Undergraduate: Ophth 432

Course 432 is meant to introduce Medical Students to basic history taking and examination of the eye. The common ophthalmic conditions will be taught, including the principles for management of these conditions. This material will be released to the students through:

Lectures
Clinical Sessions
Clinic attendance
Surgical sessions attendance

At the end of the course, the Medical Student should be able to recognize common ocular pathology, manage simple cases and know when to refer more serious problems.
Course Outline
(a) Theoretical

1. Applied anatomy and physiology of the Eye

2. Lid and lacrimal system problems

3. Red Eye and Ocular emergencies

4. Strabismus and amblyopia and leukocoria

5. Eye andSystemic Diseases

6. Neuro-ophthalmology

7. Pharmacology and Toxicology

8. Visual fields

9. Errors of refraction

10. Retinal glaucoma disorders
(b) Practicals

1. Orientation, history taking and ocular examination

2. Ophthalmoscopy and tonometry
Distribution of Assessment Marks
At the end of the six weeks rotation in Ophthalmology, the Student will sit for a Continuous Assessment Examination. This will consist of forty (40) multiple choice questions (40 marks), covering clinical aspects of the subject and topics taken in lectures and tutorials.
At the end of the cycle, he or she will sit for a Final Examination consisting of forty (40) multiple choice questions (20 marks), and an oral examination (40 marks) that will concentrate on testing the students ability to recognize clinical signs and formulate a decent differential diagnosis and treatment.
Summary

1. Continuous assessment	40 MCQ's	(40 marks)
2. Final examination	40 MCQ's	(20 marks)
3. Final Oral examination		(40 marks)
Total		100 marks

Recommended Books

Basic Ophthalmology for Medical Students and Primary Care Residents by Frank G. Berson, MD
General Ophthalmology by Vaugh and Asbury and Tabbara

Course Outline
(a) Lectures

Topic (lectures)	Time allowed
1. Applied Anatomy and Physiology + Lid and Lacrimal System Problems	2 hours
2. Glaucoma Diagnosis and Management	1 hour
3. Trachoma	1 hour
4. Red Eye	2 hours
5. Diseases of Retina and Choroid	1 hour
6. Ocular Emergencies	1 hour
7. Strabismus and Amblyopia	1 hour
8. Errors of Refraction	1 hour
9. Systemic Diseases	2 hours
10.Eye Care in Children and Prevention of Blindness	1 hour
11.Disorders of the Lens	1 hour
12.Neuro-ophthalmology	1 hour

(b) Clinical Skills
1. History taking, Ocular Examination and Tonometry: 3 hours
2. Ophthalmoloscopy: 3 hours
3. Ancillary Services: 3 hours
(c)  Topic (Tutorial)
1. Leukocoria: 2 hours
2. Ocular Pharmacology, Drug Toxicity: 2 hours
3. Ocular Emergencies: 2 hours
4. Visual Fields and Elementry Optics: 2 hours
5. Proptosis: 2 hours
Applied Ophthalmic Anatomy and Physiology

1. Embryonic Tissue Derivatives. (Not important; only as an entry topic)

2. Structure, Function and Pathology:
a) General topography:

Symmetry of lids, lid crease, relation of lids to corneas, direction of lashes
Orbital margins
Diameters of the cornea
Axial length of the globe and orbit
Power of the eye (cornea and lens)
Site of lacrimal gland, lacrimal sac and nasal opening of nasolacrimal duct.
Corneal light reflection and its importance
Ocular movements and position of gaze and muscle responsible for each movement

b) Simplified lid anatomy, function and possible pathology e.g. blepharitis, chalazion, ptosis, etc.
c) Conjunctiva - Bulbar, palpebral and Goblet cells and role in tear film, loss of Goblet cells
d) Cornea - Layers, transparency. Pathology - oedema, opacity, thinning, etc.
e) Sclera - Brief anatomy, muscle attachments. Pathology - scleritis
f) Iris/Pupil - Structure, innervation
g) Anterior Chamber and Angle

