Comprehensive Eye Service
Overview
The rotations through the Comprehensive Eye Service (CES) at UPMC Eye Center Mercy provide residents with the opportunity to learn by providing care to a diverse patient population with a broad range of ophthalmic concerns.
Services of the CES include
- routine eye exams and refraction
- screening and ongoing treatment for patients with
- cataract
- glaucoma
- diabetes
- macular degeneration
- uveitis
- follow up care from the Emergency Department
- evaluation and acute care of patients who may have visual loss or complaints but do not know their diagnosis
- daytime on-call consultation for the Emergency Department and Inpatient Services at UPMC Mercy
Curriculum
Residents can expect an environment of supervised autonomy that emphasizes the role of the resident as the primary eyecare provider.
A strong emphasis is placed on teaching and residents can expect to teach and be taught by all members of the CES team including themselves, their peers, faculty, staff, medical students and patients.
While working with the CES residents will have the opportunity to develop and refine ophthalmic skills including
- taking a thorough and focused ophthalmic history
- performing a complete ophthalmic exam including
- afferent examination (visual acuity, pupil exam and visual fields)
- retinoscopy and refraction
- ocular motility
- examination of external, anterior and posterior structures of the eye
- forming and narrowing a differential diagnosis
- creating and implementing a plan for further diagnosis and treatment
- ordering and interpreting ophthalmic diagnostic studies
- communicating with and counseling patients
- corresponding with patients’ families and other health care providers
- presenting patients in a thorough and focused manner
First year residents can expect to receive early training with ophthalmic lasers and minor procedures.
Third year residents can expect to refine their skills with these procedures and have the opportunity to teach junior residents.
First year residents can expect to receive early anterior segment operative experience.
Third year residents can expect that operative experience, particularly with cataract surgery, will be a major focus of the rotation.
Schedule
Clinical experiences begin at 8 am each weekday and continue until the last patient is discharged.
Often, clinical care is followed by a post-clinic wrap-up session during which the day’s patients and the important points they illustrated are reviewed.
Wrap-up session is generally finished by 6:30 pm.
Expectations
All residents on the service are expected to
- read and become familiar with the Educational Goals and Objectives for the rotation
- arrive on time for clinical experiences.
- provide courteous care to patients.
- take thorough histories and perform complete examinations
- work as part of the CES team sharing work with each other and the technical staff as needed
- work closely with medical students and other trainees rotating with the service
- complete timely, thorough and accurate documentation using the electronic health record
- when necessary complete correspondence with patients’ other health care team
- treat the technical and administrative staff with courtesy and respect
- complete preliminary interpretations for all studies the resident has seen
- when necessary, provide post encounter care for the patient by checking labs, filling out forms and corresponding with patients
- read on a daily basis while on the service concentrating on topics brought to the forefront during clinical experiences
In addition, third year residents are expected to
- take primary responsibility for the preoperative evaluation and postoperative care of operative patients
- assist in the supervision of junior residents when necessary, provide direction to medical students, junior residents and staff to assist with efficient patient flow
CES Educational Goals and Objectives
Overall Goals
Patient Care
- To take complete histories in an efficient, respectful manner
- To perform thorough examinations in an efficient manner
- To think through and formulate possible differential diagnoses
- To develop an appropriate management plan; in appropriate circumstances initiate it
- To demonstrate appropriate hygiene by washing before and after every patient contact
Medical Knowledge
- To establish good reading habits early. Plan to read every day. Stick to your plan.
- To Apply your what you've read as you talk to, examine, diagnose and treat your patients.
- When you are exposed to a new diagnosis in a clinical situation, read about it as soon as possible.
Professionalism
- To treat patients with respect and compassion at all times
- To treat clinical and administrative staff with respect
- To treat medical students with respect and strive to create an atmosphere conducive to education
- To arrive on-time for clinical experiences
- To prepare in advance for surgical experiences
- To work to become part of the clinical team
- To work with the faculty, staff, fellow and other residents on the service to determine your responsibilities
- To remain flexible and offer to help out with the responsibilities of others when you can
- To remain visible and available to participate in clinical care throughout the clinical session. If you leave the clinical care area make sure that other members of the service know where you are and why
- To answer your pager within 10 minutes of receiving page
Interpersonal and Communications Skills
- communicate your name and role on the service to patients and their families
- "Hello, I'm Dr. Resident, I'm a resident working with Dr. Attending today."
