Optometry Student Extern Manual

Miami VA Medical Center

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Table of contents:

Rotation Description………………………………………………………………………………………3-4

Clinic Schedules…………………………………………………………………………………………………5

When to check in with attending…………………………………………………………5

Absences………………………………………………………………………………………………………………………5

Performance Standards……………………………………………………………………………………6

Examination Template………………………………………………………………………………………7

References…………………………………………………………………………………………………………………8-9 Visual Field Analysis Tables…………………………………………………………………10

Diabetic standard 2A photo………………………………………………………………………10

Diabetic Retinopathy Management Guidelines……………………………11

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{RotationDescription}

TheMiamiVAMCeyeclinicoffersauniqueeducationalexperience.Whileouroptometryclinicisaseparateentity,weareincloseproximityandcooperationwithophthalmology.EverysubspecialtyofophthalmologyisrepresentedbyBascomPalmerEyeInstitutefacultymembersandresidents,makingconsultations,surgicalreferrals,andsharingofpatientsmutuallyefficient.WestrivetomaintainahighvolumeofpatientencountersattheMiamiVA.Becauseofthis,theoptometricinternisexposedtoadiversearrayofocularpathologies.EducationalGoals:

1. Toprovideahighlyinteractivelearningexperienceinordertofurthertheknowledge,clinicskillsandmanagementcapabilitiesoffourthyearoptometrystudents.

2. Toprovidethehighestqualityofeyecaretoournation’sveteransinatimely,efficientandfriendlywaytoensureallvisualneedsandproblemsareaddressedappropriatelyandmanagedaccordingtostandardofcareguidelines.

Thegoalsforourinternsaretobeabletocompleteanexaminatimelyfashionwiththemostaccuratediagnosisandtreatmentplan.Todothis,internsareexpectedtoseepatientsfromstarttofinish,includingcompletionofthedilatedfundusexam.Inaddition,internsareexpectedtobepreparedwithagoodsubsetofclinicalskillsandbasicclinicalknowledgeofoculardiseasepriortobeginningtheirVArotation.Itisourphilosophythatgoodclinicalskillscanonlybelearnedthroughpractice.Therefore,wewillpushourinternstoutilizetheirtimeattheVAwithefficiency.Webelieveagoalof8to12patientencountersadayisrealisticandstudentswillbepushedonadailybasistoimprovetheirspeed.AdditionalLearningIncentives/Activities:InadditiontopatientencountersattheMiamiVA,wearefortunatetohaveastrongaffiliationwiththeoptometricinternshipandresidencyprogramatBascomPalmerEyeInstitute.Ourinternshavetheprivilegetobeinvitedtoalltheeducationalmeetings,including:1. Weeklylectureseriesgivenbyoptometryfacultyandresidents2. WeeklyattendancetotheophthalmologygrandroundsatBPEI3. Weekly“slidequiz”seriesandvisualfieldlecturesbyoptometryfaculty4. WeeklyjournalclubseriesatBPEIledbyoptometrystudentsandresidents5. WeeklyimaginginterpretationconferencehostedbyBPEIophthalmologyApproximateWorkHours:Theweeklyscheduledependsonthenumberofstudentinternsperrotation.WewilltypicallyhavetwoBerkeleystudentsandonefromNOVAandwillwork4-10hourdayswithatleast2

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consecutivedaysoff.Ifthereareonlytwostudents,wewillswitchto5-8hourdays,MondaythroughSaturday,withalternatingWednesdaysandSaturdaysoff.

• Eachmorningwillbeginat8:00a.m.withtheexceptionofThursdaymorningsforgrandroundsandlecturesatBPEIat7:30a.m.Studentsareexpectedtoinclinicimmediatelyfollowing.

• Internstypicallyfinishclinicby4:30p.m.toattendafternoonlectures• TheoptometryslidequizseriesisheldonMondaysatBPEIfrom5-6:00p.m.• OptometryJournalclubisheldonTuesdaysfrom5-5:30p.m.withfluorescein/imaging

conferencefollowinguntilapproximately6:30p.m.• TheoptometrylectureseriesisThursdaymorningsfollowinggrandroundsfrom9-10:00

a.m.andleadbyBPEIoptometristsandresidentsaswellasVAstaffoptometrists.• Allfederalholidaysareobserved.

