Ophthalmology

Basic Specialist Training – National Programme

TRAINING REGULATIONS

 Basic Specialist Training will be for three years with annual hospital contracts.

 Trainees must have full registration with the Irish Medical Council

 On appointment to the programme trainees will be registered with the Irish College of Ophthalmologists by the Hospital Manpower Manager and will receive a training agreement from the Irish College of Ophthalmologists

 An individual training number will be issued to each trainee on receipt of the appropriate fee for the structured education programme (School for Surgeons for Ophthalmology). This training number is essential for recognition of Basic Specialist Training.

 Trainees will be registered with the Irish College of Ophthalmologists. Trainees who wish to transfer to another rotation must apply to the Dean of Postgraduate Education of the ICO and the Unit Programme Director detailing the reasons for this request.

 SHO posts will be advertised as part of the National BST Programme with ICO approval. Contracts of employment will be issued by the relevant hospitals.

 The BST Regional Training Programmes include 3 rotations;
(No. 1) Royal Victoria Eye & Ear Hospital & Sligo General Hospital
(No. 2) Mater Hospital, University College Hospital Galway
& Waterford Regional Hospital
(No.3) Cork University Hospital & Mid-Western Regional Hospital, Limerick

 Entry to the programme will be by competitive interview

 All SHO posts in the seven teaching units are recognised for basic specialist training (ref; ICO/EBO inspection 2007)

 Specific allocations will be determined for each trainee. Each training position has a unique post number. It is recommended that trainees spend two years in one training unit and the third year in another department.

 Maintenance of a detailed logbook by trainees is essential

 Appraisal of the six monthly rotations will be in-house using the CAPA forms issued by the College. National appraisals will be held annually in the offices of the Irish College of Ophthalmologists with the CAPA and annual assessment forms.

 Registration for the School for Surgeons for Ophthalmology takes place in the College on the second Monday of January and the second Monday of July. The annual fee for the education programme is €2,500 payable in two instalments (January & July).

Teaching Programme


 A minimum of two hours teaching per week (during the academic year) in each hospital will include case presentations, journal club, didactic lectures and audit. Attendance at the teaching programme is monitored and documented attendance at a minimum of 60% of postgraduate teaching is essential.

 The Ophthalmic Postgraduate Teaching Programme includes case presentations and a didactic lecture given by national and international invited speakers. This is currently held in the HSE/EA on Thursday afternoons at 4.30pm

 The structured education programme, delivered by the Irish College of Ophthalmologists, enhances the knowledge and skills acquired through clinical training posts. Full participation in this programme is mandatory for all Basic Surgical Trainees.

The structured education and assessment programme has four components;

1. Core Knowledge
The core knowledge component is delivered via the e-based SCHOOL for Surgeons

2. Technical Skills
This component uses the very latest in high technology teaching aids for operative surgery

3. Human Factors in the Surgical Arena
This component focuses on areas of team work and leadership, interpersonal skills and conflict resolution, crisis management, causes and avoidance of errors, stress management and time management

4. Assessment
The CAPA Process (Competence, Assessment and Performance Appraisal) is an evaluation tool which is designed to assess the progress of trainees.

EDUCATIONAL OBJECTIVES FOR OPHTHALMIC
SENIOR HOUSE OFFICERS

To obtain a comprehensive training in the knowledge of ophthalmology, including the basic sciences and management of common diseases affecting the eyes.

To attend the participate in the Teaching Programme.
To develop communications skills and a sympathetic and caring approach to patients and their relatives.

To develop skills in clinical assessment and become competent in:
• History taking
• Examination of the eyes and surrounding structures
• The use of diagnostic instruments including the direct and indirect ophthalmoscope, retinoscope, slit-lamp, tonometer and diagnostic fundus and contact lenses.
• To learn the concepts and principles of refraction.

To received training in orthoptics and the examination of children with eye disorders.

To be familiar with a number of practical procedures including syringing tear ducts, removal of corneal foreign bodies and minor lid procedures.

To gain experience in ophthalmic surgery and be introduced to microsurgical techniques.

To become familiar with the use of laser in ophthlamology.

To be able to carry out investigative techniques including visual field assessment, ocular biometry and keratometry.

