Recent News

Below I have written a guide that breaks down one of my own case studies; one that earned me a perfect score from my school’s program. Let’s start off with the introduction. Your goal is to clearly establish who the patient is, their reason for being studied, and their medical history (medications, general health, and especially the chief complaint). You want to include enough background to understand the context, but not analyse yet. Maintain a professional tone and stay factual.  You could add a sentence to indicate what the case study will illustrate.
 
GM is a 55-year old white male who has been referred to the ophthalmologist for cataract assessment and surgery. The patient’s only medical condition is granulome annulare which is treated with Topicort 0.25% topical cream, and is in good health otherwise without issues with cholesterol, hypertension, diabetes or respiratory problems. He denies use of nicotine. The patient appears to be in good form, and is not overweight nor suffering from any physical disabilities. 

His medical history was then transcribed. He has no known allergies or reactions to medication or medical products. GM responds that he has never had surgery (ocular or otherwise) or laser treatments such as LASIK or PRK when asked. 

GM’s chief complaint was a decrease in the visual acuity of his right eye. After meeting with his optometrist, he was diagnosed with a 3+ nuclear sclerotic cataract, and thus was referred to our clinic. GM reports a steady decrease in his visual acuity over the last three months, as well as cloudy vision and poorer vision while driving at night. 

I tend to not write executive summaries since they’re more implied. In the context of my work they’re redundant and the audience reads the whole study anyway. The few times I’ve included one are when the cases are more complex.

Now on to the preliminary exam / data collection. I’m not averse to a table to present data, but make sure it’s well formatted and flows well.

The routine preliminary exams were conducted. The patient’s visual acuity, intra-ocular pressure, corneal pachymetry and refraction were taken: 

	OD	OS
VA	20/200	20/20
IOP	12	11
Pachymetry	600	602
Refraction:	-7.00 / +1.00 x 60	-5.50 / +1.00 x 0

GM’s visual acuity confirmed that it was his right eye that was predominantly affected. His intra-ocular pressure fell within a normal range and his refraction revealed he has moderate to high myopia, and thus he was safe to dilate. His corneal pachymetry fell within a normal range as well. Following clinic procedure (the patient was referred by an optometrist with a precise diagnosis and not his family doctor), he was required to complete several exams before a surgery date could be reserved. After explaining the exams, fees, and options available (all patients are made aware that the exams have associated fees in a private clinic, but are covered under public health insurance in a hospital), GM opted to have the tests completed immediately before meeting the ophthalmologist. 

Three key things to take away from this section are the use of quantitative data and connecting data to interpretations (e.g. ‘His intra-ocular pressure fell within a normal range’). One thing my professor praised was including how the patient was making a decision in this process.

Clinic procedure requires four exams to be completed for a patient requiring cataract surgery: an optical coherence tomography (OCT), biometry, corneal microscopy, and a wavefront aberrometer. 

The patient’s OCT revealed no abnormalities related to glaucoma but did show lattice degeneration, and his specular microscopy showed a healthy endothelial cell layer with no signs of cell loss or trauma. GM’s OPD scan (below, left) showed no signs of astigmatism (based off the SIM K2’s angle values and low dk), thus negating the need for a Toric lens. 

Since the patient is myopic, the results using the SRK/T formula was used for his biometry (below, right).  

Good case studies gather data first, then interpret second. My original document included more results (anonymized)  which I’ve left out for brevity’s sake, but they’re used to corroborate the text. 

To sum the methodology up, show raw information, use tables or visuals, adjust jargon as necessary depending on your audience, and leave the analysis out, all while keeping a chronological order. I could have included why each test would need to be performed, but left that out since this wasn’t intended for a novice audience. What, how, and why.

Now let’s move on to the diagnosis, where we interpret the data, make decisions, and describe results.

After completing the exams, GM was introduced to the ophthalmologist to undergo an exam under dilation and to discuss his results and following treatment. The doctor confirmed the 3+ nuclear sclerotic cataract, while concluding that the patient had a normal cornea, sclera, and optic nerve free of deformations. A hole was discovered in the macula of the patient’s right eye (inferor-temporal) as well as several floaters. 