ThingsYouWillNeed:Internswillneedtobringpersonaldiagnosticlenses(20D,78/90D)andpersonalretinoscope,transilluminatoranddirectophthalmolscopeatyourdiscretion(Heineinallrooms).TheuseofpersonalgonioscopylensesandscleraldepressorsisprohibitedattheMiamiVAduetointernalsterilizationguidelinesofreusablemedicalequipment.Wehavealargesupplyofdisposable4mirrorgonioscopylensesandscleraldepressorsforclinicuse.EachexamroomisequippedwithaKeelerwirelessBIO.Itisalsorecommendedthatyoubringyourclinicwhitecoatinanticipationofcoldhospitalexamrooms.Otherwise,pleasewearclinicattirewithclosed-toeshoes(noscrubs).Parkingadvice:Parkingonsiteisavailable,butlimitedintheWestparkinglot.TheMiami-DadeTransitlightrail“CivicCenter”stationisoutsidetheVAwith$2.25fareseachwayandrunsnorth-south.Parkingatlightrailstationsis$4/dayor$10/month.Thereisa595ExpressBuswhichalsodepartsoutsideoftheCivicCenterStation.DiscountedfaresforpublictransportationcanbepurchasedattheGovernmentCenterStationwithstudentID.Absences:PleasenotifyDr.Johnsonassoonaspossibleofupcomingabsences;anofficialemailrequestispreferred:Molly.Johnson5@va.gov,cellphone:904-616-5316,office:305-575-7000x6131,oreyeclinicx3081.Pleasespeaktosomeoneinsteadofleavingvoicemail.

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ClinicalExamSchedules:(plantoalternate)

Monday Tuesday Wednesday Thursday Friday Saturday

Optometry1

Dr.Johnson

A C Apm B

Optometry3

Dr.FabianBam C Aam

Optometry5

Dr.ZannBpm A B C

Optometry6 A B C

Externsareexpectedtobereadytoseepatientsat8:00AMeveryday,exceptonThursdayswhenattendinggrandroundsatBascomPalmer,whichstartsat7:30AM.Externswillbeabletoleaveassoonasallpatientsarefinishedandcaseshavebeendiscussed.ThereisnocliniconSundays.TherearealsonoclinicsopenonFederalHolidays(NewYear’sDay,MLKJrBirthday,Washington’sBirthday,MemorialDay,IndependenceDay,LaborDay,ColumbusDay,VeteransDay,ThanksgivingDay,ChristmasDay).RequiredCheck-inPriortoDilation:

1. Pupilabnormalitynotpreviouslydocumented2. NewonsetdiplopiaorEOMabnormalitynotpreviouslydocumented3. RedEye/Uveitis4. GonioscopyifIOP>23or>3mmHgasymmetrybetweeneyes;confirmedbyattending

AncillaryTesting:Availableatourfacilityare:HVF,CirrusOCT,HeidelbergOCT,Pentacamtopographer(includesnon-contactpachymetry),fundusphotography,andB-scanUltrasound.Alltestingisperformedbystafftechniciansandmaybeperformedbystudentswhennecessary(Saturdayclinic).Itisatthediscretionofthesupervisingattendingwhetheryoumayordertestingpriortocheckingin.

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{PerformanceStandards}

Within2weeksofstartofrotation:ExaminationGoal:8patientsdaily(todilationin20-30min,completionofDFE/chartin15min)CaseHistory/Preliminaries/Vision:

KeyHistoryPointsdelineatedAccuratelensometry,pluscylinderAccurateacuitiesAssessEOM,identifygrossabnormalitiesAssessCVF,identifygrossabnormalitiesAssesspupils:identify2+APDRefractionsmustbeaccurateandcomplete,pluscylinder

SlitLamp:RecognizegrosslidabnormalitiesRecognizeconjunctivalhyperemiaorabnormalitiesRecognizegrosscornealabnormalities,stainingdefects,infiltrates,orneovascularizationRecognize,butnotgrade,atleast1+cell/flareAccuratetonometry(within2mmHg)Recognizegreaterthan1+ACC/NS/PSClenschanges

