EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Emily’s eyelid swelling?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features suggest a more serious eye condition?
• Prompt: What initial investigations would you consider if red flags were present?

Q3. How would you manage Emily’s condition?

• Prompt: What conservative and pharmacological treatment options would you consider?
• Prompt: When would surgical intervention be required?

Q4. Emily is concerned about recurrence and cosmetic impact. How would you counsel her?

• Prompt: How can she reduce the risk of recurrence?
• Prompt: What is the likelihood of long-term scarring or need for surgery?

Q5. What preventive strategies can Emily implement to maintain eyelid health?

• Prompt: How can she modify her contact lens use and screen time habits?
• Prompt: What role does eyelid hygiene play in prevention?

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THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Emily’s eyelid swelling?

Emily’s most likely diagnosis is a stye (hordeolum), given the acute onset, localised tender eyelid nodule, and absence of systemic symptoms.

Key Differential Diagnoses:

1. Stye (Hordeolum) (Most Likely) – Acute, painful, tender swelling near the eyelid margin, due to infected sebaceous gland (external) or meibomian gland (internal).
2. Chalazion – Chronic, painless, non-tender eyelid lump, due to blocked meibomian gland.
3. Blepharitis – Diffuse eyelid inflammation, irritation, and crusting, often associated with dry eyes or rosacea.
4. Preseptal Cellulitis – Diffuse eyelid swelling, warmth, erythema, but no pain with eye movement or visual changes.
5. Orbital Cellulitis (Emergency) – Proptosis, ophthalmoplegia, pain with movement, fever, requiring urgent referral.

Further assessment will confirm the diagnosis and guide treatment.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Severe eyelid swelling with systemic symptoms (concern for orbital cellulitis).
• Painful eye movements, proptosis, or restricted eye movement.
• Blurred vision, diplopia, or reduced visual acuity.
• Eyelid swelling extending beyond the localised lesion.
• Recurrent or non-resolving lesions despite conservative treatment (concern for sebaceous carcinoma).

Recommended Investigations (if red flags present):

• CT orbit – If concern for orbital cellulitis or deep abscess.
• Blood cultures, inflammatory markers (CRP, WCC) – If systemic infection suspected.
• Eyelid swab for bacterial culture – If recurrent or non-resolving lesions.

Emily has no red flags, so conservative treatment is appropriate.

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Q3: How would you manage Emily’s condition?

1. Conservative Treatment (First-Line):

• Warm compresses 3–4 times daily to promote drainage.
• Eyelid hygiene (baby shampoo diluted in warm water).
• Avoid eye makeup and contact lenses until symptoms resolve.

2. Pharmacological Therapy (If Secondary Infection Suspected):

• Topical antibiotics (chloramphenicol 0.5% eye drops QID or ointment BD for 7 days) if persistent discharge or secondary infection.
• Oral antibiotics (flucloxacillin 500mg QID for 7 days) if preseptal cellulitis or widespread erythema present.

3. When to Consider Surgical Intervention:

• If stye persists >2 weeks despite conservative treatment, consider incision and drainage.
• Recurrent chalazion may require referral to ophthalmology for excision.

4. Follow-Up and Monitoring:

• Review in 1–2 weeks to assess symptom improvement.
• Escalate care if red flags or worsening symptoms develop.

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Q4: Emily is concerned about recurrence and cosmetic impact. How would you counsel her?

1. Acknowledge Concerns & Provide Reassurance
   • “Most styes resolve within 1–2 weeks with conservative management.”
   • “There is minimal risk of scarring unless secondary infection occurs.”
2. Explain Risk Factors for Recurrence
   • Blepharitis, rosacea, and meibomian gland dysfunction increase risk.
   • Contact lens use and poor eyelid hygiene contribute to recurrence.
3. Preventive Strategies to Reduce Recurrence:
   • Regular eyelid hygiene (warm compresses, lid scrubs).
   • Avoid sharing eye makeup and replace old products.
   • Ensure proper contact lens hygiene and limit prolonged wear.
4. Discuss Cosmetic Considerations
   • “Most styes leave no long-term marks, but persistent chalazion may require minor surgical excision.”

Addressing patient concerns helps improve adherence to treatment and prevention strategies.

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Q5: What preventive strategies can Emily implement to maintain eyelid health?

1. Eyelid Hygiene:
   • Daily warm compresses to prevent meibomian gland blockage.
   • Gentle eyelid cleaning with diluted baby shampoo or commercial eyelid wipes.
2. Contact Lens Care:
   • Avoid wearing contact lenses during active infections.
   • Proper lens cleaning and storage to prevent bacterial contamination.
3. Managing Risk Factors:
   • Control dry eyes with artificial tears if needed.
   • Reduce screen time and follow 20-20-20 rule to prevent eye strain.
4. Regular Eye Examinations:
   • Annual optometrist reviews if recurrent issues.
   • Early intervention for persistent blepharitis or chalazion.

By adopting eyelid hygiene and lifestyle modifications, recurrence risk can be minimised.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing stye, chalazion, and blepharitis from serious causes.
• Identification of red flags, ensuring urgent referral if needed.
• Structured evidence-based management plan, including conservative measures, antibiotics if required, and potential surgical intervention.
• Clear patient-centred counselling, addressing concerns about recurrence, cosmetic impact, and long-term prevention.
• Preventive strategies, including eyelid hygiene, contact lens care, and reducing eye strain.

PITFALLS

• Failing to assess for red flags, missing orbital cellulitis or serious underlying pathology.
• Overprescribing oral antibiotics, when conservative treatment is sufficient.
• Not advising on eyelid hygiene, leading to increased recurrence risk.
• Delaying ophthalmology referral for persistent or recurrent chalazion.
• Lack of structured follow-up, missing treatment failure or complications.

REFERENCES

• RACGP – RACGP Clinical Guidelines for Management of Eyelid Conditions
• GP Exams – Blepharitis/stye/chalazion

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Takes a structured ophthalmic history.
1.2 Provides clear explanations of the diagnosis, treatment, and prevention.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic eye examination, including eyelid and ocular surface assessment.
2.2 Differentiates between benign and serious causes of eyelid swelling.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses blepharitis, stye, or chalazion based on clinical features.
3.2 Determines when further investigations or referral to an ophthalmologist is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate treatment plan, including conservative and pharmacological options.
4.2 Provides advice on self-care and prevention.

5. Preventive and Population Health

5.1 Educates on eyelid hygiene and preventive strategies to reduce recurrence.

6. Professionalism

6.1 Provides empathetic care and addresses patient concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation, prescribing, and follow-up.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD