College of Optometry

Clinical External Rotations

 

Externship Program Manual

Last revised: June 8, 2007


Forward

The fourth professional year of Optometry School should be one of the most exciting of your career. You will have the opportunity to work with a variety of patients and doctors. You will be able to formulate your own individual style of practicing optometry as a result of these experiences. It is our responsibility to help you plan a fourth year program that exposes you to different modes of practice (e.g., Hospitals, Public Health Services, Private Practices). We also would like for you to have familiarity with the various specialty areas (e.g., contact lenses, visual training, etc.).
Your rotation block here at the UM-St. Louis Center for Eye Care will insure that you have the basic experience for required clinical skills. This is paramount for preparing you for the State and National Board Examinations.

We encourage you to work hard and continue to read clinical literature on a consistent basis. Your attitude toward learning will be very important. In some situations you may experience personality clashes between patients and yourself or doctors and yourself. You must be professional enough to overlook these temporary obstacles and look at "the big picture" experience for your career. The College of Optometry faculty is concerned that you will have a successful externship experience. We will support you throughout the planning and duration of your fourth year.

OBJECTIVES

General Objectives:

The intent of the Externship Program is to provide the optometry student with an opportunity to be trained by outstanding practitioners in the science of primary and/or secondary care optometry. The Externship Program is an integral part of the curriculum and is designed to transform the optometry student into a complete health care professional who can apply scientific knowledge tempered by clinical insight and overall concern for the patient.

Educational Objectives:

-To develop the student's ability to apply knowledge of vision and basic sciences to prevent and/or solve problems of the vision system.
-To develop the student's ability to utilize knowledge in the behavioral, social and other health sciences to alleviate human problems.
-To develop a high level of competence in the use of modern optometric techniques, instruments and problem solving roles.
-To engender high standards of professional competence and responsibility.
-To develop the student's ability to work and communicate effectively with other health professionals and ancillary personnel in meeting patient needs.

Learning Objectives:

-To demonstrate to the student the art of the practice of optometry as evidenced by the attending doctor/practitioner.
-To widen the student's understanding of the spectrum of optometry by showing the student the clinical conditions (mental, physical and social, both acute and chronic) and their interaction with each other that make up the wide variety of health conditions in the community.
-To demonstrate where legal, the use of common diagnostic and therapeutic procedures involved in the problem solving stages of the delivery of eye care.
-To demonstrate the conscious and purposeful use and development of the doctor-patient relationship.
-To demonstrate the comprehensive care of the family from infancy to the aged, particularly in highly susceptible groups.
-To demonstrate the effect of an individual vision problem on the entire family.
-To demonstrate the role of the "health team" in patient management and continuity of care including relationships with other health professionals and agencies.
-To demonstrate preventive optometry and the importance of early diagnosis of ocular and vision anomalies, including ocularly related disorders.
-To demonstrate the practical approach of the primary care optometrist to health maintenance.
-To demonstrate the role of the optometrist in patient education.
-To demonstrate the changing patterns of optometric care and familiarize the student with emerging patterns of eye care delivery.
-To provide practical experience in the office management and business aspects of optometric practice.
-To demonstrate the civic involvement a professional owes to his community.

Private Practice Externships

Due to conflict of interest, externs will not be allowed to rotate through practices in which they have previously worked. We recognize that in a private practice the attending doctor has many concerns about bringing a stranger into the practice. Concerns relative to personalities, disruption of normal patient flow, and extern competency are very important and very real. For this reason, we encourage the attending doctor to provide a transitional period for the extern. During this period, the extern can learn the office procedures and the attending doctor can evaluate the extern's patient handling skills, competency level, etc. As the attending doctor begins to develop more confidence in the extern's abilities, it is expected that the attending doctor and extern are working shoulder-to-shoulder providing the best eye care possible to the patients. The duration of this transition period will depend on the extern's abilities, the type of practice and the experience of the attending doctor; however, only in rare cases should it take longer than three weeks. If at any time, the attending doctor feels that the extern will not meet the expectations of the attending doctor or may not be performing adequately at the end of the first three weeks - after consultations and upon recommendations of the attending doctor, the extern could be allowed to remain at the site, transferred to another site, or returned to the University for additional training. All of this is designed to prevent any disruption of the attending doctor's practice and assuring high quality educational experiences for the extern. The attending doctor is encouraged to contact the assigned externship counselor regarding problems or suggestions.