To receive guidance in the counseling of patients who are partially sighted or blind and be aware of the support services available.
To work towards and be encouraged to sit the Royal College of Ophthalmology examination leading up to the Final Fellowship.

To develop future career plans.

To participate in medical audit meetings.

To understand the principles and practice of medical research.

To acquire a knowledge of the process of management

STRUCTURED EDUCATION PROGRAMME

The Irish College of Ophthalmologists delivers the structured education component of the Basic Surgical Training Programme. The structured education component goes hand in hand with your work place training. The programme is compulsory and full participation in this programme is mandatory for all Basic Surgical Trainees.

There are four elements to the programme:
1. SCHOOL for Surgeons for Ophthalmology
2. Surgical Simulator Tutorials
3. Human Factors in the Surgical Arena Course
4. Assessment

SCHOOL for Surgeons for Ophthalmology
SCHOOL for Surgeons for Ophthalmology – SFSFO is the online element of the training programme. Each trainee is issued with a unique logon name and password to access the website. Miss Yvonne Delaney, Vice-Dean is the tutor for the SFSO. The site is found at www.schoolforsurgeons.ie

Moodles is the software package through which SCHOOL for Surgeons for Ophthalmology - SFSFO is presented.

Trainees should access SCHOOL for Surgeons on a regular recurrent basis. The course content of SCHOOL is as follows: - Cases will be presented which are relevant to Basic Specialist Trainees and which are based on the type of cases encountered in the clinic and the MRCSI (Ophth) Examination.

Journal Watch exposes trainees to relevant articles and papers in peer reviewed Journals. Assignments are given on a regular basis and trainees are expected to submit their assignments online by the due date. Each assignment is graded and trainees are expected to score a minimum of 60%.

The ophthalmology journals available in full text through the Journal Portal currently include:
- Journal of Cataract and Refractive Surgery
- Current Opinion in Ophthalmology
- Journal of Glaucoma
- Retina
- Investigative Ophthalmology and Visual Science

The site also includes RSS feeds from some of the major ophthalmology journals.

Surgical Simulator Tutorials
The College has an EYESI surgical simulator for use during the tutorials to learn the basic surgical skills of phacoemulsification. The simulator provides the opportunity to practice the steps of phacoemulsification, making easier and safer the transition to live surgery.

The Tutor for the simulator is Miss Patricia McGettrick, Consultant Ophthalmic Surgeon. Each trainee will have three supervised tutorials sessions on the simulator, each session will last for two hours.

Human Factors Course
Human Factors is a programme of personal skills for clinical and surgical training which has been developed by The Royal College of Surgeons in Ireland. It aims to give trainees the personal skills and attitudes necessary for successful practice as part of a multidisciplinary team.

The Royal College of Surgeons in Ireland has developed a programme in human factors training to equip trainees with the personal skills and attitudes required for modern clinical and surgical practice. The programme is based on a clearly defined syllabus. This syllabus includes ten modules, each of which contains four tutorials. The syllabus is arranged so that the modules can be taken in any order and a system of credits will be used to signify satisfactory completion of individual modules. Each module is designed to be delivered over a one day period and it is intended that each trainee will take three modules per annum.

The programme is delivered by acknowledged experts in the individual subject areas of each module. Each module will have precise learning objectives. The training is delivered by a combination of didactic teaching and practical work which will involve role playing and small group discussions. Audio visual support is provided. Trainees are encouraged to find solutions to human factor problems for themselves and they are given assignments on which to work between modules. There is emphasis on practical application in the work place and the assignments reflect the importance of work place application.

Assessment
Trainees on the basic specialist trainee programme will be assessed on an annual basis by a panel of representatives from the College, its Manpower Committee and the training units. The assessments provide the trainee with an opportunity to discuss their rotation and to raise any issues from the current posting. Attendance at the annual assessment is compulsory.

Trainees must also complete a CAPA form (Competence Assessment and Performance Appraisal) for each six months rotation. There are two parts to the CAPA form. Part 1 should be completed by the trainee and Part 2 should be completed by the Consultant trainer.


