Saturday, January 29, 2011

The Must Have Book for Ophthalmology Trainees in Malaysia.

The Chinese New Year is round the corner (from 3rd Feb 2011), I would like to take this opportunity to wish everybody a Happy Chinese New Year of the Rabbit. As for me, I shall take a week off from the clinic and concentrate on finishing my book on Common Short Cases for Master Students in Ophthalmology. The book is written specially for Malaysian Master Students in Ophthalmology, however, the standard is purposedly set higher and should be useful for people taking FRCS and FRCOphth. Below is the preliminary cover of the book and samples of the contents. The book would be sponsored by the AMO and published by my company Marudi Publishing.


How to approach short cases in master examination
The Short Cases represent the biggest hurdle for the master students because the candidates are expected to show their depth of knowledge and be able to shift their examinations from one part of the eye to another and sometimes extra-ocular region (for example in pupil examination, the candidates would be expected to examine the eye movement for any third nerve palsy if the pupil is fixed and dilated or neck and chest examination for signs of sympathetic damage in Horner’s syndrome).

Preparation is essential and the best way to do this would be to learn all the common examination techniques and apply them religiously in the day-to-day practice until they become second nature. Remember that the actual examination is not the place to practice your examination techniques for the first time. Otherwise, the examinations will appear hesitant and likely to miss most of the signs or fail to extend your examination to other parts of the eye or body for further clues. Your examination should appear naturally, sleek and thorough. If you could do these, the signs should be elicited easily and allows you to concentrate on the signs and formulate the differential diagnosis and management.


How to approach the patient
Examiners do not like rude candidates and you are unlikely to leave a good impression if you are discourteous to the patients or cause them pain during examination through rough handling. The only way to learn this would be to treat all your patients in your daily practice politely and avoid causing discomfort.
During the examination:

 Always introduce yourself to the patient and ask permission to perform the examinations asked of you by the examiners.

 Show concern for the patient’s comfort for example in patient’s with a red eye ask patient if it is hurting before lifting the eyelid

 Proper positioning of the patient especially when using the slit-lamp making sure the patient does not have to stretch his/her neck or bend in an awkward position.

 On completion of the examination, thank the patients and replace any items you may have to remove during the examination (such as removal of clothing for signs of chest scar in patients with myasthenia gravis or Horner’s syndrome).



What the Examiners Look for in the Candidates

a. the ability to observe/elicit all the relevant signs and piece them together.

For example, if the candidate were asked to examine the anterior segment of the right eye above, the following signs should be observed: surgical iridectomy, flat trabeculectomy, tube in the anterior chamber, pseudophakia and a corneal stitch at the temporal cornea. The examiner would expect the candidate to tie all these signs together, a good candidate would come out with :"This patient has had trabeculectomy which failed needing tubing to control the intraocular pressure. The patient later developed cataract which was removed via a temporal approach phacoemulsification to avoid disturbing the tube."


b. the ability to connect the signs seen to relevant system.

For example, the examiner may ask you to look at the patient's above and "What examinations would you like to perform on this gentleman?". Any master student should recognize the port-wine staining and this condition is associated with open angle glaucoma and sometimes brain involvement resulting in visual field defect. "I would like to examine the right eye of this patient on the slit-lamp for signs related to glaucoma and also perform a visual field examination for any evidence of left homonymous field defect."


c. the ability to elicit underlying cause(s) related to the signs observed.

For example, in the patient above. The examiner may ask: " Would you like to examine this patient and tell me what is the cause of the abnormalities seen?". A master student should be able to observe the right facial nerve palsy and lateral tarsorrhaphy and know the pathway of the lower facial nerve. The candidate should look for any signs of parotid gland tumour or operation, vesicle in the pinna (Ramsay-Hunt's syndrome), mastoidectomy scar or scalp scar for previous neurosurgery. In this patient, examination of the back of the head reveals a scar indicative of previous brain stem surgery for acoustic neuroma (see picture below).  



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