Multidisciplinary Externships

As in the private externships, the attending doctor has as his/her primary responsibility the provision of high quality patient care. For this reason, a transition period is needed to allow the attending doctor time for evaluation of the extern's capabilities. Again, if at any point the attending doctor feels that the extern will not be prepared to see patients independently at the end of the first three weeks, then the attending doctor should contact assigned externship counselor to discuss the extern's problems and the best action relative to meet extern's education and training.

While the attending doctor's primary responsibility is providing high quality patient care, the College's primary concern is the education of the extern. For this reason, we have chosen in the past not to utilize certain sites when we find that while the extern is seeing a large number of patients, the educational component is missing. We feel that we are fortunate to have so many institutional sites with attending doctors so willing to share their knowledge and experience with our externs on a daily basis.

Background Investigations

Some externships require that each extern scheduled for rotation at their facility complete a background investigation, including a fingerprint card. The site also requires completion of a vaccine/disease history form. A background check may be obtained at any police department in any state. If you are in the St. Louis area, background checks can be obtained at the St. Louis County Police Department located at 7900 Forsythe in Clayton. Their office hours are Monday - Friday, 9:00 am - 5:00 pm. The phone number is (314) 615-5317 and the cost is $9.00. Please note the fingerprint card must be completed at the police department by trained personnel. A fingerprint card, other necessary forms and documentation should be picked up at Marillac Hall, Room 331 before leaving the university for your externship year. If you are unable to pick the paperwork up in person, please provide the assistant to the Director of Externships an address and the paperwork will be mailed to you. Also, if you return your completed paperwork to the assistant to the Director of Externships they will FedEx it for you. If you choose to mail the information yourself, please don't bend the fingerprint card. Keep all payment receipts received from the police department for the background check. Bring your receipts to the externship site when it's time for your rotation and they will reimburse you for the cost.

GRADE REQUIREMENTS

Student Responsibilities: Each student will be responsible for fulfilling the following requirements.

Patient Care Logs - to be submitted on a biweekly basis. It is the students responsibility to ensure that all information submitted is correct with respect to term and log dates. If term and log dates do not correspond to the externship calendar, the log will not be accepted and the student will be notified to resubmit a corrected log.

http://www.umsl.edu/~garziar/externshippatlogform5.htm

Case Reports - two case reports are required for each rotation. Case reports are to be written on patients seen within the dates of the current rotation. The first report is due at the end of the third week and the second report is due at the end of the sixth week. Case reports are submitted by e-mail to optexternship@msx.umsl.edu. All case reports must include a title. In addition, the externs name must be included on the first page of the case report.

Case reports are not required at internal rotations (UMSL Eye Center, O-Center, East St. Louis, Harvester, Community Services, and VA-Kansas City).

Site Evaluations - Two site evaluations are required for each rotation. The first report is due at the end of the third week and the second at the end of the sixth week. Site evaluations submitted prior to the end of weeks three and six will not be accepted and the student will be notified to resubmit the log at the appropriate time. In addition it is the student's responsibility to ensure that all information submitted is correct with respect to term and year. If term and year do not correspond to the externship calendar, the evaluation will not be accepted and the student will be notified to resubmit a corrected evaluation.

http://www.umsl.edu/~garziar/externshipevalform4.htm

Service Learning Project - 1 response due at the end of the sixth week. See instructions online at:

My Gateway>majors-optometry>assignments>externship

Grades - will be based on the following factors:

Attending doctor's evaluation of your performance
Service-learning report
Case reports
Externship counselor's evaluation that is based on timeliness and thoroughness of reports. If these reports are not received in a timely manner, the grade will be reduced by one increment per report. (i.e. A to A-). Please be aware that all grades below a C- are considered failing.

