Clerkship Manual 2021-22

CLINICAL ROTATIONS &
CLERKSHIP
OPHTHALMOLOGY MANUAL
2021-2022
A student’s guide to:
 Introducing clinical rotations & clerkship
 Outcomes & Objectives
 Competencies : Communication skills, Clinical examination
skills, Critical thinking, Problem solving, Clinical reasoning and
decision making skills
Google drive link for Ophthalmology resources:

https://drive.google.com/drive/folders/1Notn_GuAFyG8uK-sIxdmxLagdBFaDVbH?usp=sharing
INDEX
Page No.
 PREAMBLE
 SECTION I:
 Ophthalmology competencies I – VII
I-
 SECTION II:
 Introduction to 3rd year Clinical Rotations 1
 Clinical Scenarios for 3rd year Clinical Rotations 3
 SECTION III: 46
 Introduction to Ophthalmology Clerkship 47
 Ophthalmology Objectives 48
 Guide to course content 63
 SECTION IV:
 Ophthalmology Clinical Skills 98
 Check Lists For Clinical Skills 152
 APPENDIX I 163
Contributions & Revision 2021 Dr Ayisha Kausar

Associate Professor of Ophthalmology
Shifa College of Medicine
3rd year case scenarios Dr Imran Janjua

Assistant Professor of Ophthalmology
Shifa College of Medicine
Acknowledgment Prof Dr Ali Tayyab

(Development of initial draft of clerkship manual)
i
PREAMBLE
The eyes are the window to the world. Vision is one of the vital factors influencing quality
of life. The ICO resolution demanded worldwide Medical Schools to launch ophthalmic
education program as part of their core curriculum, and not as an elective as offered by
some medical schools. This curricular reform aims at transforming from content based
curriculum to competency based curriculum in ophthalmology clerkship
MISSION STATEMENT
“To develop essential competencies in medical graduates so they can provide primary
eye care in line with best applicable evidence”.
In Shifa College of medicine, Ophthalmology themes are introduced during 2 nd year of

medical school in a 3 week Special senses module (SPS Module) which integrates basic
and clinical aspects. In 3rd year students have 8 weeks (2 hrs / week) ophthalmology
clinical rotations. During 4th year clerkships each medical year class (almost 100 students)
is divide into 10 small groups, having 10-12 students in each group. Each batch rotates
in ophthalmology on its turn for four weeks.
The clerkship program focuses on basic competencies (outcomes) that an undergraduate

must achieve to be able to:
1. Identify prevalent ophthalmic pathologies.

