As it’s the start of the pre-reg year, I thought I’d do an “in depth” post on each of the visits, both Stage 1 and 2.  I’ll start at the beginning: Visit One.

Your first visit usually happens when you’ve been in practice for 4 weeks.  The visit seems to be mainly focussed on introducing you to your assessor (and vice versa), seeing how you are fitting into practice, and making sure you are seeing a reasonable number of patients.  The last part is very important as I know some pre-regs who spent the first few weeks dispensing and then struggled to find relevant patient episodes – this seems to happen sometimes in practices with more than one pre-reg.

The College will send you out a letter with your Stage 1 assessor’s name on it.  When you find this out, ask your supervisor if they know them.  In fact, ask everyone if they know them.

If you manage to find a pre-reg from the previous year who had them as an assessor then you’ve hit the jackpot.  If possible, take that person out for a coffee and chat to them about their experience with your assessor.  It was during one of these chats (in work, alas, not a coffee house) that I found out that my assessor was really into safety glasses.  Yup.  Weird but true.  She apparently asked a previous pre-reg what material squash glasses frames were made from (grilamid).  She was also really into her low vision aids and recommended that I download and look through the Eschenbach catalogue (which is pretty amazing) – but that’ll come up in Visit 3.

Like all your assessor visits, Visit 1 involved a mixture of practical skills, scenarios and questions.  Let’s look at the practical skills first:

 

3.1.1 Uses instruments to measure corneal curvature and assess it’s regularity

Well, hopefully, you can use a keratometer.  After working in a practice for the last year that had an automatic keratometer (as part of the autorefractor), I’m a little rusty with my B&L and Javal Schiotz.  Before my OSCEs, I did a quick google on how to use each one and then read the appropriate sections in David Elliot’s Clinical Procedures in Primary Eye Care (a book I highly recommend).

Now, your assessor might ask you to interpret the readings you get.  Remember that the larger number is the flatter meridian.  You might get something like this:

R 7.9 @ 180   7.5 @ 90

L 7.6 @ 45      7.3 @ 135

Now, for the right eye, is that with the rule astigmatism? Yup. Remember @ 90 = x180.

What would you call the astigmatism in the left eye? Oblique.

How much of a cyl is there in each eye? I guarantee that they’ll ask this. You should remember that there’s 0.25DC for every 0.05mm difference in curvature.  So, in the right eye, we have 0.4mm difference which would be (0.4/0.05)*0.25DC=2.00DC.  My assessor said that an easier way of doing it was to remember 1.00DC = 0.2mm.  You can try the left eye yourself.

What type of lens would you fit? Depends.  Anyone with a cyl that’s -0.75DC or above should be fitted with a toric soft lens OR you could fit a spherical RGP (the tear lens will take care of astigmatism up to a couple of dioptres).  For RGPs, ignore the voodoo methods* of determining base curves that you were taught in uni and just fit on the flattest K.

Also, in case you are asked: the keratometer measures the central 3mm of the cornea and you can use it to assess the tear film (by judging the clarity of the mires).

*Like “take the difference in Ks between flattest and steepest, divide by 3 and then add to steepest meridian”.  I told my supervisor this and he was like “LOL Wut” (disclaimer: I’m paraphrasing a bit there).

 

3.1.7 Assesses the tear film

Okay, if you read the assessment framework, there’s a couple of things that stands out: SAFE METHODS and DIFFERENTIATES BETWEEN NORMAL AND ABNORMAL.  Sorry if it looked like I was shouting those things at you.

For more about dry eye, have a look at my dry eye post.  I’ll just keep it simple here:

1) Lights ON for instilling FLUO. Safety!

2) Try not to poke your px in the eye with the strip of FLUO (ask them to look up and away then gently touch the inferior nasal bulbar conjunctiva with the strip parallel to the conj).  If you want to see a corneal paper cut then have a look at this:

papercut

In case you are wondering: a piece of wadded up paper bounced off the the lip of the patient’s bin and caught her in the eye.  Yes, it was very sore.

