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Introduction Screening Details • Reporting time: 0800 hours • Date: 8th December 2013 • Time: 0900 – 1300 • Venue: Senja-Cashew Community Centre Multi-Purpose Hall • Address: 101 Bukit Panjang Road Singapore 679910 • Contact person: Ms Wong Lai Peng • Contact Number: 6219 4561 • Contact Email: [email protected] Dress Code • School of Health Sciences Polo Shirt • Long Pants/Jeans • Covered shoes Budget We have no budget for this eye screening. Light refreshments Light refreshments were provided by the Community Centre. Analysis of data A total of 105 participants were screened, ranging from age 3 to 79 years old. A total of 7 paediatrics(7%), 23 adults (22%), 75 geriatrics (71%) were screened. Paediatrics: age 16 years old and below Geriatrics: age 50 years old and above Adults: age between 17 to 49 years old Participant History Referrals 39 participants were referred to NPOC and 6 were referred to Ophthalmologist. Reasons for referral to NPOC Retinopathy include drusens, exudates, etc. Maculopathy includes Age-related Macular Degeneration, drusens or exudates within macular area, macular pigment changes, etc. Suspicious C/D ratio include large C/D ratio and large difference in C/D ratio of both eyes. Suspicious intra-ocular pressure (IOP) include high IOP and large difference in IOP between both eyes. Others consists of large exophoria and narrow Van Herick angle 15 participants were referred for cataract. 7 participants were referred for poor VA. 8 participants were referred for retinopathy. 7 participants were referred for maculopathy. 5 participants were referred for suspicious C/D ratio. 4 participants were referred for suspicious IOP. 2 participants were referred for pterygium. 3 participants were referred to have an eye examination at NPOC. 2 participants were referred for other reasons. Reasons for referral to Ophthalmologist 2 participants were referred for cataract. 2 participants were referred for diabetic retinopathy. 1 participant was referred for maculopathy. 1 participant was referred for glaucoma suspect. 1 participant was referred for ocular motility problem. Learning Points After the eye screening, our team have learnt to be aware of all stations’ criteria (pass/fail) and happenings so better update ourselves and to troubleshoot if any problems arises. This also helps us in interpreting results from all the other stations if the student helper did not record clearly. A good eye screening recording form is important to allow proper recordings of student helpers’ findings, and to let the other helpers better interpret the conditions of the participants. Punctuality was emphasized our team as we felt that it allows the eye screening to run smoothly and on time. This also made us accountable to those participants who came to register earlier. Also, our team have acquired knowledge on space usage. We were given a large area for the eye screening but however, only used a part of the area; to reduce the walking of the elderly participants. As our team did not bring the stereofly chart to the eye screening, we are sure that if we have another eye screening, we will check that all necessary equipment are packed to bring the site of eye screening. Our team, including the year 2 student helpers all learnt how to view the fundus in scotopic situation because we were unable to switch off the lights at the ophthalmoscopy station. Everyone has learnt and has to learn to be more flexible as this is an eye screening, not a perfect clinical setting. Communication is key. There is a common communication barrier during the eye screening between different races and dialects, especially amongst older participants. We should translate some of the simple instructions in other languages and dialects; and teach or help each other out when there are difficulties communicating with the participants. Communication amongst the student helpers and between stations is also equally important. Especially between the fundus stations and ophthalmoscopy station, where both stations are assessing the health of the retina, they might have similar findings; hence the need for better communications and recording. Our team have also learnt to take care of the year 2 student helpers, to ensure they are doing their duties right, and to guide them along if they encounter any problems or queries. Without everybody’s help, the eye screening would not be able to go on