2. Provide primary eye care in line with best applicable evidence.
3. Identify clinical signs that need referral to an ophthalmologist.
ii
SECTION I
OPHTHALMOLOGY
COMPETENCIES
0
OPHTHALMOLOGY COMPETENCIES FOR MBBS STUDENTS- SHIFA COLLEGE OF MEDICINE
# Outcome Competency Objectives* Teaching strategy Assessment tool
Communication Take history of a patient with gradual painless Clinical exposure OSCE,
skills loss of vision Bedside teaching Mini-CEX ,
(History taking (cataract, open angle glaucoma, refractive Role playing Faculty feedback
skill) errors, Diabetic Retinopathy, ARMD, Evidence from portfolio
Amblyopia, Retinoblastoma, Retinitis
Pigmentosa, Vit A deficiency)
Clinical Perform Bedside teaching OSCE,
1 By the end of examination skills 1. Visual acuity, Clinical exposure Mini-CEX ,
ophthalmology 2. Torch examination Role playing Portfolios with reflective
clerkship, the 3. Fundoscopy Patient simulation notes
students will be 4. Digital Tonometry Videos Self & peer assessment of
able to 5. Confrontation Visual Fields & the skill
Identify : Clinical signs of a patient with Evidence from portfolio
gradual painless loss of vision
Manage a Critical thinking/ List a differential diagnosis on the basis of Discussion group MCQS SAQ Quiz
patient with Problem solving history and examination CBD, PBL Evidence from portfolio
gradual painless Case presentation
decreased Clinical reasoning Propose a mechanism responsible for CBD, SGD, Clinical MCQS SAQ Quiz
vision disease exposure Evidence from portfolio
Case presentation
Clinical decision Suggest appropriate treatment for a patient PBL, CBD, Clinical MCQS SAQ Quiz
making/ research with gradual painless loss of vision exposure Case write up,
skills Evidence from portfolio
Critical thinking Identify potential complications of disease Pre-reading MCQS SAQ
and its management SGD Pretest/post-test/ Quiz
Communication Describes the impact of disease on individual, Role modeling, Faculty observation
skills family and society and demonstrate empathic Clinical exposure MiniCEX, OSCE
(Counselling skill) attitude towards patient Patient feedback
Evidence from portfolio
*Highlighted areas show minimum objectives required in third year
I
Sr Outcome Competency Objective Teaching strategy Assessment tool
#
Communication Take history of a patient with sudden painless Clinical exposure OSCE,
skills (History loss of vision Bedside teaching Mini-CEX ,
taking skill) (Retinal detachment, Optic Neuritis, Retinal Role playing Faculty feedback
Vascular occlusions, Vitreous Hemorrhage) Evidence from portfolio
examination skills 1. Visual acuity, Clinical exposure Mini-CEX ,
2. Torch examination Role playing Portfolios with reflective
3. Pupillary Reflexes Patient simulation notes
2 By the end of 4. Visual field examination Videos Self & peer assessment of
ophthalmology 5. Fundoscopy the skill
clerkship, the 6. Digital Tonometry & Evidence from portfolio
students will be Identify : clinical signs of a patient with
able to sudden painless loss of vision
Critical thinking List a differential diagnosis on the basis of Discussion group MCQS SAQ Quiz
Manage a Problem solving history and examination CBD, PBL Evidence from portfolio
patient with Case presentation
sudden Clinical reasoning Propose a mechanism responsible for Retinal CBD, SGD, Clinical MCQS SAQ Quiz
painless detachment, Retinal Vascular occlusion, exposure Evidence from portfolio
decreased Vitreous hemorrhage and Optic Neuritis Case presentation
vision Clinical decision Suggest emergency treatment and PBL, CBD, Clinical MCQS SAQ Quiz
making/ research appropriate referral for a patient with sudden exposure Case write up,
skills painless loss of vision Evidence from portfolio
skills family and society and demonstrate empathic Clinical exposure Mini-CEX, OSCE
(counselling skills) attitude towards patient Patient feedback
II
#
Communication Take history of a patient with red eye with Clinical exposure OSCE,
skills (History decreased vision Bedside teaching Mini-CEX ,
taking skill) (Ac. Angle closure, Anterior uveitis, Keratitis, Role playing Faculty feedback
dry eyes) and without decreased vision Evidence from portfolio
(Conjunctivitis, episcleritis, scleritis, blepharitis
etc.)
3 By the end of Clinical Perform Bedside teaching OSCE,
ophthalmology examination skills 1. Visual acuity, Clinical exposure Mini-CEX ,
clerkship, the 2. Torch examination Role playing Portfolios with reflective
students will be 3. Corneal staining Patient simulation notes
able to 4. Digital tonometry Videos Self & peer assessment of
5. Pupillary examination the skill
Manage a Identify: Clinical signs of red eye Evidence from portfolio
patient with red Critical thinking Generate a differential diagnosis on the basis Discussion group MCQS SAQ Quiz
eye Problem solving of history and examination CBD, PBL Evidence from portfolio
Case presentation
Clinical reasoning Propose a mechanism responsible for disease CBD, SGD, Clinical MCQS SAQ Quiz
exposure Evidence from portfolio
Case presentation
Clinical decision Suggest treatment for a patient with red eye PBL, CBD, Clinical MCQS SAQ Quiz
making/ research exposure Case write up,
Critical thinking Identify potential complications of disease and Pre-reading MCQS SAQ
its management SGD Pretest/post-test/ Quiz
attitude towards patient Patient feedback
Highlighted areas show minimum objectives required in third year
III
Sr Outcome Competency Objective Teaching Assessment tool
# strategy
Communication Take history of a patient with adnexal swelling Clinical exposure OSCE,
skills (History (Stye/ Preseptal cellulitis, chalazion, Tumors) Bedside teaching Mini-CEX ,
taking skill) (Nasolacrimal passage obstruction ) Role playing Faculty feedback
(Conjunctival growths, Pterygium etc.) Evidence from portfolio
(Orbit: Cellulitis, Thyroid eye disease,
Retinoblastoma)
4 By the end of Clinical Perform Bedside teaching OSCE,
ophthalmology examination skills 1. Visual acuity, Clinical exposure Mini-CEX ,
clerkship, the 2. Torch examination Role playing Portfolios with reflective
students will be 3. Extra ocular movements Patient simulation notes
able to 4. Pupillary examination Videos Self & peer assessment of
5. Regurgitation Test the skill
Identify: clinical signs of a patient with adnexal Evidence from portfolio
Manage a swelling
patient with Critical thinking Generate a differential diagnosis on the basis of Discussion group MCQS SAQ Quiz
ocular growths/ Problem solving history and examination CBD, PBL Evidence from portfolio
ocular adnexa Case presentation
swelling Clinical reasoning Propose a mechanism responsible for disease CBD, SGD, MCQS SAQ Quiz
Clinical exposure Evidence from portfolio
Case presentation
Clinical decision Suggest treatment for a patient with adnexal PBL, CBD, Clinical MCQS SAQ Quiz
making/ research swelling exposure Case write up,
Critical thinking Identify potential complications of disease and its Pre-reading MCQS SAQ
management SGD Pretest/post-test/ Quiz
IV
Sr Outcome Competency Objective Teaching Assessment tool
# strategy
Communication Take history of a patient with lid malposition Clinical exposure OSCE,
skills (History ( Entropion, Ectropion, Ptosis) Bedside teaching Mini-CEX ,
taking skill) Role playing Faculty feedback
examination skills 1. Torch examination Clinical exposure Mini-CEX ,
2. Ptosis measurements Role playing Portfolios with reflective
5 By the end of 3. Pupillary examination Patient simulation notes
ophthalmology Identify: clinical signs of a patient with lid Videos Self & peer assessment of
clerkship, the malposition the skill
students will be Evidence from portfolio
able to Critical thinking Generate a differential diagnosis on the basis of Discussion group MCQS SAQ Quiz
Problem solving history and examination CBD, PBL Evidence from portfolio
Case presentation
Manage a Clinical reasoning Propose a mechanism responsible for disease CBD, SGD, MCQS SAQ Quiz
patient with lid Clinical exposure Evidence from portfolio
malposition Case presentation
Clinical decision Suggest treatment for a patient with lid PBL, CBD, Clinical MCQS SAQ Quiz
making/ research malposition exposure Case write up,
Critical thinking Identify potential complications of disease and its Pre-reading MCQS SAQ
management SGD Pretest/post-test/ Quiz
V
#
Communication Take history of a patient with deviation of Clinical exposure OSCE,
skills (History eyes: Comitant squints, In-comitant squints Bedside teaching Mini-CEX ,
taking skill) i.e. Neurological and restrictive Role playing Faculty feedback
(eso deviation, exo deviations, vertical Evidence from portfolio
deviations)
Clinical Perform an eye examination Bedside teaching OSCE,
examination skills 1. Extra ocular movements Clinical exposure Mini-CEX ,
6 By the end of 2. Hirschberg test Role playing Portfolios with reflective
ophthalmology 3. Cover Patient simulation notes
clerkship, the 4. Uncover test and Videos Self & peer assessment of
students will be Identify: clinical signs of a patient with the skill
able to deviation of eyes Evidence from portfolio
Critical thinking Generate a differential diagnosis on the basis Discussion group MCQS SAQ Quiz
Problem solving of history and examination CBD, PBL Evidence from portfolio
Manage a Case presentation
patient with Clinical reasoning Propose a mechanism responsible for CBD, SGD, Clinical MCQS SAQ Quiz
deviation of disease exposure Evidence from portfolio
eyes Case presentation
Clinical decision Suggest treatment for a patient with PBL, CBD, Clinical MCQS SAQ Quiz
making/ research deviation of eyes exposure Case write up,
VI
#
Communication Take history of a patient with ocular, orbital or Clinical exposure OSCE,
skills (History adnexal trauma, chemical injury. Bedside teaching Mini-CEX ,
taking skill) Role playing Faculty feedback
Clinical Perform relevant examination and identify Bedside teaching OSCE,
examination skills clinical signs of a patient with ocular, orbital Clinical exposure Mini-CEX ,
7 By the end of or adnexal trauma Role playing Portfolios with reflective
ophthalmology Patient simulation notes
clerkship, the Performs eye wash in chemical injury Videos Self & peer assessment of
students will be the skill
able to Evidence from portfolio
Critical thinking Generate a differential diagnosis on the basis Discussion group MCQS SAQ Quiz
Problem solving of history and examination CBD, PBL Evidence from portfolio
Manage a Case presentation
patient with Clinical reasoning Propose a mechanism responsible for CBD, SGD, Clinical MCQS SAQ Quiz
ocular, orbital disease exposure Evidence from portfolio
or adnexal Case presentation
trauma Clinical decision Suggest treatment for a patient with ocular, PBL, CBD, Clinical MCQS SAQ Quiz
making/ research orbital or adnexal trauma exposure Case write up,
VII
SECTION Il
 Introduction to 3rd year Clinical
Rotations
 Clinical Scenarios for 3rd year
Clinical Rotations
1
INTRODUCTION TO 3RD YEAR CLINICAL ROTATIONS
ATTENDENCE
The clinical rotation starts at 8 am. Attendance will be taken separately for both activities
(Case based learning and clinical skills session). You will be marked present for the day
ONLY if you attend all the activities scheduled for that day.
ROTATION ACTIVITIES
Students will have 8 weeks (2 hrs. / week) ophthalmology clinical rotations. These
rotations are scheduled on every Wednesday morning. The schedule is displayed on 3rd
year notice board and also emailed to the students.
Due to COVID 19 pandemic, Case based discussions are shifted to online sessions.
A brief outline of daily activities is given below:
TIME SLOT MAJOR ACTIVITIES (LOCATION)

