Oculoplastics, Strabismus & Neuro-ophthalmology Elective/Rotation
Michael Garron (Toronto East General) Hospital
Thanks for visiting! I hope you will have a useful and enjoyable learning experience. This subspecialty elective is best suited for medical students with prior experience in ophthalmology. Beginning medical students are welcome, but may find the subspecialty focus difficult.
Before seeing patients, register with Michael Garron Medical Education, so that you have insurance coverage. After you have your hospital name tag, come find me in the office (K wing 306)
The office address and details can be found on the home page or “edseling.com”
Introduce yourself: If you have time, send me a mini-CV, and your top 3 objectives for this rotation.
Attire: Lab coat preferred. No open toe shoes for safety reasons. No shorts during office hours. You can either use the hospital greens (cyan blue) or bring your own.
Office managers: Sandy
Patient population: Our office specializes in oculoplastics (eyelid tumours, eyelid malpositions, eyelid reconstruction), orbit (Graves disease, orbital tumours), strabismus and neuro-ophthalmology. We only see general ophthalmology patients during the weeks we are on call or occasionally when the University of Toronto core medical students come to the office.
With COVID the schedule has become difficult to predict.
Minor surgery: Thursday pm
Main OR: Fridays and occasional Wednesday
CLINICAL CASE DIARY
Write down all the clinic/surgery cases you see during the day in a small notebook / your smartphone.
Review the cases at the end of the day/at home. Consider carrying the Wills Eye manual or Mass Eye manual with you during the day. If the office cases get repetitive, start reading your manual.
Kanski’s atlas, the American Academy medical student manual, and optics quizzes are available to you.
The emedicine ophthalmology articles are free and online
Ophthalmic history (slide script presentation is available, review our hx and px intake sheet)
Common ophthalmic problems (handout)
Vision testing, Confrontation fields, Pupil Testing, Eye movements*
Direct Ophthalmoscopy (handout)*
Smart phone Fundoscopy
Slit lamp exam (handout)
Indirect Ophthalmoscopy (tape roll). We can lend you an indirect ophthalmoscope to practice with.
Prisms: (handout) Practice alternate cover tests. Use a laser pointer 1 m from a wall, and determine the relationship between the prism bar markings and light displacement.
Suturing skills (bring some thread to the office if you don’t know how to instrument tie)
Refractive error and glasses
Operating the visual field machine
Operating the OCT
MAKE A MIND MAPS/FLOW DIAGRAMS on your approach to:
Vision Loss e.g. acute painless vs. chronic*
Double vision or eye movement abnormality*
Upon completion of your rotation, you should be able to answer most of the questions below:
INTRODUCTION TO THE OCULOPLASTICS / STRABISMUS OPERATING ROOM: GENERAL QUESTIONS
What are the elements of an informed consent?
Why are patients NPO prior to surgery?
What is reverse Trendelenberg position?
Which antiseptic(s) should you not use near the eye?
What is your surgical glove size?
What things can you do to prevent needlestick injuries?
How might flash fires start during oculoplastics procedures? How do you prevent this?
What things can you do to protect the patient’s eyes when they are unconscious?
What can you do to prevent surgical contaminants splashing in your eye?
What is the proper method of pulling a patient stretcher through a narrow doorway?
How do you ensure you will have a square knot?
Name some absorbable and non-absorbable sutures.
What calibre sutures do we normally use on the face?
What things can you do to prevent bleeding during/after surgery?
What is different about hemostasis for ocular procedures, compared to most other surgeries?
What type of cautery is used in a patient with a pacemaker?
What should you check before applying the grounding cautery pad?
What are the essential elements of an operative report?
OPHTHALMOLOGY SPECIFIC QUESTIONS (* Core competencies suggested by AAO and AUPO)
Explain the anatomy of the eye and visual system.*
What is your approach to the red of painful eye?*
How do you evaluate a patient with eye trauma?*
What are important causes of vision loss in children?*
What are some ocular manifestations of systemic disease?*
What are the most important ocular side effects of systemic drugs?*
What common ocular medications have systemic side effects?*
When should a patient be referred urgently to ophthalmology*
What is the most common operation in Ontario? If you had to explain this operation to a patient what analogies could you use?
What type of glaucoma surgeries are available? What is the intent of these procedures?
How does Starlings law relate to strabismus surgery? What are some techniques to strengthen a muscle? What can be done to weaken a muscle? What is the spiral of Tillaux?
Is a muscle “hook” a sharp instrument?
