Optometry Student Extern Manual. Miami VA Medical Center

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Edwina Phelps
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1 Optometry Student Extern Manual Miami VA Medical Center

2 Table of contents: Rotation Description 3 Clinic Schedules 4 Absences 4 Performance Standards 5 When to check in with attending 5 References 6 Visual Field Analysis Tables 7 Diabetic standard 2A photo 7 Diabetic Retinopathy Management Guidelines 8 2

3 { Rotation Description } The Miami VAMC eye clinic offers a unique educational experience. While our optometry clinic is a separate entity, we are in close proximity and cooperation with ophthalmology. Every subspecialty of ophthalmology is represented by ascom Palmer Eye Institute faculty members and residents, making consultations, surgical referrals, and sharing of patients mutually efficient. We strive to maintain a high volume of patient encounters at the Miami VA. ecause of this, the optometric intern is exposed to a diverse array of ocular pathologies. Educational Goals: 1. To provide a highly interactive learning experience in order to further the knowledge, clinic skills and management capabilities of fourth year optometry students. 2. To provide the highest quality of eye care to our nation s veterans in a timely, efficient and friendly way to ensure all visual needs and problems are addressed appropriately and managed according to standard of care guidelines. The goals for our interns are to be able to complete an exam in a timely fashion with the most accurate diagnosis and treatment plan. To do this, interns are expected to see patients from start to finish, including completion of the dilated fundus exam. In addition, interns are expected to be prepared with a good subset of clinical skills and basic clinical knowledge of ocular disease prior to beginning their VA rotation. Additional Learning Incentives/Activities: In addition to patient encounters at the Miami VA, we are fortunate to have a strong affiliation with the optometric internship and residency program at ascom Palmer Eye Institute. Our interns have the privilege to be invited to all the educational meetings, including: 1. Weekly lecture series given by optometry faculty and residents: Mondays, Thursdays 2. Weekly attendance to the ophthalmology grand rounds at PEI: Thursdays 3. Weekly slide quiz series and visual field lectures by optometry faculty: Mondays 4. Weekly journal club series at PEI led by optometry students and residents: Tuesdays 5. Weekly imaging interpretation conference hosted by PEI ophthalmology: Tuesdays Things You Will Need: Diagnostic lenses: use of personal gonioscopy lenses and scleral depressors is prohibited White coat recommended in anticipation of cold hospital exam rooms. o please wear clinic attire with closed- toe shoes (no scrubs). 3

4 Approximate Work Hours: The work days depend on the number of student interns for each rotation. We typically have one erkeley student and one NOVA student. When we have two students, the students are expected to work Monday through Saturday with alternating Wednesdays and Saturdays off. Each morning will begin at 8:00 a.m. with the exception of Thursday mornings for grand rounds and lectures at PEI at 7:30 a.m. Students are expected to in clinic by 10:15 a.m. Interns typically finish clinic by 4:00 p.m. to attend afternoon lectures All federal holidays are observed: o New Year s Day, MLK Jr irthday, Washington s irthday, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day, Christmas Day Clinical Exam Schedules: Optometry 2 Dr. McClellan Optometry 3 Dr. Fabian Optometry 5 Dr. Zann Monday Tuesday Wednesday Thursday Friday Saturday 7:30-3:00 A 7:30-11:00 12:00-3:30 (A fill- in) 7:30-3:00 7:30-2:30 A ( fill- in) OUT 7:30-3:00 A 12:00-2:30 OUT research 8:00-11:00 9:30-4:30 A ( fill- in) 7:30-3:00 A ( fill- in) 12:30-3:00 low vision OUT OUT 7:30-4:30 Absences: Please notify Dr. McClellan as soon as possible of upcoming absences; an official request is preferred: allison.mcclellan@va.gov, cell phone: , office: x6131, or eye clinic x3081. Please speak to someone instead of leaving voice mail. Parking advice: Since February 1, 2010, parking onsite is limited to patients only. Other options include: Public transportation: Discounted student fares for public transportation can be purchased at the Government Center Station with student ID. o Miami- Dade Metrorail Civic Center station is outside the VA with $2.25 fares each way, parking at rail stations is $4/day or $10/month. o 595 Express us which also departs outside of the Civic Center Station. ascom Palmer Eye Institute parking lot o through an arrangement by one of your classmates who are currently on a rotation at PEI, about a 10 minute walk across campus 4

5 { Performance Standards } Required Check- in Prior to Dilation: 1. Pupil abnormality not previously documented 2. New onset diplopia or EOM abnormality not previously documented 3. Red Eye/Uveitis 4. Gonioscopy if IOP > 23 or > 3 mmhg asymmetry between eyes; confirmed by attending Within 2 weeks of start of rotation: Examination Goal 6-8 patients daily Up to dilation in min, completion of DFE/chart in 15 min, approx. 1 patient/hour Case History/Preliminaries/Vision: Key History Points delineated Assess EOM, CVF identify gross abnormalities Assess pupils: identify 2+ APD Refractions must be accurate and complete, plus cylinder Slit Lamp: Recognize gross lid and conjunctival abnormalities Recognize gross corneal abnormalities, staining defects, infiltrates, or neovascularization Accurate tonometry (within 2mmHg) Recognize greater than 1+ ACC/NS/PSC lens changes Fundus Examination: Recognize gross retinal abnormalities such as drusen, CRVO, CRAO, hemorrhages, or exudates Visualize, not diagnose, any lesion 1DD in posterior pole or peripheral fundus up to equator Identify, not diagnose, abnormal disc (ie swollen, pale, anomalous) Must know: Main contraindications to and side effects of glaucoma medications Classification of DR, including rule, definition of high risk PDR Definition of CSME At Midterm: in addition to above, examination goal 8-10 patients daily Accurately assess etiology for decrease in vision when below 20/20 Recognize 1+ APD Recognize NVI, NVE greater than 1 DD Grade gonioscopy, recognize but not diagnose gross angle abnormalities (PAS, angle recession) Recognize macular edema Write out diagnosis and treatment plans for mildly complex cases y the end of the rotation: in addition to above, examination goal 10+ patients daily Identify CSME Grade cataracts accurately and form appropriate treatment plan Accurately identify and interpret VF analysis, correlate VF findings to optic nerve appearance Formulate diagnosis and treatment plans appropriately for moderately complex cases 5