Saturday Case Based Learning
9-10:30am (Online/ zoom)**
Wednesday Clinical Skills discussions
8 – 9 am (College SGD Room)
9 – 10am Clinical Skills (SFCHC EYE OPD, D-0 Conference room III )
Four major themes and six clinical skills are introduced in 3rd year ophthalmology
rotations. Their details are mentioned below. Clinical scenarios for each theme are given
in following section.
Clinics are the mainstay of learning. See as many patients as possible and discuss them
with your preceptor for the day or any available member of the faculty.
Students may also be given various assignments e.g. power point presentations, group
activities etc. during the rotation.
REFLECTIVE WRITING
At the end of clinical rotation you would be asked to give a reflection regarding your
learning in third year. This aims at identification of the learning gaps by the student and
devising a future action plan for improved learning. You can refer to “Gibbs reflective
cycle” for this.
CLINICAL PORTFOLIO
It is student’s responsibility to maintain the portfolio. The clinical portfolio will serve as a
collection point for all your activities during the rotation.
ASSESSMENT
The end of rotation exam will be conducted after 8 weeks. It is designed as a tool, for
yourself and your perceptors, to gauge your performance. The assessment will help you
judge the level of competence that you have achieved and if it meets the minimal set
criteria.
2
The breakdown of assessment tools with their weightage is provided in your portfolio.
THEMES & SKILLS FOR 3rd YEAR ROTATION
THEME I: GRADUAL PAINLESS DECREASED VISION

- Cataract WEEK: 1
- Refractive errors WEEK: 2
- Diabetic retinopathy WEEK: 3
- Age related macular degeneration/ Retinitis Pigmentosa WEEK: 3
- Primary open angle glaucoma WEEK: 4
THEME II: RED EYE/ SUDDEN PAINFUL DECREASED VISION

- Angle closure glaucoma WEEK: 5
- Anterior uveitis WEEK: 5
- Conjunctivitis WEEK: 6
- Keratitis WEEK: 6
THEME III: OCULAR GROWTHS & SWELLINGS

- Stye, Chalazion, Pterygium WEEK 7
THEME IV: TRAUMA/ OCULAR EMERGENCIES

- Orbital cellulitis, penetrating & chemical injury to eye WEEK 7
OPHTHALMIC SKILLS
- History Taking
- Visual Acuity: Distance & Near Acuity
- Torch Examination
- Ophthalmoscopy
- Digital Tonometry
- Pupil Examination
- Confrontation Visual Field Examination
3
CATARACT
Presenting Complaint: A 60 year-old man presented in OPD with gradual painless decreased
vision in right eye for past 3 years.
History of Present Illness: There was gradual worsening of vision over past few years. His vision
improved with glasses initially, but now there is no improvement with glasses. He consulted a
local doctor who told him that crystalline lens in right eye has opacified a phenomenon called
cataract.
Past Ocular History: Not significant
Ocular Medications: None
Past Medical History: Not significant
Surgical History: Not significant
Past Family Ocular History: Not significant
Social History: Belongs to a middle class family
Medications: None
Allergies: None
Review of systems: Not significant
Ocular Exam
OD/ Right eye OS/ Left eye
Visual Acuity (best corrected) 6/60 with -5.00 DS 6/9 with -2.00 DS
IOP (Goldman applanation) 14 mmHg 14mmHg
Pupils Round, regular, reactive Round, regular, reactive
Extraocular Movements Normal. Normal
Confrontational V.F OD Normal OS Normal
4
Slit Lamp Examination findings:
OD/ Right eye OS/ Left eye

