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Website - www.optomscenarios.co.uk

The study uses a design where optometrists’ performance on an online series of ten pre-CET vignettes is scored. The participants then choose whatever CET they wish over a six month period and at the end of this period complete a second series of ten post-CET vignettes which is broadly similar for difficulty. The vignettes are designed to assess referral decision-making for various presenting eye histories, symptoms and examination results. The intervention is a six month period of normal CET activity with practitioners allowed to choose their own CET options from those generally available to the profession. At the end of the six month period, participants will be asked to save their 'My GOC' CET statement as a PDF document and email this to the researcher. Alternatively, it can be printed and posted. Participation in the online survey is open to all UK community optometrists with the exception of those practising optometrists in the Bexley Clinical Commissioning Group area (researcher’s own area) who will be part of the pilot testing.

In order to minimise the risk of over-estimation of what optometrists actually do, the vignettes are designed on a ''supply and demand'' expert system to minimise the use of lists of options. This reduces the prompting effect of a list and instead asks the optometrist to state what tests would be performed next. All possible answers and test results are to be agreed by the expert panel. A recognised response generates a specific result and a further question on what is to be done next. A sequence list is presented as the scenario continues.

Topic choices for each set are glaucoma (2), medical retina (2), anterior eye (1), cataract (1), cornea (1), contact lens (1) refractive (1) and orthoptics (1) to reflect typical referral patterns. Both sets include paediatric cases. Each set will include what are considered 3 definite referrals, 3 definite non-referrals and 4 'grey' scenarios where there are not necessarily any unequivocally recommended responses. Initial design of the online scenarios will be piloted using six volunteer participants and any amendments following feedback incorporated with panel approval. Both sets will seek feedback on clinical and non-clinical reasons which have influenced decision making - this will include a list of options and a single free-text box. Non-clinical reasons include: lack of time, mode of practice, concern around GOC fitness to practise issues, etc.

Management options definitions

A. Refer urgently - same day or within one week

B. Refer routinely - expected waiting time can be up to 13 weeks

C. Refer to GP only (e.g. letter of information or request for blood test); but with recommendation that you do not want the GP to refer to an ophthalmology unit

D. Information to GP (No action required)

E. Monitor / manage e.g. give chloramphenicol or artificial tears

F. Give advice / leaflet e.g. Floaters and Flashes, Amsler chart

G. Recall in less than 1 year e.g. 3 - 6 - 9 months

H. Recall in 1 year

I. Recall in 2 years

J. Recommend new Rx

K. No change in Rx - no clinically significant need for change

L. No Rx

M. Other: Please complete ‘Free text’ box together with reason behind your decision

Reasons: (tick or complete all applicable boxes)

1. Ophthalmology assessment / opinion for suspect pathology

2. Second opinion to ensure all is well

3. Complying with NICE guidance

4. Complying with College(s) guidance

5. No enhanced scheme in my area

6. Practice/practitioner not accredited for local community scheme

7. Time pressure within practice to fully work up referral

8. Concern over potential litigation with missing pathology

9. Other 'Free text box

Outcomes and Scoring:

SET A

Outcome

Score

SET B

Outcome

Score

1

Cataract 1

Referred 1

25.5

11

Glaucoma 1

Grey 1

31

2

Glaucoma 1

Grey 1

33

12

Orthoptics 1

Referred 1

26

3

Contact lens 1

Referred 2

32.5

13

Retina 1

Referred 2

22

4

Retina 1

Grey 2

26.5

14

Glaucoma 2

Not referred 1

21

5

Cornea 1

Grey 3

27

15

Anterior Eye 1

Not referred 2

19.5

6

Retina 2

Referred 3

28

16

Cornea 1

Referred 3

21

7

Anterior Eye 1

Not referred 1

26

17

Retina 2

Grey 2

27

8

Refractive 1

Not referred 2

29

18

Contact lens 1

Grey 3

29.5

9

Glaucoma 2

Grey 4

31

19

Refractive 1

Not referred 3

26

10

Orthoptics 1

Not referred 3

22

20

Cataract 1

Grey 4

28

280.5

251

Set A

1) Classification - Cataract 1 / Referred 1 / Score 25.5

You are about to examine a 45 year old patient named Paul who is new to the practice. You know nothing about him and are starting with a blank record. This is his first test for 20 years.

a) What is the first action/test in your examination of this patient?

Choices:

Result:

score

1 History and Symptoms

Complains of very blurred vision when driving generally or watching TV - has been getting worse for about 6 months. No previous spectacles or ocular history. GH: Good. Med: Nil now. Systemic steroids 2 years ago for a suspect rheumatoid arthritis. Stopped after 6 months. FH: Nil.

2.5

(combined with 2,3 and 4)

2 General Health

Good

0

3 Medications

Nil now. Systemic steroids 2 years ago for a suspect rheumatoid arthritis. Stopped after 6 months

0

4 Family History

Nil

0

5 Vision

RV 6/24 LV 6/12

0.5

6 VA (with own correction)

This is not considered clinically necessary in this scenario

0

7 Retinoscopy or auto-refractor

R -1.25/-0.50 x 75

L -1.00DS

Approximate result as central lens opacities noted in both eyes

1

8 Refraction

R -1.00/-1.00 x 75 6/12 N8

L -0.75DS 6/12 N6-

1

9 Cover test / Muscle balance

Dist: 2XOP Ө Near: 8XOP Ө

0.5

10 Motility & Convergence

Full and single to 10cm

0.5

11 Stereopsis


0

12 Pupil reactions

PERLA

1

13 Accommodation

R=L=3D

0.5

14 Cycloplegic Refraction


0

15 IOP Non-contact (NCT) or Non-Goldmann Tonometry (NGT

R 18,17,17,18 L19,18,18,18 (mmHg).

1 (only 1pt in total scored for 15 and 16 if both used)

16 Goldmann/Perkins tonometry (GAT)

(at same visit)

R 17 L 19 (mmHg).


