Ophthalmololgy Clerkship

Ophthalmology Clerkship

We offer 2 or 4-week elective rotations and 4-week sub internships.

Welcome to the Ophthalmology Department of the Walter Reed National Military Medical Center . For many rotators this will be the only time you will have the opportunity to be exposed to the discipline of ophthalmology in your career. Patients normally value their sight only second to life itself and in some surveys of the elderly ahead of that! 13% of all wartime traumas are ophthalmic. 60% of all intracranial tumors can be detected with a full ophthalmic eye exam. Many systemic illnesses affect the eye as a target organ and timely evaluation for visual problems can often detect occult systemic illness. We feel it is an exciting and rewarding field of medicine and surgery. If fact, eye complaints account for a substantial amount of presenting complaints in general and primary care settings. The information you take away will help you in your clinical practice later.

You will be issued a required reading text, Basic Ophthalmology for Medical Students and Primary Care Residents.

Schedule:

Rounds are held in the large conference room in our eye clinic from 8 to 9 AM each Friday morning of the rotation.

Grand Rounds are held the second Friday of each month from 8-10:30 AM with George Washington Hospital Center or at USUHS medical school.

Generally, medical students and interns will spend your weeks in our urgent care clinic with our duty ophthalmologist, seeing a variety of commonly encountered urgent eye problems and learning how to perform a good eye examination, or spend time in the retina, glaucoma, cornea, plastics, or comprehensive clinics. This will allow you to refine your examination skills and expand your knowledge base in these key areas. Time will also be allotted to observe selected cases in the operating room to become familiar with how basic eye surgery is performed. You may interact and have a chance to work with our civilian ophthalmology residents on service during your rotation here.

Our goal is to assure that you complete your rotation with the confidence to recognize and treat common and emergent eye conditions, and to refer patients for ophthalmologic evaluation when appropriate.

Evaluation:

Your evaluation will be based on:

1. Your performance in the clinic(s) based on personal observation of the staff you worked with. (60%)
2. An examination given at 9:00 AM on the last Friday of your rotation (30%)
3. The skills check-off form completed. (10%)

Practical Goals for Rotators:

EYE EXAM / GENERAL PRINCIPLES

• Measure and record visual acuity.
• Assess pupillary reflexes.
• Understand how to measure intraocular pressure and its significance.
• Evaluate visual fields by confrontation.
• Evaluate basic ocular motility.
• Dilate pupils of patients in whom a more detailed evaluation of posterior segment is indicated.
• Use of direct ophthalmoscope to assess optic disc features and red reflex.
• Know the basic ocular anatomy.
• Know the common medications potentially toxic to the eye and which patients on these medications need to be referred and how often.
• Know the basic actions and risks of the commonly used ocular medications, including systemic risks and those most likely to cause allergic or ocular side effects.
• Understand the basic optics of myopia, hyperopia, astigmatism and presbyopia.

CORNEA

• Know how to recognize and manage subconjunctival hemorrhage.
• Distinguish a corneal abrasion from a corneal ulcer and know how to manage each upon initial presentation.
• Know the proper indications and technique of patching the eye.
• Know the differential diagnosis of the “red eye” and how to manage initially and when to refer.
• Be able to use a slit lamp to distinguish the tear film, corneal layers, anterior chamber, iris and lens.
• Know how to recognize and treat HSV keratitis.
• Know how to manage dry eyes and initial presentation of Bell’s Palsy.
• Know the basic management of contact lens related problems.
• Know when to suspect and recognize a penetrating anterior segment injury.

GLAUCOMA

• Understand the definition of glaucoma and the possibility of silent presentation.
• Understand the basic mechanisms of open vs. closed angle glaucoma.
• Understand the treatment modalities of glaucoma.
• Know the basic side effects of glaucoma medications.
• Recognize blebitis or impending enophthalmitis is a patient with prior glaucoma surgery.
• Estimate the gross C/D (cup to disc) ratio by color clues of the optic nerve with the direct ophthalmoscope and recognize gross asymmetry of the optic nerve if it exists.

ORBIT/PLASTICS

• Recognize proptosis and understand its causes and significance.
• Recognize congenital vs. acquired ptosis and its basic causes and significance.
• Know how to differentiate pre-septal from orbital cellulitis and initial clinical approach to each.
• Understand the basics of orbital prostheses.
• Recognize the features of potential common cancers of the lids and orbital adnexa.

TRAUMA

• Recognize and initially manage a penetrating eye injury.
• Recognize and initially manage a blow out fracture of the orbit.
• Recognize and initially manage a hyphema.
• Recognize and initially manage lid lacerations and implications for occult injury.
• Recognize and initially manage chemical burns or splashes to the eye.

RETINA

• Know the visual symptoms of posterior vitreous detachment and retinal detachment and when to refer.
• Understand the basic features of diabetic retinopathy, when to refer and the mechanism for loss of vision if not treated. How laser treatment prevents vision loss in these patients.
• Recognize rubeosis of the iris and its basic causes and impact on the intraocular pressure.
• Know the visual symptoms of acute vein vs. arterial occlusive disease of the eye and how to initially manage.
• Know the visual symptoms of macular disease and basic pathology of age-related macular degeneration and when to refer these patients.
• Know the symptoms of retinitis pigmentosa.
• Be familiar with retinopathy of prematurity and who needs to be screened for this condition.

NEURO-OPHTHALMOLOGY

• Know the symptoms and signs of optic neuritis and its significance.
• Know how to assess for ocular migraine or visual symptoms associated with common migraines.
• Recognize anisocoria and understand its significance.
• Recognize an acute CN III palsy and its significance.
• Understand the basic anatomy of the visual pathway from the optic nerve to the occipital cortex.
• Understand and learn to recognize the presentation of temporal arteritis and its initial management.
• Know how to assess for afferent pupillary reflex and its clinical significance.

PEDIATRICS/STRABISMUS

• Know how to assess for eye alignment using corneal reflex, cover-uncover and alternate cover tests and the significance of the findings.
• Recognize abnormal versions.
• Recognize leukocoria with a direct ophthalmoscope in an infant or young child and understand its significance.
• Recognize nasolacrimal duct obstruction and how to manage it in the first year of life and when to refer.
• Understand the underlying basics of amblyopia and the significance of early recognition and referral.

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