Boundary of anterior chamber
Component of angle
Open angle and closed angle

h) Ciliary body

Component
Muscle, innervation, attachment to scleral spur
Accommodation, attachment of zonule
Aqueous secretion, adrenergic receptor and carbonic anhydrase
Relation of vitreous base

i) Limbus

Junction between conjunctiva, cornea and sclera
Site of most intraocular surgeries

j) Lens - Position, diameter, fine anatomy, clarity, accommodation
k) Retina/Macula/Optic Nerve Head, Layer: sensory and RPE, blood supply

Anatomical specification of macula, arcuate nerve fiber and vessels
Optic nerve head (Blind spot), papillomacular bundle
Rod 120 million, cone 7 million, optic nerve fiber 1 million
Relation of retinal topography and VF
Importance of decussation at chiasm
No fluorescein leakage

l) Choroid - Brief anatomy, importance
m) Vitreous - Attachment; base, around disc, macula, blood vessel, Pathology; Retinal tears, etc.
n) Orbit.

Bone; ethmoiditis
Muscle; innervation and function
Optic nerve length
Blood vessels
Nerves
Fissure

o) Lacrimal System

Tear film, 3 layers and function
Tear secretion
Tear excretion, including lacrimal pump
Pathology; Epiphora, NLD system, KCS-Schirmer test, Lacrimal gland disorder, dacrocystitis, DCR

Glaucomas - Diagnosis and management
1) Criteria in Common
a. Increase IOP
b. Angle specification
c. Optic nerve pathology
d. VF characteristics
2) Types, Etiology, Mechanism and Management
a) Open angle glaucoma

Primary; Definition, mechanism, diagnosis, management
Secondary; Inflammation, angle recession, hetrochromia, pigment dispersion, phacolytic and pseudoexfoliation

b) Angle Closure

Primary; Sub acute, acute, chronic, definitions, mechanism, diagnosis, management
Secondary; Neovascular, phacomorphic, and tumor

c) Congenital

Primary; Presentation, mechanism, diagnosis, management, inheritance and incidence
Secondary; Rubella, neurofibromatosis, Sturge Weber syndrome, etc.

Trachoma
1) Introduction

Serious health problem in Saudi Arabia
Most common cause of treatable blindness in Saudi Arabia
Afflict 500 million people in the world
20 million people are blind from trachoma
Cause by chlamydia trachomatitis, which is the most common human pathogen
Associate with low socio-economic status
Large reservoir in children
Transmitted by poor hygiene and crowding, flies and the use of common

2) Clinically

Obligate intracellular
Incubation period: 5-10 days
Symptom; Irritation, FB sensation, tearing, mucopurulent discharge
Modified MacCallan stages:
Immature follicle and early corneal change
Mature follicles and papillary hypertrophy and pannus and limbal follicle or Herbert's pits.
Conjunctival scarring and mild activity
Inactive trachoma
Diagnosis of trachoma - 2 of the following:

NB: The presence of follicles in any combination indicates activity
- Active Trachoma: Follicles of palpebral conj., Limbal follicles, Vascular pannus
- Inactive Trachoma: Conjunctival scarring, Herbert's pits, Avascular pannus
3) Complication and Sequelae

Eye lid
Lacrimal apparatus
Conjunctiva
Cornea

4) Pathology/Investigation/Vaccination
5) Treatment
Red eye
1.Causes of Red Eye: Conjunctivitis, iritis, keratitis (abrasion and FB), angle closure, glaucoma, corneal ulcer. Comparing of the following parameters: onset, vision, pain, photophobia, discharge, types of infection, state of the cornea, pupillary size, others
2. Types of conjunctivitis: DX and management: Bacterial, chlamydia, viral, allergy including vernal
3. Types of corneal ulcers: DX and management: Bacterial, Dendritic and Zoster and Fungal
4. Corneal FB; Welder's keratitis
5. Subconjunctival hemorrhage
Disease of Retina and Choroid
1. Retinal detachment
a) Types:

Rhegmatogenon
Exudative
Tractiona

b) DX and management
c) Predisposing factors: Trauma, myopia, vitreoretinal degeneration (including lattice), aphakia, etc.
2. Diabetes Mellitus
3. Hypertension
4. Retinopathy of prematurity (retrolental fibrop.)
5. Retinal vascular occlusion - artery and vein
6. Retinitis pigmentosa
7. Retinoblastoma
8. Malignant melanoma of the choroid
9. Choroiditis and retinitis (a few examples, no detail, Toxo and TB)
Ocular Emergencies
1. Classification including presentation and management
a) Immediate action (within 1 hour):

CRAO
Chemical burn
Endophthalmitis

b) Very urgent (within 3 - 6 hours)

Ruptures globe
Endophthalmitis
Acute angle closure glaucoma

c) Urgent (within 6 - 24 hours)

Blunt trauma
RD
External ocular infection

2. Selected subjects, presentation and management
a) Corneal abrasion
b) Corneal ulcer
c) Giant cell arteritis
d) Hazardous works and ocular protection
e) Blowout fracture
Strabismus
1. Definition
2. Ocular muscles, innervation and function
3. Types of ocular deviation: Concomitant and non-concomitant
4. Diagnosis: Corneal reflection and cover test
5. Adaptation: Abnormal head position, suppression and amblyopia
6. Association of strabismus
7. Therapy
8. Non comitant and deviation

Symptoms
Etiology
Diagnosis
Therapy

Amblyopia
1. Definition
2. Importance of early detection, including visual development
3. Predisposing factors.
4. Presentation and detection.
5. Role of General Practitioner and urgency to refer.
6. Management
Errors of Refraction
1. Principles of optics
2. Types of retractive errors in myopia, hypermetropia (+aphakia), astigmatism, presbyopia

Problem: Symptoms, principles and correction

3. Optical correction:

Glasses (different types) - C.L. (types)
IOL (types)- LVA

4. Surgery for refractive errors, R.K., epikeratophakia & PKP
Systemic Diseases of the eye
Include: Endocrine, cardiovascular, connective tissue, muscle, skin, infection and inflammation and hereditary and hematopoetic disorders
1. Endocrine diseases:
a. Graves disease
b. Parathyroid gland disorder
c. Diabetes Mellitus - Detail/Retina section
2. Cardiovascular disorder:
a. Aging
b. Hypertensive retinopathy - Detail retina section
4. Disorders of connective tissue, muscle and skin
a. Mafran Syndrome
b. Sjogren Syndrome
c. Rheumatoid arthritis
d. Chronic juvenile arthritis (Still's)
e. Ankylosing spondylitis
f. Giant cell arteritis
g. SLE
h. Behcet's disease
i. Reiter's syndrome
j. Myasthenia gravis
k. Steven Johnson's Syndrome
l. VKH
3. Infection and inflammation disorders,
a) Syphilis:

Congenital - triad
Acquired - 1ry, 2ry, 3 ry

b) TB
c) Leprosy
d) Venereal transmitted diseases:

chlamydia: inclusion conjuctivitis and opthalmia nenonatorum
viral: lymphogranuloma venereum, H. simplex

e) Toxoplasma - Detail in retina section,
f) Toxocariasis.
g) Onchocerciasis
h) Rubella
I) Measles
j) Cytomegalic inclusion disease: congenital / acquired
k) Adenovirus - PCF & EKC
l) Sarcoidosis
4. Hereditary disorders
a) Trisomy (Down Syndrome)
b) Mucopolysacchoroidosis; e.g. Hurler Syndrome
c) Wilson's disease.
d) Albinism
e) Homocystinurea
f) Galactosaemia
5. Disorders of hematopoetic system
a) Sickle cell anemia
b) Polycythaemia
c) Multiple myeloma
d) Leukemia
Eye care in children and prevention of amblyopia and blindness
1. Introduction
a) Persons responsible about eye care in children
b) Importance of children's eye care
2. Amblyopia: Definition and types
3. Ocular disorders in children leading to amblyopia and blindness: Presentation, management, precautions and prevention.
a) Genetically determined; e.g. cataract, glaucoma, and retinoblastoma
b) Acquired condition; e.g. trauma and infection
c) Others; e.g. retinopathy of prematurity
4. Recommendation and conclusion: screening of all newborn children at different stages of life is highly recommended to ensure early detection and management of the different disorders that may lead to amblyopia and blindness
5. Causes of blindness in Saudi Arabia: including percentage of treatable and preventable blindness
Disorders of the Lens
1. Brief embryology of the lens
2. Brief congenital disorders; e.g. coloboma , etc.
3. Causes of ectopia lentis; e.g. Marfan, Homocrystin urea and trauma.
4. Cataract;
a) Definition
b) Etiology

