Conditions of the Eye

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the American Academy of Ophthalmology, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

The goal of these guidelines is to familiarize the family practice resident with the impact of ocular illness and dysfunction and to help the resident become aware of potential ophthalmologic damage from relatively innocent symptoms.

Family physicians remain committed to helping patients and their family members adjust to acute or chronic illnesses that may significantly affect daily life and family function. Therefore, family practice residents must learn to maximize visual function through the control of environmental factors, management of disease and preventive care. The resident must learn to minimize deterioration of function through the initiation of appropriate treatment, including rapid referral where necessary. Finally, the family practice resident must learn when social/psychological intervention is appropriate in patients with ocular dysfunction.

Attitudes

The resident should develop attitudes that encompass:

A supportive and compassionate approach to the care of the patient with ocular disease, especially in the case of someone with deteriorating vision.
Recognition of the effects of loss of visual function.
Recognition of the importance of the role of support systems in the health of patients with ocular disease.
Understanding of the role of the ophthalmic consultant, including identifying the different roles of ophthalmologists, optometrists, and opticians.

Knowledge

The resident should develop knowledge of:

Normal anatomy, physiology, development of aging of the eye and ocular function (see also Curriculum Guidelines for Care of the Older Adult)
Psychological and adaptive needs of patients with chronic ocular deterioration
Effects of drugs and toxins on ocular function and disease
Effects of ocular drugs on systemic function
Understanding of the ocular disability of elderly patients and the importance of regular assessment and maintenance of functional capacity (see also Curriculum Guidelines for Care of the Older Adult)
Ocular complications of systemic illness
Guidelines for appropriate intervals for vision evaluation from birth to senescence
Initial diagnosis, management, and appropriate referral criteria for common eye problems
1. Refractive errors
  1. Nearsightedness (myopia)
  2. Farsightedness (hyperopia)
  3. Presbyopia
2. Skin and adnexal disorders
  1. Infections
    1. Hordeolum
    2. Preseptal cellulitis
    3. Orbital cellulitis
    4. Dacryocystitis
  2. Inflammation
    1. Graves’ disease
    2. Chalazion
  3. Eyelid disorders
    1. Entropion and extropion
    2. Ptosis
  4. Benign tumors
    1. Milia
    2. Papilloma
    3. Keratoacanthoma
    4. Nevus
    5. Xanthelasma
    6. Dermoid
  5. Malignant tumors
    1. Basal cell carcinoma
    2. Squamous cell carcinoma
    3. Lymphoma
    4. Malignant melanoma
    5. Retinoblastoma
3. Conjunctival disorders
  1. Conjunctivitis
    1. Viral conjunctivitis
    2. Herpes simplex conjunctivitis
    3. Herpes zoster conjunctivitis and keratitis
    4. Bacterial conjunctivitis
    5. Allergic conjunctivitis
  2. Conjunctival nevus
    1. Pterygium
    2. Pinguecula
  3. Conjunctival tumors
4. Corneal diseases
  1. Superficial trauma/infections
    1. Corneal abrasion
    2. Keratitis
    3. Corneal ulcers
  2. Dry eye and associated diseases
5. Iritis
  1. Unequal pupils
  2. Afferent pupillary defect
  3. Adie’s pupil
  4. Horner’s syndrome
6. Cataracts
7. Glaucoma
8. Retinal disease
  1. Associated with visual loss
    1. Central retinal vein occlusion
    2. Branch retinal vein occlusion
    3. Central retinal artery occlusion
    4. Retinal detachment and vitreous hemorrhage
  2. Associated with medical conditions
    1. Hypertension
    2. Diabetes mellitus
  3. Macular degeneration
  4. Age-related changes
9. Optic nerve disorder
10. External muscular disorders
  1. Cranial nerve palsies
11. Trauma
  1. Blunt
  2. Penetrating
Appropriate indications for special procedures in ophthalmology and ophthalmoradiology
1. Fluorescein angiography
2. Ocular ultrasound
3. Visual field testing
4. Magnetic resonance imaging/Computed tomography of the eye
Implications of recommendation for refractive eye surgery
Prevention of eye injury and vision loss

Skills

Evaluation skills
1. Performance of specific procedures and interpretation of results
  1. Tests of visual acuity, visual fields, and test for occular motility
  2. Direct ophthalmoscopy
  3. Flashlight examinations
  4. Fluorescein staining of the cornea
  5. Tonometry
  6. Slit lamp examination
2. Performance of physical examination in patients from newborns to adults, with emphasis on understanding normal neurologic and motor responses as well as appearance
3. Using the clinical exam to localize the problem and generate the differential diagnosis and management planning
4. Formulating a rational plan of investigation and management, including assessment of severity and need for immediate expert assistance
Management skills
1. Formulating a plan of management, investigation and need for expert advice with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
2. Management and recognition of the prevalent and treatable diseases listed under "Knowledge" with consultation as appropriate
3. Management and coordination of psychosocial and family issues, including long-term care of debilitating ocular conditions, necessary environmental adaptation and use of community resources
4. Appropriate medications
5. Proper use of diagnostic tests and medications
  1. Mydriatics
  2. Topical anesthetics
  3. Corticosteroids
  4. Antibiotics
  5. Glaucoma agents

Implementation

Implementation of this core curriculum is best achieved within the capabilities of the particular residency program and at the discretion of the residency director. Experience should include the opportunity to provide direct patient care under supervision, with emphasis on common treatable problems, prevention of deterioration and ocular emergencies. Family practice residents planning to provide care to communities without readily available consultation resources may need additional training experience with specialist assistance.

Resources

Berson FG. Basic Ophthalmology for Medical Students and Primary Care Residents. San Francisco, CA: The American Academy of Ophthalmology, 1999.
Chawle HB. Ophthalmology: A Symptom-based Approach. Woburn, MA: Butterworth-Heinemann, 1999.
Trobe JD. The Physician's Guide to Eye Care. San Francisco, CA: The American Academy of Ophthalmology, 2000.
Vaughan D, Asbury T, Riordan-Eva P. General Ophthalmology. Stamford, CT: Appleton and Lange, 1999.
Wu G. Ophthalmology for Primary Care. Philadelphia, PA: WB Saunders, 1997.