smoothly. Teamwork between student helpers is what can impact the eye screening the most. Discussion Troubleshooting Registration Problems: Initially, the registration form number was jumbled up as they did not take the forms according to ascending numbers. So at some point of time when we went over to management to check the number of patients we had, we saw registration number 30 when there are still registration number 20 form. Problem solving: So we just continue using the form but start with the smallest form number first. Eventually, the form number was in ascending order and no repetition of numbers. Visual Acuity Problems: There are some student helpers who did not write down their names so it was difficult to find the person if the helpers in management station have questions regarding the results. Aided or unaided was not circled so it is time consuming for the people at management to ask the participant or for them to circle it again. Our group set the criteria for both distance and near, however we only included the distance VA criteria in the recording form. We should have included both distance and near VA so that the student helpers will not be confused. Tonometry Problems: One of the I-care machine was not able to work halfway through the screening. We did not bring spare batteries thus we were unable to determine if the I-care was down due to low battery. Time was not recorded down on the paper; it is an important data as IOP is affected by the time taken. Ophthalmoscopy Problems: Recording was not done properly and some of the blanks such as ‘Neural Retinal Rim’ were not filled up. It was difficult for the student helpers to manage the participants if there are blanks in the form. Lighting was an issue because the place is too bright and we were unable to switch off the lights as the management station would be affected. Problem solving: Inform all ophthalmoscopy helpers to fill in all the blanks. The helpers were able to adapt to the bright environment and able to perform the tests with minimal help. Fundus Photography Problems: There was a long queue for fundus photo and the some participants waited for a very long time. Student helpers circled ‘pass’ even when abnormalities such as drusens, exudates or haemorrhages were observed in their fundus. Participants were not referred to Additional Tests station when abnormalities were seen. Recording such as C/D ratio was not recorded on the form after fundus photo was taken, leaving blanks on the form. Additional Test Problems: We did not bring Stereofly test on that day even though it was included in the packing list. Thus, we were unable to perform stereopsis for paediatrics. Recording for slit lamp was not included in the screening form; there was actually no check box for student helpers to tick under ‘slit lamp’ if they want participant to undergo this test. Management Problems: ‘Pass’ or ‘fail’ was circled wrongly as VA criteria was unclear. ‘Pass’ or ‘fail’ and name of student helper were not recorded in some forms. Participants with arcus senilis were not referred to General Practitioner. Problem solving: Student helpers in charge of management went over to take a look at fundus photo to record in the form and decide whether to refer the participant or not. Ushers Problem: Helpers from VA station were asked to stand outside the hall to recruit participants in instead of ushers. So there were lesser manpower in the VA station. Fundus Camera Problems: The extension plug which comes together with the fundus camera belongs to Mandarin was however, brought back to school instead. The Community Centre in-charge gave us a call to notify us about this incident. Problem solving: We called Mandarin and told them that we will deliver the extension plug to them personally. Roles and Contributions Name Roles Contributions on the day of eye screening Wong Kai Lin • Leader • In-Charge of ‘Additional Tests’ station - Briefed the student helper • Ensured the flow of the eye screening - Make sure every stations runs smoothly Heng Irene on the different tests to do in additional station, 1 week before the eye screening. - Briefed the student helpers on the pass/fail criteria and ensured that they know how to perform the tests and clear of the recording before the eye screening commences. • Made decisions with the assistant leader - Makes the final decision • Troubleshoot questions and problems faced in other stations (the whole eye