Lids and Lashes NAD NAD
Conjunctiva/Sclera NAD NAD
Cornea NAD NAD
Anterior Chamber Quiet , deep Quiet , deep
Iris NAD NAD
Lens Nucleus Sclerosis +++ Nucleus Sclerosis +
Anterior Vitreous NAD NAD
Dilated Fundus Examination: NAD NAD
Rlevant Pictures: Right Eye Rlevant Pictures: Left Eye
CRITICAL QUESTIONS:
1. What is anatomical composition of human crystalline lens? How does the lens contribute to the vision
and maintains its transparency?
2. What are various mechanisms of lens opacification?
3. What are different types of cataract and classification (congenital /acquired) ?
4. What are the different methods to treat cataract?
5
MYOPIA
Presenting Complaint: A 9 year old school student has been referred to eye clinic by school
physician because she can’t read white board while sitting in last row.
History of Present Illness: Vision becomes better when she comes closer to the white board. No
difficulty in reading or writing from book.
Social History: Not significant
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
Visual acuity 6/36 6/24

Visual acuity with
6/6 6/6
pin-hole
Cycloplegic
-2.00 DS -1.75 DS
Refractive correction
ROUND , REGULAR , ROUND , REGULAR ,
Pupil
REACTIVE (RRR) REACTIVE (RRR)
Lens CLEAR CLEAR
CDR 0.3, temporal crescent at disc CDR 0.3, temporal crescent at disc
Fundus Macula healthy Macula healthy
Periphery Normal Periphery Normal
6
CRITICAL QUESTIONS:
What is myopia? What are the different options to treat myopia?
7
HYPERMETROPIA
Presenting Complaint: A five year old child was brought by his mother with the complaint of
inability to see television from a distant place.
History of Present Illness: Mother of a five year old child has noted her child sits very close to television
screen while watching cartoons. He also complaints of eye strains and headaches on prolonged near work.
Past Ocular History: The child was prescribed convex glasses on his previous visit.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye

Visual acuity with pin-
6/6 6/6
hole
Cycloplegic Refractive
+ 4.00 Ds + 4.25 Ds
correction
Pupil Round , Regular , Reactive Round , Regular , Reactive
Lens Clear Clear

CDR 0.1 CDR 0.1
Fundus Macula Healthy Macula Healthy
8
CRITICAL QUESTIONS:
What is hypermetropia? What are the different options to treat hypermetropia?
9
ASTIGMATISM
Presenting Complaint: A 25 year old man has noticed blurry vision both for far and near and eye
strain.
History of Present Illness: He experiences eye strain and headache when he tries to focus on
something. These symptoms increase on reading and writing. The text seems to be tilted and letters
seem to be running after each other.
Past Ocular History: He was previously diagnosed with astigmatism.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye

Visual acuity with pin-
6/12 6/9
hole
Refractive correction -2.00 DS / - 1.50 DC x 900 - 1.75 DS / - 1.50 DC x 900
ROUND , REGULAR , REACTIVE ROUND , REGULAR ,
Pupil
(RRR) REACTIVE (RRR)
Lens CLEAR CLEAR
CDR 0.3 CDR 0.3
10
CRITICAL QUESTIONS:
What is astigmatism? Which type of lens is used to treat astigmatism?
11
PRESBYOPIA:
Presenting complaint: A 50 years old male complains of difficulty in reading small fonts. He
never used glasses before.
History of Present Illness: The patient has difficulty in reading the newspaper. The text becomes
legible when he moves the paper away from his eyes.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
Near Vision N 10 N 10
Refraction + 1.50 DS for near + 1.50 DS for near

Round , Regular , Reactive
Pupil Round , Regular , Reactive (RRR)
(RRR)
Lens CLEAR CLEAR
CDR 0.3 CDR 0.3
12
CRITICAL QUESTIONS:
What is presbyopia? What is its mechanism and management?
13
DIABETIC RETINOPATHY
Presenting Complaint: A 50 years old diabetic female presented with gradual painless decrease
in vision in her left eye.
History of Present Illness: The patient’s vision is getting gradually worse over last 3 years, with
no improvement with glasses.
Ocular Medications/ Allergies: None
Past Medical History: Diabetic for the past 15 years. Hypertensive and hyperlipidemia for last
5 years.
Medications: She has been advised Tab Metformin, Lisinopril and Simvastatin. Non-compliant
with treatment.
Ocular Exam
Right Eye Left Eye
Best Corrected Visual acuity 6/9 6/36
Ant Segment Normal Normal
Lens Early cortical cataracts Early cortical cataracts

Dot-blot Hemorrhages And Hemorrhages, Edema And
Cotton wool spots. Hard Exudates At Fovea
Fundus
( i.e. Non Proliferative (i.e Diabetic Macular Edema +
Diabetic Retinopathy (NPDR)) NPDR)
Intra Ocular Pressure
12 14
(IOP) mmHg
14
Right eye Left eye
CRITICAL QUESTIONS:
1. What is the mechanism of leakage of vessels in diabetic retinopathy?
2. What are the signs and symptoms of diabetic retinopathy?
3. What are different stages of diabetic retinopathy?
4. What are the treatment options for diabetic retinopathy?
15
AGE RELATED MACULAR DEGENERATION (ARMD):
Presenting Complaint: A 70 years old male has noted that he is having difficulty in reading
newspaper and margins of the objects appear curvy.
History of Present Illness: He has been using glasses for near but his symptoms have aggravated.
His peripheral vision is intact.
Past Ocular History: Bilateral cataract surgery 10 years ago.
Past Medical History: Dyslipidemia
Personal history: Smoker, 1 pack per day for last 50 years
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
Visual acuity 6/36 Counting Fingers At 2 Meters
Lens Pseudophakic Pseudophakic

