Case Report Guidelines

The following steps will provide information to guide you successfully to completion of your Case Report.

Step 1: Submitting Case Reports

All case reports are to be submitted to the online candidacy system. A minimum of one, and up to five case reports will be required, based on the requirements of the point system.

Clinical Candidate Point System (PDF)

All clinical candidates must write at least one case report. The first case report should be submitted to the system within 60 days of submitting your application and no later than April 1st of the year you plan to sit for the oral exam. All written work is due no later than June 1st of the year you plan to sit for the oral exam. In addition to the case report, you must also submit your plan for achieving 50 points, which is due no later than April 1st.

Clinical Candidate’s Proposed Plan for Written Requirements (Word)

Step 2. Purpose

The purpose of written case reports is to demonstrate one's commitment to the Academy’s goal of lifelong learning. Case reports should display technical skills and knowledge, level of professionalism and ability to care for the patients. Keep in mind that the case reports you write are a reflection of you and your skills, more than they are about the patient about whom you are writing.

Step 3. Patient Selection

Cases should be representative of the patients you work with and care for on a daily basis. They should reflect different aspects of your optometric practice, and should be cases that are/were either entirely managed yourself or co-managed to conclusion. Exotic cases are interesting, but any case chosen should be representative of your best work and clinical judgment. It is recommended that at least one case involving disease, treated by you or referred to another professional for treatment, should be included. You may not submit case reports about any patients you saw before you became a licensed optometrist.

Step 4. Building A Case Report
  1. A case report is a scientific writing, and should ideally follow the writing style exhibited in refereed journals.

  2. It should be written in third person, past tense.

  3. Assiduously spell-check and grammar-check all work.

  4. Support clinical conclusions and be able to justify clinical decisions at the oral exam.

  5. Patients should be followed to conclusion of the condition reported.

  6. All writing should be your original work. Only one author is allowed on case reports. Note that case reports will be checked for plagiarism. Plagiarism is grounds for termination of your candidacy. Have a colleague review your case report prior to submission or request a mentor from your Regional Chair.

  7. Case reports must be submitted no later than the following deadlines: April 1st for the first case report, and June 1st for all written work.

Written case reports, required as part of your application for Fellowship, require a discussion section that will include information referenced from the literature. It is expected that all of your writing represent your own work. Be familiar with what needs to be cited and how to reference information taken from other sources.

  • Plagiarism is defined by the Merriam-Webster dictionary as 1) stealing and passing off (the ideas or words of another) as one's own; 2) using (another's production) without crediting the source; or 3) committing literary theft: presenting as new and original an idea or product derived from an existing source.

  • All case reports will be checked for plagiarism. Plagiarism is considered a violation of the Standards of Conduct of the AAO and, if verified, is grounds for termination of your application for Fellowship.

  • Before submitting your case report, seek the advice of your Regional Chair or request a mentor if you have questions or are unsure about what constitutes plagiarism.

Step 5. Organizational Guidelines for Case Reports
  1. Cover Page: The first page is a cover sheet with the candidate’s name, address, telephone number, e-mail address, case report title and number and a brief abstract (approximately 10 lines) of the attached case report. Include key words used.

  2. Introduction: Your paper should begin with a 1-2 paragraph introduction that provides background information on the topic of the case report.

  3. Case Report: Thoroughly describe each visit the patient was seen and examined. Maintain HIPAA compliance and eliminate any references to health-protected information of your patient. Each visit should be thoroughly documented including history, examination findings, decision-making, treatment and patient education.

    The initial visit should include the patient’s chief complaint, age/ethnicity, sex and date of examination as well as a thorough documentation of history (history of present illness; medical, ocular, family and social histories; medications; allergies). 
Documentation of the examination should identify all findings including pertinent negatives.  All medications instilled in the patient’s eyes, as part of the examination should be recorded by concentration and quantity. A complete differential diagnosis should be included, indicating how the final diagnosis was determined. Treatment protocol should demonstrate depth of knowledge and be justifiable should it vary from the current standard of care. Separate each follow up visit so there is a clear chronology of your examination and treatment of the patient.

    If the patient was referred to a specialist, the reason for referral, differential diagnoses and expected outcomes should be discussed. If a patient is referred to another provider for a procedure or further testing, include a copy of that provider’s report as well as any follow-up with the patient after the procedure was done. 


