Introduction to the physical examination of the eye
A physical examination of the eye is a critical element of vision screening. The environment for the physical examination should be arranged to be as private as possible. Lighting should be adequate, and equipment should be arranged on a clean surface. The worker should be prepared for the physical examination with a clear description of what will be done. In addition, all required tools need to be readily available.
The physical examination of the eye starts before the worker enters the vision testing room. When the worker is collected from reception, watch the worker respond to instructions, how he / she walks and navigates through the clinic, and orientates to the facilities in the vision testing room, this is all part of the “meet – seat – and – greet”. The technician and the worker must be seated comfortably, at the same level, and privacy must be maintained. This is followed by the history which has been discussed above. Explain each step of any procedure or examination and ensure that the worker understands and gives verbal consent, (as there is no invasive procedures a written consent is not required). An examination of the eye includes an external examination, examination by ophthalmoscope, and an assessment of the various functions of the eye. After completion of the physical examination the vision is tested. When recording the findings of an eye examination comment if the person wears spectacles, has blindness or any visual impairment including photosensitivity, pain, or itchiness.
Inspection:
Discreetly observe the patient for facial symmetry and profile. This can be done during the history taking. Observe the patient’s face from the front and the side. Obvious asymmetry may indicate underlying conditions such as neoplastic growths, muscle atrophy or hypertrophy, and neurological problems.
Inspect the overall appearance of the face – are the eyes and ears at the same level? Use a pencil and measure from the tip of the outer eye to the tip of the ear lobe, this should be at the same level and then from the edge of the nose to the edge of the inner eye.
Is the head an appropriate size for the body? Is the face symmetrical – no drooping of the face on one side (eyes or lips)? This can happen in Bell’s palsy, Guillain-bar or after a stroke. See Figure 7.9 below for examples. Are the facial expressions symmetrical – no involuntary movements, twitches, or ticks? Any lesions? Test cranial nerve VII – facial nerve by asking the patient to close their eyes tightly, smile, frown, puff out the cheeks and assess whether they can do this with ease?
Figure 7.9: Examples of Asymmetry22
Figure 7.10: Comparison between Symmetrical and Asymmetrical23
During the inspection of the eyes, observe the eyebrows, eyelids, eyelashes, lachrymal apparatus and around the eyes for any abnormalities before looking at the eye itself. Always conduct an eye inspection after the worker has removed his / her glasses.
Conditions of the external structures of the eye and what to assess during inspection:
Eyebrows:
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Assess the skin under the hair for the presence of skin conditions like psoriasis, dermatitis, and eczema.
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Distribution and thickness of the hair – is it thick, thin, or missing
Assess the eyelids for swelling and infections called blepharitis.
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Look for styes and meibomian cysts.
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Blepharoptosis - eyelid droops low enough to obscure the field of vision, can be congenital or develop with aging, after trauma or a stroke.
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Blepharospasm – involuntary twitching, blinking, or shutting of the eyelids cause by prolonged screen time, sleep deprivation or fatigue. This needs to be queried as it may not be seen on inspection.
Assess the skin under the hair for the presence of skin conditions like psoriasis, dermatitis, and eczema
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Distribution and thickness of the hair – is it thick, thin, or missing.
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Discharge or crusting on the eyelashes which could indicate infections of the eye.
Lachrymal apparatus
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Assess for excessive tearing (Epiphora). The most frequent reason for this is a blocked nasolacrimal duct. It is also common in menopause due to hormone changes.
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Assess for dry eyes, caused by too little tears. Commonly found in dry winters, caused by heaters and air conditioners, and presents as red irritable scratching or inflamed eyes.
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This needs to be queried as it may not be seen on inspection.
When recording the findings of an eye inspection comment if the person wears spectacles, is blind (which eye) and describe the abnormality, duration of the problem and treatment used.
Table 7.1 Common Abnormalities of the Eye which can be identified during the examination
Exemplo
Image depicting an Abnormality of the Eye
Name of Abnormality
Seborrheic dermatitis24
Note the crusting and scally appearance of the skin under the hair.
