CCE-CBD-154

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Sarah’s red eye?

• Prompt: Explain how you differentiate between benign and serious causes.
• Prompt: What features would prompt urgent ophthalmology referral?

Q2. How would you confirm the diagnosis of episcleritis in this rural setting?

• Prompt: Discuss examination findings and use of diagnostic tools (e.g., phenylephrine test).
• Prompt: How do you exclude more serious pathology?

Q3. What is your management plan for Sarah?

• Prompt: Include pharmacological and non-pharmacological management.
• Prompt: Discuss safety netting and red flags for immediate review.

Q4. Would you investigate for underlying systemic disease at this stage?

• Prompt: What conditions would you consider?
• Prompt: How would rural access influence your decision?

Q5. How would you address Sarah’s concerns about potential vision loss?

• Prompt: Discuss communication strategies to reassure and educate.
• Prompt: Explain long-term prognosis and follow-up.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

---

Q1: What are your differential diagnoses for Sarah’s red eye?

Answer:

When assessing Sarah’s red eye, several differential diagnoses need to be considered. A systematic approach is essential to differentiate benign causes from sight-threatening emergencies.

Differential Diagnoses:

• Episcleritis (likely diagnosis): Typically presents with sectoral redness, mild discomfort, and no vision changes.
• Scleritis: More severe pain, potential visual impairment, may not blanch with phenylephrine drops. Often associated with systemic autoimmune diseases.
• Conjunctivitis (infective or allergic): Diffuse redness, possible discharge, itching (allergic), minimal pain.
• Keratitis: Painful, photophobia, possible corneal opacity, reduced vision.
• Acute Anterior Uveitis (Iritis): Photophobia, consensual photophobia, blurred vision, perilimbal redness.
• Angle-Closure Glaucoma: Acute painful red eye, nausea/vomiting, cloudy cornea, fixed mid-dilated pupil.
• Foreign body/corneal abrasion: Trauma history, FB sensation, positive fluorescein staining.

Key Differentiating Features:

• Pain severity: Mild in episcleritis vs. severe in scleritis.
• Photophobia and visual acuity: Absent in episcleritis but often present in more serious conditions.
• Pupil and intraocular pressure (IOP) changes: Normal in episcleritis, altered in acute glaucoma and iritis.
• Response to phenylephrine drops: Episcleral vessels blanch; scleral vessels do not.

Urgent referral indicators:

• Severe pain not relieved by simple analgesia
• Decreased visual acuity
• Hypopyon or corneal clouding
• Elevated IOP
• Significant photophobia
• Suspicion of scleritis, keratitis, or acute glaucoma

Guidelines referenced include RACGP Red Eye Assessment Guidelines and Therapeutic Guidelines: Ophthalmology.

---

Q2: How would you confirm the diagnosis of episcleritis in this rural setting?

Answer:

Confirmation in a rural setting involves a thorough history and examination, given limited access to ophthalmic tools.

History:

• Onset and duration: Gradual over 1–2 days typical of episcleritis.
• Pain: Mild, dull ache.
• Vision: No loss of vision or photophobia.
• Systemic disease history: Check for autoimmune diseases (family history of rheumatoid arthritis).

Examination:

• Visual Acuity: Normal in episcleritis.
• External Inspection: Sectoral redness, typically temporal or nasal.
• Conjunctiva/Cornea: Clear cornea, no discharge.
• Phenylephrine (2.5%) Test: Blanching of superficial episcleral vessels supports episcleritis.
• Pupil Response: Normal.
• IOP: Normal if measured.

Exclusion of serious pathology:

• Scleritis: Diffuse redness, severe pain, no blanching with phenylephrine.
• Keratitis: Fluorescein staining needed; negative in episcleritis.
• Iritis: Photophobia, ciliary flush, irregular pupil.

Given rural constraints, careful examination and red flags help rule out emergencies before confirming episcleritis.

---

Q3: What is your management plan for Sarah?

Answer:

General Principles:

• Reassure Sarah this is a benign, self-limiting condition.
• Educate about the condition, expected course (1–2 weeks), and potential recurrences.

Pharmacological Management:

• Topical lubricants (artificial tears): To relieve irritation.
• NSAIDs (e.g., ibuprofen 400 mg TDS): For symptomatic relief.
• Topical corticosteroids: Only under ophthalmologist advice, generally avoided in primary care.

Non-pharmacological Management:

• Cool compresses.
• Avoid triggers (e.g., environmental irritants).

Safety Netting:

• Return immediately if vision decreases, pain worsens, or symptoms persist beyond two weeks.
• Advise urgent review if photophobia or discharge develops.

Follow-up:

• Review in 1–2 weeks or earlier if concerns arise.

Referral:

• Not routinely needed unless atypical features or recurrent episodes suggest systemic disease.

---

Q4: Would you investigate for underlying systemic disease at this stage?

Answer:

Initial Assessment:

• As this is Sarah’s first episode and mild, immediate investigations are not always necessary.
• However, history (mother with RA) raises suspicion for autoimmune disease.

When to Investigate:

• Recurrent episodes.
• Bilateral involvement.
• Signs of scleritis.

Possible Investigations:

• Full blood count, ESR, CRP.
• ANA, RF, anti-CCP.
• Consider HLA-B27 if indicated.

Rural Context:

• Given limited access, primary investigations may be initiated in consultation with a rheumatologist.
• Early referral if systemic autoimmune disease is suspected.

---

Q5: How would you address Sarah’s concerns about potential vision loss?

Answer:

Communication Strategies:

• Provide reassurance: Episcleritis does not cause vision loss.
• Explain that her vision is currently 6/6 and unaffected.
• Use clear, empathetic language.

Education:

• Describe the eye’s anatomy and how episcleritis differs from conditions that threaten sight.
• Emphasise self-limiting nature and benign prognosis.

Action Plan:

• Safety netting: When to return.
• Encourage questions and provide written information.

Long-term Prognosis:

• Episcleritis is often self-limiting.
• Recurrence possible, but management effective.
• Address her anxiety: Offer follow-up appointment for reassurance.

---

SUMMARY OF A COMPETENT ANSWER

• Clear differentiation between benign and serious red eye causes.
• Thorough history and examination to confirm episcleritis.
• Comprehensive management plan with both pharmacological and non-pharmacological interventions.
• Rational approach to investigation in a rural context.
• Empathetic reassurance addressing the patient’s concerns about vision.

---

PITFALLS

• Failure to exclude sight-threatening causes like scleritis or acute glaucoma.
• Omitting phenylephrine blanching test, missing diagnostic confirmation.
• Inappropriate use of corticosteroids without specialist input.
• Inadequate safety netting, risking missed progression.
• Neglecting the potential systemic link, especially with autoimmune history.

---

REFERENCES

• RACGP Guidelines on Red Eye Assessment
• Mayo Foundation for Medical Education and Research on Ophthalmology (2024 update)
• Murtagh’s General Practice 8th Edition (Chapter on Ophthalmology)

---

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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health needs and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.
3.2 Demonstrates diagnostic reasoning.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Prescribes and monitors therapies appropriately.

5. Preventive and Population Health

5.1 Provides care that includes health promotion and illness prevention activities.

6. Professionalism

6.1 Adopts a patient-centred approach to care.
6.2 Demonstrates ethical practice.

9. Managing Uncertainty

9.1 Manages uncertainty in diagnosis and management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages the patient with an urgent eye condition (to exclude).

12. Rural Health Context (RH)

RH1.1 Provides comprehensive, evidence-based care appropriate to rural settings.

Competency at Fellowship Level

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