The results of his exams were discussed with the patient, and we discussed his options with regards to lens choice. Since the cataract only affects the right eye, he was told he could have a contact lens in his unaffected eye, or to wear glasses with a neutral lens in his right eye, only to change glasses while reading. The patient confirmed several times that he would prefer to remain slightly myopic; he was used to wearing glasses to see far and remove them for reading and wanted to continue to do so, thus a target refraction post-surgery of -2.0 was decided upon instead of 0, and the biometry results were recalculated and a lens power of 14.5D was selected. 

Further risks and benefits were discussed, such as issues relating to anisometropia as well as possible outcomes of the cataract surgery itself (inflammation / infection, bleeding, edema). He was then referred to a retinologist to assess and correct the lattice degeneration via laser photocoagulation. 

You want to keep this section clear, well-documented and medically grounded.  A few key takeaways here are patient preferences (keeping a slight myopia), risks and benefits, and the outcome (which diopter was selected, and a referral to retina). A good way to approach it is to explain the clinician’s choices rather than just tell them. Connect the symptoms to the tests and demonstrate reasoning, not just facts. As always, potential pitfalls are relying on jargon.

On to the outcome. I was told many students forget to include follow-up data in a case study. As always, stick to the facts.

After having his lattice degeneration successfully treated, GM was informed he would be operated on in two months’ time, and his macular hole wasn’t significant enough to warrant surgical intervention. A prescription was filled with instructions to start the day of the surgery consisting of Predforte (1 gtt OD qid during Week 1, 1 gtt OD tid during Week 2, 1 gtt OD bid during Week 3, and 1 gtt OD die during Week 4 post-op), Nevanac (1 gtt OD tid for one month), and Vigamox (1 gtt qid OD for one week). 

The patient was seen two months later, within 24 hours of his surgery for a post-op exam. He was compliant with his eyedrops. His visual acuity had improved and was able to see 80/20 without glasses with his right eye (60-1/20 through stenopeic holes), and his IOP remained stable at 14 mmHg. 

GM’s two-week post-op appointment yielded an acuity of 50-2/20 in the operated eye (40/20 through stenopeic holes) and his IOP was once again 14 mmHg. He reported continued compliance with his eyedrops. 

After dilation, refraction showed a sphere of -2.25, a cylinder of 1 and a 36° axis. Further examination with the doctor concluded that the surgery had been completed without complication and that his eye was healing well. The patient was pleased and he was told to return in case there were any incidences of redness or ocular pain, and that he could meet with his optometrist to have the new lens made for his right eye. 

And finally, the conclusion:

A patient-centered approach was essential in this case, particularly in determining thetarget postoperative refraction. By respecting the patient’s preference to remain mildly myopic, the surgical plan was tailored to preserve his accustomed visual function, thereby optimizing postoperative satisfaction. The selection of an appropriate intraocular lens power using the SRK/T formula further contributed to achieving the desired refractive outcome.

Postoperative follow-up demonstrated significant improvement in visual acuity, stable intraocular pressure, and an uncomplicated healing process, underscoring the success of both the surgical intervention and postoperative management. Overall, this case illustrates the importance of individualized care, thorough preoperative assessment, and collaboration in achieving favorable visual and clinical outcomes in cataract surgery.

Be clear, keep a structure, and never add new information. Summarize the key phases of the case (diagnosis, preoperative workup, surgical planning, and outcome) without rehashing every detail, linking the process to the outcome. Synthesize by pulling together the key themes, rather than repeat, without forgetting to highlight important decisions like choosing a target refraction based on patient preference. Those points reinforce that this wasn’t just a routine cataract case, but one requiring individualized care.

Another effective element is the emphasis on patient-centered care. Bringing attention to the decision to maintain mild myopia shows an understanding that success in ophthalmology isn’t purely anatomical or acuity–based, but also tied to patient satisfaction and lifestyle.

I could have discussed the potential long-term considerations (such as a retinal detachment), which could elevate the conclusion from a summary to a more analytical wrap-up. If it’s significant I might reflect on any lessons learned or discuss how a case study can integrate into a larger clinical practice, but it’s rare.

That’s it!