Xanthelasma26
Cholesterol deposits under the skin of the eyelids.
Blepharitis27
Inflammation if the eyelids.
Chalazion/melbonmium cyst28
A chalazion is a swollen bump on the eyelid. It happens when the eyelid’s oil gland clogs up. Styes are painful and Chalazion are not.
Stye28
A stye (also called a hordeolum) is a small, red, painful lump that grows from the base of your eyelash or under the eyelid. Most styes are caused by a bacterial infection.
Ptosis29, 30
Drooping bottom or top eyelids with the distance between the upper eyelid and lower eyelid. Ptosis occurs due to an abnormality in the structures that elevate the upper eyelid. In severe cases, ptosis can obstruct the pupil and cause visual field impairment. Etiologies include both congenital and acquired causes.
Dry eyes31
Caused by too little tears. More common is dry winters, caused by heaters and air conditioners, presents as red irritable scratching or inflamed eyes.
Excessive tearing32
Excessive tearing (Epiphora). The most frequent reason for this is a blocked nasolacrimal duct. It is common in menopause due to hormone changes.
Jaundiced sclera33
Yellow sclera is associated with jaundice and may indicate hepatitis (A or B), other liver dysfunction or a blood disorder.
Blue sclera34
Blue sclera is associated with osteogenesis imperfecta.
Pterygium35
The pterygium causes irritation or a decrease in visual acuityas , it grows over the pupil. It occurs most often in hot climates.
Symblepharon36
It is a partial or complete adhesion of one or both eyelids to the eyeball, associated with infection or trauma such as burns.
Subconjunctival haemorrhage37
This is a bleed in the subconjunctiva, caused by infection or trauma, conjunctivitis, coughing or in patients who are on anticoagulants.
Allergic conjunctivitis38
Allergic conjunctivitis is caused by a hypersensitive reaction to a specific antigen (seasonal) or airborne mold spores and the pollen of trees, grasses, and weeds. Atopic conjunctivitis (atopic keratoconjunctivitis) is caused by dust mites animal dander and other non-seasonal allergens.
Bacterial conjunctivitis38
Bacterial conjunctivitis is most commonly caused by staphylococcus aureus, Streptococcus pneumonia and Haemophilus. Most bacterial conjunctivitis is acute starting in 1 eye and frequently spreads to the opposite eye within a few days. Often has a mucopurulent discharge.
Viral conjunctivitis39
Viral conjunctivitis is often an acute, contagious conjunctival infection associated with an infection of the upper respiratory tract. Symptoms are often limited to one eye at a time, include irritation, photophobia and watery discharge. Conjunctivitis may accompany the common cold and viral infections, especially measles, chickenpox, rubella, and mumps.
Cataracts40
As the worker ages the lens stiffen, and this leads to the formation of cataracts which causes loss of clarity in vision. Common symptoms of cataracts include cloudy or blurred vision, sensitivity to light and glare, frequent prescription changes for glasses or contact lenses, poor night vision, colour vision changes and dimming, double vision in a single eye.
Arcus senilis41
Arcus senilis is a half-circle of grey, white, or yellow deposits. it’s found on the outer edge of the cornea. It’s made of fat and cholesterol deposits. In the elderly, arcus senilis is common and is usually caused by aging.
Anisocoria42
Anisocoria is a condition in which the pupil of one eye differs in size form the pupil of the other eye.
Gently pull the lower eyelid downward and ask the patient to look up. The conjunctiva should be pink NOT red and swollen.
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Check for a pterygium, a triangular-shaped growth of conjunctival and fibrovascular tissue over the limbus and the superficial cornea.
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Check for a Symblepharon which is an abnormal finding of the external eye in which an adhesion forms between the palpebral conjunctiva and bulbar conjunctiva, often caused by infection or trauma.
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Assess for allergies – allergic conjunctivitis is a common finding in the occupational health setting.