3) In fact, before you do anything with FLUO, you can check the tear meniscus.  It should be around 0.3mm in height and even across the lower lid.  If you want to be really posh, you can turn your slit lamp beam horizontal, focus on the meniscus, make the beam the same width as the meniscus then read off the beam width.  I would preface this by saying: the more stuff you attempt to do in your assessment, the more chance of something going wrong.  Don’t suddenly try something new during your assessment – if you want to do this, practise it a few times first.

4) <10s FTBUT is dry, <5s is severely dry and <1s is my right eye.

Your assessor might ask about your treatment of dry eye.  Don’t treat if it is asymptomatic, think about drops (hypromellose QDS) for aqueous deficient and warm compresses and lid massage for evaporative.

 

3.1.9 Assesses pupil reactions

Dim lights to a level where you can still make out the difference between pupil and iris (if you have a blue or green eyed person to do pupil reactions on then great, it’s so much easier than someone with dark brown eyes).

Bring pen torch up from the inferior temporal side to shine into pupil then remove light, repeat three times, watching for direct and consensual response.  Note if the response is brisk, slow or absent.

Are the pupils equal and round?

Now you do the swinging flashlight test.  The main issue you’ll have with this test is being too fast.  You need to move the light quickly across from one eye to the other but then wait a couple of seconds to see if there is dilation**.  I count “One. Mississippi. Two. Mississippi” in my head when doing this as I had feedback that I wasn’t allowing enough time for the pupil to dilate.

**there’s always a tiny bit of dilation because it takes a moment for you to swing the flashlight over.  The eyes will both dilate a bit but then should constrict again.  An RAPD looks weird and is difficult to miss if you are paying attention.

Oh, and my assessor asked me what RAPD stood for and what that actually it meant.  In preparation, I had revised all the pupil reactions notes I had from uni as well as consulting Mr Elliot’s fabulous tome and Root Atlas (google it, it’s amazing).

You will need to show your assessor a record card that has pupils on it.  Now, you should be doing pupils on all your patients so this shouldn’t be a problem.  Make sure you are getting the patient’s consent and marking it on the card as VCG or OCG if verbal or getting them to sign the card.

Don’t worry if you haven’t managed to see an RAPD in your first month in practice.  I think I saw three in a whole year (two of them were long standing and one of them was my supervisor’s patient that she called me in to see).

 

4.1.2 Measures and verifies optical appliances taking into account relevant standards where applicable

If you’ve read some of my previous posts, you’ll know that I don’t do well with focimetry.  I don’t know why – I’m fine with every other machine in practice***, in fact, I practically have joy of machines.

Anyway, before my Visit 1, our NQ Optom told me to hide the manual focimeter.  I didn’t, taking the stance that, even if I suck at focimetry, I should be honest about it.  After all, it’s part of the job.

After deciding to take the bull by the horns and practise verifying glasses, I discovered that our focimeter was broken.  It wasn’t broken in a catastrophic way, just in a lot of small ways that made it difficult to use.  It was temperamental, needing some love and attention that I wasn’t happy providing.  I think it sensed that I hated it so it seemed to become more temperamental as time went on.

Now, the competency says “verifies” and apparently assessors are supposed to give you an Rx and ask if the specs you’re measuring are made to that Rx (within BS tolerances).  My assessor just whipped out a spare pair of her specs (a tiny pair of rimless varis) and asked me to check the Rx.   They were Nikon lenses (which we don’t do in practice because our DO doesn’t like them) but I didn’t recognise the symbol so there was lots of wasted time as I searched for little sheet that would allow me to mark up the lenses (which we didn’t have because we don’t do those lenses, sigh).  I finally came up with an answer, which my assessor seemed happy with, so I managed to pass.  She did comment that I was very confident during my assessment, until that point, where I seemed to just fall apart.

***except the hand held Pulsair but I’m sure everyone hates that.

 

I’ll stop there for the moment and put all the non-practical parts of Visit 1 in a separate post.

 

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