty of Medicine, and the University of Toronto.  Students and faculty members are expected to familiarize themselves with their rights and responsibilities as defined in the pertinent documents, available at www.md.utoronto.ca.

By the end of Ophthalmology Clerkship, the clinical clerk will demonstrate the foundation of knowledge, skills and attitudes necessary for the practice of Ophthalmology from the perspective of the primary care physician.

A)  General Compentencies

• Medical expert
• Communicator
• Collaborator
• Manager
• Health advocate
• Scholar
• Professional

The clinical clerks will be able to:

1. Medical expert 
   1. Demonstrate the ability to initially assess and manage common ophthalmic problems presenting to the primary care physician (see B2 below)
   2. Demonstrate the ability to rapidly recognize and initiate management of ocular emergencies and trauma
   3. Demonstrate the ability to distinguish those ophthalmic conditions requiring immediate referral to an ophthalmologist
   4. Take a focused history and perform a physical examination for patients presenting with common ocular symptoms
   5. Develop a working differential diagnosis and management plan
   6. Develop plans for investigations and interpret these investigations
   7. Understand and explain the risks and benefits of investigations and treatments
   8. Demonstrate competency in basic diagnostic and procedural skills relevant to the ophthalmic conditions (see B1 below)
2. Communicator
   1. Communicate effectively and emphathetically with patients and their families
   2. Demonstrate thorough and clear documentation and charting, with concise recording of pertinent positive and negative findings
   3. Demonstrate the ability to manage difficult or violent patients in the eye clinic
   4. Demonstrate the ability to council and educate patients and families in the eye clinic
   5. Provide clear discharge instructions for patients and ensure appropriate follow-up care
   6. Demonstrate the ability to present a patient case in a clear, concise and complete manner
3. Collaborator
   1. Establish and maintain effective working relationships with colleagues and other healthcare professionals
   2. Discuss the roles of the various providers of hospital care and the role of the ophthalmologist in triaging consults from the emergency department, operating room, and in-patient units
   3. Demonstrate knowledge of community resources available to the ophthalmologist
   4. Respect the role of the patient's primary care physician by soliciting input in the assessment, the development of the care plan, and follow-up
4. Manager
   1. Demonstrate appropriate and cost-effective use of investigations and treatments
   2. Develop organizational skills and efficiency in managing patients and maintaining patient flow
   3. Develop an understanding of the factors contributing to resource issues in the eye clinic
5. Health advocate
   1. Demonstrate an awareness of the underlying psychosocial and socioeconomic problems that may precipitate an eye clinic visit
   2. Discuss the role of the ophthalmologist in the healthcare system and how it relates to other hospital and community health services
   3. Demonstrate an understanding of legal and ethical issues surrounding ophthalmic care
   4. Identify opportunities for primary and secondary prevention in the eye clinic and council patients accordingly
6. Scholar
   1. Access and critically appraise the literature relevant to ophthalmic care
   2. Understand the many unique learning and teaching opportunities available in ophthalmology
7. Professional
   1. Recognize and accept his or her limitations and know when to ask for help
   2. Protect information provided by or about patients, keeping it confidential, and divulge it only with the patient's permission except when otherwise required by law
   3. Be reliable and responsible in fulfilling obligations
   4. Recognize situations where common medical errors may occur in the eye clinic

B) Educational Core Objectives

In addition to the general objectives listed in the course outline, the specific course objectives are outlined below regarding:

• Skills (clinical and technical)
• Problem-based

SKILLS

By the end of the Ophthalmology Clerkship rotation, the student should be able to demonstrate basic proficiency in the following skills.