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Assesses for the presence of bacterial or viral conjunctivitis. Often caused by an infection, allergy or irritation and characterized by very red conjunctiva, a discharge and, sometimes discomfort and itching, commonly called pink eye.
Whilst the lens is not examined by the technician during vision screening it is important to note the common conditions of the lens. Based on the history provided by the worker certain lens conditions may be considered as the possible cause.
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Cataracts: As the worker ages the lens stiffens, and this leads to the formation of cataracts which causes loss of clarity in vision. There are other, less common causes of cataracts as well, including heredity, birth defects, chronic diseases such as diabetes, excessive use of steroid medications, and certain eye injuries. Common symptoms of cataracts include cloudy or blurred vision, sensitivity to light and glare, frequent prescription changes for glasses or contact lenses, poor night vision, colour vision changes and dimming, double vision in a single eye.
During the assessment of the iris note the colour of the iris and compare 1 eye against the other as 1 iris may have a different colour to the other and this must be recorded.
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Assess the shape of the iris again comparing 1 eye against the other.
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Look for Arcus Senilis which is grey, white, or yellow deposits in the outer edge of your corn ea but looks like it is circling the iris. It's made of fat and cholesterol deposits. In older adults, arcus senilis is common and is usually caused by aging however is younger adults this is a concern and should be referred. Arcus senilis is benign and does not interfere with vision, however it may signal high cholesterol
The presence of more fat in your blood can cause problems when it builds up in your eye. Like high blood pressure, it's hard to diagnose underlying problems.
During the assessment of the pupils note the size and shape of the pupil and compare 1 eye against the other.
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Anisocoria is when 1 pupil is larger than the other. Sometimes, this can be a symptom of a serious eye problem. People with anisocoria include those who have a nervous system problem, a history of damage to the eye, risk of having a stroke, a viral infection, or Adie’s tonic pupil (when one pupil does not respond to light as well as the other pupil)19
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Pupil size may help identify patients who are at risk for medical emergencies due to illegal drug use.
Figure 7.14: Different abnormalities Identified during inspection47
Palpation of the Eye
The only palpation done of the eye is when measuring intraocular pressure (IOP). Whilst this is usually measured by an optometrist at a diagnostic assessment, this method can assist in assessing IOP initially. It is possible to detect very high IOP using your fingertips. The accuracy is better if the examiner is familiar with this examination method, practice it first on yourself and then on your colleagues (with their permission) before assessing workers.
Note:
If you do not detect anything abnormal, the eye pressure may still be dangerously high. If the history or symptoms suggest glaucoma, or if the patient is using steroid medication or has recently undergone eye surgery, you must refer them to a centre where their IOP can be accurately assessed37.
Ask the person being assessed to close their eyes and look down. Place the tips of both index fingers on the closed upper eyelid. Keeping both fingertips in contact with the upper eyelid, apply gentle pressure through the closed eyelid, first gently pressing on the eye with the right index finger, then with the left, and then with the right again (Figure 7.5). Repeat on the other eye. A normal eye should feel a bit like a tomato that is just ripe: not solid, nor very soft It is important to compare the two eyes with one another. An eye with very high IOP will feel abnormally hard and solid.37
Assessment of the various functions of the eye
The next set of assessments is usually done after inspection and palpation. These assessments require basic tools or equipment and patient co-operation. The assessments test whether the various parts of the eyes are functioning normally.
The pupils – dilate, constrict, and accommodate Convergence and divergence Light reflex Blink reflex Cardinal fields of gaze or cardinal muscle assessment and cranial nerves
Assessing the pupils
The pupil’s function is assessed in various ways. Testing whether the pupils react to light and accommodate is one of the first assessments done on the eyes. Accommodation is the ability of the eye (lens) to change its focus from distant to near objects and vice versa. This process is achieved by the lens changing its shape. Explained another way, accommodation is the adjustment lens of the eye to keep an object in focus on the retina as its distance from the eye varies. It is the process of adjusting the focal length of a lens.
“PEARLA” / “PERRLA”
This is an acronym that means “Pupils equal and round and reactive to light and accommodation”.