17 Visual Fields - confrontation or similar method

Appear full R&L

0

18 Visual Fields - Frequency doubling technology (FDT)

Full Field R&L


19 Visual Fields - Threshold controlled

Full Field R&L


20 Direct Ophthalmoscopy (un-dilated)

Central lens opacities R & L No clear view of discs and blurred view of retina. No clear view of maculae

0

21 Volk Un-dilated assessment

Central lens opacities R & L, 0.30 CD:R&L. What can be seen of peripheral retina appears healthy but poor view of macula R&L

1

22 Volk Dilated assessment

Post sub-capsular lens opacities R & L, 0.30 CD:R&L. Retina appears healthy with good view of healthy maculae and periphery R&L

3

23 Photography

R & L blurred images (undilated and dilated)

0

24 Van Herick's

Open angles 4 R&L

1

25 Gonioscopy

This is not considered clinically necessary in this scenario Open angles

0

26 Keratometry or topographer

This is not considered clinically necessary in this scenario R 7.60 x 7.50 L 7.50 x 7.50

0

27 Slit Lamp exam (external and anterior eye) without fluorescein

No abnormalities seen R&L

1

28 Pachymetry

This is not considered clinically necessary in this scenario R 545 microns L 550 microns (no correction factor needed)

0

29 OCT

This is not considered clinically necessary in this scenario No abnormalities R&L

0

30 Optomap


No abnormalities R&L

0

31 Amsler

Normal

1

32 If none of these or text is not recognised

This is not recognised, please try again

0

b) Which test would you do next?

Repeat same options in a)

c) Which test would you do next or would you now make a management decision?


Repeat c) until management decision.

Make management decision

For management decision options: (click or complete all applicable boxes)

Select only one from A-D

A Refer urgently

0

B Refer routinely

5

C Refer to GP only

0

D Information to GP

0

E Monitor / manage

0

F Give advice / leaflet

3

Select only one from G-I

G Recall in less than 1 year

1

H Recall in 1 year

1

I Recall in 2 years

0

Select only one from J-L

J Recommend new Rx

0

K No change in Rx

1

L No Rx

0

M Other: Please complete ‘Free text’ box together with reason behind your decision.

Reasons: (tick or complete all applicable boxes) see list in template

Subsequent question - Assuming no major symptoms and no complaints of driving vision issues, if Paul had corrected VA's of RVA 6/9- N6 and LVA 6/9- N6, Binocular VA 6/9, would you:

a) Refer ?

b) Not refer ?

2) Classification - Glaucoma 1 / Grey 1 / Total score 33

Alice, aged 82 years, attends your practice for a NHS sight test; she is a new patient to the practice. Alice is wearing varifocals and these have been measured by one of your support staff:

R +0.25/-0.75 x 90 +2.50Add

L +0.50/-0.75 x 80 +2.50Add

NB Her pupil diameters are 5mm.


Choices:

Result:

score

1 History and symptoms

Alice has noticed that the left eye has not been so clear (Dist & Near) for the last 6 months. She is not getting any headaches. Alice says she had bilateral cataract extractions about two years ago. No change in spectacles or other problems when tested one year ago. She has just received a reminder from the previous practice. No other relevant ocular history. GH: Good for age / raised cholesterol and being monitored for raised BP. Med: Simvastatin 20mg daily. FH: Sister has glaucoma.

2.5


2 General health

Good for age / raised cholesterol and being monitored for raised BP

0

3 Medications

Simvastatin 20mg daily

0

4 Family history

Sister has glaucoma

0

5 Vision

RV 6/9 LV 6/12

0.5


RVA 6/6- LVA 6/7.5-

1


R +0.50/-1.00 x 90

L +1.00/-1.00 x 85

1

8 Refraction

R +0.50/-0.75 x 90 6/6 +2.50Add N5

L +1.25/-1.00 x 75 6/6 +2.50Add N5

1

9 Cover test / muscle balance

Dist: Ortho Near: 4XOP Ө

0.5

10 Motility & convergence


0.5

11 Stereopsis

This is not considered clinically necessary in this scenario 60 secs

0

12 Pupil reactions

PERLA (pupil diameters are 5mm).

1

13 Accommodation


0

14 Cycloplegic refraction


0

15 Non-contact (NCT) or non-Goldmann tonometry (NGT)

R 23,24,23,24 L 24,23,24,25 (mmHg)

1


(at same visit)

R 22 L 22 (mmHg)

3


Appear full R&L

0


Full field R&L



Full field R&L


20 Direct ophthalmoscopy (un-dilated)

Bilateral IOL's, clear media, A/V 1:2 CD:R0.45 L0.45, ISNT followed, no disc haemorrhages or bayoneting etc. Healthy maculae and no fundus lesions detected

0

21 Volk un-dilated assessment

Bilateral IOL's, clear media, A/V 1:2 CD:R0.45 L0.45, ISNT followed, no disc haemorrhages or bayoneting. Healthy maculae

1

22 Volk dilated assessment

Bilateral IOL's, clear media, A/V 1:2 CD:R0.45 L0.45 ISNT followed, no disc haemorrhages or bayoneting. Healthy peripheral retinae and maculae

3

23 Photography

0

24 Van Herick's

Assessed as grade 4 open

1

25 Gonioscopy

Open angles- all structures visible

0



0


No pathology observed

1

28 Pachymetry

575µm R&L corrected values R 20 L 20 (mmHg) based on the instrument manufacturer information.

0 (not in general practice, but wish to see if used)

29 OCT

Normal optic nerve thicknesses


30 Optomap

No abnormalities seen


31 Amsler

No distortion

1



0


As a) adding

Choices:

Result:

score

33 Repeat NGT pressures at another appointment

R 22,23,22,21 L 22,23,24,22 (mmHg)

1

34 Repeat GAT pressures at another appointment

R 21 L 21 (mmHg)

5

35 Repeat FDT at another appointment


0

36 Repeat visual Fields - Humphrey/ Dicon / Henson at another appointment


0

37 Contact lens fitting assessment


0

38 Lid eversion

This is not considered clinically necessary in this scenario - healthy under lids R&L

0

39 Fluorescein assessment

This is not considered clinically necessary in this scenario - no staining observed R&L

0


Repeat same options in b)



For management decision options: (tick or complete all applicable boxes)


A Refer urgently

0

B Refer routinely

1

C Refer to GP only

0

D Information to GP

1

E Monitor / manage

5


1



0

H Recall in 1 year

1

I Recall in 2 years

0


J Recommend new Rx

1

K No change in Rx

0

L No Rx

0



Subsequent question - If pressures had been R 25,25,26,25 L 25,26,25,27 (mmHg) NCT or NGT (Non Goldmann Tonometry) all else normal, would you :

a) Refer to HES without further investigation ?

b) Repeat using NCT or NGT ?

c) Repeat using GAT as you are accredited for repeat measures ?

d) Repeat using GAT even if not accredited ?

3) Classification - Contact lens 1 / Referred 2 / Score 32.5

George, aged 48 years, attends for his annual contact lens check, combined with a sight test. His last contact lens check was one year ago. His records show that he has been wearing varifocal spectacles and monthly soft lenses in a monovision modality for the last five years with a multipurpose solution regime. George was seen by your colleague previously. He has just entered your consulting room wearing the contact lenses (R 8.60/14.00 +1.50DS L 8.60/14.00 +0.75DS) which he has worn today as he knows you want to check the fit.