- present patients to the attending in a succinct but complete way
- maintain timely and legible medical records
- talk when you should talk, listen when you should listen
Practice Based Learning and Improvement
- learn to recognize feedback from faculty, fellows, fellow residents, patients and students
- accept that feedback constructively and work to improve based on it
- accept your role as a teacher as well as a learner. Work to educate students, fellow residents, faculty, staff and patients
Systems Based Practice
- work for the benefit of your patients to communicate with other health care providers
- act as an advocate for your patient within the health care system
- become aware of the costs of diagnostic and therapeutic interventions. Consider these costs as you recommend and prescribe these interventions.
In addition, to these goals please see the topic and level specific medical knowledge and patient care goals below.
Fundamentals
PGY-2 level goals
Medical Knowledge
- To describe the basic principles of optics and refraction.
- To list the indications for and to prescribe the most common low vision aids.
- To identify the key examination techniques and management of basic and most common medical problems in the subspecialty areas of glaucoma (e.g., primary open angle glaucoma), cornea (e.g., dry eye, microbial keratitis), orbit and oculoplastics (e.g., common lid lesions, ptosis), retina (e.g., macular disorders, retinal detachment, diabetic retinopathy), and neuro-ophthalmology (e.g., optic neuropathy, ocular motor neuropathy, pupillary abnormalities, visual field defects).
- To describe indications for, performance of, and complications of common anterior segment surgery, (e.g., cataract extraction, trabeculectomy, peripheral iridectomy).
- To describe the common but serious genetic ocular disorders (e.g., retinal and macular dystrophies).
Patient Care
- To perform the basic anterior segment (e.g., basic refraction, basic retinoscopy, slit lamp biomicroscopy) and posterior segment examination skills (e.g., dilated fundus examination, use of magnification and lenses, Hruby lens, 90 Diopter lens, three mirror Goldmann contact lens) and to understand and use basic ophthalmic instruments (e.g., tonometer, lensometer).
- To triage and manage ocular emergencies (e.g, central retinal artery occlusion, giant cell arteritis, chemical burn, acute angle closure glaucoma, endophthalmitis, traumatically open globe).
- To perform minor external and adnexal surgical procedures (e.g., chalazion excision, corneal foreign body removal, use of foreign body corneal drill for removal of a rust ring, conjunctival biopsy, corneal scraping).
- To recognize the most common ophthalmic histopathology findings and to recognize basic histopathology of common ocular lesions (e.g., retinal detachment, pterygium, corneal button removed at keratoplasty).
PGY-4 level goals
Medical Knowledge
- To describe the advanced principles of optics and refraction (e.g., pre- and post-refractive surgery,higher order aberrations).
- To list the indications for and uses of advanced low vision aids.
- To identify the key examination techniques and management of complex but common medical and surgical problems in the subspecialty areas of glaucoma (e.g., complicated or post-operative primary and secondary open and closed angle glaucoma), cornea (e.g., unusual or rare types of microbial keratitis), ophthalmic plastic surgery (e.g., less common and more complex lid lesions, re-operation or complex or recurrent ptosis), retina (e.g., complex retinal detachment, tractional retinal detachments and severe proliferative diabetic retinopathy, proliferative vitreoretinopathy), and neuroophthalmology (e.g., unusual optic neuropathy, neuroimaging, supranuclear palsies, uncommon visual field defects).
Patient Care
- To perform the most advanced anterior segment (e.g., complex refractions, advanced retinoscopy,advanced slit lamp biomicroscopy) and posterior segment examination skills (e.g., drawings of retinal detachments; interpretation of macular disorders with slit lamp biomicroscopy).
- To manage or supervise the more junior trainees (e.g., medical students or medical residents) in the management ocular emergencies (e.g, central retinal artery occlusion, giant cell arteritis, chemical burn, angle closure glaucoma, endophthalmitis).
- To perform more advanced external and adnexal surgical procedures (e.g., lacrimal gland procedures,complex lid laceration repair, e.g., canalicular and lacrimal apparatus involvement).
- To perform and treat complications of common anterior segment surgery, (e.g., cataract extraction,trabeculectomy, peripheral iridectomy).
- To recognize and evaluate the major genetic ocular disorders (e.g., neurofibromatosis I and II, tuberous sclerosis, von Hippel Lindau syndrome, retinoblastoma, retinitis pigmentosa).