It is of great importance that trainees actively engage with all the elements of the training programme to get the maximum benefit from the structured education available. In order that each post and rotation is recognised by the College for the purposes of basic specialist training and the subsequent recognition of training posts for inclusion on the Register of Medical Specialists, trainees must ensure that all the aspects of the course are completed during each year.

The course fee is €2,500 per annum and covers all of the parts including online access, human factors course and sessions on the surgical simulator. The fee is payable in two parts


 Participation in the structured education programme, attendance at the six monthly and annual assessments and return of completed CAPA and assessment forms is mandatory for the certificate of completion of basic specialist training (CCBST)

 Success in the MRCSI (ophth) examination or equivalent is a requirement for CCBST

 Applicants to the Higher Surgical Training Programme must have a CCBST and a validated surgical logbook to include;
50 cataract procedures,
50 lasers
50 minor procedures,

Note; Each hospital should have a dedicated teaching area with library facilities, internet access, photocopying facilities, audio visual aids and digital projection.
 

BASIC SPECIALIST TRAINING IN OPHTHALMOLOGY
SURGICAL PROCEDURES

Number of procedures needed

1. Laser Capsulotomy
Pan-retinal photocoagulation
Peripheral iridection (YAG 50
2. Miscellaneous
(a) Minor Surgery Ectropion/Entropion 5
Incision and curettage of Meibomian
cyst and papilloma 20
Electrolysis and trichiasis 5
(b) Lacrimal Irrigation of lacrimal passage
Lacrimal probing
Punctal surgery 12
(c) Trauma Lid and facial lacerations 3

3. Strabismus Horizontal muscle procedure 5
4. Cataract Extracapsular cataract surgery
Phacoemulsificaiton and other intraocular procedures 50


A Certificate of Eligibility of Entry to Higher Surgical Training (CEEHST) will be awarded to trainees who have competed basic specialist training, to include the above minimum numbers of surgical procedures, been successful in the MRCSI exam and have validated CAPA appraisals for a minimum of 2 years. This level of training is necessary for those trainees who wish to apply for the Higher Surgical Training Programme.
 

Ophthalmic Surgery

Trainees who wish to enter Higher Surgical Training will be eligible to apply after a minimum of 2 years of Basic Specialist Training (Royal College of Ophthalmologists).

Entry Requirements for Higher Surgical Training (HST)

1. MRCSI (ophth) or equivalent
2. Microsurgical skills course
3. Documented evidence of surgical procedures
   (a) 50 intraocular procedures
   (b) 50 miscellaneous
   (c) 50 Laser procedures
   See enclosed list

Basic Specialist Training Programmes in Ireland

• Rotation 1;Royal Victoria Eye and Ear Hospital Dublin and Sligo General Hospital.
• Rotation 2; Mater Hospital Dublin and University Hospital Galway and Waterford Regional Hospital
• Rotation 3; Cork University Hospital and Limerick Regional Hospital

Basic Specialist Training in Ophthalmology
Surgical Procedures

N.B Intraocular procedures and strabismus surgery for Higher Surgical Training only (3 and 4).

Postgraduate Training in Ophthalmology in Ireland

It is the policy that Fellowships should be taken the last 6 months and not during modular training.
Trainees who wish to stay a further 6 months may complete 5 years as a Specialist Registrar.

N.B. Academic appointments can be recognised for Higher Training as long as educationally approved.

Educational Objectives for Ophthalmic Senior House Officers

To obtain a comprehensive training in the knowledge of ophthalmology, including the basic sciences and management of common diseases affecting the eyes.

To attend the participate in the Teaching Programme.

To develop communications skills and a sympathetic and caring approach to patients and their relatives.

To develop skills in clinical assessment and become competent in:

• History taking
• Examination of the eyes and surrounding structures
• The use of diagnostic instruments including the direct and indirect ophthalmoscope, retinoscope, slit-lamp, tonometer and diagnostic fundus and contact lenses.

To learn the concepts and principles of refraction.

To received training in orthoptics and the examination of children with eye disorders.

To be familiar with a number of practical procedures including syringing tear ducts, removal of corneal foreign bodies and minor lid procedures.

To gain experience in ophthalmic surgery and be introduced to microsurgical techniques.