Choices:

Result:

score


George works in an air-conditioned office. He has been wearing his contact lenses (R near L dist) more in the last month (14 hours a day, 7 days a week) as he has broken his spectacles. He reports that he has been sensitive to light and the right eye has been red and moderately painful for the last 2 days. No previous history of eye problems. GH: good. Med: Nil FH: Mother has glaucoma.

4.5

(combined with 2,3and 4)

2 General Health

Good

0

3 Medications

Nil

0

4 Family History

Mother has glaucoma

0

5 Vision

RV 6/18- N10 LV 6/6 N10

0


Varifocals R +0.75DS VA 6/12 +1.00Add N8 L +0.75DS 6/6 +1.00Add N5

CLs RVA 6/18 N8 LVA 6/6 N8

1


R +0.50DS (central shadow on ret)

L +0.50DS

(Contact lenses removed)

1

8 Refraction

R +0.75DSVA6/12 +1.00Add N5

L +0.75DSVA6/6 +1.00Add N5

(Contact lenses removed)

1



0.5


Full & single to 12cm

0.5

11 Stereopsis


0

12 Pupil reactions

PERLA

1

13 Accommodation

This is not considered clinically necessary in this scenario - R=L=3D

0



0

15 Non-contact (NCT) or Non-Goldmann Tonometry (NGT)

R 18,21,20,18 L19,20,18,19 (mmHg)



(at same visit)

R 17 L 19 (mmHg)



Appear full

0


Full field R&L



Full field R&L



Clear media: A/V 2:3 CD:0.2 R&L, maculae clear.

1 (only 1pt in total scored for 20, 21 and 22 if any of these are used)







23 Photography

Normal images R&L


24 Van Herick's

Assessed as grade 3 (open)

1

25 Gonioscopy

Open angles

0


R distorted reflex no reading

L 7.65 x 7.75

1


Lid oedema R, conjunctival hyperaemia R with? grey lesion centrally in cornea. Some discharge noted. Some cells noted in anterior chamber. No lens opacities noted. L all clear.

3

28 Pachymetry

This is not considered clinically necessary in this scenario - R No reading L 545 microns (no correction factor needed)

0

29 OCT

No abnormalities


30 Optomap

No abnormalities


31 Amsler

This is not considered clinically necessary in this scenario. No distortion R&L

0



0

b) What would you do next?

As a) adding

Choices:

Result:

score



0



0



0



0


Central, good diameter, good corneal coverage, good movement on push up R&L; both lenses in good condition

1

38 Lid eversion

Difficult due to swollen lids RE, clear LE

1


R central corneal ulcer stains, some excavation of epithelium (approx. 3.5mm in diameter) ?tissue necrosis. Suspect microbial keratitis L clear.

5

c) What would you do next or would you now make a management decision?

Repeat same options as b)

Repeat c) until management decision:




A Refer urgently

5

B Refer routinely

0

C Refer to GP only

0

D Information to GP

0

E Monitor / manage

0


1



1

H Recall in 1 year

0

I Recall in 2 years

0


J Recommend new Rx

0

K No change in Rx

1

L No Rx

0



Subsequent question - If George's corneal lesion was in the periphery and the eye not red or painful, would you:

a) Refer?

b) Not refer, advise and monitor?

4) Classification - Retina 1 / Grey 2 / Total score 26.5

Susan, aged 61 years, who is an existing patient at the practice walks into the waiting room; you are standing near the reception and have the next appointment slot free. She sees you and tells you that she has noticed some floaters in the right eye with some flashes recently and asks can you see her. Susan explains she has not wanted to bother you until a friend said she should come in. You get the record card out and note that her last eye test was 4 months ago with you and you gave her a new prescription for varifocals and one year recall. You found nothing abnormal and your refractive findings were:

R -6.00/-1.00 x 180 6/6 +2.00Add N5

L -5.25/-1.00 x 10 6/6 +2.00Add N5

You agree to see the patient straight away.


Choices:

Result:

score


Susan reports that she has noticed a larger floater & occasional flashes in the RE, onset about 6 weeks ago. However, no flashes have been noticed for the last 3 weeks. Generally, floater is about the same. No recent trauma. No significant ocular history. GH: Generally good, raised blood pressure. Med: Enalapril 20mg daily increased dose since last visit - well controlled. FH: Late mother suffered from diabetes

2

(combined with 2.and 3)

2 General Health

Generally good, raised blood pressure

0

3 Medications

Enalapril 20mg daily increased dose since last visit - well controlled

0

4 Family History

Late mother suffered from diabetes

0

5 Vision

RV 6/60 LV 6/60

0


RVA 6/6 N5 LVA 6/6 N5

0.5


R -5.75/-1.00 x 180

L -5.00/-1.00 x 180

0

8 Refraction

R -6.00/-1.00x180 6/6 +2.00Add N5

L -5.25/-1.00x10 6/6 +2.00Add N5

There is no change in prescription

0



0



0

11 Stereopsis

This is not considered clinically necessary in this scenario - 60 secs

0

12 Pupil reactions

PERLA

1

13 Accommodation

R=L=1.5D

0



0


R 18,17,16,15 L 18,19,17,18 (mmHg)



(at same visit)

R 17 L 16 (mmHg)



Appear full

0


Full field R&L

0


Full field R&L

1


Media: Floaters observed RE, both lenses clear, A/V 1:2 CD:0.35 L 0.45. Maculae clear but you cannot see anything in periphery

0


Media: Weiss ring R and other floaters observed R>L, both lenses clear, A/V 1:2 CD:0.35 L 0.45. Maculae clear. You cannot see anything in far periphery

0


Media: Weiss ring R and other floaters observed R>L , both lenses clear. A/V 1:2 CD:0.35 L0.45. Maculae clear. You see nothing abnormal in the peripheral retina

5

23 Photography

Normal images R&L


24 Van Herick's

Assessed as grade 4 - Open

1

25 Gonioscopy


0



0


No Shafer's sign (tobacco dust). No abnormal signs.

3

28 Pachymetry

This is not considered clinically necessary in this scenario - R 545 microns L 545 microns (no correction factor needed)

0

29 OCT

Normal macula layers


30 Optomap

No signs of retinal tears R&L


31 Amsler

This is not considered clinically necessary in this scenario - no distortion R&L

0



0

b) What would you do next?

Repeat same options as a)

c) What would you do next or would you now make a management decision?

Repeat same options as a)


Management decision



A Refer urgently

0

B Refer routinely

3

C Refer to GP only

0

D Information to GP

0

E Monitor / manage

5


3



1

H Recall in 1 year

0

I Recall in 2 years

0


J Recommend new Rx

0

K No change in Rx

0

L No Rx

0



Subsequent question - Had a new patient come in as before and you were booked up for the next appointment slot, would you:

a) Refer to HES without examination?

b) Agree to see patient at the end of the morning clinic (either privately or under PEARS)?

c) Tell the patient to book in to see you in next available slot on another day?