Congenital:
Inflammatory, e.g. Rubella
Metabolic, e.g. Galactosaemia
Chromosomal, e.g. Down Syndrome
Hereditary, e.g. Wilson Disease
Complicated:
Drug induced, e.g. steroid
Irradiation
Trauma
Uveitis
Senile

c) Management:- Include congenital, unilateral, bilateral and type of surgery

Adult surgery
Treatment of aphakia
Management of amblyopia in children

5. Lens induced ocular problem
a) Phacomorphic glaucoma
b) Phacolytic glaucoma
c) Phacoallergic uveitis
d) Posterior subluxation
e) Anterior subluxation
f) Aphakic retinal detachment
Neuro-ophthalmology
1. Applied Neuro-anatomy
a) Visual pathway:

optic nerve, lesion, pappilitis and VF
Chiasm, lesion, and VF
Tract, lesion, and VF
Radiation, lesion and VF
Cortex, lesion and VF

b) Pupil:

Reflexes; Direct, consentual and near
RAPD
Argyl Robertson pupil (light / near dissociation)
DDX of Anisocoria
Miosis: Drugs, inflammation, sleep, Horner's syndrome, syphilis and pontine hemorrhage
Mydriasis: Drugs, trauma, angle closure glaucoma, midbrain lesion and Cr.III nerve palsy

c) Motor nerves

Cr. III n. palsy; Difference between posterior communicating aneurysm and D.M
Cr. IV n. palsy
Cr. VI n. palsy; False localizing in increased ICP, DM and S. hypertension. part of sign of cerebello-pontine angle tumors
Cr. VII n. palsy: Exposure keratitis, Bell's phenomenon.

2. Raised I.C.P. and papilloedema

Space occupying lesion
Difference between papilloedema and papillitis

3. Cerebrovascular disorders and ocular signs

Atheroma of carotid -- unilateral amaurosis fugax, CRAO and BRAO
Atheroma of basilar system -- bilateral amaurosis fugax, cortical blindness
Aneurysm of posterior communicating artery -- complete painful Cr. III n. palsy
Aneurysm of carotic in cavernous sinus -- carotid cavernous fistula -- pulsating proptosis
Carotid sinus thrombosis
Giant cell arteritis -- Ischaemic optic neuropathy

Leukocoria
1. Definition: White pupil and importance
2. Retinoblastoma, cataract, retinopathy of prematurity, PHPV, etc.
3. Management
Proptosis
1. Definition
2. DX of proptosis and R/O pseudo proptosis condition
3. DDX of proptosis in children - investigation and management
i.e. orbital cellulitis, opt. n. glioma, rhabdomyosarcoma, neuroblastoma, leukemia, capillary haemangioma
4. DDX of proptosis in adults - investigation and management: i.e. Graves disease, meningioma (optic nerve sheath and spheniod) cavernous haemangioma, carotid cavernous fistula, carotid sinus thrombosis
5. Classification of proptosis depending on direction: axial, upward, down and medially, down and laterally
6. Classification of proptosis depending of bilaterality: Graves disease, carotid cavernous fistula, carotid sinus thrombosis, neuroblastoma, leukemia
Ocular Toxicology
1. Complication of topical administration:

mechanical
pigmentation
ocular injury: e.g. topical anesthetic or preservative
sensitivity
comparison between topical and systemic use of dose