GENERAL INFORMATION

Externship changes will only be made for emergency or extraordinary circumstances determined by the Director of Externships. Changes can only be made for the following reasons:

Serious illness/accident of self or immediate family (defined as spouse, parents, or children)
Death of immediate family member
Unforeseen emergency/urgent situations

ATTENDANCE POLICY

Attendance is mandatory. The hours and days of office and patient care activity are subject to the schedule by the attending doctor, the Assistant Dean for Clinical Programs and the Director of Externships. If illness, attending doctor vacations, etc., prevents students from maintaining their scheduled routine, the Assistant Dean for Clinical Programs or the Director of Externships should be notified immediately. All absences, with the exception of illness, must have prior approval. Internal sites (UEC, O-Center, East St. Louis, Harvester, St. Louis Community Services) must obtain approval from the Assistant Dean for Clinical Programs. External sites must obtain approval first from the attending doctor, then from the Director of Externships.

These Directors, within limitations, will determine how and when student absences will be made up. In the event that any absences are not made up to the satisfaction of the attending doctor and the Directors by the end of a respective grading period, and the student otherwise has a passing grade, then an "incomplete" grade will be registered for the period. The incomplete grade will be removed only with the satisfactory make-up for the absence.

During the externship year, students may be excused from their clinical assignment one (1) day per rotation. However, if a student is absent more than three (3) days at one externship site, the time must be made up. If you are at an internal site, it remains the discretion of the Assistant Dean for Clinical Programs to grant the request. If you are at an external site, it remains the discretion of the attending doctor and the Director of Externships to grant the request. The decision to grant an excused absence from any externship rotation should be based on, but not limited to, patient load and student staffing availability.

For all anticipated absences, students must complete the appropriate Personal Leave Form at least two weeks prior to the anticipated leave day.

To submit your request from an internal site you will need to use this web site:

http://www.umsl.edu/~optrgarz/Request_Absence.html

To submit your request from an external site you will need to obtain the Personal Leave Form from:
My Gateway>Majors-Optometry>Assignments>Externships>External Site Absence Request

Students need to have the attending doctor sign the form and fax the approved form to the Director of Externships at (314) 516-6708.

Extern-Attending Doctor Interaction

It has been found that the most crucial period of an externship is the first three weeks. During this period, the attending doctor and extern are developing a working relationship that will be continued throughout the externship. The important aspect of this period is a development of honesty, straightforward communication between the extern and attending doctor. A tool that has been used successfully in the past is to develop specific educational objectives that can be met during the externship.
Externs are required to comply with the standard office procedures of each externship site. Some attending doctors may require participation at seminars, local optometric society meetings, screenings, etc. Externs are expected to participate. Any questions or concerns regarding these requirements should be discussed with the Externship Counselor (faculty member assigned to the site).

The Director of Externships and the Externship Counselor fill a supportive role for the attending doctor and extern with the goal of providing the best possible education program for the extern and a rewarding experience for the attending doctor.
The Externship Counselor is a liaison that will give consultation for both the extern and attending doctor. The Director of Externships will make the final decision on evaluation of the externship site as well as the extern's performance.

Required Texts and/or Equipment

Externs are expected to supply their personal equipment, e.g., hand diagnostic set, etc., as were required at the school during the third year. Externs are also expected to fulfill reference-reading assignments deemed necessary by the attending doctor.

Decorum

The student is expected to present a professional appearance while in the attending doctor's establishment. This is to include meeting the attending doctor's dress requirements whether it is casual dress or clinic coats. It is the student's responsibility to blend in with the attending doctor's style of practice.

UM-St. Louis Center for Eye Care

Most students will be required to rotate through the UM-St. Louis Center for Eye Care. A limited number of students may be selected to substitute approved external rotations in contact lenses and BV/Peds in place of the UM-St. Louis rotation. The department heads must approve these substitute rotations.
If problems or questions arise, please feel free to contact the College of Optometry at (314) 516-5606 or Dr. Alexander Harris, OD at (314) 516-5603.

Sample Case Reports

Case Report #1 Central Serous Retinopathy (CSR)

Background

Central Serous Retinopathy (CSR) or Idiopathic Central Serous Retinopathy (ICSR) typically occurs in young to middle-aged males (20-50 years old) of Caucasian, Hispanic, or Asian descent1. Although this condition usually presents with unilateral visual distortion, the underlying retinal pigment epithelium (RPE) disease is often bilateral. CSR has been frequently linked to type-A personalities and high levels of stress2. It has also been associated with pregnancy, sarcoidosis, systemic lupus, hemodialysis, hypercortisolism, inhaled steroids, and organ transplantation. CSR is characterized by a local sensory retinal detachment with or without RPE detachment and is generally located in the region of the macula3.

