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  • Tackling a Clinical Case You Have Never Seen Before

    Taking a clinical case you've never seen before.

    It’s 2 a.m. You’re in the middle of what feels like an endless call night. And in between triaging open globes, endophthalmitis and closed angles, you’re called to see a patient with … well, who knows what’s going on?

    Stay calm! We have all been there before. Thankfully, there are many resources and strategic steps available to help you tackle a clinical case you’ve never seen before.

    Write Down Pertinent Positives and Negatives

    List out parts of the clinical history and exam that you think could be relevant to the overall diagnosis.

    Focus especially on the ocular “vital signs”: pupils (presence of relative afferent pupillary defect, or RAPD), vision, pressure, motility/alignment and visual field. With neuro-ophthalmology complaints, consider checking color plates. Also, what could potentially be unique on the clinical exam? Try taking photos of the potential pathology on your phone to share with your senior resident and/or attending.

    The more data points you have, the better you can tackle what feels like a nebulous complaint.

    Rule Out Vision- and Life-Threatening Conditions

    Full stop.

    Do your due diligence to ensure that your patient does not have a condition that could cause them to permanently lose vision or lose their life.

    Pull Out Your Handy Online and Electronic Resources

    Online resources like EyeWiki and the University of Iowa’s EyeRounds are incredibly helpful for finding similar cases and following how to evaluate and manage a patient.

    The Wills Eye Manual is also available online to Academy members through the Academy website and has chapters dedicated to the differential diagnosis of ocular signs and symptoms, which can be incredibly helpful for generating a differential diagnosis.

    Escalate the Case

    When you are unsure of what’s going on, call in your senior. If you’re the senior, call your attending. If you’re an attending, call a colleague. Especially when you’re just starting, you’ll need to call for help. But do your due diligence before calling (see steps above). Put in the investigative effort first, and then escalate.

    Monitor Progress

    Especially when you’re unsure about the diagnosis or prognosis, it is essential to arrange for appropriate follow- up for patients in order to monitor their progress and assess their response to any treatments you’ve initiated.

    Document your findings meticulously for easy reference in the future as the case continues to evolve.

    Be honest with patients about the rarity or complexity of their condition. Ensuring that patients understand what’s happening fosters trust and compliance.

    Cherie Fathy MD with colleagues
    Dr. Fathy with her Wills Eye residency attendings: Zeba Syed, MD (cornea), Nadia Haqqie, MD (cornea), and Yoshihiro Yonekawa, MD (retina).

    Reach Out to Your Community

    The amazing thing about ophthalmology is that it really is a small, well-connected family. Subspecialties have listservs where people share difficult, puzzling cases to seek out the opinions of other ophthalmologists across the globe (for example, Keranet for cornea content). The Ophthalmology Moms Group also has several posts a day where complex cases are shared and advice is doled out respectfully. (Note: You do not need to be a mom to join!)

    Sometimes, tackling a clinical case also means recognizing your limits and referring the patient to a colleague. This is not a sign of weakness, but rather speaks to your professional integrity and patient-centered care.

    Facing an unfamiliar clinical scenario is an integral part of the learning curve in the early years as an ophthalmologist. Embrace these challenges as opportunities to enhance your diagnostic skills, expand your knowledge and ultimately provide better care for your patients.

    Remember, the mark of a skilled ophthalmologist isn’t just in knowing all the answers, but in knowing how to find them and apply them in clinical practice.


    Cherie A. Fathy, MDCherie A. Fathy, MD, joined the Academy in 2018. She completed her residency at Wills Eye Hospital in Philadelphia and her cornea fellowship at Wilmer Eye Institute at Johns Hopkins Hospital in Baltimore.