5) Classification - Cornea 1 / Grey 3 / Score 27

John, aged 17 years, attends for a NHS sight test. He is a student and a spectacle wearer. His last eye examination was 2 years ago and he is new to the practice. His current spectacles (2 years old) are:

R -0.25/-1.25 x 155

L -0.25/-0.50 x 10


Choices:

Result:

score


John has noticed some blurred vision in the RE at both distance and near - gradual onset over 6 months. First spectacles 4 years ago for occasional wear. No other ocular history.GH: Good. Med: Nil. FH: Father is myopic

2.5


2 General Health

Good

0

3 Medications

Nil

0

4 Family History

Father is myopic

0

5 Vision

RV 6/24 N6- LV 6/7.5 N5

0.5


RV 6/12 N6- LV 6/7.5 N5

1


R -0.50/-2.25 x 145 (? very slight shadow on retinoscopy reflex)

L -0.25/-1.25 x 10 Clear reflex

1

8 Refraction

R plano/-2.50 x 165 6/6-1 N6

L -0.25/-1.25 x 10 6/6 N5

1



0.5



0.5

11 Stereopsis


0

12 Pupil reactions

PERLA (large pupils)

1

13 Accommodation

This is not considered clinically necessary in this scenario R=L=12D

0



0

15 Non-contact (NCT) or Non-Goldmann Tonometry (NGT

R 15,13,14,15 L 16,17,17,15 (mmHg)

0


(at same visit)

R 13 L 15 (mmHg)

0


Appear full

0


Full field R&L

0


Full field R&L

0


Clear media R & L, A/V 2:3 CD:R0.20 L0.25, ISNT followed, maculae appear healthy



Clear media R & L, A/V 2:3 CD:R0.20 L0.25, ISNT followed, healthy maculae



Clear media R & L clear media, A/V 2:3 CD:R0.20 L0.25, ISNT followed, maculae appear healthy


23 Photography

Normal fundus R&L


24 Van Herick's


1

25 Gonioscopy

This is not considered clinically necessary in this scenario –

Angle open R&L

0


R 7.00 x 7.40 (mires possibly very slightly distorted)

L 7.30 x 7.40

3


R ? suggestion of very faint vogts striae (unsure) L clear

3

28 Pachymetry

R 485µm L 515µm corrected

R17 L17 (mmHg)


29 OCT


0

30 Optomap

This is not considered clinically necessary in this scenario - No abnormalities R&L

0

31 Amsler

This is not considered clinically necessary in this scenario - No distortion R&L

0



0





Repeat c) until ready to make a management decision

Management decision



A Refer urgently

0

B Refer routinely

3

C Refer to GP only

0

D Information to GP

1

E Monitor / manage

5


1



1

H Recall in 1 year

0

I Recall in 2 years

0


J Recommend new Rx

1

K No change in Rx

0

L No Rx

0



Subsequent question - If the best RVA had been 6/9-. would you :

a) Refer ?

b) Not refer ?

6) Classification: Retina 2 / Referred 3 / Score 28

Peter, aged 42 years who is an existing patient at your practice attends for a NHS sight test (he made his appointment earlier today). His last examination was one year ago and he was recently sent a reminder to return. He mentioned to the receptionist that he was very worried that he was not seeing as well and he has been noticing some floaters and occasional flashes recently. His records show he is amblyopic in the left eye with VA of 6/12.

His present spectacles are :

R-3.00/-1.50 x 75

L-3.50/-2.00 x 115


Choices:

Result:

score


Peter reports floaters and occasional flashes in temporal / inferior field RE for one week only, tends to notice the flashes in low light conditions only. History of myopia and refractive amblyopia LE as a child. GH: Good - although patient is a heavy smoker. Med: Nil. FH: Father has Glaucoma

2.5

(combined with

2,3 and 4)

2 General Health

Good - although patient is a heavy smoker

0

3 Medications

Nil

0

4 Family History

Father has Glaucoma

0

5 Vision

RV 6/60 LV 6/60

0.5


RVA 6/6 LVA 6/12 (same with pinhole)

1


R -3.00/-1.25 x 85

L -3.75/-1.50 x 110

1

8 Refraction

R-3.00/-1.50 x 75 6/6 N5

L-3.50/-2.00 x 115 6/12 (amblyopic) N6

No change in refraction

1



0.5



0.5

11 Stereopsis


0

12 Pupil reactions

PERLA

1

13 Accommodation

R=L=4D

0



0


R 13,14,13,12 L18,17,16,15 (mmHg)



(at same visit)

R 12 L 16 (mmHg)



R ? suspect inferior field. LE Full

0


R 2 blocks affected in lower inferior field

L Full field



R inferior field loss LE Full



Media: numerous floaters RE - pupils are 3mm in diameter. A/V 2:3 CD:R0.2 L 0.3. Maculae clear. Not able to view periphery

0


Media: numerous floaters seen A/V 1:2 CD:R 0.2 L0.3 Maculae clear. You note a possible detachment area in superior retina RE

1


Media: numerous floaters seen A/V 1:2 CD:R 0.2 L0.3 Maculae clear. You note a tear in the superior retina LE

5

23 Photography

RE suspicious area superior retina LE Normal.


24 Van Herick's

Assessed as 4 (open)

1

25 Gonioscopy

This is not considered clinically necessary in this scenario - Angle open R&L

0


This is not considered clinically necessary in this scenario - R 7.85 x 7.72 L 7.85 x 7.65

0


Tobacco dust seen at front of vitreous

5 (only if dilated in 22)

28 Pachymetry


0

29 OCT



30 Optomap -

R Clear

L Retinal tear seen superior retina


31 Amsler

This is not considered clinically necessary in this scenario - no distortion

0



0

b) What test would you do next?

Repeat same options as in a)

c) What would you do next or would you make a management decision?

Repeat same options as in a)




A Refer urgently

5

B Refer routinely

0

C Refer to GP only

0

D Information to GP

0

E Monitor / manage

0


0



1

H Recall in 1 year

1

I Recall in 2 years

0


J Recommend new Rx

0

K No change in Rx

1

L No Rx

0



Subsequent question

If the patient had an NHS sight test 4 months ago and presented with the same symptoms, how would you manage this patient:

a) Direct to HES without examining patient

b) Privately

c) Under PEARS (if currently accredited)

d) Under a NHS sight test

7) Classification: Anterior Eye 1 / Not referred 1 / Score 26

Julie, aged 44 years, arranges a NHS sight test appointment with your receptionist over the phone to see you because she had a reminder. The appointment was made two weeks ago. She now comes in for the appointment with an injected right eye. No spectacles are worn.