Upon evaluation, the optometrist may notice a hyperopic shift in the patient's refractive error. This is due to the elevation of the sensory retina. Amsler grid findings are usually abnormal, with central or paracentral scotomas and/or metamorphopsia1. Indirect ophthalmoscopy reveals a shallow, round or oval, serous retinal detachment or pigment epithelial detachment (PED), often outlined by a glistening reflex. Occasionally, multiple detachments may be seen2. In long-standing cases, deep yellow precipitates appear at the level of the RPE. The dome of the elevated retina is often caused by a small RPE detachment, while a larger sensory retinal detachment surrounds this area2. Most cases of CSR occur beneath the macula, blunting the foveal reflex. This condition is caused by an idiopathic leakage of fluid from the choroid into the subretinal space due to a dysfunctioning RPE1.
CSR is generally self-limiting and can be diagnosed by clinical evaluation. However, fluoroscein angiography is useful in providing the most definitive diagnosis and can also rule out a choroidal neovascular membrane in atypical cases3. Two patterns are often seen on fluoroscein testing: a smoke stack appearance or an ink-blot appearance. Single or multifocal leakage can be seen in 93% of CSR patients, with a smoke stack appearing in 7%2.

Full visual recovery occurs in 50-60% of patients one to four months after CSR has been diagnosed. 94% of CSR cases have been reported to regain a Snellen visual acuity of 20/30 or better2. When associated with pregnancy, symptoms usually resolve by the third trimester. However, recurrence rates can be as high as 50% and usually occur within one disc diameter of the original leakage site. Five percent of CSR patients have been found to develop subretinal neovascular membranes2.
In most CSR cases, no treatment is necessary and the condition is completely self-limiting. The optometrist should carefully rule out all other causes of retinal detachment1. Four months should be allowed before any intervention is considered. If the CSR has not resolved after four months, interventive laser photocoagulation should be offered to the patient3. Other indications for photocoagulation include intolerance of symptoms, formation of turbid subretinal fluids or fibrosis, a case of severe recurrence, cystoid macular edema development, choroidal neovascular membrane development, or formation of exudative retinal detachment. Occupational needs (i.e. pilots) requiring quicker recovery time or poor vision in the fellow eye due to CSR are also important in determining whether to treat the condition2. Low-intensity direct laser photocoagulation should be used for CSR instead of indirect laser procedures. Direct photocoagulation has been proven to shorten the duration of the condition by two months. However, no effect on final visual acuity or recurrence rate is offered by laser treatment. In addition, photocoagulation should not be used within 0.5 disc diameters of the fovea2.

Optometrists should take the time to carefully educate CSR patients of their condition. This may include a discussion of lifestyle modifications, diet, psychological counseling, and home monitoring of vision if warranted. Yearly eye examinations should also be strongly encouraged3.

Case Report


P.B., a 35-year-old Caucasian female, presented to O'Donnell Eye Institute on March 15, 2004 for an emergency visit. Her chief complaint was relatively sudden blurring of vision in the right eye with a small black spot in the center of vision. She had no visual complaints regarding the left eye. P.B. noticed the blurred vision in her right eye the afternoon before and reported that the blurriness and black spot were constant throughout the day. She rated her symptoms as moderate in severity. She had never experienced these symptoms in the past and had no associated symptoms (i.e. headache, irritation). She had not taken any medications or used any treatment to relieve the blurriness.

P.B. reported that her last eye examination was one year ago at a local optometrist's office. She did not wear glasses or contact lenses. The patient's ocular history was unremarkable (no cataracts, glaucoma, trauma, surgery, or disease). Family ocular history revealed that the patient's mother and father had cataracts, and her father had glaucoma. Family medical history revealed that P.B.'s maternal grandfather experienced high blood pressure and diabetes mellitus. P.B.'s medical history was unremarkable (i.e. no high blood pressure, heart disease, respiratory conditions, or diabetes). However, she was 28 weeks pregnant and reported taking prenatal vitamins. She was not allergic to any medications. After further investigation, P.B. reported an increased amount of stress over the past three weeks due to her pregnancy and job as a dental hygenist. She also reported having two small children (ages two and four) at home.

