CCE-CBD-165

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the most important diagnoses to consider in Sarah’s case, and how do you differentiate them?

• Prompt: Discuss the differential diagnosis and reasoning
• Prompt: Highlight red flags that need urgent referral
• Prompt: Discuss the relevance of her history of gardening and contact lens use

Q2. What are your immediate management steps for Sarah in this rural practice setting?

• Prompt: Discuss treatment, including eye protection, antibiotics, and pain management
• Prompt: Outline follow-up plans and safety netting

Q3. How would you counsel Sarah about preventing similar eye injuries in the future?

• Prompt: Discuss the role of protective eyewear
• Prompt: Include lifestyle and occupational health advice

Q4. When should Sarah be referred to an ophthalmologist?

• Prompt: Explain criteria for urgent vs non-urgent referral
• Prompt: Discuss rural considerations in referral pathways

Q5. What potential complications should you monitor for in Sarah’s case?

• Prompt: Discuss risks of secondary infection and delayed healing
• Prompt: Explain complications of corneal abrasion

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the most important diagnoses to consider in Sarah’s case, and how do you differentiate them?

Answer:

In Sarah’s case, the primary concern is identifying the cause of her abnormal eye sensation, which presents as a gritty feeling, tearing, photophobia, and decreased visual acuity.

Key Differential Diagnoses:

• Corneal Abrasion (most likely):
  • History: Acute onset following foreign body exposure (gardening).
  • Symptoms: Foreign body sensation, tearing, photophobia.
  • Examination: Positive fluorescein stain with linear epithelial defect.
• Corneal Foreign Body:
  • History: Direct history of something entering the eye.
  • Examination: Visualised foreign body on slit lamp or eyelid eversion. None found here.
• Infective Keratitis:
  • Risk factors: Contact lens use (although Sarah wasn’t wearing them at the time).
  • Symptoms: Pain, photophobia, discharge.
  • Examination: Infiltrate or ulcer on the cornea with surrounding inflammation.
  • Red flag: Urgent referral required if suspected.
• Uveitis (Iritis):
  • Symptoms: Pain, photophobia, blurred vision.
  • Examination: Constricted pupil, cells in anterior chamber.
  • Less likely given history and absence of these signs.
• Conjunctivitis:
  • Symptoms: Redness, discharge, mild irritation.
  • Less likely due to photophobia and vision changes.

Red Flags to Consider:

• Vision loss not explained by abrasion.
• Severe pain disproportionate to findings.
• Corneal ulcer or infiltrate suggesting keratitis.
• Hypopyon, suggesting endophthalmitis.
• Evidence of penetrating trauma.

Sarah’s history of gardening without eye protection and a linear epithelial defect with fluorescein staining supports a diagnosis of corneal abrasion. However, vigilance for signs of secondary infection is necessary, particularly considering her history of contact lens use.

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Q2: What are your immediate management steps for Sarah in this rural practice setting?

Answer:

The immediate management focuses on symptom relief, preventing infection, and promoting healing.

Management Steps:

• Topical Antibiotics:
  • Choice: Chloramphenicol 0.5% eye drops, 1 drop every 2 hours initially, then reduce frequency as symptoms improve.
  • Alternative: Ointment at night for comfort.
• Pain Control:
  • Options: Oral analgesia (e.g., paracetamol or ibuprofen).
  • Cycloplegic drops (e.g., cyclopentolate) if photophobia is severe.
• Eye Protection:
  • Provide an eye patch only if necessary (not routinely recommended as it may delay healing).
• Avoid Contact Lens Use:
  • Advise Sarah not to wear contact lenses until fully healed.
• Education:
  • Importance of hand hygiene and avoiding touching the eye.
  • Signs of worsening infection (increased pain, discharge, vision changes).
• Follow-Up:
  • Review in 24-48 hours to assess healing.
  • If no improvement or worsening, consider referral.
• Documentation:
  • Record examination findings and management steps.

Rural Considerations:

• Discuss transport options if referral becomes necessary.
• Ensure access to follow-up (telehealth if available).

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Q3: How would you counsel Sarah about preventing similar eye injuries in the future?

Answer:

Counselling Sarah involves preventative education and lifestyle modifications.

Key Points:

• Protective Eyewear:
  • Emphasise the importance of wearing safety glasses during gardening, DIY, or any tasks with potential for eye injury.
• Contact Lens Hygiene:
  • Remind her about the risks associated with improper contact lens use.
  • Stress avoiding contact lenses during activities with a high risk of dust or debris.
• General Eye Safety:
  • Avoid rubbing eyes with dirty hands.
  • Seek medical attention early if symptoms occur.
• Occupational Advice:
  • As a teacher, she may not face significant risk, but encourage awareness and preparedness.
• Education on Eye Health:
  • Encourage regular eye checks, especially given her myopia.

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Q4: When should Sarah be referred to an ophthalmologist?

Answer:

Sarah should be referred to an ophthalmologist if:

Urgent Referral:

• Symptoms worsen despite treatment (pain, redness, vision loss).
• Signs of infective keratitis (white corneal infiltrates).
• Large or central corneal defects.
• Persistent epithelial defects after 72 hours.
• Evidence of foreign body not removable in GP setting.

Non-Urgent Referral:

• Recurrent corneal abrasions.
• Concerns about chronic dry eyes or ocular surface disease.

Rural Considerations:

• Consider access limitations and early referral if uncertainty.
• Liaise with local ophthalmology services or teleophthalmology.

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Q5: What potential complications should you monitor for in Sarah’s case?

Answer:

Complications to Monitor:

• Infective Keratitis:
  • Secondary infection, particularly in contact lens wearers.
• Corneal Ulceration:
  • If healing is delayed or infection develops.
• Scarring:
  • Leading to permanent vision impairment if the abrasion is large or infected.
• Recurrent Corneal Erosion Syndrome:
  • Potential in cases of large or slow-healing abrasions.
• Pain Management Issues:
  • Inadequate pain control impacting quality of life.

Follow-Up:

• Review Sarah within 48 hours.
• Ensure timely escalation if complications suspected.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis with reasoning.
• Appropriate immediate management including topical antibiotics and pain relief.
• Clear patient education on eye safety and injury prevention.
• Defined referral criteria aligned with rural considerations.
• Awareness of potential complications and appropriate follow-up plans.

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PITFALLS

• Missing serious diagnoses like infective keratitis or penetrating trauma.
• Failure to evert the eyelid to exclude retained foreign body.
• Inadequate follow-up advice leading to missed complications.
• Overuse of eye patching, which may delay healing.
• Neglecting to address preventive measures, such as eye protection.

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REFERENCES

• RACGP Guidelines
• Therapeutic Guidelines (Ophthalmology)
• Australian Prescriber on Corneal abrasions management
• Murtagh’s General Practice, 8th Edition

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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 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 findings accurately and comprehensively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.
3.2 Rationally selects and interprets relevant investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements a management plan collaboratively.
4.2 Provides appropriate emergency care.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses practice systems effectively and safely.

8. Procedural Skills

8.1 Performs procedural skills effectively.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty effectively.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients with potentially life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates understanding of rural healthcare challenges.

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Competency at Fellowship Level

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