Choices:

Result:

score


Julie is booked in for a routine check but has had a red right eye in last 3 days, no discharge & no pain/discomfort. No previous ocular history. GH: Good, but recent cold and cough. Med: Nil. FH: Mother has glaucoma.

2.5

(combined with 2,3

and 4)

2 General Health

Good, but recent cold and cough

0

3 Medications

Nil

0

4 Family History

Mother has glaucoma

0

5 Vision

RV 6/6 LV 6/6

0.5


This is not necessary in this scenario

No spectacles are worn

0


R -0.25DS

L -0.25DS

1

8 Refraction

R -0.25DS VA6/5 N5

L -0.25DS VA6/5 N5

1



0.5



0.5

11 Stereopsis


0

12 Pupil reactions

PERLA

1

13 Accommodation

5D

1



0


R 10,11,10,12 L 12,11,13,12 (mmHg)



(at same visit)

R 10 L 11 (mmHg)



Appear full

0


Full Field R&L



Full Field R&L



Clear media R&L, A/V 2:3 CD:R0.25 L0.25, ISNT followed, healthy maculae

0







23 Photography

Normal images


24 Van Herick's


1

25 Gonioscopy

This is not considered clinically necessary in this scenario –

Angle open R&L

0


This is not considered clinically necessary in this scenario - R 7.70 L 7.75

0


R bulbar sub-conjunctival haemorrhage, cornea clear, no discharge. L all appears clear, no cells in anterior chamber. No lens opacities R&L.

3

28 Pachymetry


0

29 OCT

This is not considered clinically necessary in this scenario - No abnormalities R&L

0

30 Optomap


0

31 Amsler

This is not considered clinically necessary in this scenario - no distortion R&L

0



0


As a) plus

Choices:

Result:

scoring



0



0



0



0



0

38 Lid eversion

Healthy under lids R & L

1


clear - no staining with fluorescein R&L

1






A Refer urgently

0

B Refer routinely

0

C Refer to GP only

0

D Information to GP

3

E Monitor / manage

3


1



0

H Recall in 1 year

1

I Recall in 2 years

0


J Recommend new Rx

0

K No change in Rx

0

L No Rx

1



Subsequent question

Had the patient not had an appointment but came in to the practice with these symptoms, and you were full, would you:

a) Refer direct to GP/urgent care without examination ?

b) See between patients for quick check ?

c) Agree to see patient in your lunch hour (either privately or under PEARS) ?

d) Tell the receptionist to make the appointment in next available slot on another day ?

8) Classification - Refractive 1 / Not referred 2 / Score 29

Susan, aged 47 years attends for a routine NHS sight test. She is an existing patient. Previous records show her refraction two years ago was:

RV 6/7.5 +0.50DS VA 6/6 +0.75Add R N5

LV 6/7.5 +0.50DS VA 6/6 +0.75Add R N5

She wears +1.25DS reading spectacles.

Susan mentions to the receptionist that she is finding her vision more blurred at distance. She brings along a diabetic eye screening letter which says she had early signs of diabetic retinopathy at her last screening 7 months ago. Susan is due for screening again in 5 months. The receptionist notes this on a memo slip to you.


Choices:

Result:

score


Susan complains of slightly blurred distance vision, has been able to read without spectacles recently. She reports HbA1c has been a bit high recently but coming down since increased medication started a week ago. Seeing practice nurse again in 2 weeks’ time. No other relevant ocular history. GH: Type 2 Diabetes for 12 months - raised cholesterol, normal blood pressure. Med: Metformin 1500mg and Simvastatin 20mg daily. FH: Father has had cataract surgery recently.

2.5


2 General Health

Type 2 Diabetes for 12 months - raised cholesterol, normal blood pressure

0

3 Medications

Metformin 1500mg and Simvastatin 20mg daily

0

4 Family History

Father has had cataract surgery recently

0

5 Vision

RV 6/12 LV 6/12

0.5


Near: R N5 L N5 and R N6 L N6 without

1


R -0.50DS

L -0.50DS

1

8 Refraction

RV -0.50/-0.25 x 80 VA 6/6 +1.00Add N5

LV -0.50/-0.25 x 105 VA 6/6 +1.00Add N5

1


Dist and Near: Ortho

0.5



0.5

11 Stereopsis


0

12 Pupil reactions

PERLA

1

13 Accommodation

R=L=2.25D

0



0


R 20,20,21,21 L 21,20,21,22 (mmHg)



(at same visit)

R 20 L 20 (mmHg)



Appear full

0


Full field R&L



Full field R&L



Difficult view as small pupils. media clear R&L, A/V 2:3, healthy discs CD:0.3 R&L, 2 micro-aneurysms temporal to the R fovea. L no diabetic signs as far as seen but generally a poor view of the periphery in both eyes.



Difficult view as small pupils. media clear R&L, A/V 2:3, healthy discs CD:0.3 R&L, 2 micro-aneurysms temporal to the R fovea, L macula appears clear but cannot see wider peripheral fundi.



Clear media R&L, A/V 2:3, healthy discs CD:0.3 R&L, 2 micro-aneurysms temporal to the R fovea, no macular oedema seen R&L. No other retinopathy seen in either eye.

3

23 Photography

Images show R images with 2 micro-aneurysms temporal to macula, normal L image


24 Van Herick's

Assessed as Grade 3 - open

1

25 Gonioscopy

This is not considered clinically necessary in this scenario - angle open R&L

0



0


No abnormalities seen

1

28 Pachymetry

This is not considered clinically necessary in this scenario R 543 microns L 547 microns (no correction factor needed)

0

29 OCT

Scans show no oedema


30 Optomap

This is not considered clinically necessary in this scenario -

2 micro-aneurysms seen temporal to the R fovea, no other retinopathy seen


31 Amsler

This is not considered clinically necessary in this scenario No distortion R&L

0



0








A Refer urgently

0

B Refer routinely

0

C Refer to GP only

5

D Information to GP

5

E Monitor / manage

1


1



1

H Recall in 1 year

0

I Recall in 2 years

0


J Recommend new Rx

0

K No change in Rx

1

L No Rx

0



Subsequent question - If you had no information regarding the diabetic screening result, would you:

a) Refer?

b) Inform GP?

c) Not refer?