Entering visual acuity at distance was 20/40 OD and 20/20 OS unaided. No improvement was noted with pinhole OD, OS. A full subjective refraction was not performed; however, the patient did note mild improvement in visual acuity when plus lenses were held in front of her right eye (hyperopic shift). External examination revealed no signs of irritation or any notable abnormalities. Pupils were round, equal, responsive to light, and did not display an afferent pupillary defect. Cover test revealed no strabismus with only a mild exophoria at near (5 prism diopters). EOM's were full without restriction OU. Confrontations were FTFC OU. Amsler grid findings were normal OS with a small scotoma inferior to fixation and metamorphopsia OD.
Slit lamp examination revealed clean lids and lashes OU. The conjunctiva was healthy and clear OU. The cornea was also clear and without stain OU. The iris was clear with no signs of inflammation in the anterior chamber OU. The lens showed trace nuclear sclerosis OU. Intraocular pressures by Goldmann applanation tonometry were 17 mm Hg OD and 16 mm Hg OS at 10:42 a.m.

P.B. was dilated using 2.5% Phenylepherine and 1% Mydriacyl OU at 10:44 a.m. Dilated fundus examination revealed healthy optic nerves OU, with C/D ratios of 0.4/0.4 OU. Vessels were healthy OU without hemorrhage, exudate, or hollenhorst plaques. The macula was healthy with a positive foveal reflex OS. However, a small sensory retinal detachment was noted just superior to the fovea OD. The elevated region did not show any yellow precipitates or RPE detachment. The foveal reflex was blunted OD. Fluoroscein angiography confirmed the diagnosis of central serous retinopathy OD by a classic smoke stack appearance, demonstrating leakage of fluid beneath the retina. The peripheral retina was also evaluated and no holes, tears, or detachments were noted OU.

After P.B. was diagnosed with CSR, a thorough explanation was provided regarding signs, symptoms, progression, and prognosis. No treatment was encouraged at this time. If the CSR did not resolve after 3-4 months, photocoagulation would be considered. P.B. was scheduled for a follow-up appointment in one month to reevaluate the condition and advised to return as needed if symptoms worsened. She was told that her symptoms were probably linked to pregnancy and increased stress levels and would most likely resolve spontaneously.

Conclusion

Central serous retinopathy generally presents in middle-aged males (10:1 over females). However, CSR should always be considered in the diagnosis of a sensory retinal detachment. It is crucial to educate the patient and monitor him/her as needed. Although most cases are self-limiting, these patients should not be lost to follow-up due to the possibility of CME, CNV, and long-standing CSR symptoms. Direct laser photocoagulation has proven to be the best possible treatment for severe or recurrent CSR cases that lie outside the foveal avascular zone.

References
1. Friedman, Pineda, and Kaiser. The Massachusetts Eye and Ear Infirmary Illustrated
Manual of Ophthalmology. Philadelphia, 1998: pages 276-277.
2. Alexander, Larry J. Primary Care of the Posterior Segment. New York , 2002:
pages 124-130.
3. Kanski, Jack J. Clinical Ophthalmology. Washington, 2000: pages 418-420.


Case Report #2 Streff Syndrome

Examination

A shy 9-year-old female presented to the clinic for an eye examination with the chief complaint of "blurry vision at distance and near". The Child Extended Questionnaire revealed that BB occasionally got headaches and eyestrain and has always had difficulty seeing distant objects. She had an eye examination 1 year ago and was prescribed lenses, through which she was still unable to see. This questionnaire also asks the patients about the stability of their life at home. Approximately 1 year ago, BB's grandmother moved into the home and as a result, her parents have been spending much time taking care of the grandmother.
Prior to the examination, a Keystone Visual Skills Test was performed. BB was a very slow responder throughout this procedure and tended to close her left eye. It was noted that she was consistently over-convergent. The distance and near acuity targets were very difficult for her to see. She was only able to see a couple of targets at both distances. Her stereopsis and color vision were also very poor. BB also had difficulty with the Copy Forms Test. She reversed a lot of the shapes and added extra lines.
Examination by the attending revealed the following information:

Habitual Rx: OD +2.50-0.25x095
OS +1.50-0.75x060

Steroposis: 400 sec of arc with no RX

Visual Acuity:
Distance: OD 20/200, OS 20/200, OU 20/100
Near: OU 20/200+
(with and without Rx yielded the same results)
Cover Test:
Distance: ortho
Near: 5 XP'
(Patient reported monocular diplopia OD & OS)
EOM's: FROM
Pursuits: Patient noted 2 balls while in motion

NPC: To the nose

Distance Retinoscopy: OD +0.50 DS (variable)
OS +0.75 DS (variable)

Vision was not improved with the addition of any lenses so further testing could not be performed at this visit.