screening) - Made necessary changes in the floor plan and allocation of wasmanpower (Asked 2 students to usher participants in from outside as the community centre did not state the eye screening is at level 2 when they publicise). • Co-ordinate with the community centre regarding the refreshments and no. of participants • To solve any anger/disputes/unhappiness amongst the students • Guided the student helper in my station with the tests that she is not familiar with • Conducted tests at the ‘Additional Station’ • Assistant Leader • In-Charge of Ushers - Briefed the student helpers about ushering and their location of duty, 1 week before and on the day on eye screening. •Usher the participants to the respective stations - Ensure that the whole screening goes smoothly - Make sure they did not skip any compulsory stations • Clarify doubts for my helpers in my usher station - Make sure they do not bring patients to the wrong station to avoid any unhappiness • Report any facility problems (AirConditioner and the lighting) with the community centre members and asked them to fix it - To make patients and helpers comfortable - To have a darker area for ophthalmoscopy • Clear the doubts for visual acuity (VA) criteria - To avoid wrong recording and clear confusion • Debrief for all at the end of the screening - Summarise everything by informing the number of participants and discuss the problems faced in every stations. - To thank all the helpers for helping and collect feedback forms from the helpers Fiona Lee Hui Ping • In-Charge of Registration - Briefed the student helpers about registration (things to take note), 1 week before and on the day of eye screening. • In-Charge of Manpower allocation - Recruited student helpers for the eye screening. Berlinda Tan Ying Bing • In-Charge of Manpower allocation - Recruited student helpers for the eye screening. • Helped in briefing the student helpers on the procedure, grading and recording of the shadow test, 1 week before the eye screening. • Helper in ‘Ophthalmoscopy’ station Lim Qian Hui • Troubleshoot problems faced in ‘Registration’ station • Ensure the registration was done correctly and accurately, with the necessary tests indicated for paediatrics • Guided the student helpers in the station • Assisted in ushering participants from ‘Registration’ station to ‘Visual Acuity’ station • Mark attendance of student helpers • Assisted in setting up chairs and tables • Performed ophthalmoscopy on participants • Troubleshooting problems faced on the ophthalmoscopy station • Ushered participants from IOP station to ‘Ophthalmoscopy’ station • Ushered participants from ‘Ophthalmoscopy’ station to ‘Fundus Photography’ station. • In-Charge of Floor plan • Assisted in setting up the tables - Gathered pictures of eye and chairs according to the floor screening location and did a plan layout floor plan for the eye screening. • Helped in briefing the student helper for ‘Additional Tests’ station on the tests to do, 1 week before the eye screening. • Helper in ‘Management’ station • Impromptu planning and rearrangement of our setup due to the large space • Managing participants, giving advice and answering their queries. Checked their near VA and did some small tests for certain individuals. • Sort out participant records’ after the eye screening Leong Li Tat • In-Charge of ‘Fundus Photography’ station - Briefed the student helper on the pass/fail criteria and points to take note, 1 week before and on the day of eye screening. - Guided the student helper on the operation of the fundus camera • In-Charge of Data Management - Collating and analysis of data obtained from the eye screening • Helped in the setting up of tables and chairs • Perform fundus photo taking for the patients • Taught and demonstrated the usage of the fundus camera to year 2 helpers • Troubleshooting any problems that surfaced from fundus camera Shen Li Peng • In-Charge of ‘Tonometry’ station - Briefed the student helpers on points to take note for taking eye pressure and the criteria, 1 week before the eye screening. - Briefed the student helpers on the pass/fail criteria of the station before the eye screening commences. • In-Charge of Data Management - Collating and analysis of data obtained from the eye screening • Helped in setting up the station on the day of the eye screening • Measured IOP for participants during the eye screening and ensuring the station runs smoothly • Troubleshooting any