9) Classification - Glaucoma 2 / Grey 4 / Score 31

Colin, a 45 year old male patient, attends the practice; he has broken his frame. Colin is a new patient and you are conducting a NHS sight test as patient is receiving income support. Your receptionist has measured the lens as:

R +0.75/-0.75 x 180 +0.75Add

L +0.75 /-0.75 x 180 +0.75Add


Choices:

Result:

score


Colin has broken his spectacles, distance is OK but reading with them has been getting blurred for about 3 months. Only wears for driving, TV and reading. No headaches. No other previous ocular history. GH: Good but raised cholesterol 6.1. Med: Simvastatin 20mg / daily. FH: Colin tells you his grandfather had glaucoma and father has heart problems.

2.5

(combined with 2.3 and 4)

2 General Health

Good but raised cholesterol 6.1

0

3 Medications

Simvastatin 20mg / daily

0

4 Family History

Colin tells you his grandfather had glaucoma and father has heart problems

0

5 Vision

RV6/12 LV6/12

0.5


RVA 6.7.5 LVA 6.7.5

1


R +1.00/-0.75 x 170

L +1.00 /-0.50 x 170

1

8 Refraction

R+1.00/-1.00 x 180 6/6+ +1.00Add N5

L+1.00/-0.75 x 175 6/6- +1.00Add N5

1


Dist: 2ESO Ө Near: 4XOP Ө

0.5


Full & single to 10 cm

0.5

11 Stereopsis

This is not considered clinically necessary in this scenario 50 secs

0

12 Pupil reactions

PERLA

1

13 Accommodation

R=L=2.25D

0



0


R 23,22,23,22 L 24,23,23,22 (mmHg)

1


(at same visit)

R 21 L 22 (mmHg)

1


Appear full fields R&L

0


Full field R&L

1 (only 1pt in total scored for 18 and 19 if both


Full field R&L

1 (only 1pt in total scored for 18 and 19 if both


Clear media, A/V 2:3 CD:R0.25 L0.3, ISNT followed, maculae appear normal appearance



Clear media, A/V 2:3 CD:R0.25 L0.3, ISNT followed, foveae reflex seen



R clear media, L peripheral lens opacities noted, A/V 2:3 CD:R0.25 L0.3, ISNT followed, bright foveae reflexes

3

23 Photography

Normal images


24 Van Herick's

Assessed as 4 - open

1

25 Gonioscopy

Assessed as Open angles




0


Nothing abnormal seen - no lens opacities (un-dilated)

1

28 Pachymetry

575µm R&L corrected as R 19 L 20 (mmHg)


29 OCT

Discs are normal


30 Optomap



31 Amsler

This is not considered clinically necessary in this scenario. No distortion R&L

0



0


as a) adding

Choices:

Result:

score


R 21,21,22,21 L 22,21,21,22 (mmHg)

3


R 21 L 21 (mmHg).

5



0



0



0

38 Lid eversion


0



0






A Refer urgently

0

B Refer routinely

3

C Refer to GP

0

D Information to GP

0

E Monitor / manage

5


0



1

H Recall in 1 year

1

I Recall in 2 years

0


J Recommend new Rx

1

K No change in Rx

0

L No Rx

0



Subsequent question - What would your actions be if Colin was 75 years old and you found repeated measurements of R 22 L 22 (mmHg) by NCT, confirmed by Goldmann (all else being the same):

a) Refer ?

b) Not refer ?

10) Classification - Orthoptics 1 / Not referred 3 / Score 22

A concerned mother brings her daughter, Zoe, aged 4½ years for her first NHS sight test. They have just sat down in your consulting room. You notice that your receptionist has put a note with the record card to say that the mother has noticed the RE turning in. For visual acuity testing in this scenario please assume that you have a printed near card with large letters that you use for the child to match with letters you point to on the Snellen chart (described below as “letter matching”).


Choices:

Result:

score


Mother reports that she has noticed the right eye turning in. Onset 6 months ago, more when Zoe is tired. She does not complain of headaches. Today, Zoe appears cooperative but only knows a few of the letters. GH: Good. Med: Nil. FH: No previous family history of strabismus.

2.5


2 General Health

Good

0

3 Medications

Nil

0

4 Family History

No previous family history of strabismus

0

5 Vision

RV 6/9 letter matching with you pointing to a letter in a Snellen line LV 6/9 letter matching

0.5


This is not considered appropriate please try again

0


R +2.00/-0.50 x 90 6/7.5 letter matching with you pointing to a letter in a Snellen line

L +2.50/-0.50 x 1156/7.5 letter matching

1

8 Refraction

Unable to get any result on subjective

0


CT 10 R Esophoria with slow recovery Ө D&N (without Rx). Ortho (with Rx)

1



1

11 Stereopsis

Titmus fly, animals, and circles 100 secs

1

12 Pupil reactions

PERLA

1

13 Accommodation

R=L=14D

1


R +3.00/ -0.50 x 90

L +3.50/-0.50 x 115

5



0


(at same visit)


0



0



0



0


Zoe will not keep eyes still. You are able to get a reasonable view of the discs and maculae. Estimated as CD 0.3 R&L and maculae normal

1


Zoe finds reaching the slit-lamp head rest difficult and does not keep head or eyes still

0


Zoe finds reaching the slit-lamp head rest difficult and does not keep head or eyes still

0

23 Photography


0

24 Van Herick's


0

25 Gonioscopy


0



0


Zoe finds the slit-lamp test difficult. Does not keep still

0

28 Pachymetry


0

29 OCT


0

30 Optomap


0

31 Amsler


0



0






Management decision



A Refer urgently

0

B Refer routinely

0

C Refer to GP

0

D Information to GP

0

E Monitor / manage

5


0



1

H Recall in 1 year

0

I Recall in 2 years

0


J Recommend new Rx

1

K No change in Rx

0

L No Rx

0



Subsequent question - If Zoe's VA's had been:

RVA 6/7.5 letter matching LVA 6/9 letter matching (all other readings the same), would you:

a) Rx and refer ?

b) Rx and monitor ?

c) No Rx and refer ?

d) No Rx and monitor ?

Set B

11) Classification - Glaucoma 1 / Grey 1 / Score 31

Jim, aged 68 years, attends for a routine NHS sight test. He is an existing patient. His demeanour suggests he is suffering from dementia. He is accompanied by his wife who is also Jim's carer. His distance and reading Rx from 2 years ago is:

Dist R -0.75DS Reading R +1.25DS

L -0.75DS L +1.25DS


Choices:

Result:

score


You ask about his eyesight and Jim answers slowly but fairly coherently, saying everything is fine. However, his wife reports she has been noticing that he is not as interested in watching TV as he was before. He does not use his spectacles or read much. Other than this, his wife cannot give any more information about his eyesight. His records show mild cataract changes last visit with IOPs of R 17 L18 (mmHg) and full fields. GH: Mild dementia / hypertension. Med: Enalapril 10mg daily - BP well controlled. Galantamine 8mg twice a day. FH: Older brother (deceased) had glaucoma.