Drusen (Yellow Spots at level Choroidal Neovascular Membrane,
Fundus of Bruch’s membrane) Hemorrhages, Red Spot On Macula
i.e. Dry ARMD (i.e. Wet ARMD)
Intra Ocular
16 14
Pressure
16
(IOP) mmHg
Right eye Left eye
CRITICAL QUESTIONS:
1. What is ARMD and how does it affect vision?
2. What are the systemic risk factors for ARMD?
3. What are different types of ARMD?
4. What are the treatment options for ARMD?
17
RETINITIS PIGMENTOSA:
Presenting Complaint: A 15 years old student comes to you with the complaint that he finds it
difficult to see in the dark.
History of Present Illness: He has good vision in light. He never had pain in his eyes.
Past Family Ocular History: His father has similar complaints since his teenage.
Medications: None
Allergies: None
Ocular Examination:
Right Eye Left Eye
Lens Clear Clear

Pale waxy disc, attenuated vessels, Pale waxy disc, attenuated vessels,
Fundus mid periphery bone spicule mid periphery bone spicule
pigmentation pigmentation
13 14
(IOP) mmHg
18
CRITICAL QUESTIONS:
1. What is retinitis pigmentosa?
2. What is its inheritance pattern and how does it affect night vision?
3. What are the treatment options?
19
PRIMARY OPEN ANGLE GLAUCOMA (POAG)
Presenting Complaint: A 65 years old university teacher has noticed gradual painless decrease
in vision in his left eye.
History of Present Illness: There is no history of pain or any redness.
Past Ocular History: Myopic. Uses glasses.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye

Refraction -2.00 DS -2.5 DS
Ant Segment Formed , Quiet Formed , Quiet
Lens Clear Clear
CDR 0 .5 CDR 0.8
Cup Disc Ratio CDR
Neuroretinal rim: pink Neuroretinal rim: pale
20 30
(IOP) mmHg
EOM Normal Normal
CONFRONTATIONAL
Normal Peripheral Field Defects
VISUAL FIELDS
20
CRITICAL QUESTIONS:
1. What is the mechanism of maintenance of normal intra ocular pressure?
2. What is the mechanism of glaucomatous optic neuropathy in glaucoma?
3. What are different options to treat open angle glaucoma?
4. What is the proper technique of putting eye drops?
21
ACUTE CONGESTIVE GLAUCOMA (ACG)
Presenting Complaint: A 45-year-old hyperopic lady presents in emergency with redness,

watering and severe eye pain in her right eye.
History of Present Illness: The pain started 12 hours ago and has become progressively worse.
It is associated with nausea and vomiting, headache, markedly reduced & blurred vision and seeing
haloes around lights. She also had a similar episode in her right eye 6 months back for which she
took treatment from some local clinic. Details of that treatment are not available.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye

Visual acuity COUNTING FINGERS (CF) 6/6
Refraction +2.5 DS +2.5 DS
Conjunctival Congestion Cornea Clear
Ant Segment
Cornea Hazy, AC Shallow AC Shallow
Pupil Vertically Oval, Mid Dilated Round , Regular , Reactive
Lens Ant. Capsular Opacity Normal
Fundus Pale Disc , View Hazy Normal
60 20
(IOP) mmHg
Not Visible Due To Corneal
Gonioscopy Narrow Angles
Edema
22
CRITICAL QUESTIONS:
1. What are the risk factors of angle closure in acute congestive glaucoma?
2. What is the emergency management of ACG?
3. What is the long term management of ACG?
23
ACUTE ANTERIOR UVEITIS
Presenting Complaint: A 37-year-old female patient presented with pain, red eye and blurred
vision for last 3 days.
History of Present Illness: The pain started 3 days ago which gradually increased in intensity.
There is no history of any trauma or infection. There is no associated headache or nausea &
vomiting.
Past Ocular History: She has history of such episodes alternating between both eyes. Her problem
responds to topical steroids.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye

Congested conjunctiva, Normal conjunctiva,
Anterior segment
Mild Corneal haze Clear cornea
Ant Chamber Cells ++++, Flare+++, Hypopyon Quiet
Pupil Miosed, Posterior Synechiae Round , Regular , Reactive

Lens Anterior Capsular Opacity Normal
Fundus No View Normal
08 16
(IOP) mmHg
24
CRITICAL QUESTIONS:
1. What is anterior uveitis? What are its signs and symptoms?
2. What is the management of anterior uveitis?
3. How will you differentiate it from Acute congestive glaucoma?
25
VIRAL CONJUNCTIVITIS
Presenting Complaint: A 10 year old boy presented in OPD with history of watering and redness
in his eyes for last 4 days. The problem involved right eye first and later involved the left eye also.
History of Present Illness: There is mild lid tenderness in both eyes. The discharge is clear and
watery. He is also having sore throat and low grade fever.
Past Family Ocular History: His father had similar ocular complaints a week ago.
Medications: None
Allergies: None
Ocular exam:
Right Eye Left Eye

