The College of Optometrists

hi, received information from college re exam timetables. it mentioned a mock cdm case study being available on line? anyone know where abouts this is? cheers!

joanne

Its on this address in this web site;

http://www.college-optometrists.org/index.aspx/pcms/site.education.Examinations.Scheme_For_Registration.final_assessment_guidance_regs/

Just one case study......... but makes u think. Do u think the appearance of the macula is normal atrophy or amd. The px hasn't reported sudden drop in vision, so would the appearance prompt any referral??

Interested in any thoughts.

difficult to say whether dry or wed amd. but near va n5 R+L. guess u would say u would amsler.

would you worry bout convergence on a 89 yr old? prescribe the 2 base out to help his exo? if so can we prescribe prism just at near in vari's or would he have to move to bifs/2 sep pairs?

also do fields look ok? would you repeat them with one point missed in right nad 3 points missed in left?

what bout colour vision.....left he got 9 so that fine. is 8 acceptable in R?

thoughts on how you would tackle this px in cdm exam appreciated

??? haemorrhages at left fovea?? wet amd?

this is what i thought

further questioning on reduced near vision( sudden or gradual) old RX cenration is 65.5, patients PD =67 Didnt see the relevance of Accommodation being measured!! i thought the fundus showed Dry ARM in both eyes, with RPE hyperpigmentation in the left eye colour vision is ok?(i would have expected a lower score in the left eye than the right as ARM is greater in LE than RE :?) any views? i thought fields were ok for a 89 yr old wih cataracts and ARM, but would like to repeat in 6/12 time to check on any progression. (disc look healthy)

advice px has cataract which results in glare effect . needs to shade eyes (use hat) from sunlight especially when crossing roads. referral if px wants

advice px had ARM, which is resulting in reduced near vision give px amsler chart to self monitor. advise on diet and supplements

new rx, SVN as will provide larger F.O.V and magnification. dispense prism in reading rx advice on lighting and working distance when reading the newspaper.

review patient in 1YR

any views on whether varifocals should be dispensed with modified O.C's , maybe RE 33.5 LE 33 why the patient has jerky movment on motility any advise on what examiners are looking for in this exam will be appreciated

Just a thought - I am not sure if vari's come with add of +4.00. I like the way you advise to hold the book closer than normal. Also he would have to be advised not to trip up on stairs etc for safety.

I think I would do an Amsler and give him one to self monitor given the drusen and odd pigment at the macula of the left eye.

I think that much of his problem's from the cataracts -

-nice case isn't it?

sorry if someone has already said this but arent we meant to refer routinely for opthalmological confirmation of diagnosis for AMD? because it isnt mentioned in H&S that he has been or seen anyone at the hospital and also due to his vision at the moment isnt it fairly that he had CNV or if he has by referring to the hospital routinely wouldnt you cover yourself and have the opinion of an opthalmologist considering sudden vision loss in wet AMD takes about 3-6 months to occur, also referral for cataract extraction if he so wishes and if he was complaining of glare crossing the road (danger to px safety) and also in the view of preserving the view of the macula for better AMD monitoring??

diagnosis: Dry AMD advice: lighting, amsler (and adv use), excercise, antioxidant rich foods, vitamins for eyes like icaps that contain leutin & xanthalin for preservation of the normal workings of the retina, adv px glare most probably from cataract ask if would like removed, explain procedure roughly and timescale 3months adv pros &cons of surgery adv need to refer to opthalmolists to decide if he feels it should be done or if we are to monitor him again in 12 months and also to check possible degeneration at the back of the eye due to involutoional changes. adv change in rx justified because even though i am refering the px rx increases N.V, adv shades in sun, hat with brim in the meantime, recall 12 months.

isnt the xop bit much for a 89 yr old to handle at near?? may get probs with diplopia on prolonged reading??

Opinions appreciated.

kam

Few points in response Kam.

We're not legally obliged to routinely refer for dry AMD. Referral is indicated if a) you're not confident of the diagnosis and would like a second opinion, b) if the patient requests a formal confirmation of diagnosis of the condition and c) if the vision has dropped to a level where LVAs and consideration for blind/sight impaired registration are worthwhile. If the macula appears flat, atrophic and vision loss is gradual I would feel that referral is not warranted, provided the Px is able to go about their life with any visual loss encountered.

I don't understand how sudden loss of vision takes 3-6 months. Contradiction in terms surely? Could you clarify this?

Cataract surgery should be mentioned I agree, and referred if the patient is keen to have surgery based on appropriate advice.

The XOP at near is significant yes, 1-2 dioptres of base-in prism could be incorporated into the near Rx if the patient shows signs of difficulty maintaining fusion, e.g. symptoms of dipopia, 'straining' to read small print, slow recovery movement on cover test. I wouldn't be too concerned about him needing more prism in the future at aged 89. It's also important however to consider the large increase in reading addition being Rxed. Will he like the closer reading distance? Would a simple magnifier be more appropriate for smaller print, reducing the demand on his convergence system?

I've gone on enough, these are my thoughts on this one. I'm not convinced there's definite 'correct' answers fot these, as long as you can justify your reasoning and it's safe practice I don't think you'll be pulled up.

i read in a text book that from the approx onset of exudative amd to sight loss the timescale was 3-6months, so i was thinking that if, as someone above was thinking, exudative amd was suspected then by refering the px routineley, given that the V.A doesnt suggest serous detachment has occured, would be within this 3-6month time scale ensuring that if CNV was occuring it would be actioned upon at the hospital by an opthalmologist by means he/she may feel necessary, also wouldnt a fluoroscein angiography be useful??

please let me knw your thoughts.

But if you suspect exudative AMD you must be seeing one or more of macula haemorrhage, juxtafoveal exudate or CNV. If you saw these in a diabetic patient would you refer routinely? I'd want these people seen within a month maximum, probably sooner. If you aren't sure then a quick phone call to the local eye dept for some advice is always worthwhile. Any possibly treatable maculopathy with potential irrerversible central visual loss should be looked at pretty soon in my opinion.

An FFA would be essential rather than useful if wet AMD is present. Many membranes cannot be detected clinically and fluorescein is therefore used to distinguish occults from classics when considering PDT.

very very valid point didnt think of it in that way, i was just assuming definately dry amd and referal to be cautious.

thanks for the useful insight.

kam