To become familiar with the use of laser in ophthlamology.

To be able to carry out investigative techniques including visual field assessment, ocular biometry and keratometry.

To receive guidance in the counseling of patients who are partially sighted or blind and be aware of the support services available.

To work towards and be encouraged to sit the Royal College of Ophthalmology examination leading up to the Final Fellowship.

To develop future career plans.

To participate in medical audit meetings.

To understand the principles and practice of medical research.

To acquire a knowledge of the process of management

The Membership of the Royal College Surgeons in Ireland Ophthalmology Examination

The MRCSI Ophth. Examination comprises of:
• Part I - Basic Science
• Part 2 - Clinic Methods
• Part 3 - Clinical

Part 1 - Basic Science
The Part 1 examination in Ophthalmology will assess a wide range of knowledge in basic science.

The examination content will include anatomy and embryology of the head and neck, including the central nervous system and, in particular, the visual system. Knowledge of the general principles of physiology will be required, with an emphasis on their relation to the visual system.

In addition to this, a basic understanding of the physics of light (including optics) will be required as well as knowledge of genetics, molecular biology, pharmacology, immunology and pathology. Questions on basic statistical methods may also be included.

Part 2 - Clinical Methods
An understanding of the theoretical aspects of refraction and the practical ability to perform this are essential for all ophthalmologists, and optics and refraction will form half of the Part 2 examination

In the practice of clinical medicine, it is imperative that the patient be correctly assessed from both the point of view of taking a history and performing an examination. In addition, it is important that investigations can be accurately assessed. For this reason, the second half of the Part 2 examination will consist of clinical methods. There will be a written part to this examination and the practical part of the examination will be conducted as an objectively structured clinical examination (OSCE).

Part 3 - Clinical
This part of the examination will be mainly clinical but will include an oral examination in ocular pathology.


Limits on attempts
Candidates must successfully complete the examination within two years of first attempting
Part 3
 

Curriculum of Basic Specialist Training in Ophthalmology

1. Accident and Emergency Ophthalmology
2. Disorders of the lids, lacrimal drainage apparatus, adnexae and orbit
3. External eye disease, sclera, cornea and anterior uvea
4. Disorders of refraction, the crystalline lens and zonules
5. Disorders of aqueous production and drainage
6. Vitreoretinal disorders
7. Medical retinal and choroidal disorders
8. Disorders of the optic disc and visual pathway
9. Ocular motility, strabismus, amblyopia and diplopia
10. Disorders of the eye and visual system affecting children

1. Accident and Emergency Ophthalmology

Essential topics/experience
To have become familiar with the following:

• Superficial ocular trauma: including assessment and treatment of foreign bodies, abrasions and minor lid lacerations
• Severe blunt ocular injury: management of hyphaema - recognition and initial management of more severe injury.
• Severe orbital injury: recognition and initial care of corneal and scleral wounds; recognition of acqueous leakage and tissue prolapse.
• Retained intraocular foreign body; anticipation from history, confirmation of X-ray and CT scan.
• Sudden painless loss of vision; recognition of retinal arterial occlusion, central retinal vein occlusion, acute ischaemic optic neuropathy, optic neuritis, urgency of treatment.
• Severe intraocular infection; recognition and initial investigation and management of hypopyon.
• Acute angle closure glaucoma; recognition and acute reduction of intraocular pressure.
• Liaison with Radiological department, Microbiologist, ENT and Faciomaxillary surgeons.

Practical Skills
To have undertaken (under supervision until proficient) the following:

• Removal of superficial foreign bodies
• Corneal epithelial debridement
• Repair of minor conjunctival/lid lacerations
• YAG iridotomy

Background theory/principles
To have gained an awareness of the following:

• Eye protection and prevention of injury
• Lateral canthotomy and inferior cantholysis for retrobulbar haemorrhage
• Chemical/alkali burns of the conjunctiva and cornea
• · Drug penetration into the eye and vitreous
• Use of intravitreal antibiotics, including dosage and potential complications

2. Disorders of the lids, lacrimal drainage apparatus, adnexae and orbit

Essential topics/experience
To have become familiar with the following:

• Abnormal lid position; including assessment of ectropion, entropion, ptosis, trichiasis, lagophthalmos and exposure.
• Abnormal lid swelling, including chalazion, stye, retention cysts, papilloma and basal cell carcinoma.
• The watering eye, including the distinction between excessive lacrimation and epiphora, blepharitis, recognition and investigation of nasolacrimal obstruction.
• Orbital swelling, including dysthyroid eye disease, distinguishing intraconal from extraconal space-occupying lesions, orbital cellulitis, recognition of compressive optic neuropathy.
• Liaison with Neurosurgeons, ENT, Endocrinologists and prosthetic service.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Use of exophthalmometer
• Syringing and probing
• Incision and curettage for chalazion
• Wedge biopsy and removal of papilloma, etc.
• Tarsorrhaphy
• Electrolysis/cryotherapy for trichiasis
• Surgery to involutional ectropion/entropion

Background theory/principles
To have gained an awareness of the following:

• Sebaceous carcinoma of lid and squamous cell carcinoma
• Cicatricial malposition of the lids
• Management of ptosis and blepharospasm
• Canaliculus repair
• Dacryocystorhinostomy
• Orbital and lacrimal tumours and their treatment
• Inflammatory orbital and lacrimal diseases and their treatment
• Paranasal sinus disease
• Use of radiographs, MRI, CT scan
• Enucleation, evisceration and fitting of prosthesis
• Excenteration

3. External eye disease, sclera, cornea and anterior area

Essential topics/experience
To have become familiar with the following

• Infectious external disease, including viral, bacterial and chlamydial conjunctivitis.
• The dry eye, including symptoms, assessment of reduced tear production and tear film stability and treatment.
• Allergic and atopic eye disease recognition and management.
• Corneal ulceration from viral and bacterial disease, marginal keratitis.
• Complications of contact lens wear.
• Corneal oedema, opacity and ectasia, indications for corneal transplantation, standards of care in donor eye procurement, signs of corneal graft rejection and other complications.
• Epislceritis, recognition and management.
• Anterior uveitis, including classification, differential diagnosis, systemic associations, investigations and treatment.
• Liaison with microbiology, immunology.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Conjunctival sampling and corneal scraping for microbiological investigations.
• Pachometry for corneal thickness.
• Keratometry and Placido’s disc.
• Removal of corneal sutures.
• Retrieval of donor eyes for transplantation (5)

Background theory/principles
To have gained an awareness of the following:

• Acanthamoeba keratitis and fungal keratitis
• Cicatricial conjunctival disease.
• Punctal occlusion
• Corneal topography and specular microscopy
• Corneal stromal dystrophies, interstitial keratitis.
• Corneal biopsy, indications.
• Chemical injury of the cornea and conjunctiva.
• Therapeutic contact lenses and their complications.
• Corneal transplantation, immunology of rejection.
• Limbal stem cell transplantation.
• Autoimmune corneal and scleral disease including peripheral ulcerative keratitis.
• Use of immunosuppressive therapies.
• Management of pterygium.
• Conjunctival and uveal tumours.
• Aniridia and other dysgenesis.
• Fuch’s heterochromic cyclitis.

4. Disorders of refraction, the crystalline lens and zonules

Essential topics/experience
To have become familiar with the following:

• Ametropia, including hypermetropia, myopia, astigmatism and their complications.
• Accommodation problems, including spasm and presbyopia.
• Lens opacifications, including types of cataract, relationship of opacity to symptoms, contribution to visual loss in co-morbidities, systemic associations, cataract surgery and its complications.
• Pseudoexfoliation of the lens capsule, including its recognition and significance.
• Calculation of intraocular lens power, according to the patient’s needs.
• Liaison with contact lens service.

Practical Skills
To have undertaken (under supervision until proficient) the following:

• Retinoscopy with trial lenses and subjective refraction.
• Correction of refractive error by spherical, cylindrical and multi-focal lenses.
• Lens neutralisation and use of focimeter.
• Biometry and keratometry for intraocular lens calculation.
• Surgery for routine cataract, including extracapsular extraction and phacoemulsification with intraocular lens insertion, management of intra-operative complications (50 cataracts or other intraocular procedures).
• YAG laser posterior capsulotomy (20).