2. Ocular reaction of syst. drug:

ethyl alcohol
methyl alcohol
chloroquine
ethambutol
contraception pill
hypervitaminosis A and hypovitaminisis A

Ocular pharmacology, drug toxicity and proptosis
1. Ocular Pharmacotherapeutics
a) Chrolinergic Stimulating Drugs:

Local effect
System effect

i) Direct acting:

e.g. Miochol
e.g. Pilocarpine - mechanism of action in both angle closure and open angle glaucoma

ii) Indirect acting

Reversible
Irreversible; e.g. phospholine iodide with action, side effect and precautions

iii) Cholinergic blocking agents:

Mechanism
Ocular effect
Systemic effect
Examples of drugs and duration of action.
Atropine, Scopolamin, Homatropine, Cyclopentolate and Tropicamide

b) Adrenergic compounds

Adrenergic stimulating: e.g. Epinephrine, Propine, Phenylephrine
Adrenergic blocking: e.g. Timolol - effect, mechanism, side effects

c) Carbonic Anhydrase Inhibitor

Effect, side effect and type

d) Osmotic agent

Mechanism, therapy and drugs.

e) Anti-inflammatory

Glaucocorticoid (therapy, side effect)
Antihistaminic, sodium

f) Antibiotics

Penicillin, Cephalosporin, Aminglycoside, Tetracyclin, Chloramphenicol
Effect, side effect

g) Ocular mycosis chemotherapy

Amphotericin B, Nystatin, Natamycin

h) Antiviral
I) Local anesthetic - topical, infiltration, effect and side effect, manifestation of syst. toxicity
j) Dye: Flourescein & Rose bengal

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Course Materials

Textbooks References

Basic Ophthalmology for Medical Students and Primary Care Residents. By Frank G. Berson, MD
General Ophthalmology. By Vaugh, Asbury and Tabbara
Lecture Notes: Ophthalmology. By Bruce James and Anthony Bron

Syllabus

Lectures

Topics (Lectures)	Time Allowed
Applied Anatomy and Physiology	1 hour
Lid and Lacrimal System	1 hour
Red Eye and Ocular Emergencies	2 hours
Strabismus, Amblyopia and Leukocoria	2 hours
Errors of Refraction	1 hour
Eye and Systemic Diseases	2 hours
Neuro-ophthalmology	1 hour
Ocular Pharmacology, Drug Toxicity	2 hours
Acute Visual Loss	1 hour
Chronic Visual Loss	1 hour

Clinical Skills

External Ocular Examination, Ocular Motility and Alingment	3 hours
Visual Acuity and Ophthalmoscopy	3 hours
Visual Field, Tonometry and Pupil Examination	3 hours

Sample Exam

1. Tear film and lacrimal system: - All true except:

Mucin is produced by goblet cells
Oily secretion that delay evaporation of tear is produced by meibomian glands
Lower punctum drains most of tear to lacrimal sac
Nasolacrimal duct open into the middle meatus of the nose
Fossa for lacrimal gland is situated in the anterior, upper and outer quadrant of the orbit

2. The corneal sensation is supplied by a branch of:

The Third Nerve
The Fourth Nerve
The Fifth Nerve
The Sixth Nerve
The Seventh Nerve

3. Acute dacryocystitis mean:

Infection of the lacrimal gland
Infection of the lower canaliculus
Infection of the lacrimal sac
Infection of the nasolacrimal duct
Infection of the caruncle

4. The management of acute angle closure glaucoma may include the following except:

Intravenous Mannitol
Intravenous Diamox
Timolol eye drops
Epinephrine eye drops
Oral glycerol

5. A 13-year old girl has 20/100 visual acuity in each eye at distance, 20/20 at near, and pinhole acuity 20/25. Most likely the light rays from an object located 20 feet away from her are coming to focus:

On her retina
In front of her retina
Behind her retina
No focus at all
In her pupil