FundusExamination:RecognizegrossretinalabnormalitiessuchasCRVO,CRAO,hemorrhages,orexudatesVisualize,notdiagnose,anylesion≥1DDinposteriorpoleorperipheralfundusuptoequatorIdentify,notdiagnose,abnormaldisc(ieswollen,pale,anomalous)

Mustknow: Maincontraindicationstoandsideeffectsofglaucomamedications

ClassificationofDR,including4-2-1rule,definitionofhighriskPDRDefinitionofCSME

AtMidterm:inadditiontoaboveAccuratelyassessetiologyfordecreaseinvisionwhenbelow20/20Recognize1+APDRecognizeNVI,NVEgreaterthan1DDGradegonio,recognizebutnotdiagnosegrossangleabnormalitiesRecognizemacularedemaWriteoutdiagnosisandtreatmentplansformildlycomplexcasesBytheendoftherotation:IdentifyCSMERecognizePAS/anglerecessionGradecataractsaccuratelyandformappropriatetreatmentplanAccuratelyidentifyandinterpretVFanalysis,correlateVFfindingstoopticnerveappearanceFormulatediagnosisandtreatmentplansappropriatelyformoderatelycomplexcases(diabetes,glaucoma,andmaculardegeneration)

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{ExaminationTemplate}CC: POHx: 1. PMHx: 1. patient is oriented to time, place, and person Visual Acuity cc R L WRx: OD: OS: MRx: OD: OS: pupils: round and equally reactive, no APD OU CVF: FTFC OD, OS EOM: full range of motion OU Ocular Tension - by applanation with 1 gtt proparacaine OU and Na fluorescein dye APR 09, 2012 11:52 R L slit lamp: lids: clear OU conj: clear OU cornea: clear OU A/C: deep and quiet OU iris: clear OU lens: clear OU ant. vit: clear OU DFE: 1 gtt 2.5% phenylephrine, 1 gtt 1.0% tropicamide OU vitreous: clear OU C/D: nerve: pink, distinct margins OU macula: clear, flat OU vessels: healthy, 2/3 OU periphery: no breaks, holes, tears 360 OU Impression/Plan: 1.

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{References} Glaucoma:

1. NaturalHistoryofNormal-tensionGlaucoma.CollaborativeNormal-TensionGlaucomaStudyGroup.Ophthalmology2001;108:247–253

2. MichaelA.Kass,MD;etal.OcularHypertensionTreatmentStudy(OHTS).ArchOphthalmol.2002;120:701-713

3. DelayingTreatmentofOcularHypertension:TheOcularHypertensionTreatmentStudy.ArchOphthalmol2010;128(3):276-287.

4. TheAdvancedGlaucomaInterventionStudy(AGIS).ControlledClinicalTrials15:299-325(1994).

5. FactorsforGlaucomaProgressionandtheEffectofTreatment:TheEarlyManifestGlaucomaTrial(EMGT).ArchOphthalmol/Vol121,Jan2003;121:48-56.Controlled

Diabetic

1. EarlyTreatmentDiabeticRetinopathyStudyResearchGroup(ETDRS):Treatmenttechniquesandclinicalguidelinesforphotocoagulationofdiabeticmacularedema.EarlyTreatmentDiabeticRetinopathyStudyReportNumber2.Ophthalmology94:761-774,1987.

2. TheDiabetesControlandComplicationsTrial(DCCT)ClinicalTrialsinOphthalmology:ASummaryandPracticeGuide.1998:49-70

3. TheDiabeticRetinopathyVitrectomyStudyResearchGroup.Earlyvitrectomyforseverevitreoushemorrhageindiabeticretinopathy.Two-yearresultsofarandomizedtrial.ArchOphthalmol1985;103:1644–1652.

Vascular:

1. Hayreh,Sohan,MD:PrevalentMisconceptionsaboutAcuteRetinalVascularOcclusiveDisorders.ProgressinRetinalandEyeResearch24(2005)493–519.

2. StandardCarevsCorticosteriodforRetinalVeinOcclusion(SCORE):ArchivesofOphthalmologyVol.127No.9.September2009.

3. Campochiaro,PA.AStudyoftheEfficacyandSafetyofRanibizumabInjectioninPatientsWithMacularEdemaSecondarytoBranchRetinalVeinOcclusion(BRAVO).PaperpresentedatTheAmericanSocietyofRetinaSpecialistsRetinaCongress,October4,2009;NewYork.