problems with the equipment and handling difficult participants Yeo Yuen Wen Clarissa • In-Charge of ‘Ophthalmoscopy’ station - Briefed the student helpers on pass/fail criteria of ophthalmoscopy and points to take note of, 1 week before the eye screening. - Briefed the student helpers on shadow test and ophthalmoscopy procedures, grading and recording before the eye screening commences. • In-Charge of Logistics - Collected the necessary equipment and charts needed for the eye screening. • Ensured the good flow between the previous station (Tonometry) and ‘Ophthalmoscopy station’, and the next station (Additional Tests, Fundus Photography, or Management) - Asked the students helpers to help in ushering the participants from the ‘Tonometry’ station to ‘Ophthalmoscopy’ station • Helped in setting up the station - Sufficient chairs for the waiting area and the testing area • Troubleshooting any problems faced in the station - Ensure that all student helpers are able to perform the tests in normal lighting conditions • Clarify and doubts by the student helpers Lee Yun He • In-Charge of ‘Management’ station - Briefed the student helpers on pass/fail criteria, referral criteria and points to take note of, 1 week before and on the day of eye screening. - Briefed the student helpers on pass/fail criteria, referral criteria, near VA criteria and other points to take note, before the eye screening commences. • In-Charge of Logistics - Collected the necessary equipment and charts needed for the eye screening. • Ensured the ‘Management’ station is smooth flowing - Ensure that the student helpers know how to manage participants’ condition • Provide assistance to student helpers if the need arises • Managed participants of a caseby-case basis, giving appropriate advices and answered to their queries • Ensured that all student helpers know what to do with the Ngee Ann Polytechnic Optometry Centre (NPOC) vouchers - To be given out to participants who are interested to have full general eye examination at NPOC • Double check the results recorded by other stations when the pass/fail criteria was not recorded properly Sri Devi D/O Banogaran • In-Charge of creating the eye screening recording forms and referral forms • Helped in briefing the student helpers on near visual acuity measurement criteria and things to take note of, 1 week before the eye screening. • Helper in VA station • Helped in setting up the ‘Visual Acuity’ (VA) station before the eye screening started • Checking the visual acuity of the participants • Helped in ushering participants from the VA station to the Tonometry station • Alternated with the co-helper in pointing the chart/conversing with the participant and recording of the VA Madinah Bte Mohamed Rahim • In-Charge of ‘Visual Acuity’ (VA) station - Briefed the student helpers on VA criteria and things to take note of, 1 week before the eye screening. - Briefed the student helpers on VA criteria before the eye screening commences. • In-Charge of creating the eye screening recording forms and referral forms • Helped in setting up the station on the day of the eye screening • Ensured that helpers paired up for easier testing of VA • Ensured the stations runs smoothly and does not jam up - Set an order so that each pair knows when to go first, second, and subsequently. • Troubleshooting any problems and clarification of VA criteria • To gather helpers back to the station when they dispersed themselves •Checking the VA of the participants Score and Area of Improvement for Individual Team Member Name Score Area of Improvement Wong Kai Lin 9.1 / 10 To be more proactive in addressing issues and problems Heng Irene 9.1 / 10 To handle situations and problems more efficiently on the day of screening Fiona Lee Hui Ping 8.3 / 10 Should have been more specific during the briefing Berlina Tan Ying Bing 8.4 / 10 Could have been more proactive in her station (ophthalmoscopy) Lim Qian Hui 8.5 / 10 Should be more aware of what is happening at her station (management) Leong Li Tat 7.6 / 10 Should check the student helper’s assessment during eye screening as she wasn’t present for briefing Shen Li Peng 7.9 / 10 Could have participated more in the discussions Yeo Yuen Wen Clarissa 8.8 / 10 Could have coordinated the flow better, to delegate team mates whether who to attend to which participant Lee Yun He 8.7 / 10 Should be more aware of what is happening and guide the rest if they are unsure of the referral Sri