  4. Discussion Section: This section should describe the diagnosis in greater detail including the epidemiology and pathophysiology where appropriate. Use this section to further discuss your decision making process. Explain variations from normal relating to your specific patient’s presentation. Discuss the standard of care for the condition and why you may have deviated from it. If there are alternative treatments, explain each and discuss advantages and drawbacks.

    The discussion should be your original writing, and should refer to the specifics of your case report. Any information gathered from outside sources should be properly documented. 
Plagiarism is considered a violation of the Standards of Conduct of the AAO and, if verified, is grounds for termination of your application for Fellowship.
     

  5. Conclusion: Summarize what the reviewer should take away from your case report both in terms of the topic and your management of the patient.
     

  6. References: The last page of the case report should be a bibliography of the references used in developing the case report. Sources may be textbooks, computer, Internet, or library-based research of peer-reviewed journals. Whenever possible, references should be current in the last 5-7 years.

Step 6. Elements of Evaluation of Case Reports

The quality of the case report will be considered by the committee as an indication of the quality of care that you provide your patients on a daily basis. Primary elements evaluated include: 

  • Complexity of the Case Report: An extremely complex case report is usually an interesting one, but it requires the candidate to really do his/her homework to support the clinical decisions. Remember that the assessment of case reports is based on how the case was managed, not on the uniqueness of the case (no matter how interesting).
     
  • Appropriate Data Collection: Each visit should be thoroughly documented. Do ensure patient confidentiality in all documents. The initial examination should be a comprehensive one and all findings must be documented. Subsequent visits should follow the same format with all findings documented in a detailed manner. If a patient is referred to another provider for a procedure or further testing, include a copy of that provider's report, as well as your follow-up with the patient after the procedure was done. In the discussion, explain the reasons for further testing and/or referral as well as the results and what impact they had on the diagnosis and treatment plan. Patients should be followed to conclusion.
     
  • Appropriate Diagnosis: Clinical decisions, based on a differential diagnosis, should be thoroughly explained in the discussion section of the case report. If the patient has more than one problem (i.e., a diabetic with binocular vision anomalies), the clinical issues surrounding all problems must be addressed in the final diagnosis. All problems with which the patient presents should be evaluated and managed. If the patient has less than 20/20 visual acuity, a clinically substantiated reason must be found.
     
  • Appropriate Treatment: The treatment protocol should demonstrate depth of knowledge and be justifiable should it vary from the current standard of care. In the discussion, describe the alternative treatments for each diagnosis and the advantages and drawbacks of each. Be prepared to discuss the reasons for choosing the selected course of action. The case report should demonstrate that the patient's problems were resolved over the course of time you managed the patient (if resolvable). The chosen treatment should be supported by the cited references and explained in the discussion.
     
  • Terminology, grammar, spelling and organization: A well-written case report is a pleasure to read; a poorly written one is torture, no matter how interesting the case or how adept the clinician. Although the writing per se does not have much effect on the total score, it can’t help but affect how the reviewer evaluates the paper. Use the very best writing skills, spell-check and grammar--check all work, and have someone proofread the paper. The case report should be entirely your original work. Writing that is plagiarized from other sources will not be accepted, and may be cause for dismissal as a candidate.

Sample Case Report 1 (PDF)

Sample Case Report 2 (PDF)

Step 7. Case Report Submissions
  1. Upon notification of acceptance of the candidate’s application, the Regional Chair expects to receive the Clinical Candidate’s Proposed Plan for Written Requirements and the first case report within 60 days, and no later than April 1.

  2. The Regional Chair will review the first case report and provide written evaluation of the case report. Once the first case report has been accepted, the Regional Chair will instruct you as to how to submit the balance of your written work. 

  3. All written work must be submitted no later than June 1 in order to be evaluated in time for oral examinations in the same calendar year. 

  4. You must complete all requested corrections and modifications to your written work no later than August 1 in order to be cleared for the oral examination in the same calendar year.

Step 8. Questions

For assistance or guidance in the preparation of the case reports please contact your Regional Admittance Committee Chair.

Step 9. Notification of Acceptance of Written Work

Your Regional Chair will notify you when your written work has been approved and you are cleared to schedule your oral exam. You must contact the Vice Chair of Admittance Committee no later than August 15 to schedule your oral examination. Oral examinations will be scheduled on a first come first serve basis.