Features
Core subject 1 - Communication skills
We continue our weekly look at the GOC core competencies by expanding our argument over the significance of good communication skills for accurate history and symptoms taking.
For the purposes of guiding the pre-registration optometrists through their year in practice, the GOC suggests a list of competencies within each core subject which need to be achieved as the year progresses (the first quarter requirements were outlined in this series - Optician, July 1, 2005). In order to demonstrate the ability to take an accurate history from a variety of patients with a range of optometric conditions, it is perhaps useful to think of some specific examples.
In order to teach or coach trainees in this discipline, most researchers have found the use of trained actors to be very useful. It is then appropriate to train the actor to understand their assumed problem, such that only through precise questioning might an appropriate assessment or management strategy be adopted. Such methods work well with small groups of trainees.
PATIENT WITH ANTERIOR UVEITIS
There are several reasons why this condition presents a challenge demanding accuracy of questioning. First of all, the wide range of presentations of uveitis in general is reflected in the variation of symptoms. A pars planitis may be asymptomatic, for example. Secondly, it is often stated that acute anterior uveitis has such characteristic symptoms that a careful questioning should readily identify the disease. Obviously, a similar list could be made for most ocular conditions, but this would be beyond the scope of a single article and represent a complete pathology text.
| Anterior uveitis needs careful questioning (Image courtesy of J Kanski, Clinical Ophthalmology, 4th edition, Butterworth-Heinemann) |
The symptoms suggestive of acute anterior uveitis (iritis and iridocyclitis) are:
Pain
This is typically a deep-pressure type of pain felt in or behind the eyeball. There may be an associated headache-like pain around the eye. More superficial pain or irritation, burning, itching or foreign-body awareness is usually denied by the patient. Though not a recommended procedure in an optometry clinic, a topical anaesthetic would have little impact upon the pain.
The pain is usually of sufficient severity to cause a spastic closure of the lid. In some instances, because of the subjective variation in response to pain, the patient may feel quite unwell, though this is highly patient specific. Pain is also notorious as a symptom in that one person's severe pain is another's 'stuff and nonsense'. Careful questioning, as well as experience with such presentations, is important.
Photophobia
This is usually present, though ranges from very mild to severe. The variation may depend upon subjective responses of the patient, the depth of spasm of the iris and to a lesser extent the severity of flare and lacrimation. The patient may simply find light uncomfortable, or may require lights to be reduced or extinguished altogether. The photophobia may also add to the need to close the eye, which may make examination of the anterior chamber very difficult.
Visual disturbance
Interestingly, visual reduction is usually more marked in chronic uveitis, even though the discomfort may be much more mild, if present at all.
In acute conditions, the vision may be normal or of varying degrees of haziness. The extent of the lacrimation may lead to variability in the vision upon blinking.
Lacrimation
This is usually present and may be so severe as to lead to tearing and epiphora. It is important that the secretion is examined for the presence of any mucus or purulent component, which may give clues of a secondary or a causative association, such as a severe infection.
Once these symptoms are established, they may be interpreted in the light of the well-known clinical signs:
The history may then complete the picture and establish the underlying cause:
Obviously the initial suspicion of acute anterior uveitis by an optometrist is sufficient to warrant immediate referral to an ophthalmologist, but the condition is used here to illustrate the way that symptoms alone may influence the clinical decision process. Compare this with the extreme severity of pain and the visual disturbance due to corneal oedema that would occur with acute angle-closure glaucoma.
The condition is very commonly associated with systemic disease. Very occasionally a patient inquires why an optometrist is asking about general health. It is always appropriate to underline that an eye examination is a 'health check' as well as a 'vision check' and, as such, knowledge of anything that may influence eye health is important. A good example to cite to the patient is always handy.
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