Ординатура / Офтальмология / Английские материалы / The Professional Qualifying Examination A Survival Guide for Optometrists_Eperjesi, Hodgson, Rundström_2004

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22A patient walks into your practice demanding his/her case records. What do you do?

23What laws other than the Opticians Act must opticians comply with in everyday practice?

24What is a contract?

25What could you do if somebody refused to pay for their sight test or refused to collect their glasses? What would you do?

26How would your legal obligations differ when performing an NHS sight test as opposed to a private sight test?

27You examine an elderly patient and find their vision to be satisfactory and the patient is happy. The eyes are healthy but you note early lenticular opacities. Would you;

(a)Inform the patient?

(b)Inform the GP?

(c)See again in 12 months?

(d)All three?

28A patient walks into your practice with a receipt for payment for a pair of glasses bought two years ago. The patient is asking for reimbursement because the lenses are scratched. What would you do?

29Do patients have to pay VAT on spectacles now?

30If you refer a patient for cataracts and the ophthalmologist additionally diagnoses glaucoma, how do you stand legally?

31How would you stand if the ophthalmologist found that you had missed:

(a)Anterior uveitis?

(b)Retinal tear?

32What is the legal position of an optometrist who recommends nutritional supplements?

33Can an optometrist prescribe all types of POM?

34What is a signed order?

35Which professional takes the responsibility for a signed order supplied on a POM?

36What do you understand by the term shared-care?

37Do you have to be registered with the CO in order to practise?

38Do you have to be registered with the GOC in order to practise?

39Do you have to be a member of the AOP in order to practise?

40What is meant by the term indemnity insurance?

41What is a good source of information on employment law?

42If a company agrees over the phone to provide you with locum work for one day but cancel on the day you arrive in practice, has a contract been broken?

43If you fail to turn up for a locum day that has been agreed over the phone, has a contract been broken?

44Is VAT payable on an eye examination fee?

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45What is meant by post-payment verification?

46If a person falls on some stairs in your practice, despite there being a sign advising ‘take care’, are you obliged to pay compensation?

47Are there any employment laws that restrict the opening times of optometry practices?

48What is the difference between the titles optometrist and optician?

49Can a GP issue a prescription for glasses?

50Can an ophthalmologist issue a prescription for contact lenses?

51A patient that you advised to have LASIK undergoes the procedure but is not happy with the outcome. Are you obliged to pay them compensation?

52A refractive surgeon offers to provide you with a ‘finders fee’ for each patient you refer for refractive surgery. Is this legal?

53Can an unqualified person supply glasses to a person who is registered partially sighted?

54Can an unqualified person supply glasses to anyone?

55Under what circumstances can a dispensing optician supply contact lenses?

56Can a dispensing optician supply low vision devices?

57Under what circumstances could you re-examine a child after one month and claim an NHS fee?

58Can a spectacle voucher be supplied for plano tinted spectacle lenses?

59Are plano coloured contact lenses classed as a medical device?

60Is it legal for non-ophthalmic outlets to sell plano coloured contact lenses?

61Is it legal to prescribe R and L 0.25/ 0.25 75?

Questions on case records can be very diverse. Any mistakes or inconsistencies will be queried. If you see that you have made a mistake then admit it. Perhaps say that with the benefit of further experience you would modify your actions in future.

It is a good idea to know the areas that your case records cover, e.g. diabetes/ use of drugs, because the examiners will probably ask questions about these topics.

14.6 MORE INFO?

Taylor, S. Law in Optometric Practice. Oxford: Butterworth-Heinemann, 2002. College of Optometrists. Code of Ethics and Guidelines for Professional Conduct.

College of Optometrists, 1991.

The Opticians Act. HMSO, 1989.

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examination of patients. These tasks may include examination of patients, assessment of slides and consideration of the results of a variety of patient investigations. Five minutes will be allotted to each task.

(ii)Oral

This part of the exam lasts 20 minutes and will be with two examiners. Where the oral exam follows the practical it may commence with the candidate being asked to discuss the results of the tasks performed during the station examination. This will then extend to a more general discussion.’

Assessment

‘In every case the examiners will look to see that candidates have:

(i)Demonstrated accurate observation.

(ii)Not failed to recognize any significant sign or symptom.

(iii)Made logical deductions from their findings.

(iv)Related visual defects to ocular pathology with an ability to suggest a possible prognosis with particular reference to the incidence of ocular diseases.

(v)Searched for possible secondary to primary conditions (e.g. glaucoma following uveitis).

(vi)Related ocular findings to possible systemic disease.

(vii)Indicated (where appropriate) the need for and urgency of referral or reporting and a familiarity with the procedures thereof.’

15.2 THE EXAMINATION FORMAT

The examination is split into two parts, and either practical or oral may come first. During the practical exam there will be an invigilator (known as the ‘ring master’), much the same as the Dispensing practical (which is also a station exam). At each station there will be a brief outline of the history of the case (and it will be brief – one or two lines perhaps – be careful, for most relevant information may not be immediately obvious). You will be required to describe what you see, to give your diagnosis and the management you propose. Here you can’t be too cautious – all cases are likely to have some abnormality, and even if it is not pathological should still require a letter informing the patient’s GP.