Congested conjunctiva, inferior Congested conjunctiva, inferior
Conjunctiva
fornix has follicular reaction fornix has follicular reaction
Anterior segment Clear cornea Clear cornea
Anterior Chamber Quiet Quiet
Lens Clear Clear
Fundus NAD NAD
Regional lymph
Bilateral submandibular tender lymphadenopathy
nodes
26
CRITICAL QUESTIONS:
1. Describe brief anatomy of conjunctiva. What is the pathophysiology of viral conjunctivitis?
2. What is the treatment of viral conjunctivitis?
3. What are the general measures to maintain ocular hygiene and avoid spread of infection?
27
BACTERIAL CONJUNCTIVITIS / OPHTHALMIA NEONATORUM
Presenting Complaint: A 10 days old neonate is brought in OPD with sticky discharge and
matting of lashes for 2 days.
History of Present Illness: The discharge started 2 days ago. It is mucopurulent and there is
history of matting of eyelashes. It is difficult to open the eyelids in the morning. The child was
delivered at home through SVD.
Medications: None
Allergies: None
Ocular Exam:
Right Eye Left Eye

Erythematous lid margins, Erythematous lid margins,
Lids
Sticky eyelashes Sticky eyelashes
Congested conjunctiva, Congested conjunctiva,
Anterior segment Mucopurulent discharge, Mucopurulent discharge,
Clear cornea Clear cornea
Anterior Chamber Quiet Quiet
Lens Clear Clear
Fundus Normal Normal
28
CRITICAL QUESTIONS:
1. What are the causative pathogens of Ophthalmia neonatorum and bacterial conjunctivitis?
2. What are the preventive measures to avoid this condition?
3. What are the treatment options of bacterial conjunctivitis?
29
VIRAL KERATITIS
Presenting Complaint: A 55 years old male presented in OPD with decreased vision, pain and
watering of his right eye since 4 days.
History of Present Illness: The pain started 4 days ago. It was of moderate intensity. There is
clear watery discharge. No history of matting of lashes.
Past Medical History: Diabetic. Uncontrolled with oral hypoglycemics.
Medications: Oral Metformin
Allergies: None
Ocular Exam
Right Eye Left Eye
VISUAL ACUITY 6/60 6/6
Lids Normal Normal
Congestion
Conjunctiva Normal
Clear watery discharge
Dendritic ulcer
Cornea Clear
Fluorescein stain positive
Anterior chamber Formed and quiet Formed and quiet
Pupil Round , regular , reactive Round , regular , reactive
Lens Clear Clear
30
CRITICAL QUESTIONS:
1. What are the risk factors of viral keratitis?
2. What is fluorescein stain and what are its uses in ophthalmology?
3. What is the treatment of viral keratitis and what is the role of topical steroids in herpetic
keratitis?
31
BACTERIAL KERATITIS
Presenting Complaint: A 35 year old contact lens user comes to you with ocular pain and
decreased vision since one day.
History of Present Illness: The patient experienced pain in the eye one day back. It started few
hours after she had a finger nail injury to cornea, while removing her contact lens. Pain is severe
in intensity associated with photophobia. There is also associated redness and watery discharge.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
Lids Normal Normal
Conjunctiva Congestion Normal
Cornea Corneal ulcer and stromal abscess Clear
Anterior chamber Hypopyon Formed and quiet
Pupil Round , sluggish reaction Round , regular , reactive
Lens Clear Clear
32
CRITICAL QUESTIONS:
1. What are the risk factors of bacterial keratitis? Which organisms are most commonly involved?
2. What is the treatment of bacterial keratitis and what is the role of topical steroids in this case?
33
PTERYGIUM
Presenting Complaint: A 45 years old farmer presented in OPD with the complaints of irritation,
watering and decreased vision from his left eye.
History of Present Illness: The symptoms started one year ago for which he took some treatment
from local doctors with temporary relief. The symptoms kept on increasing with time. Initially his
vision was not affected but for last 2 months he has also developed complaints of blurry vision.
Ocular Medications: Some eye drops from local pharmacy. Details are not available.
Past Medical/ Surgical History: Not significant
Medications/ Allergies: None
Ocular Exam
Right Eye Left Eye
Visual Acuity 6/6 6/36
Refraction -- 0.5 DS/ +3.5 DC @ 90ͦ
Lids Normal Normal