2.5


2 General Health

Mild dementia / hypertension

0

3 Medications

Enalapril 10mg dailywell controlled

Galantamine 8mg twice a day

0

4 Family History

Older brother (deceased) had glaucoma

0

5 Vision

RV 6/18 LV 6/36

0.5


RVA 6/9 LVA 6/18

1


R -1.00DS

L -1.50DS

1

8 Refraction

R-1.00DS 6/7.5 +2.00 Add N5

L -1.50DS 6/7.5 +2.00Add N5

1


Cover Test only - Ortho D&N, no other results possible

0.5


Appear full & single to18cm (although difficult to assess)

0.5

11 Stereopsis


0

12 Pupil reactions

PERLA

1

13 Accommodation


0



0


R 20,21,22,21 L21,22,20,21

(mmHg)

1


(at same visit)

R 21 L 22 (mmHg)

1


Results of confrontation are suggestive of full fields R&L - not conclusive

0


RE Full

LE 4 blocks superior field

Fixation errors RE 0/3 LE1/3

False Positive errors RE 0/3 LE 2/3



RE Full field

LE Superior VF loss

False Positives 4/21

False Negatives 0/1

Suspect VF defect from ptosis LE



Very mild cataract changes in both eyes, AV 1:2 CD:R 0.50 L0.60, drusen at both maculae. Small pupils

1


Very mild cataract changes in both eyes, AV 1:2 CD:R 0.50 L0.55 assessed as healthy discs, drusen noted at both maculae

1


Peripheral cataract changes in both eyes, AV 1:2 CD:R 0.50 L0.55 assessed as healthy discs, ISNT followed, fine drusen at both maculae. No retinal swelling noted

3

23 Photography

Images show fine drusen at both maculae, otherwise healthy appearances


24 Van Herick's

Assessed as R 3 L3 open angles

1

25 Gonioscopy


0



0


Arcus, slight ptosis LE, otherwise no other abnormal signs on cornea or anterior eye

1

28 Pachymetry

R 565µm L 575µm corrected R 20 L 19 (mmHg)


29 OCT

OCT Normal nerve fibre thickness R&L


30 Optomap

Macular drusen R&L, no other abnormalities noted


31 Amsler

Attempted, but no useful result

1



0


As a) plus

Choices:

Result:

score


R 20,20,20,21 L21,19,20,20

(mmHg).

1


R 20 L 20 (mmHg)

3


RE Full

LE (with lid raised) Full

Fixation errors RE 0/3 LE 0/3

False Positive errors RE 0/3 LE 0/3

1


RE Full field

LE With lid raised no superior VF loss now. However, now 1 missed point LE centrally where clear previously

3



0

38 Lid eversion


0



0





A Refer urgently

0

B Refer routinely

1

C Refer/ information to GP only

0

D Information to GP

0

E Monitor / manage

5


0



0

H Recall in 1 year

1

I Recall in 2 years

0


J Recommend new Rx

1

K No change in Rx

0

L No Rx

0



Subsequent question - If Jim had repeat pressures of R 23 L 23 by GAT (visual fields, discs and Van Herrick normal) would you?

a) Refer

b) Not refer and monitor

12) Classification - Orthoptics 1 / Referred 1 / Score 26

Christine aged 52 years attends for a NHS sight test. It is 3 years since her previous test and she is new to the practice. She wears reading spectacles only and is worried that her eyes have changed.


Choices:

Result:

score


Sudden onset of double vision 1 week ago and slight droopy R lid, was having no problems previous to this. Recent headaches. Previous bilateral lens implants 3 years ago. Had R sub-conjunctival haemorrhage 6 months ago. Has worn reading spectacles for 5 years, no previous ocular problems. GH: High blood pressure (controlled) but otherwise in good general health and feeling well. Med: Enalapril 10mg daily. FH: Mother has diabetes.

2.5


2 General Health

High blood pressure (controlled) but otherwise in good general health and feeling well

0

3 Medications

Enalapril 10mg daily

0

4 Family History

Mother has diabetes

0

5 Vision

RV6/24 L6/18

0.5


Dist: RVA 6/7.5 LVA 6/7.5 Near: wears reading Rx R+3.25/-0.50 x 90 N8 L+2.75DS N8+ Binoc N6-

1


R +1.75/-0.50 x 90

L +1.25/-0.25 x 90

1

8 Refraction

R +1.75/-0.50 x 90 6/6 +2.25Add N5

L +1.25/-0.25 x 90 6/6 +2.25Add N5

1


Cover test D: 10 RXOT R8 HYPOT N:15 RXOT 4 HYPOT

1


Paralysis of R medial rectus, R superior rectus and R inferior rectus. No convergence.

3

11 Stereopsis


0

12 Pupil reactions

R pupil is dilated (8mm) L normal (5mm)

1

13 Accommodation

Reduced accommodation in R 1.00D, L 2.00D

1



0


R 19, 20,18,19 L 18,19,20,19 (mmHg)



(at same visit)

R18 L18 (mmHg)



Appear full R&L

0


Full Field R&L



Full Field R&L



Bilateral IOL's, A/V 1:2 healthy discs CD:0.3 R&L, clear maculae

1


Bilateral IOL's, A/V 1:2 healthy discs CD:0.3 R&L, clear maculae

3 (only 3pt in total scored for 21 and 22)


Bilateral IOL's, some PCO starting at edge of IOLs. A/V 1:2 healthy discs CD:0.3 R&L, clear maculae

3 (only 3pt in total scored for 21 and 22)

23 Photography

Normal images R&L


24 Van Herick's

Assessed as grade 2 narrow

1

25 Gonioscopy


Both angles assessed as adequate

0


This is not considered clinically necessary in this scenario R 7.82 x 7.80 L7.77 x 7.80

0


No abnormities observed but have to lift R lid to see all of cornea.

1

28 Pachymetry

This is not considered clinically necessary in this scenario R 745 microns L 750 microns (no correction factor)


29 OCT

No abnormalities found from macular or disc scans


30 Optomap

No abnormalities seen R&L


31 Amsler

This is not considered clinically necessary in this scenario No distortion R&L

0



0








A Refer urgently

5

B Refer routinely

0

C Refer to GP only

0

D information to GP

0

E Monitor / manage

0


0



0

H Recall in 1 year

1

I Recall in 2 years

0


J Recommend new Rx

0

K No change in Rx

1

L No Rx

0



Subsequent question - Had Christine just noticed a slight droopy lid RE for six months (with 25% pupil coverage, normal pupillary reactions and no particular adverse effect of vision and ocular muscle balance tests were normal, would you :

a) Refer ?

b) Not refer ?