Background theory/principles
To have gained an awareness of the following:

• Basis of spectacle intolerance from poor dispensing or defective prescription.
• Use of logMAR charts in assessment of acuity.
• Alternatives to capsular IOL fixation.
• Combined cataract and glaucoma/corneal transplantion surgery.
• Ectropia lentis and Marfan’s syndrome.
• Contact lenses and refractive surgery.
• Therapeutic contact lenses.
• Fluidics and ultrasonics.
• Intraocular lens design and biomaterials.

5. Disorders of aqueous production and drainage

Essential topics/experience
To have become familiar with the following:

• Glaucomatous optic neuropathy, recognition and investigation.
• Glaucoma suspects, including ocular hypertension.
• Rubeotic glaucoma recognition, differential diagnosis and management.
• Hypotensive agents, topical and systemic drugs affecting intraocular pressure and their complications.
• Glaucoma drainage surgery, indications, complications and their treatment.
• Hypotony, including its causes and consequences.
• Liaison with glaucoma shared care schemes.

Practical Skills
To have undertaken (under supervision until proficient) the following:

• Applanation tonometry
• Assessment of peripheral and central anterior chamber depth, including pachometry.
• Assessment of irido-corneal angle structures by gonioscopy.
• Methods of optic disc cup measurement.
• Visual field testing, including Goldmann/kinetic perimetry and automated static perimetry.

Background theory/principles
To have gained an awareness of the following:

• Risk factors for primary open-angle and normal-tension glaucoma
• Other secondary glaucomas, including phacolytic, pigmentary, erythroclastic, pseudo-exfoliative and silicone-oil glaucomas.
• Posner Schlossman syndrome.
• Chronic closed angle glaucoma.
• Malignant glaucoma
• Tonopen, Perkins and non-contact tonometry.
• Scanning laser ophthalmoscopy and nerve fibre layer analysis
• Argon laser trabeculoplasty
• Prevention of glaucoma bleb failure e.g. using anti-metabolites
• Drainage tubes and stents.
• Cycloablation.

6. Vitreoretinal disorders

Essential topics/experience
To have become familiar with the following:

• Flashes and floaters, complications of posterior vitreous detachment and recognition of retinal tears.
• Vitreous haemorrhage, from retinal tears or neovascularization – initial management.
• Retinal detachment, classification, predisposition, recognition and urgency of treatment, recognition of proliferative vitreoretinopathy.
• Senile/acquired retinoschisis, - recognition.
• Liaison, with Low Vision services.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Scleral indentation with indirect ophthalmoscopy.
• Retinal drawing
• Cryopexy and laser (via slit-lamp and indirect ophthalmoscope delivery systems) for retinal tear.

Background theory/principles
To have gained an awareness of the following:

• B-Scan ultrasound for opaque media.
• Vitreoretinal surgery, including closed intraocular microsurgery, scleral buckling and internal tamponade.
• Intraocular foreign body, complications and management.
• Other vasoproliferative vitreoretinopathies including sickle cell retinopathy, retinopathy of prematurity, Eales’ disease.
• Genetic vitreoretinal disease – Stickler syndrome, X-linked retinoschisis.
• Asteroid hyalosis
• Choroido-retinal coloboma

7. Medical Retinal and Choroidal disorders

Essential topics/experience
To have become familiar with the following:

• Diabetic retinopathy, classification, screening strategies, management.
• Hypertensive and arteriosclerotic retinopathy, including macroaneurysms and branch retinal vein occlusion.
• Retinal vascular occlusions, recognition of ischaemic and exudative responses, rubeosis.
• Macular diseases, including recognition of age-related maculopathy, subretinal neovascularization, cystoid macular oedema, macular hole, related symptomatology and urgency of treatment.
• Fluorescein angiography, indications, complications and interpretation.
• Liaison with diabetologists, vascular surgeons and low vision services.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Assessment of macular function (Amsler Chart, Watske Allen slit beam test)
• Scatter laser photocoagulation of the peripheral retina (20)

Background theory/principles
To have gained awareness of the following:

• Fundus imaging including scanning laser ophthalmoscopy.
• Indocyanine green angiography.
• Electrodiagnostic tests and dark adaptation.
• Genetic retinal disease, retinal dystrophies, retinoblastoma.
• Differential diagnosis and treatment of malignant melanoma.
• Macular laser photocoagulation, principles and laser safety.
• Toxic maculopathy and central serous retinopathy.
• Intraocular lymphoma.
• Intermediate and posterior uveitis, toxoplasmosis, toxocara and sympathetic ophthalmia, retinal vasculitis.
• Coats’ disease, other telangiectasis and the retinal phakomatoses.
• AIDS-related opportunistic infections and anti-AIDS treatment.
• Low vision aids, including optic principles and fitting.