Congested
Conjunctiva Normal Triangular fleshy growth extending from medial
canthus towards cornea
Cornea Clear Fleshy conjunctival growth on cornea
Anterior chamber Formed and quiet Formed and quiet
Round , regular ,
Pupil Round , regular , reactive
reactive
Lens Clear Clear
34
CRITICAL QUESTIONS:
1. What are the risk factors of this disease?
2. What is the pathophysiology?
3. What are the treatment options?
4. What are the complications if left untreated?
35
STYE
Presenting Complaint: A young patient presents to ophthalmology OPD with pain and swelling
in right upper eyelid for last 2 days.
History of Present Illness: The pain is associated with swelling at the lid margin.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
Swollen, Tender
Lids Normal
Pus Point At The Base Of Eyelashes
Conjunctiva Normal Normal
Cornea Clear Clear
Anterior chamber Formed And Quiet Formed And Quiet
Lens Clear Clear
36
CRITICAL QUESTIONS:
1. What are the risk factors of this disease?
2. Which organisms are involved in its pathophysiology?
3. What is its management?
37
CHALAZION
Presenting Complaint: An 18 years old girl presented with painless swelling in her right eyelid
for past 2 weeks.
History of Present Illness: The swelling is away from the lid margin. It is gradually increasing in
size. It is not associated with pain or tenderness. The overlying skin is mobile and no signs of
inflammation are present.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
Non-Tender
Lids Normal
Swelling Away From The Lid Margin
Conjunctiva Congested Palpebral Conjunctiva Normal
Cornea Clear Clear
Anterior chamber Formed And Quiet Formed And Quiet
Lens Clear Clear
38
CRITICAL QUESTIONS:
1. What is the pathophysiology of this disease?
2. What are its differentiating features from Stye?
2. How will you manage it?
39
ORBITAL CELLULITIS
Presenting Complaint: A 22 years old female presents to emergency with high grade fever, right
sided ocular pain and swelling for last 3 days.
History of Present Illness: The patient developed swelling and pain of her right eye 3 days back
which has gradually increased in severity. She is not able to open her right eye and attempt to move the
eyeball triggers pain.
Past Medical History: She has history of sinusitis since 1 week
Medications / Allergies: None
Ocular Exam
Right Eye Left Eye
VISUAL
6/60 6/6
ACUITY
EYEBALL Proptosis Normal
Lids Swollen Normal
Congested, Chemosed
Conjunctiva Normal
Prolapsed From Palpebral Aperture
Cornea Clear Clear
Anterior
Formed And Quiet Formed And Quiet
chamber
Pupil Sluggish Reaction Round , Regular , Reactive
EOM Restricted And Painful Normal
40
CRITICAL QUESTIONS:
1. What is Orbital cellulitis? Which structures are involved in Orbital cellulitis?
2. What are its predisposing factors?
3. What is its management plan?
4. What are its potential complications?
41
CHEMICAL INJURY TO THE EYE
Presenting Complaint: A 45 years old fabric factory worker came to you with severe pain and
burning in eyes since half an hour.
History of Present Illness: There is history of instillation of some chemical in his eyes, he brought
the bottle with him.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
VISUAL ACUITY Counting Fingers Counting Fingers
ADNEXA Burnt Skin Burnt Skin
Conjunctiva Congested and Chemosed Congested and Chemosed
Cornea Hazy, more than 180 º limbal ischemia Hazy
Anterior chamber Hazy View, Formed Hazy View, Formed
Lens Hazy View Hazy View
42
CRITICAL QUESTIONS:
1. What are the effects of chemical injury to the eye?
2. How will u manage the case in emergency?
3. What are the long term complications of chemical injury?
43
PENETRATING INJURY TO THE EYE
Patient History: A young laborer is brought to emergency with ocular pain and intense watering
since one hour.
History of Present Illness: He was working with chisel and hammer when something struck his
eye.
Medications: None
Allergies: None
Ocular Exam
Right Eye Left Eye
Visual acuity 6/6 Hand movements
Lids Normal Normal
Conjunctiva Normal Congested
Corneal laceration
Cornea Clear
Iris prolapse from the wound
Anterior Shallow
Formed and quiet
chamber Hyphema
Pupil Round , regular , reactive Irregular, non-reactive
Lens Clear Hazy
44
The clinical picture and CT is shown below.
CRITICAL QUESTIONS:
1. What should be the management plan for such cases?
2. Which investigations are helpful if you suspect Intra-ocular foreign body (IOFB) in a patient
with penetrating trauma?
3. Which investigation is contraindicated if you suspect a metallic IOFB?
45
SECTION III
 Introduction to Ophthalmology Clerkship
 Ophthalmology Objectives
 Guide to course content
46
INTRODUCTION TO OPHTHALMOLOGY CLERKSHIP
ATTENDENCE
The clerkship starts at 8 am. Attendance will be taken separately for all (activities) time
slots. You will be marked present for the day ONLY if you attend all the activities
scheduled for that day.
CLERKSHIP ACTIVITIES
The clerkship program runs for 4 weeks. The schedule is posted on the department’s
notice board and also emailed to the students. A brief outline of daily activities is given
below:
TIME SLOT MAJOR ACTIVITIES (LOCATION)

8 – 10 am 1. Case discussions (SFCHC/SIH , see schedule for
details)
10:30am – 1 pm 1. Clinics (SFCHC/ SIH)
2. Operation theater rotations
2 – 3 pm Clinical Skills (SFCHC)
MINI CEX
During week 3, you will be required to take your Mini-CEX. This exercise is designed to
help you gauge your progress. Use this tool to work on areas that need improvement.
Please refer to ‘Mini-CEX form’ in your portfolios for more on the Mini-CEX assessment.
CLINICAL ACTIVITIES
Clerkship students are expected to stay in clinics during rotation timings. Clerkship
rotation focuses on clinical interaction with patients. See as many patients as possible
and discuss them with your designated perceptors or any member of the faculty.
Management plans will incorporate best applicable evidence. Students will be
encouraged to formulate management plans keeping in mind the current best practices
and evidence that can be locally applied and learn to tailor them to suit patient’s beliefs
and social standings OT rotations are designed to familiarize you with ocular surgical
techniques.
CLINICAL PORTFOLIO
It is student’s responsibility to maintain the portfolio. The clinical portfolio will serve as a
collection point for all your activities during the Clerkship. The portfolio will include your
attendance and performance evidence.
47
ASSESSMENT
The end of rotation assessment is designed as a tool, for yourself and your perceptors,
to gauge your performance. The assessment will help you judge the level of competence
that you have achieved and if it meets the minimal set criteria.
The breakdown of assessment tools with their weightage is provided in your portfolio.
CONTACTS
SFCHC Eye clinic: 3766
Dr Sulman Jaffar: 3392, 13434
Dr Ayisha Kausar: 3775, 15858
Dr Imran Janjua: 3766
D Aila Asif, Dr Waqas Saeed, Dr Salman Tariq 3766
1. DR SULMAN JAFFAR: sulmanjaffar@gmail.com, sulman.scm@stmu.edu.pk