13) Classification - Retina 1 / Referred 2 / Score 22

Mary aged 45 years attends for an eye examination. It is 10 years since the last one and she is new to the practice. She is using +1.00DS ready readers.


Choices:

Result:

score


Mary wears reading Rx only. Lots of computer work. Complains of headaches and has noticed a tiny blurry patch in front of left eye for 2 weeks. Has been rubbing her eye, but it has not getting any better. No other previous ocular problems. GH: Quite good but has high blood pressure. Med: Bendroflumethiazide 5mg once a day. FH: Mother has wet AMD.

2.5


2 General Health

Quite good but has high blood pressure

0

3 Medications

Bendroflumethiazide 5mg once a day.

0

4 Family History

Mother has wet AMD

0

5 Vision

RV 6/9 LV 6/9-

0.5


Near R N5 L N6

0


R Plano/-1.00 x 85

L Plano /-1.25 x 90

1

8 Refraction

R Plano/-1.00 x 75 6/6 +1.50Add N5

L Plano /-1.00 x 90 6/7.5 +1.50Add N6

1



0.5



0.5

11 Stereopsis

This is not considered clinically necessary in this scenario 40secs

0

12 Pupil reactions

PERLA

1

13 Accommodation

R=L=2.25D

0



0


R 12,13,11,14 L 16,15,16,15 (mmHg)



(at same visit)

R 15 L 16 (mmHg)



Appear Full

0


RE full field

LE missed square below fixation



RE Full Field

LE points missed below fixation (see plot)



Clear media R&L, A/V 2:3 CD:0.2 R&L, R healthy fundus L haemorrhages noted superiorly between disc and fovea (small pupils)



Clear media R&L, A/V 2:3 CD:0.2 R&L. R healthy fundus L haemorrhages noted superiorly between disc and fovea = branch vein occlusion noted above macula (small pupils)



Some peripheral lens changes R&L. Clear media R&L, A/V 2:3 CD:0.2 R&L. R healthy fundus L haemorrhages within nerve fibre layers superiorly between disc and fovea = branch vein occlusion noted above macula

3

23 Photography

R normal L see photograph


24 Van Herick's

Assessed as grade 4 - Open

1

25 Gonioscopy


Angles open R&L

0



R 7.90 x 7.80 L 7.85 x 7.75

0


Nothing abnormal seen externally, no lens opacities.

1

28 Pachymetry


R 745 microns L 750 microns (no correction factor)

0

29 OCT

RE normal see LE scan


30 Optomap

RE normal, LE branch vein occlusion noted above macula


31 Amsler

RE no distortion

LE Some blurriness below fixation

1



0








A Refer urgently

1

B Refer routinely

5

C Refer to GP only

0

D Information to GP

0

E Monitor / manage

0


0



0

H Recall in 1 year

1

I Recall in 2 years

1


J Recommend new Rx

0

K No change in Rx

1

L No Rx

0



Subsequent question - What would your action be if Mary presented with just a flame haemorrhage between the disc and fovea and LVA was 6/6 ?

a) Refer to HES

b) Refer to GP

c) Not refer

14) Classification - Glaucoma 2 / Not referred 1 / Score 21

Shanti, aged 69 years, attends for a routine NHS sight test. You have not seen the patient before, but she is an existing patient at the practice. No previous photos are available and the records show CD ratios were 0.3 R&L at the last test 2 years ago. She is wearing ready-mades for reading.


Choices:

Result:

score


No problems are reported by the patient, no headaches, wears ready readers +2.50DS. No history of ocular problems in the past. GH: Type 2 diabetes onset 3 years ago - good control. Med: Metformin 1000mg and simvastatin 20mg daily. FH: Late mother had glaucoma.

2.5


2 General Health

Type 2 diabetes onset 3 years ago - good control

0

3 Medications

Metformin 1000mg and simvastatin 20mg daily

0

4 Family History

Late mother had glaucoma

0

5 Vision

RV 6/9- N10 LV 6/9- N10

0.5


Near: R N5 L N5

1


R +0.50DS

L +0.50DS

1

8 Refraction

R +0.50DSVA6/6 +2.25Add N5

L +0.50DSVA6/6 +2.25Add N5

1



0.5



0.5

11 Stereopsis


0

12 Pupil reactions

PERLA

1

13 Accommodation


0



0


R 15,14,15,15 L16,17,17,16 (mmHg)



(at same visit)

R 14 L 16 (mmHg)



Appear full R&L

0


Full field R&L



Full field R&L


20 Direct ophthalmoscopy (un-dilated)

Slightly hazy mediae, A/V 1:2: CD:R0.45 L0.45, ISNT followed, healthy maculae. Cannot see rest of fundi well.

0

21 Volk un-dilated assessment

Slightly hazy mediae, A/V 1:2 CD:R0.45 L0.45, ISNT followed and assessed as large discs, healthy maculae, no signs of diabetic retinopathy.


22 Volk dilated assessment

Haze and mild lens changes in periphery R&L, A/V 1:2 CD:R0.45 L0.45, ISNT followed and assessed as large discs, healthy maculae, no diabetic retinopathy


23 Photography

No abnormal signs on images


24 Van Herick's

Assessed as grade 3 - open

1

25 Gonioscopy

Open angles

0 (not in general practice, but wish to see if used



0


Slight lens opacities noted R&L. No other abnormal signs.

1

28 Pachymetry

R 555µm L 565µm corrected R 13 L 15 (mmHg).


29 OCT

OCT: Normal nerve fibre thickness


30 Optomap


0

31 Amsler

This is not considered clinically necessary in this scenario- no distortion R&L

0



0


Repeat options as in a)


Repeat options as in a)




A Refer urgently

0

B Refer routinely

1

C Refer to GP only

0

D Information to GP

0

E Monitor / manage

5


1



1

H Recall in 1 year

1

I Recall in 2 years

0


J Recommend new Rx

0

K No change in Rx

1

L No Rx

0



Subsequent question - If Shanti had healthy large discs (ISNT followed) with CD ratios of R0.6 L0.6 with normal pressures and visual fields, would you ?

a) Refer

b) Not refer

15) Classification: Anterior Eye 1 / Not referred 2 / Score 17

Anne, 41 years old, complains of an irritable RE to your receptionist. She has already seen the pharmacist a few weeks ago and mentions that the GP has now suggested she make an appointment with you to check it out. She is an existing patient and her last NHS sight test with you was only 5 months ago.

Findings then were:

R +0.25DSVA6/6 N5

L +0.25DSVA6/6 N5

No abnormal results were recorded e.g. ophthalmoscopy, NCT and visual fields

You agree to see Anne as your ne

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