Ophthalmic Education:
Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist: Chapter 7. Glaucoma
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- Basic Level Goals: PGY-2
- Standard Level Goals: PGY-3
- Advanced Level Goals: PGY-4
Basic Level Goals: PGY-2
A. Cognitive Skills
- Describe the epidemiology and genetics of primary open angle glaucoma (POAG).
- Perform evaluation of POAG.
- Describe the mechanics of aqueous humor dynamics and the anatomy of the anterior chamber and its angle, and of the ciliary body.
- Describe basic tonometry and understand the principles of tonography.
- Describe optic nerve and nerve fiber layer anatomy in glaucoma.
- Describe fundamentals of perimetry, including kinetic and automated static perimetry.
- Describe principles, indications, and basic techniques of gonioscopy, including normal and abnormal findings.
- Describe principles of medical management, including indications for and side effects of treatment options (e.g., topical and systemic medications) for simple glaucoma (e.g., POAG, primary angle closure glaucoma).
- Describe and recognize normal tension glaucoma ("low tension glaucoma").
- Describe the features of and recognize primary and secondary angle closure glaucoma and aqueous misdirection.
- Recognize hypotony and describe the clinical features (e.g., Seidel test for transconjunctival leakage).
- List the main results of the major clinical trials in glaucoma (e.g., Glaucoma Laser Trial, Normal Tension Glaucoma Study, and Advanced Glaucoma Intervention Study [see Appendix]).
B. Technical/Surgical Skills
- Perform basic tonometry (e.g., applanation, Schiotz [if applicable], tonopen, airpuff) and recognize the pitfalls and artifacts of the testing.
- Perform basic gonioscopy (e.g., recognize angle structures, identify angle closure).
- Perform stereo examination of the optic nerve, using 90 diopter or other lens.
- Interpret manual (e.g., Goldmann) and automated (e.g., Humphrey, Octopus) visual fields in routine glaucoma.
- Perform corneal pachymetry and relate the findings to interpretation of intraocular pressure.
Standard Level Goals: PGY-3
A. Cognitive Skills
- Describe the epidemiology and perform screening for routine and more advanced primary and secondary open angle glaucoma.
- Describe the treatment of disturbances of aqueous humor dynamics.
- Describe the more complex etiologies for, evaluation of, and treatment of glaucoma (e.g., angle recession, inflammatory, steroid-induced, pigmentary, pseudoexfoliative, phacolytic, neovascular, postoperative, malignant, lens particle glaucomas; plateau iris; glaucomatocyclitic crisis; iridocorneal endothelial syndromes; aqueous misdirection).
- Describe more advanced tonometric and tonographic (if applicable) methods (e.g., diurnal curve).
- Describe more advanced optic nerve and nerve fiber layer anatomy in primary and secondary glaucoma and recognize typical and atypical features associated with glaucomatous cupping (e.g., rim pallor, rapid progression, central acuity loss, hemianopic or other non-glaucomatous types of visual field loss).
- Describe more advanced forms of perimetry (e.g., kinetic and automated static visual fields) and perimetry strategies (e.g., threshold testing, supra-threshold testing, special algorithms).
- Describe the principles, indications, and more advanced anatomic findings and gonioscopic features of primary and secondary glaucomas (e.g., plateau iris, appositional closure).
- Describe the principles of medical management of more advanced glaucomas (e.g., advanced POAG, secondary open and closed angle glaucomas, normal tension glaucoma)
- Describe the features of, recognize, and treat primary angle closure glaucoma and aqueous misdirection.
- Describe the clinical features of, recognize, and treat less common etiologies of ocular hypotony.
- Describe the results and apply the conclusions to clinical practice of the major clinical trials in glaucoma (e.g., Glaucoma Laser Trial, Normal Tension Glaucoma Study, and Advanced Glaucoma Intervention Study [see more complete list of clinical trials in Appendix 1]).
- Recognize and treat the various adult secondary glaucomas.
- Describe the features of primary infantile and juvenile glaucomas.
- Describe and apply specific medical treatments of more advanced glaucoma.
- Describe the principles of laser treatments of glaucoma (e.g., indications, techniques, and complications, and use of various types of laser energy, spot size, laser wavelengths).