Turn the lights off or dim them. Ask the worker to look at an object or picture directly behind you keeping the eyes open. This dilates the pupils. Normal pupil size should be 3 to 5 mm and equal. The pupils should be round and equal in size.
Using an examination / pupil torch shine a light coming in from the side in each eye near each ear bringing the light towards the centre of the eye. Test each eye separately. The pupil being assessed is the one with the light shining in it, it should constrict, note the dilated size and constricted size (for example: pupil size reduced from 3 mm to 1 mm and back to 3mm). At the same time assess the pupil not being tested as it should constrict and dilate at the same time. Repeat the test on the 2nd eye. If both eyes react the same by dilating and constricting and dilating again, they are reactive to light and accommodate.
Video 7.1: PEARRLA Exam1
https://www.youtube.com/watch?v=aM0ipmW3ikc
Convergence and Divergence
Convergence is the ability to turn the two eyes inward toward each other to look at a close object. We depend on this visual skill for near-work activities such as desk work, working on a smartphone type device, and for sports when catching a ball. When the eyes converge, they start focusing and the pupils get slightly smaller. This set of three processes – technically termed convergence, accommodation, and miosis – is known as the near triad. Divergence is the opposite of convergence and is the ability to turn the two eyes outwards to look at a distant object and the pupils dilate. This skill is required for any distance activities such as reading, driving, and watching TV. If the eyes are unable to converge effectively this may cause double vision when looking at close objects. Convergence can be affected by the functioning of the muscles and varies with age.
The room should be well illuminated so examiner can notice minimal changes in eye movements. The worker should be seated in front of the technician and look directly at an object, called the fixation object, in the mid-sagittal plane. The technician should sit infront of the worker so that the eyes of both (technician and worker) are at the same level.
Hold the fixation object at approximately 50 cm away from the worker in the mid-sagittal line. The technician should move the fixation object slowly and smoothly in the mid-sagittal plane closer to the workers’ nose. Move slowly at approximately 40cm in 10 seconds. Ask the worker to follow the fixation object with the eyes. The technician should watch both eyes of the worker to ensure both eyes move smoothly and symmetrically inwards and back to 50cm. The pupils should start dilating and constricting as the fixation object gets closer to the nose, this is convergence and once the eyes have followed the fixation object back to the 50cm position is divergence.
The mid-sagittal plane of the head
Create an imaginary line from the top to the bottom of the head (in the horizonal line)
Create an imaginary line the top to the bottom of the head in the middle of the face (in the vertical line)
A corneal light reflex test, also known as the Hirschberg test, is a simple test that checks eye alignment. This is done by observing how light is reflected from the cornea of the eyes. This assessment is particularly useful for testing for strabismus (misalignment of the eyes).
Ask the worker to stare at an imaginary picture of an object behind you, the technician. From a distance of 60cm in the mid-sagittal line, shine a light source (from a small examination torch) equally into the worker’s eyes. Observe the reflection of light off the cornea, in both eyes, they should be in the same position in each eye and should appear as a pin-point white (dot) light near the centre of the pupil in each eye see figure 7.17 below. If the light reflects in a different position, this is a misalignment of the eyes and an abnormal finding. The location of the corneal reflex will appear asymmetrical or “off centre” of the pupil in the deviating eye.
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A strabismus (squint) is a condition in which the eyes do not line up with one another. Strabismus: is when the eyes don't look in exactly the same direction at the same time. Strabismus is classified by the direction the eye turns see figure 7.19:
Amblyopia (also called lazy eye) is reduced vision in one eye caused by abnormal visual development early in life. The weaker eye often wanders inward or outward. It develops when there’s a breakdown in how the brain and the eye work together, and the brain can’t recognize the sight from 1 eye. Over time, the brain relies more and more on the other, stronger eye — while vision in the weaker eye gets worse.