Stress Retinoscopy: OD +0.50 DS OS +0.50 DS
The addition of the above Stress Point Lenses improved stereopsis from 400 sec of arc to 60 sec of arc. The Keystone Visual Skills Test was repeated and showed improved color vision and stereopsis with these lenses.

Internal Ocular Health: unremarkable

The above examination results and the case history led Dr. Scott to diagnose BB with Non-malingering Syndrome (Streff Syndrome). She prescribed +0.50 DS OU and is having BB return to the clinic in 6 weeks for an extended progress evaluation.

Discussion

In the few short weeks that I have been working with Dr. Scott, I have observed three examinations where Streff Syndrome has been diagnosed. I believe there are two reasons why she encounters a higher percentage of these patients: (1) 75 % of her patients are pediatric (2) Most of her patients are referrals from other doctors who cannot figure out what is going on with the patient. When parents bring in their children who are referred to the Vision Enhancement Clinic, they are frustrated because they do not know what is going on with their child and prior to this no one else knew either. By having this first hand experience and seeing how aggravated the parents are with the previous doctors they have been to, I feel that this subject is one that I need to become more educated about. I would not be doing my pediatric patients justice if I did not become familiar with the signs and symptoms of this diagnosis.

Streff Syndrome is also known as Functional Bilateral Amblyopia or Non-malingering Syndrome. The onset of this disorder can be triggered by physical or psychological trauma or an alteration in the demands put on an individual. It usually occurs around the age of puberty, which is when stress -induced disorders are most prevalent. Of the three patients who I have observed to be diagnosed with Streff Syndrome, one child's parents just whet through a divorce, one was adopted a few years previously, and as I mentioned above, BB now had her grandmother living with her and her family. These children are quiet and do not let their feelings out. Instead, they hold everything in, their thoughts and feelings build up, and eventually their visual processing is affected. From what I can discern, this Syndrome occurs because there is a break down between the visual motor function and sensory function. Somehow these individuals are unable to look, focus, and process what they are seeing.

Children who manifest this Syndrome are often shy, unsure and hesitant individuals. They also will tuck their chin down and may have a dull facial expression. During the examination, you will notice that the harder they child tries the worse it seems to get. Visual acuity is equally reduced to less than 20/30 in both eyes and at all distances. Determining the diagnosis of Streff Syndrome is very important because these children are often times misdiagnosed. At first the practitioner may think that the child has refractive amblyopia or nearsightedness. However, retinoscopy results do not match up with the loss in acuity because they will have little if any refractive error. This rules out any type of refractive component as the cause of the vision loss. These individuals are frequently misjudged as malingering. In just my short amount of experience I have noticed that true malingerers are vocal and have figured out what answers they have to say in order to make you think they need glasses. As I mentioned above, patients with Streff Syndrome are slow responders and are unsure of their answers.

Once you determine that the patient sitting in your chair has Streff Syndome, it is important to educate both the parent and child about what is going on. Parents need to understand the reasons behind the onset of this condition. It is important to reassure the parent and child that this condition is generally self-limiting and that low plus lenses may help to hasten the resolution of this syndrome. Dr. Scott finds that most patients recover normal distance vision within approximately six weeks and thus, schedules a progress evaluation at that time. Other treatment options include vision therapy (to gain accommodative and convergence flexibility) and actively reducing the stress causing factors in the patients live.

I find Streff Syndrome to be a very fascinating anomaly. Prior to this rotation, I would have referred BB to someone to figure out why her vision was decreased. However, now that I have a feel for what this type of patient is like, I will be more capable and confident of identifying and treating this patient on my own. I feel lucky to have had to opportunity to work at the Vision Enhancement Clinic. I have gained invaluable knowledge in the field of Behavioral and Pediatric Optometry.

References

Press, Leonard J., et. al. Clinical Pediatric Optometry. Newton: Butterworth-Heinemann, 1993.
Personal communication with Dr. Carol Scott