How can the surgeon monitor the patient’s vital signs during an operation, without looking at the anesthesia machine? Why might the anaesthesiologist ask the ophthalmic surgeon to stop surgical manipulations during a strabismus surgery?
What does the specialty of oculoplastic (oculofacial) surgery entail?
A patient has cosmetic blepharoplasty, and that night has severe discomfort with a swollen eye, vision loss, RAPD and high intraocular pressure. What is the diagnosis, and what should you do?
What are the names for the eyelid malpositions where:
- The eyelid is too droopy
- The eyelid is inverted. What are the mechanisms for the involutional form of this disorder?
- The eyelid is everted
What are the most common skin cancers?
What is the most common orbital disease in an adult?
A patient has tender skin protruberance at the medical canthal tendon, and a purulent eye? What is the problem and what are the short and long term treatments?
A patient has a large tumour behind his globe, lateral to the optic nerve. How can this be removed?
What does diabetic retinopathy look like?
If a patient has a retinal detachment, do we stitch the retina back on to the sclera?
A child has leukocoria. What should you consider?
An adult has a white cataract. What should you consider?
Under what situations is an eye removed? What are the different types of surgical procedures for eye removal?
OPHTHALMIC HISTORY: 1) Ask about change in DISTANCE vision because presbyopes complain so much
2) Vision loss & Diplopia: Did you cover one eye? (monocular&horizontal respect=eye / binocular & vertical respect=brain)
3) Fleeting pins and needles; itchy-scratchies burnies, reflex tearing: = Dry eye
4) Vision loss or diplopia in the elderly: rule out giant cell arteritis
OPHTHALMIC EXAM: 1) Record acuity in each eye separately. (Kleenex or patient’s palm as occluder, not fingers because they can see through the gaps) Kids will peek. Parent must cover eye or tape occlude to check.
If patient unable to see eye chart can walk them up halfway, then Finger Counting, then Hand Motions, then Light Perception +/- projection
2) Pupils: room lights off; patient looks in distance. Horner’s syndrome is easily missed. When checking RAPD shine light on each eye for 2 seconds before moving to the other side as quickly as possible.
3) Efficient field testing: count fingers on either side of midline (young children: hand motions game)
4) In walk-in clinic/private office: use an illuminated magnifier if no slit lamp
5) Slit lamp won’t work: Is electrical timer on wall? Check cords. Check pilot light and bulb. Check round knob at bottom of column. Check toggles e.g. magnifier. Check focus of eye pieces. Release the lock.
6) Direct ophthalmoscope: get close to patient; aim slightly nasal
7) Easy to miss trichiasis, entropion, floppy eyelids
EYE DROPS (OD=right eye; )OS=left eye; OU=both eyes; gtt=drop; ung=ointment)
*Dilating drops: Tropicamide 1% (Mydriacyl) short acting dilator: stings
Cyclopentolate 1% (Cyclogyl) intermediate length dilator and cycloplegic
Topical anesthetic: Tetracaine/Proparacaine (Stings and later feels cold and numb)
Artificial tears: Refresh, Liposic, Refresh, Isoptotears 1% Bion Tears, Celluvisc (thicker, preservative-free)
Lubricating ointment: Lacrilube, TearGel
Antibiotic drop: Polysporin, Tobrex, Vigamox
Antibiotic-Steroid drop/ung: Tobradex (Be wary prescribing topical antibiotic-steroids as non-specialist)
Some Glaucoma drops without cardiorespiratory side effects in adults: Brimonidine (Alphagan), Latanoprost (Xalatan), Pilocarpine, Dorzolamide (Trusopt)
CORNEAL FOREIGN BODIES: Remove with Chalazion curette (blunt) rather than needle. Evert lid
HOSPITAL CONSULTS: (Best exam in an examining lane. Bedside exam will not be as detailed.)
Can’t read: Is the bifocal in the right position for the supine patient?
Trauma patients: Can we dilate? (or are neuro-vitals essential)
Perimetry: If the patient can’t do confrontation fields, we won’t be able to do perimetry
Eyelid lacerations: Exclude globe rupture before suturing lid. No knots on corneal side
OUTPATIENT CONSULTS: 1) Dry Eyes: a very common complaint. Patients may have reflex tearing
2) Flashes & Floaters: you can try dilating and looking with direct ophthalmoscope
3) 3rd nerve palsies: CTA/MRA to exclude aneurysm, especially if pupil-involved
4) Ask patient/parents to bring video/photo of perceived problem for ophthalmologist
5) Eyelid tumours / Eyelid surgery: Respect the cornea!