4. BrownDM.Safetyandefficacyofintravitrealranibizumab(Lucentis)inpatientswithmacularedemasecondarytocentralretinalveinocclusion.TheCRUISEStudy.PaperpresentedatTheAmericanSocietyofRetinaSpecialistsRetinaCongress,October4,2009;NewYork.

5. TheCentralVeinOcclusionStudyGroup.Evaluationofgridpatternphotocoagulationformacularedemaincentralveinocclusion.Ophthalmology.1995Oct;102(10):1425-33.

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MacularDegeneration:1. TheAge-RelatedEyeDiseaseStudyAREDS:ControlClinicalTrials1999;20:573–6002. MinimallyClassic/OccultTrialoftheAnti-VEGFAntibodyRanibizumabintheTreatment

ofAge-RelatedMacularDegeneration(MARINAStudyGroup)3. Anti-VEGFAntibodyfortheTreatmentofPredominantlyclassicChoroidal

NeovascularizationinAgeRelatedMacularDegeneration(ANCHOR)4. ClinicalclassificationofAge-relatedMacularDegeneration.Ophthalmology

2013;120(4);844-851.

Vitreo-Retinal:1. CollaborativeOcularMelanomaStudy:IV.Ten-yearMortalityFindingsandPrognostic

Factors.AmJOpthalmol2004;138(6):936-9512. Choroidalnevustransformationintomelanoma:analysisof2514consecutivecases.

Archophthalmol2009;127(8):981-7.3. Naturalhistoryofposteriorvitreousdetachmentwithearlymanagementasthepremier

lineofdefenseagainstretinaldetachment.Asymptomaticretinaltears.Ophthalmology1994;101(9):1503-13.

4. RevisedRecommendationsonScreeningforChloroquineandHydroxychloroquineRetinopathy.Ophthalmology2011;118:415-422.BaselineDFEwithinfirstyearofinitiation,ifnormal,repeatatminimumin5yearsHVF10-2(whiteonwhite)+oneofthefollowing:OCT,mfERG,orFAF

5. IsscreeningforinterferonretinopathyinhepatitisCjustified?BrJOphthalmol2004;88:1518-1520.

6. Evidence-basedanalysisofprophylactictreatmentofasymptomaticretinalbreaksandlatticedegeneration. Ophthalmology.2000Jan;107(1):12-5.

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{Glaucoma}

AbnormalVFCriteria:ifanyofthe3ispresentonarepeatableVF,itisconsideredabnormal1)ClusterCriteria:3non-edgecontiguouspointsonthesamesideofthehorizontalmeridian,all<5%Pandone<1%(includingthetwomostnasalpointsona30-2andallpointsona24-2)2)GHT:outsidenormallimits...checkspairedsectorsofmatchedNFLbundledefects3)PatternDeviation<5%ormore(outsidethenormal90%range)VFSeverity:1)MildDefect:MD>(betterthan)-5db(24-2)or-6db(30-2),nopointsinsidecentral5degrees<20db,TargetIOP20-30%belowbaseline2)ModerateDefect:MD>-10db(24-2)or-12db(30-2),nopointsinsidecentral5degrees<10db,1hemifieldcanhaveapointincentral5degrees10-20db,butnotbothhemifieldsTargetIOP30-40%belowbaseline3)SevereDefect:MD<(worsethan)-10db(24-2)or-12db(30-2),anypointinsidecentral5degrees<10db,bothhemifieldshavecentralpoint<20db,TargetIOP40-50%belowbaselineVFprogression:defectshouldbepresentonaminimumoftwosuccessivefields1)establishabaselineVF=averageof2-3fields2)progressionfrompreviously"normal"field=Clustercriteria(seeabove)3)progressionfrompreviously"abnormal"field=2contiguouspointsonsamesidehorizontaldecreaseby10db,andthatpointmustbelowerthananyvalueobtainedinapreviousVF/baselineVF4)confirmationofprogressionmustbepresentin4outof5confirmingVF

{DiabeticRetinopathy}

StandardPhotograph2A:MildNPDR CSME:Definition

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