1. Directed ocular history
   1. Elicit and characterize the chief complaint utilizing an understanding of the differential diagnosis and symptom complexes for common problems including visual loss, the red eye and ocular trauma
   2. Extract pertinent information from:
   3. Past medical history, including surgery and trauma
   4. Family history of amblyopia, strabismus, glaucoma and retinal detachment Medications with possible ocular effects and toxicology
   5. Review of systems
2. Clinical Examination Techniques | Visual acuity measurement

• Physiologic basis
  • Distance, near
  • Use of pinhole
• Techniques of pediatric vision screening
  • Fixation patterns
  • Sheridan Gardiner and illiterate E's
• Visual fields evaluation
  • Confrontational fields to detect retinal, optic nerve, chiasmal and cortical lesions
  • Central visual fields and central scotomas
• Pupil examination
  • Detection of anisocoria   
  • Direct and consensual light reflex and clinical significance
  • Relative afferent pupillary defect (RAPD) and clinical significance
• Extraocular muscle evaluation
  • Hirschberg, cover test, alternate cover test and strabismus testing
  • Cardinal positions of gaze for the individual extraocular muscles
• External ocular examination
  • Ptosis, proptosis, eyelid lesions and lacrimal apparatus
• Slit lamp examination
  • Proficiency in anterior segment examination
  • Conjunctival and corneal lesions
  • Anterior chamber depth and iritis
  • Lens opacities
  • Use of the slit lamp magnification to remove corneal foreign bodies
  • Use of fluorescein and cobalt blue filter to detect corneal abrasions, ulcers, foreign bodies, etc.
• Intraocular pressure (IOP) measurement
  • Should be aware of techniques for IOP measurement
• Ophthalmoscopy
  • Direct funduscopy with identification of the optic nerve, vascular arcades and macula region

3. Technical skills

• Eyelid eversion to remove retained foreign bodies
• Application of an effective eye patch

PROBLEM-BASED

By the end of the Ophthalmology Clerkship rotation, the student should understand the following concepts and/or be able to demonstrate an approach to patients presenting to the Emergency Department (based on real or simulated encounters) with the following problems or conditions (including differential diagnoses, investigations and initial treatments).  These conditions are covered in the Brain and Behaviour course and/or Mechanisms, Manifestations and Management of Disease (MMMD) course:

a) Structure and basic physiology of the eye
•    Aqueous dynamics and glaucoma
•    Retinal vasculature and function
•    Extraocular muscle function and innervation
•    Neuroanatomy of the eye and visual pathways

b) Cornea and anterior segment (the red eye)
•    Differential diagnosis of the red eye

c) Lens and cataracts
•    The healthy lens, accommodation and presbyopia
•    Cataracts

d) Glaucoma
•    Glaucoma overview and classification
•    Primary open angle glaucoma (POAG)
•    Angle closure glaucoma (ACG)
•    Secondary glaucoma

e) Retina
•    Age-related macular degeneration (AMD)
•    Retinal detachment
•    Diabetic retinopathy
•    Hypertensive retinopathy
•    Retinal vascular occlusive diseases
•    Introduction to sickle cell retinopathy, HIV retinopathy
•    Introduction to intraocular malignancies, drug-Induced retinopathies

f) Neuro-ophthalmology
•    Examination of the optic nerve (CN II)
•    Diseases of the optic nerve
•    Visual field abnormalities
•    The pupil and anisocoria
•    Extraocular motility and ocular misalignment
•    The eyelids and neuroophthalmology
•    Migraine and headaches

g) Oculoplastics and orbital diseases
•    Diseases of the eyelids, orbit and lacrimal system
•    Inflammatory diseases of the eyelids
•    Eyelid malpositions
•    Eyelid tumours
•    Graves disease

h) Ocular trauma
•    Evaluation of ocular trauma
•    Trauma of the eyelids, orbit and adnexa
•    Trauma of the eye
•    Open globe injury

i) Pediatric ophthalmology
•    Vision assessment in children
•    Extraocular muscles and eye movements
•    Strabismus
•    Amblyopia
•    Common pediatric presentations: leukocoria, congenital cataracts, pediatric glaucoma, nasolacrimal duct obstruction, preseptal and orbital cellulitis, ophthalmia neonatorum
•    Shaken baby syndrome

j) Ocular pharmacology
•    Diagnostic agents
•    Therapeutic agents
•    Glaucoma
•    Antibacterial
•    Antiviral
•    Steroids
 

Course Director

Jennifer Calafati    

Education Co-ordinator

Sandra Gauci       

Student Representative 

Toni Jin