KIDS: 1) Amblyopia potential until age 8 yo. 2) Can check refraction (retinoscopy) in neonates 3) Can check acuity Sheridan Gardner (letter pointing game) often by age 2.5 yo or sometimes younger
4) Parents frequently right about exodeviations, but often mistaken about esodeviations
5) Child’s right side [Parents left side] 6) Kids blocked tear ducts: Roll Q tip downwards
HOMEWORK: A) Make an analogy to explain to patients: 1) Cataract surgery 2) Wet/Dry Macular degeneration
B) Construct a mind map / flow diagram on your approach to Vision Loss You can organize by monocular/binocular with age, time frame, pain, or anatomical references
FOR ELECTIVE MEDICAL STUDENTS SPENDING >=2 WEEKS IN THE OFFICE: PREPARE 5 MINUTE (MAXIMUM) PRESENTATIONS ON:
- Critique of recent journal article in ophthalmology / general medicine that is important to ophthalmologists AND
- A statistics topic from the American Journal of Ophthalmology (or British Journal of Ophthalmology) Statistics and Ophthalmology series or Common Mistakes in Using Statistics. (see below)
If you need a CaRMS letter after your CaRMS rotation is done, remind me which article or project you did, so I can use it in your letter.
SELF STUDY MODULES FOR MEDICAL STUDENTS AVAILABLE IN THE OFFICE
Optics (3 question and answer modules)
Glaucoma (AAO 2018 EyeNet Articles)
Retina (AAO 2018 EyeNet Articles)
Refractive and Cataract Surgery (AAO 2018 EyeNet Articles)
STATISTICS AND OPHTHALMOLOGY
It is important to be able to learn and interpret articles by yourself.
The Role of Statistics in Ophthalmology
Anne L. Coleman
American Journal of Ophthalmology, Vol. 147, Issue 3
Descriptive Statistics in Ophthalmic Research
Fei Yu, Abdelmonem A. Afifi
American Journal of Ophthalmology, Vol. 147, Issue 3
Risk Interpretation, Perception, and Communication
Nicholas P. Jewell
American Journal of Ophthalmology, Vol. 148, Issue 5
Nicholas P. Jewell
American Journal of Ophthalmology, Vol. 148, Issue 4
The Use and Interpretation of Linear Regression Analysis in Ophthalmology Research
- John Boscardin
American Journal of Ophthalmology, Vol. 150, Issue 1
Nonparametric vs Parametric Tests of Location in Biomedical Research
Christina M.R. Kitchen
American Journal of Ophthalmology, Vol. 147, Issue 4
Correlation, Agreement, and Bland–Altman Analysis: Statistical Analysis of Method Comparison Studies
American Journal of Ophthalmology, Vol. 148, Issue 1
Logistic Regression Analysis: Applications to Ophthalmic Research
Stanley Lemeshow, David W. Hosmer Jr
American Journal of Ophthalmology, Vol. 147, Issue 5
Survival Analysis: Applications to Ophthalmic Research
David W. Hosmer Jr, Stanley Lemeshow
American Journal of Ophthalmology, Vol. 147, Issue 6
Current Research in Biostatistics
Abdelmonem A. Afifi, Fei Yu
American Journal of Ophthalmology, Vol. 149, Issue 3
Bayesian Methods for Data Analysis
Robert E. Weiss
American Journal of Ophthalmology, Vol. 149, Issue 2
Propensity Score Methods
Donald B. Rubin
American Journal of Ophthalmology, Vol. 149, Issue 1
Missing Data: What a Little Can Do, and What Researchers Can Do in Response
Thomas R. Belin
American Journal of Ophthalmology, Vol. 148, Issue 6
Statistical Genetic Approaches for Mapping Ophthalmic Trait and Disease Genes
American Journal of Ophthalmology, Vol. 148, Issue 2
Binary Eye Data GLMM, GEE
COMMON MISTAKES IN USING STATISTICS
PRACTICAL “CAREER” INFORMATION
The ophthalmic job market, IF you are applying for ophthalmology
Economics of running an office
Medicolegal problems (read the informed consents)
Once every 6-8 weeks, our office is on call 7 days. Your rotation may not coincide with my call weeks. Medical students have the OPTION of attending the ER on evenings and weekends when patients are referred.
Weekends on call, the usual hours I run the clinic are Saturday and Sunday from 10-11:30 am. The number of weekend patients we see is very variable, depending on the cases seen by the emergency room doctors the night before.
It is not mandatory for the medical students to be on call with me, but I think it is a very practical “real world” experience, and you are welcome to accompany me.