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Anisocoria is when the pupils are NOT equal in size, one pupil larger than the other. This can occur at birth or develop later in life see figure 7.20
Figure 7.16: Normal alignment and corneal light reflex52
Figure 7.17: Abnormal eye alignment and corneal light reflex53
Video 7.2: Corneal Reflex Exam2 https://www.youtube.com/watch?v=j57G7N1CnOE
Video 7.3: Examination of the Pupils3 https://www.youtube.com/watch?v=wpG62cJMJcE
Figure 7.18: Anisocoria. Top picture are normal pupils42
Testing the Cardinal Muscles and Cranial Nerves
As discussed in Chapters 1 and 2 (the anatomy and physiology of the eye), eye movement is controlled by 3 cranial nerves and 6 cardinal muscles / extraocular muscles. Therefore, the technician is required to test the cranial nerve and muscles to assess normal function.
The room should be well illuminated so the examiner can notice minimal changes in eye movements. The worker should be seated in front of the technician and look directly at an object, called the fixation object, in the mid-sagittal plane.
The technician should sit in front of the worker so that the eyes of both (technician and worker) are at the same level. Hold the fixation object at approximately 50 – 60cm away from the worker in the mid-sagittal line. Ask the worker to follow the fixation object without moving the head – follow the direction of the object with the eyes The technician always starts and ends in the midline position. Move the fixation object slowly from the middle of the eye and to each of the 8 positions indicated in Figure’s 7.21 and 7.22 returning back to the midline – there are 9 positions to be tested however 8 are physically tested as the neutral position is held to start with. The order does not matter.
Front middle – looking straight ahead (neutral position)
Superior (straight up)
Inferior (straight down)
Superior and oblique (to the side of the nose and up)
Superior and oblique (to the side of the ear and up)
lateral (straight to the side of the ear)
Medial (straight to the side of the nose)
Lateral and inferior (down and to the side of the ear)
Medial and inferior (down and to the side of the ear)
The eyes both left and right should move smoothly, together without any uncontrolled, and involuntary movements and be able to follow the fixation object easily. Uncontrolled or involuntary movements of the eye is called a nystagmus. These movements often result in reduced vision and depth perception and can affect balance and coordination. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern. By assessing the cardinal fields of gaze all the cranial nerves – III (oculomotor), IV (trochlear), VI (abducens) have been tested
Figure 7.19: The 9 Cardinal Fields of Gaze54
Figure 7.20: 9 Cardinal Positions or Fields of Gaze55
Video 7.4: Cardinal Fields of Gaze4 https://youtu.be/lrO4pLB95p0
Blink Reflex
The corneal reflex, also known as the blink reflex or eyelid reflex is an involuntary blinking of the eyelids elicited by stimulation which is controlled by the trigeminal and facial cranial nerves. The reflex occurs at a rapid rate of 0.1 seconds. The purpose of this reflex is to protect the eyes from foreign bodies and bright.
The room should be well illuminated so the examiner can notice minimal eye movements. Prepare a clean piece of cotton wool, ensuring there is a thin strand. Approaching the worker’s eye from the side (ear), out of his / her line of sight. Lightly touch the thin strand of cotton wool on the eyelashes. Observe for blinking, of the cornea is touch observe tearing in that eye (direct corneal reflex). At the same time, observe the other eye, it should blink and or tear at the same time (consensual corneal reflex). Repeat the process with a clean piece of cotton wool in the other eye.
Fundoscopy – not a requirement of the vision screening course
Whilst this assessment is not required for vision screening and will not be assessed for completeness a short segment is included for practitioners who do perform this assessment and are already using this technique as part of the eye examination. By looking through the various lenses of an ophthalmoscope, the trained examiner can view and assess the internal structures of the eye. Fundoscopy is a test that is used to examine the back of the eye including the optic nerve head (called optic disc), retina and major blood vessels. The fundoscopic examination is typically only performed in certain situations (e.g., suspected intracranial hypertension or stroke). The ophthalmoscope is not difficult to use but it requires some practice. Try to get in the habit of using the ophthalmoscope to perform the examination in every eye examination.