8. Disorders of the optic disc and visual pathways

Essential topics/experience
To have become familiar with the following:

• Swollen optic disc, differential diagnosis, recognition and evaluation of papilloedema, ischaemic optic neuropathy (arteritic and non-arteritic), acute optic neuritis and congenital optic disc anomalies.
• The atrophic optic disc, recognition and differential diagnosis, clinical evaluation of optic nerve function.
• Visual pathway disorders, identification of site and nature of lesion from history, examination and investigations, transient ischaemic attacks.
• Liaison with neurologists, neurosurgeons, endocrinologists and vascular surgeons.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Goldmann visual fields
• Examination of the cranial nerves
• Temporal artery biopsy

Background theory/principles
To have gained an awareness of the following:

• Benign intracranial hypertension
• Compressive optic neuropathy
• Optic nerve glioma
• Chiasmal lesions
• Visual evoked responses
• Neuro-imaging including CT, MRI and carotid doppler
• Carotid endarterectomy
• Multiple sclerosis and its ophthalmic manifestations
• Higher cortical dysfunction, including the visual agnosias.

9. Ocular Motility, Strabismus, Amblyopia and Diplopia

Essential topics/experience
To have become familiar with the following:

• Concomitant strabismus, screening strategies, epicanthus, accommodative aspects, interpretations of orthoptic report, indications for surgery.
• Amblyopia, anisometropic, stimulus-deprivation, strabismic prevention and treatment using occlusions.
• Incomitant strabismus, cranial nerve palsies including diabetic mononeuropathies, significance of painful third nerve palsy and of pupil sparing, prediction of post-operative diplopia.
• Liaison with neurologists, orthoptists.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Eye movement evaluations
• Cover test (including alternate and prism)
• Stereo tests
• Cycloplegic refraction
• Horizontal muscle surgery

Background theory/principles
To have gained an awareness of the following:

• Nystagmus
• Ocular motility syndromes (Duane’s, Brown’s)
• Use of botulinum toxin
• Ocular myopathies and the neuromuscular junction
• Supranuclear eye movement disorders
• Fresnel prisms
• Oblique muscle, vertical muscle and adjustable suture surgery
• Electromyography.

10. Disorders of the Eye and Visual System affecting children

Essential topics/experiences
To have become familiar with the following:

• The approach to infants, children and their parents.
• Ophthalmia neonatorum, diagnosis and management.
• Congenital nasolacrimal obstruction: recognition and management
• Ametropia in children, significance and treatment
• The apparently blind infant, normal and delayed visual maturation
• Liaison with paediatricians, geneticists.

Practical skills
To have undertaken (under supervision until proficient) the following:

• Assessment of vision in children, fixation, preferential looking, single and linear optotype tests.
• Cycloplegic refraction and prescribing for children.
• Fundoscopy in children.

Background theory/principles
To have gained an awareness of the following:

• Congenital nystagmus
• Ocular albinism
• Congenital glaucoma, diagnosis and management.
• Congenital cataract, diagnosis and management including prevention of amblyopia.
• Leucocoria, differential diagnosis including retinoblastoma.
• Retinopathy of prematurity, screening and treatment.
• Genetic and developmental disorders, Leber’s amaurosis, X-linked schisis, Coats’ disease.
• Paediatric neurological diseases.
• Presentation of raised intracranial pressure in infancy and childhood.
• Ophthalmic signs of child abuse
• Orbital cellulitis presenting in children.
• Orbital tumours in children, including rhabdomyosarcoma.
• Services for the rehabilitation of the visually disabled child.