- Describe the surgical treatment of glaucoma: (e.g., trabeculectomy, combined cataract and trabeculectomy, setons, and cyclodestructive procedures, including indications, techniques, and complications).
B. Technical/Surgical Skills
- Perform YAG laser posterior capsulotomy for uncomplicated posterior capsule opacity.
- Perform argon or YAG laser peripheral iridotomy for routine angle closure glaucoma.
- Perform argon laser trabeculoplasty.
- Perform cyclophotocoagulation.
- Perform routine first trabeculectomy with or without antimetabolites.
- Describe and manage a flat anterior chamber.
- Perform routine revision of filtering blebs.
Advanced Level Goals: PGY-4
A. Cognitive Skills
- Describe the features of the most complex and most advanced forms of primary and secondary open angle glaucoma.
- Describe the mechanics of aqueous humor dynamics in the most advanced and complex etiologies of glaucoma (e.g., angle recession, combined or multifactorial glaucoma, traumatic or inflammatory glaucoma, pigmentary dispersion glaucoma).
- Apply in clinical practice tonometric and tonographic methods (e.g., diurnal curve) in complicated or atypical cases of glaucoma.
- Apply the most advanced knowledge of optic nerve and nerve fiber layer anatomy and describe techniques, methods, and tools for analyzing the nerve fiber layer.
- Recognize and evaluate atypical or multifactorial glaucomatous cupping (e.g., rim pallor).
- Describe, interpret, and apply the results of the most complex and advanced forms of perimetry, including special kinetic and automated static perimetry strategies (e.g., special algorithms) in atypical or multifactorial glaucoma.
- Describe the principles and indications, and apply to clinical practice the findings of gonioscopy in the most complex primary and secondary glaucomas.
- Describe the principles of medical management of the most advanced and complex glaucoma (e.g., advanced POAG previously treated with medicine, laser or surgery; secondary glaucomas).
- Describe, recognize, and treat the most advanced cases of primary open angle glaucoma (e.g., monocular patients, repeat surgical cases), normal tension glaucoma, and secondary glaucomas (e.g., inflammatory glaucoma, angle recession).
- Describe the features of, recognize, and treat the most advanced cases of primary angle closure glaucoma and complex glaucomas (e.g., postoperative cases, secondary angle closure, aqueous misdirection).
- Describe the clinical features of ocular hypotony, and recognize and treat common and uncommon etiologies (e.g., choroidal detachment, leaking trabeculectomy bleb).
- Describe the results, apply the conclusions, and critically analyze the major clinical trials in glaucoma (e.g., Glaucoma Laser Trial, Normal Tension Glaucoma Study, and Advanced Glaucoma Intervention Study), as well as describe and use other publications in the management of glaucoma patients (see Appendix 1).
- Recognize and treat uncommon adult secondary glaucomas.
- Describe the features of and treat or refer the primary infantile and juvenile glaucomas.
- Describe and apply specific medical treatments in the most complex and most advanced glaucoma cases (e.g., refractory glaucoma, monocular patients, non-compliant patients).
- Describe the principles, indications, and complications of laser treatment of more advanced or complex glaucoma (repeat procedures).
- Describe the more advanced surgical treatment of glaucoma: (e.g., trabeculectomy, combined cataract and trabeculectomy, setons, and cyclodestructive procedures, including indications, techniques, and complications).
B. Technical/Surgical Skills
- Perform YAG or argon laser procedures in glaucoma patients (e.g., monocular patient, repeat laser, vitreous lysis, suture lysis).
- Perform laser peripheral iridotomy for more advanced glaucoma (e.g., monocular patient, acute angle closure, hazy cornea).
- Perform laser treatments (e.g., argon laser trabeculoplasty, iridoplasty) for more advanced glaucoma cases (repeat treatments, monocular patient).
- Perform cyclophotocoagulation for more advanced cases (e.g., prior surgery, monocular).
- Perform routine and repeat trabeculectomy with or without antimetabolites.
- Describe, manage, and treat surgically, if necessary, a flat anterior chamber.
- Perform more advanced techniques for the revision of filtering blebs (e.g., failing bleb, leaking bleb)
- Recognize and treat complications of glaucoma surgery blebs.
Next: Chapter 8. Neuro-Ophthalmology
Also see: Table of Contents of the Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist
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