The five-minute period must allow enough time to read through the brief history and either examine the image, or if the task involves the examination of a patient, slit lamp biomicroscopy or ophthalmoscopy – still leaving enough time to write your findings down. Work swiftly through the exam and do not be too concerned if you cannot arrive at a firm diagnosis. For this exam the most important thing is to recognize that something is abnormal and to know

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how it should be investigated and managed. Familiarize yourself with the record sheet to be used in the exam, which should have been sent to you by the CO. This has three boxes for you to write in:

1 Please describe what you have seen.

2Based on the case history given and your observations above, indicate your provisional diagnosis.

3 Indicate your immediate management of the patient.

The 20 -minute oral examination may begin with a discussion of one or more cases encountered in the practical if this part is taken subsequently, although in my experience this rarely happens. However, this is a broad subject and therefore examiners will try to work through as many aspects as possible. Common sight-threatening and treatable eye diseases tend to require greater depth of knowledge than unusual conditions or rare syndromes. Questions may vary from asking about differential diagnosis of certain abnormalities to surgical techniques and possible complications.

15.3 WHAT DO THE EXAMINERS SAY?

The following comments are assimilated from the responses of several examiners.

(a)What advice would you give to a candidate preparing for the exam?

It is important for the candidate to understand the significance of what they see in the eye. They must revise basic anatomy and physiology and relate it to disease aetiology. It is also necessary to classify referrals – routine, urgent and emergency. Study sightor life-threatening conditions thoroughly as these are pass or fail areas. Think about how a disease may present in the practice. Discuss cases with your supervisor and fellow students and if possible with an ophthalmologist.

(b)What areas of the subject require:

(i)Sound knowledge?

Aetiology, signs, symptoms and referral criteria for common treatable sight-threatening (or life-threatening) diseases, e.g. glaucoma, diabetic eye disease, cataract, and also methods of examination – when to dilate, assess fields and so on, and knowledge of management of certain conditions that the optometrist might be asked to monitor after informing the GP, e.g. ocular hypertension.

(ii)Reasonable knowledge?

Pharmacological and surgical treatment of all eye diseases, but especially the more common occurrences. Surgical techniques and complications, especially cataract operations. Systemic medication and ocular side effects. Pupil defects and neurology.

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(iii)Some knowledge?

Diseases not often encountered, especially those that eventually become so obvious that they will be diagnosed but where early or late diagnosis does not affect prognosis. Many hereditary disorders fit this description. Supplementary methods of examination used by the ophthalmologist, especially fundus photography and fluorescein angiography.

(c)What do you look for in the successful candidate?

Practical management of every-day situations and confidence with management; if a candidate doesn’t know, then they show they are prepared to refer to text books or seek advice from the GP or ophthalmologist.

(d)What brings people’s marks down?

Confident statements that are wrong, and throwaway statements that cannot be backed up, such as ‘I would dilate all patients even if it wasn’t clinically justified just for my own practice’. Dangerous management. Prevarication by candidates who are aware that they are lacking and

try to highjack (sic) the exams by dramatics and other delaying tactics.

One examiner states that ‘bigheaded overconfidence and sarcastic remarks to the examiner which rubs (sic) him up the wrong way’ as a reason for bringing marks down. I find it difficult to believe that anybody in the situation that a PQE candidate is in when taking the

exams would be sarcastic to the examiner. However, this demonstrates the importance of thinking carefully about your answers and communicating them in a logical and professional manner so that they cannot be misconstrued.

(e)What are the commonest causes of failure?

Lack of basic knowledge or a disorganized, unprofessional attitude. In our opinion, a very important point was raised by one examiner, namely, the inability to perceive a serious condition in a common symptom and thus not take management seriously. Not referring a possible medical emergency appropriately is an instant failure. However, it is unlikely that you would be failed for not knowing about rare diseases.

(f)What subject areas do candidates place too little importance on? Related anatomy and physiology, and how the aetiology of a disease affects prognosis and referral criteria. How pathology would present in practice.

(g)Any other comments?

Students should not expect to be examined in every detail on obscure ocular diseases. Rather they should leave the examiner with the overall impression that basic fundamentals of aetiology, recognition of signs and symptoms, and principles of management are well understood. The candidate should ensure that more common lifeor sight-threatening

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conditions, where early treatment is necessary for full recovery, are thoroughly understood. Note that because this is such a broad subject, rote learning doesn’t work. The candidate should also understand that in practice presenting signs and symptoms might be very different from textbook cases.

15.4 HELP AND ADVICE

This is perhaps the only exam where students undertaking their pre-registration year in the HES are at a distinct advantage over those in private practice. However, those students in private practice should have at least one half-day session a week spent with an ophthalmologist in a clinic. Sometimes arrangements may be made for a block release of two weeks in a hospital, but I feel that continuous contact with an ophthalmologist throughout the whole year is more helpful – especially as it allows you to ask questions about cases you see each week in practice. However your time in the HES is arranged, it is important to spend this time wisely. Try to avoid being pushed into performing refractions while you are there. The purpose of the hospital experience is to gain as much knowledge as possible from the ophthalmologist, to gain an insight as to how her clinics are run, and what referral criteria are used in your area and what information is expected in referral letters and such like. If you are holding a hospital pre-registration position then it is likely that much of your time is spent refracting only, so make sure you are also allocated some premium time with an ophthalmologist.