Prepare the equipment, room, and person being assessed:
Check that the ophthalmoscope works—the batteries may be flat, or it may not have been charged. Some ophthalmoscopes have a small cover over their aperture which, if closed, may lead you to think that it is not working. Switch the room lights off or dim them, but don’t make the room too dark. Explain to the worker that a bright light is going to be used which can temporarily dazzle them and that the examination is being done to view the internal structures of the eye. Position the worker so that he or she is comfortable but sitting up Ask the worker to fixate (stare) at an object behind the examiner (for example, the corner of the room or curtain rail or picture). This spot should be located so that they are looking slightly away from you when they are examined—that is, to the left when you examine the right eye and vice versa. Ask the worker NOT to blink and to look at the fixation spot no matter what. It is best to examine the worker’s left eye with your own left eye and right eye with your own right eye—this takes practice. Try to keep your other eye open. Place your hand on the worker’s forehead so that your fingers are splayed but your thumb is on the upper lid. This is important as you will use your thumb to hold the patient’s lid open and also the joint of your flexed thumb is exactly where your forehead needs to end up.
What is the examiner looking for?
Red reflex: Media opacities obscure the red reflex (corneal scars, cataract, and vitreous haemorrhage, and asteroid hyalosis). Optic disc: Look for optic disc size, colour (pallor, congestion), cup disc ratio, margins, haemorrhages, new vessels, collaterals. The pale and clearly demarcated disc may be optic atrophy. Pathological cupping is a sign of glaucoma. New vessels on the disc are common in proliferative diabetic retinopathy. Yellow-grey disc with blurred margins with or without haemorrhages may be papilloedema Vessels: Start at the disc and follow the vessels out to look for hypertensive and arteriosclerotic changes. Look as far as the mid-periphery for scars (inflammatory, laser), haemorrhages, exudates, pigment (white, black), and pigmented lesions. Examine arteries, veins (slightly thicker), and perivascular fundus. Look also for microaneurysms, blot haemorrhages, hard exudates which if there is a history of diabetes could indicate diabetic retinopathy; cotton wool spots (fluffy white patches), vessel changes such as venous beading, and venous loops are pre proliferative changes. Macula: Find the macula temporal to the disc. The foveal reflex is seen better with a green (red-free) filter and is at two-disc diameters away from the disc and 1.5 degrees below the horizontal (the whole field of view is 8 degrees).
Figure7.21: A Normal Fundoscope59
Video 7.5: How to do a fundoscopy5 https://www.youtube.com/watch?v=SVuP5Td23AQ
Video 7.6: The Assessment of the Eye6 https://www.youtube.com/watch?v=pgSj3l9iV6k&t=7s
In-person Training
Specifically for bookings for a group of minimum 10 learners
The training program includes a pre-learning phase that allows participants to familiarize themselves with foundational concepts before engaging in in-person interactions with the facilitator.
Following the pre-learning phase, participants will have the opportunity to meet with the facilitator in a physical classroom setting. This direct interaction is crucial for addressing any questions or concerns that may have arisen during the self-study period.
Additionally, the physical classroom component is designed to facilitate hands-on practical training. This aspect of the program allows participants to apply theoretical knowledge in real-world scenarios, enhancing their understanding and retention of the material. Working under the guidance of an experienced facilitator, learners can practice skills, collaborate with peers, and gain valuable insights that are difficult to achieve through online learning alone.
Overall, this structured approach—combining pre-learning with direct facilitator contact and practical classroom experiences—ensures a comprehensive and effective learning journey that accommodates various learning styles and maximizes participant engagement.
Blended Learning
Self-pased learning combined with weekly online contact sessions with a facilitator and in-person practical training days
This combination allows learners to work through the theory at their own pace while still interacting with instructors on a weekly basis through regular question and answer online contact sessions.
The online part is flexible, letting learners study whenever it works best for them.
Live sessions help build a sense of community and support.
The in-person classes are important for hands-on learning, giving learners the chance to practice their skills with guidance from experienced mentors.
This well-rounded approach improves learning by meeting different learning styles and preferences.
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