Devi D/O Manogaran 8.4 / 10 To be more proactive and give more suggestions during discussion Madinah Bte Mohamed Rahim 8.5 / 10 Could have organised the VA station better (eg. Arranging the seats, number of seats) Geriatric Eye Health – Common ocular conditions in elderly *Note: Please avoid jargons and keep to layman terms. . Brief description of condition (Includes etiology, signs, symptoms etc) Arcus Senilis ● ● Management ( Includes treatment, advice etc) it is a grey or white arc around ● Arcus Senilis in patients below the surface structure of the 50 years of age should be eye which is known as referred for a lipid profile, since it cornea. may indicate hyperlipidemia, Eventually, the arc may hypercholesterolemia, or become a complete ring hyperlipoproteinemia. around the cornea. ● It is most commonly seen in elderly patients. ● Arcus senilis is common in However, the relationship between arcus senilis and cardiovascular older adults. It is caused by disease is yet to be established. fat deposits accumulating in the edge of the cornea. Pinguecula Pinguecula is a common benign growth on conjunctiva also known as the white part of the eye. It can grow at either nasal or temporal side and due to long term UV exposure. Can affect one eye or both eyes. Signs -Yellowish-white deposits on the nasal or temporal side of conjunctiva Asymptomatic -Advise Px to wear UV protection sunglasses Symptomatic -Advise Px to use artificial tears to provide lubrication due to uneven conjunctiva which causes dry eyes -If inflamed(pingueculitis), refer for steroidal treatment Symptoms -dry eyes -irritation/scratchiness -foreign body sensation Pterygium - Extra growth on the white part of the eye and extends into the cornea and contains visible blood vessels. - Common in people who are exposed to sunlight often or engaged active outdoor activities. Cataracts - For those who have no complaints, treatment is not required - Artificial tears may be used to lubricate the eyes and prevent the pterygium from getting inflamed - Mild steroids for inflammation. - Many do not experience or feel it and may not know of its existence but in some cases it may get inflamed and irritated. Vision will be affected if it grows into the cornea. -Surgery to remove the pterygium if vision is affected. Vision is good after removal. However, the pterygium may return after removal - Clouding of the lens, blocking light rays from entering the eye, causing blurring of vision Management: - Common in the elderly due to - Surgery, especially for dense cataracts where vision is affected ageing - Advise patient to wear UV protection sunglasses Causes: - Degeneration of the lens - Exposure to Ultra-Violet light - Long term use of medications e.g. Steroids Symptoms: - Blurry vision at all distances - Glare - Diplopia - The need to constantly update the prescription, which becomes increasingly unsatisfactory Types of Cataract: - Age related Cataracts (Nuclear Sclerosis, Cortical Cataracts, and Posterior Subcapsular cataracts) - Congenital Cataracts; present at birth or formed during a baby’s first year - Secondary Cataracts; results from certain diseases or medications - Traumatic Cataracts; results from an injury to the eye Glaucoma Suspect Glaucoma is an eye disease that causes high eye pressure in the eyeball that presses onto the optic nerve head resulting in permanent visual field loss. Glaucoma can be divided into angle closure glaucoma and open angle glaucoma. Treatment of glaucoma can be eye drops, tablets, laser treatment or surgery intervention. Signs: Typically, there are no signs and symptoms as disease progress gradually. Acute angle closure glaucoma: - Red eye - Eye Pain - Nausea and vomiting - Headache Open angle glaucoma: - Seeing halos - Watery eyes - Pain around the eye - Fluctuating eye pressure Age-Related Macular Degeneration Suspect Age-related Macular degeneration (AMD) is the damage of the macula, a small spot near the centre on the retina responsible for our sharpest vision. There are two types of AMD, dry AMD and wet AMD. There is currently no treatment for dry AMD. Patients are advised to take supplements like anti-oxidant, beta carotene and omega-3 fatty acids to slow down progression of disease. Wet AMD is usually treated with injections or laser treatments to seal dry AMD of vessel leakages and stopping Dry AMD is the breakdown of the abnormal vessel growth light-sensitive cells, causing intravitreal anti-VEGF