During my pre-registration training I did not carry out a single refraction at the hospital. All of my time was spent with the ophthalmologist discussing each of his cases and usually he would ask questions. I found this approach extremely helpful in preparing for examiners questions.

The Practical

Equipment to take to the exam

Don’t forget your ophthalmoscope and new batteries!

History

This brief outline may give a useful insight to the nature of the problem. However, be careful for it may equally be misleading – so don’t jump to conclusions.

Examination of the image is fairly straightforward and will often be a textbook example of a particular abnormality; the image may even be straight out of one of Kanski’s books. Watch for differential diagnoses and therefore different prognoses.

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working out from basic knowledge the answers to more obscure problems. Differential diagnosis and presentation in practice commonly cause the candidate problems. Don’t mention obscure conditions unless you know them well, and if you do not know the answer to a question it is often worth admitting this. The examiner will usually change the topic or may guide you through working out the answer from facts that you do know. Of course if you are not sure what the examiner is asking then the same question may be rephrased more coherently. Often the question will be of the form where a patient attends with a particular symptom. While it is important not to dismiss common symptoms that may sometimes indicate very serious conditions, it is also important not to automatically assume the worst case scenario. A thirteen- year-old girl with bilateral visions of 6/18 but normal fundus signs is likely to be 1 dioptre myopic and unlikely to have a pituitary tumour. Remember the adage, ‘if you hear hooves then it is probably horses because zebras are rare’. The examiner will lead from one topic to the next. Thinking out loud in a logical fashion usually gains encouragement from the examiner, and even if the candidate arrives at the wrong conclusion she will be encouraged to try again.

Be aware when preparing for this subject that there is some overlap with the Binocular Vision and Drugs exams.

Where to get experience

HES, specialist clinics – diabetic, orthoptic, laser and such like. In practice, write your own referral letters and learn to make your own decisions. You can do this by making a provisional decision and then checking with your supervisor. Confer on cases with fellow students at local optical society meetings and attend at least one refresher course geared to pre-registration students that dedicates a session to this exam.

One final point. Keep reading OT and Optician, for there will be a number of articles about ocular pathology throughout your year. Also it is important to keep up to date with the politics of the profession, for this may sometimes influence the topics examined, e.g. with the introduction of shared-care schemes for diabetic patients in many areas it has become even more important to assess the extent of retinopathy, and to know when the condition may be safely managed in the practice and when the condition must be referred.

15.5 PAST EXAM QUESTIONS

Most PQE questions are intended to provoke a conversation with the candidate. One-word answers are not expected; most examiners prefer a discussion and will prompt or guide the candidate where appropriate into greater depth or detail, or towards another subject.

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1 Discuss different types of cataract, their causes and appearances. 2 What is the difference between wet and dry AMD?

3What would you expect if you could see no red reflex on ophthalmoscopy? Name as many causes as possible.

4A thirteen-year-old girl presents with bilateral reduced vision (6/18) but no fundus signs. What could be the problem?

5A patient attends with a unilateral painful red eye present for the last five days. What could it be? How would you examine this patient?

6How would you look for cells in the anterior chamber? What type of illumination would you use?

7 A patient has no vision in one eye and you notice that the other eye is developing disciform macular degeneration. Is disciform macular degeneration a disease that develops quickly? How would you manage this patient?

8 What is glaucoma?

9 Can iritis result in glaucoma? If so, is it of quick onset?

10What sort of people are prone to glaucoma? Is this the same for chronic and acute?

11A patient presents with floaters. What is your action and advice?

12What conditions might warrant a direct referral?

13How would you differentially diagnose acute ischaemic optic neuropathy and papilloedema?

14What is a dystrophy? What corneal dystrophies do you know of?

15What kinds of corneal ulceration are there? Are there any types associated with soft contact lens wear?

16If a patient attends with a dendritic ulcer, why would you phone the GP, having already referred by letter?

17How does diabetes affect blood vessels?

18How would you examine a diabetic patient?

19What fundus signs would indicate to you that the retinopathy is preproliferative, or proliferative?

20What histologically are cotton wool spots?

21What are the ocular features of thyroid eye disease?

22A patient presents with unilateral sudden painless loss of vision. What are the possible causes? Describe the vascular supply to the eye.

23How would you treat a red eye?

24How would you look for a retinal detachment? What would you do on finding one?

25What may cause inflammatory cells to be present in the vitreous?

26How can the fundus be obscured?

27Describe the phacoemulsification procedure. What other surgical techniques are used for cataract extractions and what are the possible complications? How may induced astigmatism be reduced?

28What ocular conditions may contra-indicate cataract extraction surgery?