- To recognize uncommon or rare but classic ophthalmic histopathology findings.
Retinoscopy and Refraction
PGY-2 Level Goals
Medical Knowledge
- To identify the principles and indications for retinoscopy.
- To describe the major types of refractive errors.
- To describe basic ophthalmic optics and optical principles of refraction and retinoscopy.
- To describe the indications for and to use trial lenses or a phoropter for simple refractive error.
- To describe the basic principles of a keratometer.
Patient Care
- To perform the technique of retinoscopy.
- To identify media opacities with retinoscopy.
- To perform an integrated refraction based upon retinoscopic results.
- To perform elementary refraction techniques (e.g., for myopia, hyperopia, accommodative add)
- To perform objective and subjective refraction techniques for simple refractive error. To perform retinoscopy for detecting simple refractive errors.
PGY-4 level goals
Medical Knowledge
- To describe the most complex types of refractive errors, including post-operative refractive errors , post-keratoplasty, and refractive surgery.
- To describe the most advanced ophthalmic optics and optical principles of refraction and retinoscopy, including higher order aberrations.
Patient Care
- To perform the most advanced refraction techniques (e.g., irregular astigmatism, pre- and postrefractive surgery).
- To perform objective and subjective refraction techniques in the most complex refractive error, including astigmatism and post-operative refractive error.
- To utilize the most advanced ophthalmic optics and optical principles for refraction and retinoscopy, including higher order aberrations.
- To perform the most advanced techniques using trial lenses or the phoropter for more complex refractive errors, including modification and refinement of subjective manifest refractive error, cycloplegic retinoscopy and refraction, and post-cycloplegic refraction, irregular astigmatism, post-keratoplasty, and refractive surgery cases.
- To use the keratometer for detection of subtle or complex advanced refractive error.
- To use more advanced refraction instruments and techniques (e.g., distometer, automated refractor, corneal topography).
Cataract and Lens
PGY-2 Level
Medical Knowledge
- To describe the indications, evaluation and management, and intra- and post-operative complications of cataract surgery and other anterior segment procedures.
- To formulate the differential diagnoses of cataract and evaluate the normal and abnormal lens.
- To identify the most common causes and types of cataract (e.g., anterior polar, cortical nuclear sclerotic, posterior subcapsular).
- To list the basic history and examination steps for cataract evaluation pre-operatively.
- To describe the steps in cataract surgical procedures.
- To define the elementary refraction or contact lens fitting techniques prior to considering cataract extraction to obtain best corrected vision.
- To describe the major etiologies of dislocated or subluxated lens (e.g., trauma, Marfan’s syndrome, homocystinuria, Weill-Marchesani syndrome, syphilis).
- To be familiar with the techniques of intracapsular cataract extraction, extracapsular cataract extraction, and phacoemulsification.
- To describe the following:
- Basic ophthalmic optics as related to cataracts
- Types of IOLs
- Types of refractive error in cataract
- Retinoscopy techniques for cataracts
- Subjective refraction techniques for cataract patients
- To identify and describe the mechanisms of the following instruments in the evaluation of cataracts, including:
- Lensometer
- Autorefractor
- Retinoscope
- Phoropter
- Keratometer
- Slit lamp biomicroscope
- Glare and contrast testing devices
- Potential acuity meter
Patient Care
- To perform the complete pre-operative ophthalmologic examination of cataract patients.
- To perform optimum refraction of the post-cataract surgery patient.
- To develop and exercise clinical and ethical decision-making in cataract patients.
- To develop good patient communication techniques regarding cataract surgery.
- To perform routine and advanced cataract surgery and intraocular lens (IOL) placement.
- To manage basic and advanced clinical and surgical cataract problems.
- To effectively diagnose and manage intraoperative and post-operative complications of cataract surgery.
- To perform basic slit lamp biomicroscopy, retinoscopy, and ophthalmoscopy.
- To evaluate and classify common types of lens opacities.
- To perform subjective refraction techniques and retinoscopy in patients with cataracts.
- To perform direct and indirect ophthalmoscopy pre- and post-cataract surgery.
- To perform basic steps of cataract surgery (e.g., incision, wound closure) in the practice lab.
- To assist at cataract surgery and perform patient preparation, sterile draping, anesthesia.