injection: visual loss. ● macugen wet AMD ● lucentis Wet AMD is a degeneration of ● avastin the retina caused by abnormal ● eyelea growth blood vessels that leak intravitreal anti-VEGF stops the fluid or blood into the region of growth of abnormal vessels hence the macula reducing the leakage of fluids onto the retina Ihotodynamic therapy: ● seal of leaky vessels without killing of macula cells ● do not reduce abnormal vessel growth laser photocoagulation: ● seal off leaks of vessels ● kills of healthy macula cells too ● not commonly used anymore Retinopathy: Diabetic Retinopathy It is one of the leading cause of legal blindness among patients. Management: Treat underlying causes, manage and control diabetes. → Prevention of DR Occurs when elevated blood sugar levels cause blood vessels Treatments: in the eye to swell, be damaged and leak into the retina. - Early stages of diabetic retinopathy often can be treated with laser surgery called photocoagulation.This procedure seals the blood vessels to prevent them from leaking or growing. - Advanced stages of diabetic retinopathy, it can be treated by vitrectomy. A surgery where it removes scar tissue, blood, and cloudy fluid from inside the eye Signs and Symptoms: - Floaters - Blurred Vision - Blank or dark areas in field of vision - Poor night vision - Vision loss Risk Factors: - Long duration of diabetes - Pregnancy - Poor Metabolic Control - Hypertension - Renal Disease - Obesity Prognosis: Photocoagulation: - Unable to restore lost vision. - Chances of blindness can be lowered up to 90% Vitrectomy - Able to improve your vision. - Hyperlipidemia - Anaemia - Smoking Types of Diabetic Retinopathy: •Mild nonproliferative diabetic retinopathy (NPDR) •Moderate NPDR •Severe NPDR •Very Severe NPDR Proliferative diabetic retinopathy (PDR) -CSME: Clinically Significant Macular Edema Clinical Signs: - Micro aneurysms - IRMA (Intraretinal Microvascular Abnormalities) - Intraretinal haemorrhages - Exudates - Cotton wool spots - Venous beading - Neovascularization - Pre-retinal haemorrhages - Vitreous haemorrhage - Traction retinal detachment - Macular Edema Retinopathy: Hypertensive Retinopathy Hypertensive Retinopathy is the damage to the retina caused by Hypertension in the eye. High blood pressure causes the blood vessel in the retina to be damaged. Therefore putting pressure on the optic nerve. This causes vision issues. Signs: ● ● ● ● Microaneurysms Retina & macular oedema Retinal hemorrhages Retinal lipid deposits Control hypertension ● Diet changes ● Medications ● ● Cotton-wool spots Nipping of A/V Symptoms: ● Sudden vision loss ● Headaches ● Double vision ● Dim vision References: 1. What is a pinguecula and a pterygium?. (n.d.). Retrieved from http://www.geteyesmart.org/eyesmart/diseases/pinguecula-pterygium.cfm 2. Chitra Badii: Making Sense of Hypertensive Retinopathy (Aug, 2012). Retrieved on 21/1/14 from http://www.healthline.com/health/hypertensive-retinopathy 3. Kean Theng Oh: Ophthalmologic Manifestation of Hypertension (Sept, 2012). Retrieved on 21/1/14 from http://emedicine.medscape.com/article/1201779-overview#a11 4. MedicineNet.com (1996) Glaucoma Retrieved on 21 January 2014 from http://www.medicinenet.com/glaucoma/page4.htm#what_are_glaucoma_symptoms_and _signs 5. What's the relationship between arcus senilis and high cholesterol (2014) retrieved from http://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/expertanswers/arcus-senilis/faq-20058306 6. Pterygium. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002006/ 7. National Eye Institute. Age-Related Eye Diseases and Conditions: See well for a Lifetime. Retrieved on 26 January 2014 from http://www.nei.nih.gov/nehep/programs/visionandaging/materials/VandAToolkit_Mod2_P owerpoint_508.pdf 8. Prabhakar, D. (2012). Diabetic Retinopathy. Retrieved on 26 January 2014 from http://www.slideshare.net/drdevin/16-sep-2012-phfi 9. Nazario, B. (2011). Diabetes Complications: Eye Problems and Blindness. Retrieved on 26 January 2014 from http://www.webmd.com/diabetes/ss/slideshow-eye 10. Kalra, P. (2012). Diabetic Retinopathy. Retrieved on 26 January 2014 from http://www.slideshare.net/paavankalra/diabetic-retinopathy-12254969 11. Aggarwal, G. (2012). Diabetic Retinopathy. Retrieved on 26 January 2014 from http://www.slideshare.net/drgarima9/diabetic-retinopathy-15800903 12. Keenan, J. P. (n.d.). Retrieved on 26 January 2014 from http://www.webmd.com/eyehealth/cataracts/health-cataracts-eyes