6. Glaucoma can be caused by one of the following:

Anti-hypertensive drugs
Anti-diabetic drugs
Carbonic anhydrase inhibitors
Tetracycline
Steroids

7. All true for accommodation except:

Strong in aphakic patient
Weak in presbyopic patient
Paralysed by cycloplegics
Stimulated by cholinergic drugs
Relaxed on looking to a distant object

8. In open angle glaucoma, all true except:

Topical beta blockers are used for treatment
Laser iridotomy is usually done to reduce intraocular pressure
Family history may be present
It is a disease of middle and elderly age
Patient may have advanced glaucoma with normal visual acuity

9. In the presence of traumatic hyphaema you may think of/or do all the following except:

Reassure the patient and advice him to resume his normal activity
Examine the eye for other possible complications of trauma
Possibility of secondary haemorrhage within 5 days
Surgical removal of the blood may be considered if secondary glaucoma is initiated
Referral to ophthalmologist is needed

10. All true for astigmatism except:

It means different refractive power of the eye in different meridians
May result from corneal scarring
Can be corrected by surgery
Corrected by cylindrical lenses
It does not cause amblyopia in children

11. All pass through Superior ophthalmic fissure except:

Trochlear nerve
Abducent nerve
Lacrimal nerve
Sympathetic nerve
Maxillary nerve

12. The maxillary nerve passes through:

Foramen oval
Foramen rotandoum
Foramen spinosum
Foramen magnum

13. Screening for Retinopathy Of Prematurity is at:

2 weeks.
2 – 3 weeks.
At birth
4 – 6 weeks.
After 7 weeks.

14. Which light's wavelength having high frequency:

Blue
Yellow
Green
Violet
Orange

15. Characteristic features of laser are include the following except:

Monochromatic
Directionality
Polarized
Incoherent

16. Average volume of the orbit is:

25 cc
30 cc
20 cc
40 cc
35 cc

17. Aqueous Humor formation is by:

Diffusion
Ultra filtration
Active secretion
Both a & b
All the above

18. The following structures are normally seen in anterior chamber angle EXCEPT:

Ciliary body band
Trabecular meshwork
Sclera spur
Blood can be seen in schlems canal.
Peripheral anterior synechiae

19. Type I Neurofibromatosis associated with all EXCEPT:

Leish nodules.
Wilm's tumor.
Absence of the patella.
Acoustic neuroma

20. The following antibiotics are Bacteriostatic Except:

Chloramphenicole
Erythromycin
Tetracycline
Ciprofloxacin

21. In fungal keratitis the following can be used except :

Amphotericine B
Fluconazole
Nystatine
Fluroquinolones

22. In retinoblastoma, a pathological report must clearly note :

Choroidal involvement
Optic nerve head involvement
Size of the tumor
Type of the tumor cells

23. What is the spherocylindrical lens which it's spherical equivalent is + 0.75 :

+ 2.50 - 1.50 X 90
+ 2.50 + 1.50 X 30
+ 2.50 - 3.50 X 30
+ 3.00 – 2.00 X 75
-1.00 - 2.50 X 112

24. Which of the following masquerade syndromes can present like orbital cellulitis :

Retinoblastoma.
Rhabdomyosarcoma.
Uveal melanoma.
Myocitis.
All

25. Retinopathy of Prematurity one false:

Can regress spontaneously.
Is associated with low birth weight.
Cryotherapy used in treatment of ROP having good outcome
Laser is less effective than cryotherapy
Stage V carrying the poorest outcome.

26. Thinnest part of the sclera :

At equator
At limbus
At macula
Underneath the extra-ocular muscle insertions

27. follicular conjunctivitis is more superior in which disease:

adult inclusion conjunctivitis
Trachoma
VKC
EKC

28. The bony orbit is formed by all of the following except:

Forntal bone
Zygomatic bone
Temporal bone
Ehtmoidal bone
Lacrimal bone

29. The most common cause of orbital cellulitis in children is:

Direct trauma
Acute sinusitis
Following eye surgery
Spreed of infection from the eyelid

ماجد سليمان الخراشي