- To perform the following steps of cataract surgery in the practice lab or under direct supervision, including any or all of the following:
- Wound construction
- Anterior capsulotomy/capsulorrhexis
- Instillation and removal of viscoelastics
- Extracapsular and phacoemulsification techniques (e.g., sculpting, divide & conquer, phacochop)
- Irrigation and aspiration
- IOL implantation (e.g., anterior and posterior)
PGY-4 Level goals
Medical Knowledge
- To define the more complex indications for cataract surgery (e.g. better view of posterior segment), describe the performance of and describe the complications of more advanced anterior segment surgery (e.g., pseudoexfoliation, small pupils, mature cataract, hard nucleus, black cataract, posttraumatic, zonular dehiscence), including more advanced procedures (e.g., secondary IOLs and indications for specialized IOLs, capsular tension rings, iris hooks, use of capsular staining).
- To describe the indications for, techniques of, and complications of cataract extraction in the context of the subspecialty disciplines of glaucoma (e.g., combined cataract and glaucoma procedures, glaucoma in cataractous eyes, cataract surgery in patients with prior glaucoma surgery), retina (e.g., cataract surgery in patients with scleral buckles or prior vitrectomy), cornea (e.g., cataract extraction in patients with corneal opacities), ophthalmic plastic surgery (e.g., ptosis following cataract surgery), and refractive surgery (e.g., cataract surgery in eyes that have undergone refractive surgery).
- To describe the instruments and techniques of cataract extraction including extracapsular surgery and phacoemulsification (e.g., trouble-shooting the phacoemulsification machine, altering the machine parameters).
- To understand indications for and technique of intracapsular surgery (e.g., rare cases may require this procedure or patients may have had the procedure performed previously).
- To describe indications for and instrumentation and techniques used to implant foldable and nonfoldable IOLs.
- To describe the evaluation and management of common and uncommon causes of post-operative
endophthalmitis. - To describe the indications for, mechanics of, and performance of A scan ultrasonography and calculation of IOL power.
Patient Care
- To independently evaluate complications of cataract and IOL implant surgery (e.g., posterior capsular tears, choroidal effusions).
- To perform repositioning, removal or exchange of IOLs.
- To perform phacoemulsification in a practice setting (e.g, animal or practice lab) and then in the operating room, including mastery of the following skills:
- Wound construction
- Anterior capsulotomy/capsulorrhexis
- Viscoelastics
- Intracapsular, extracapsular and phacoemulsification-techniques (e.g., sculpting, divide & conquer, phaco-chop, stop and chop)
- Instrumentation and techniques of irrigation and aspiration
- IOL implantation (e.g., anterior and posterior, special IOLs)
- IOL repositioning, removal or exchange
- To perform implantation of foldable and non-foldable IOLs.
- To perform intraoperative and postoperative management of any event that may occur during or as a result of cataract surgery, including:
- Vitreous loss
- Capsular rupture
- Anterior or posterior segment bleeding
- Positive posterior pressure
- Choroidal detachments
- Expulsive hemorrhage
- Elevated intraocular pressure
- Use of topical and systemic medications
- Astigmatism
- Post operative refraction (simple and complex)
- Corneal edema
- Wound dehiscence
- Hyphema
- Residual cortex
- Dropped nucleus
- Uveitis and cystoid macular edema (CME)
- Elevated intraocular pressure and glaucoma
Ophthalmic Practice
PGY-2 Level Goals
Systems Based Practice
- To describe the fundamentals and principles of medical ethics in ophthalmology (e.g., patient care decision-making, informed consent, competency issues, ethics of inter-collegial relations, risk management, privacy issues).
- To describe the basics of ophthalmic practice management (e.g., contractual negotiations, hiring and supervising employees, financial management, working with associates, billing/collecting).
- To describe the basics of the health care system and reimbursement, as appropriate to the local, regional, and national market of the trainee (e.g., third party payers, managed care, Medicare (USA), medical documentation, Medicaid (USA), private insurance, nationalized health care systems (UK, Canada, others).
PGY-4 Level Goals (in addition to PGY-2 Level goals)
Systems Based Practice
- To demonstrate proficiency in more advanced principles of medical ethics (e.g., informed consent in children, the mentally ill or disabled, or the demented patient; physician and industry relationships; acceptance and disclosure of gifts or consultation fees).
- To utilize in clinical practice the principles of practice management (e.g., starting a practice, economics of starting a practice, licensing and credentialling applications).
- To utilize in clinical practice more advanced aspects of health care reimbursement (e.g., denials of claims, hospital contracting, electronic billing).