6 { References } Glaucoma: 1. Natural History of Normal- tension Glaucoma. Collaborative Normal- Tension Glaucoma Study Group. Ophthalmology 2001;108: Michael A. Kass, MD; et al. Ocular Hypertension Treatment Study (OHTS). Arch Ophthalmol.2002;120: Delaying Treatment of Ocular Hypertension: The Ocular Hypertension Treatment Study. Arch Ophthalmol 2010;128(3): The Advanced Glaucoma Intervention Study (AGIS). Controlled Clinical Trials 15: (1994). 5. Factors for Glaucoma Progression and the Effect of Treatment: The Early Manifest Glaucoma Trial (EMGT). Arch Ophthalmol/Vol121, Jan 2003;121:48-56.Controlled Diabetic 1. Early Treatment Diabetic Retinopathy Study Research Group (ETDRS): Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Ophthalmology 94: , The Diabetes Control and Complications Trial (DCCT) Clinical Trials in Ophthalmology: A Summary and Practice Guide. 1998: The Diabetic Retinopathy Vitrectomy Study Research Group. Early vitrectomy for severe vitreous hemorrhage in diabetic retinopathy. Two- year results of a randomized trial. Arch Ophthalmol 1985; 103: Vascular: 1. Standard Care vs Corticosteriod forretinal Vein Occlusion (SCORE): Archives of Ophthalmology Vol.127 No.9. September Campochiaro, PA. A Study of the Efficacy and Safety of Ranibizumab Injection in Patients With Macular Edema Secondary to ranch Retinal Vein Occlusion (RAVO). Paper presented at The American Society of Retina Specialists Retina Congress, October 4, 2009; New York. 3. rown DM. Safety and efficacy of intravitreal ranibizumab (Lucentis) in patients with macular edema secondary to central retinal vein occlusion. The CRUISE Study. Paper presented at The American Society of Retina Specialists Retina Congress, October 4, 2009; New York. Macular Degeneration: 1. The Age- Related Eye Disease Study AREDS: Control Clinical Trials 1999;20: Clinical classification of Age- related Macular Degeneration. Ophthalmology 2013;120(4); Vitreo- Retinal: 1. Collaborative Ocular Melanoma Study: IV. Ten- year Mortality Findings and Prognostic Factors. Am J Opthalmol 2004;138(6): Choroidal nevus transformation into melanoma: analysis of 2514 consecutive cases. Arch ophthalmol 2009;127(8): Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.asymptomatic retinal tears. Ophthalmology 1994;101(9): Revised Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy. Ophthalmology 2011;118: a. aseline DFE within first year of initiation, if normal, repeat at minimum in 5 years HVF 10-2 (white on white) + one of the following: OCT, mferg, or FAF 5. Evidence- based analysis of prophylactic treatment of asymptomatic retinal breaks and lattice degeneration. Ophthalmology Jan;107(1):

GHT: outside normal limits... checks paired sectors of matched NFL bundle defects 3. Pattern Deviation < 5% or more (outside the normal 90% range) VF Severity: 1. Mild Defect: a.

7 { Glaucoma } Abnormal VF Criteria: if any of the 3 is present on a repeatable VF, it is considered abnormal 1. Cluster Criteria: 3 non- edge contiguous points on the same side of the horizontal meridian, all < 5% P and one <1% (including the two most nasal points on a 30-2 and all points on a 24-2) 2. GHT: outside normal limits... checks paired sectors of matched NFL bundle defects 3. Pattern Deviation < 5% or more (outside the normal 90% range) VF Severity: 1. Mild Defect: a. MD > (better than) - 5 db (24-2) or - 6 db (30-2), no points inside central 5 degrees < 20db b. Target IOP % below baseline 2. Moderate Defect: a. MD > - 10db (24-2) or - 12 db (30-2), no points inside central 5 degrees <10db b. 1 hemifield can have a point in central 5 degrees 10-20db, but not both hemifields c. Target IOP 30-40% below baseline 3. Severe Defect: a. MD < (worse than) - 10db (24-2) or - 12db (30-2) b. any point inside central 5 degrees <10db, both hemifields have central point < 20db c. Target IOP 40-50% below baseline VF progression: defect should be present on a minimum of two successive fields 1. establish a baseline VF = average of 2-3 fields 2. progression from previously "normal" field = Cluster criteria (see above) 3. progression from previously "abnormal" field = a. 2 contiguous points on same side horizontal decrease by 10 db, and that point must be lower than any value obtained in a previous VF/baseline VF 4. confirmation of progression must be present in 4 out of 5 confirming VF { Diabetic Retinopathy } Standard Photograph 2A: Mild NPDR CSME: Definition 7

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Optometry Student Extern Manual. Miami VA Medical Center

Optometry Student Extern Manual Miami VA Medical Center Table of contents: Rotation Description 3-4 Clinic Schedules 5 When to check in with attending 5 Absences 5 Performance Standards 6 Examination Template