2. DR AYISHA KAUSAR: ayisha_kausar.scm@stmu.edu..com
3. DR IMRAN JANJUA: janjua.doc@gmail.com
4. DR AILA ASIF: ailaasif@hotmail.com
5. DR WAQAS SAEED: mwaqassaeed01@gmail.com
6. DR SALMAN TARIQ: sally_tariq@yahoo.com
48
 BACKGROUND KNOWLEDGE:
The students are expected to recall basic eye structure, function& examination. This
includes but not restricted to
1. Gross structure & function of the 3 layers of the eyeball& the bony orbit
2. The structure & function of the focusing system of the eye with emphasis
on image formation and its aberrations (acuity, color vision)
3. The physiology of eye movement
4. Visual fields –definition & testing
5. Tear formation & drainage system
49
 FAMILIARITY WITH COMMON DIAGNOSTIC & INVESTIGATIONS:
Through the course of the clerkship the students will gain familiarity with the following:
1. Fundus Fluorescein Angiography (FFA)
2. Optical coherence Tomography
3. A-Scan Ultrasonography
4. B-Scan Ultrasonography
5. Automated visual field analyzer
6. Corneal Topography
The students will be required to only:
1. Identify the utility of the test
2. Understand the applicability of the test
 See pictures as appendix I.
50
 INTRODUCTION TO OBJECTIVES
As such the objectives that need to be achieved are listed thematically,

based on consistent patient presentations. The listed objectives form the
baseline level of competency for undergraduate students in the
ophthalmology program. Use these as a guide rather than to do list.
THEME 1: A PATIENT WITH GRADUAL PAINLESS DECREASED

VISION
OBJECTIVES:
1. Create a differential for gradual, painless loss of vision for this patient
a. Cataracts
b. Glaucoma (Open Angle)
c. Diabetic retinopathy
d. Age Related Macular Degeneration (ARMD)
e. Refractive errors
f. Retinitis Pigmentosa (night blindness/ strong family hx)
g. Retinoblastoma (Only in Children < 2 years age)
h. Vit A. Deficiency (Also causes dry eyes/ Skin)
2. Perform an eye examination and Identify clinical signs focusing on parameters that
help in narrowing down the differential diagnosis
a. Visual acuity
b. Torch examination
c. Confrontation visual fields
d. Distant & direct ophthalmoscopy
e. Digital tonometery
3. Propose a mechanism responsible for the disease (Clinico-Pathological Correlation)

and its natural progression.
a. Cataracts: Mechanism of cataract formation
b. Glaucoma: Mechanism of glaucomatous damage
c. Diabetic retinopathy: Mechanism of diabetic retinal damage
d. Age Related Macular Degeneration (ARMD): Mechanism of dry & wet
degeneration
e. Refractive errors: Mechanism of image formation & its aberrations
f.Retinitis Pigmentosa: Mechanism of night vision damage
g.Retinoblastoma: Mechanism of loss of vision + threat to life
51
h.Vit. A Deficiency: Mechanism of visual loss
4. Design a management plan

Common: Counseling
Specific:
a. Cataracts: Investigations. Surgery (when & how to intervene) and post-surgical care
b. Glaucoma: Investigations. Medical management (selecting treatment, identify if
treatment is working) & surgical management (when to intervene)
c. Diabetic retinopathy: Glycemic control, Lasers and Anti-VEGFs, Vitrectomy.
d. Age Related Macular Degeneration: Investigations. Monitoring & nutrients (Dry), anti-
VEGF (Wet)
e. Refractive errors: Determination of errors of refraction, Non-interventional
management (glasses, contacts). Interventional management (Excimer Laser).
f.Retinitis Pigmentosa: Patient education, low vision aid
g.Retinoblastoma: Patient education, radio therapy,
enucleation, palliative therapy
h. Vit. A Deficiency: Vit A. therapy
5. Identify Potential complications of disease & its management

a. Cataracts: Phaco-morphic, phaco-lytic glaucoma. Per- and Post- operative
complications.
b. Glaucoma: Tunnel vision. Effects of drugs. Per- & Post-operative complications
c. Diabetic retinopathy: Proliferation. Macular Edema. Vitreous hemorrhage. Retinal
detachment.
d. Age Related Macular Degeneration: Progression to wet ARMD
e. Refractive errors: Pathologic myopia, anisometropia & amblyopia
f. Retinitis Pigmentosa: Cataracts, Blindness, occupation and mobility issues.
g. Retinoblastoma: Metastasis, prosthetic eyes.
h. Vit. A Deficiency: Temporary visual loss (neural + tear deficiency). Conjunctival
keratinization (Bitot spots)
52
THEME 2: A PATIENT WITH SUDDEN PAINLESS DECREASED VISION
OBJECTIVES:
1. Create a differential for sudden, painless loss of vision for this patient
a. Retinal detachment
b. Retinal artery occlusion
c. Retinal vein occlusion
d. Optic neuritis
e. Vitreous hemorrhage
a. Visual acuity , Projection of light
c. Confrontation visual fields
d. Pupillary examination
e. Distant & direct ophthalmoscopy
f. Digital Tonometry

a. Retinal detachment: Rhegmategenous, tractional or exudative separation of
neural retina.
b. Retinal artery occlusion: “white” infarct, Cherry red spot
c. Retinal vein occlusion: “Red” infarct,
d. Optic neuritis: Inflammation of the optic nerve. Differentiate from papilledema
e. Vitreous hemorrhage: in acute Posterior vitreous detachment, form neo-
vessels as in proliferative diabetic retinopathy, vein occlusions etc.

Common: Counseling
Specific:
a. Retinal detachment: Investigations incl. B-scan. Intervention (basic techniques
only), post- intervention care.
b. Retinal artery occlusion: Investigations. Intervention (other eye), follow-up plan
c. Retinal vein occlusion: Investigations. Intervention (other eye), follow-up plan
d. Optic neuritis: Investigations. Intervention, follow-up.
e. Vitreous hemorrhage: Investigations incl. B-scan. Isolate cause and manage
accordingly.
53
a. Retinal detachment: Glaucoma, permanent loss of vision & field
b. Retinal artery occlusion: Loss of vision & filed other eye, neo-vascularization.
Manage fellow eye
c. Retinal vein occlusion: Loss of vision & field other eye, neo-vascularization.
Laser treatment. Manage fellow eye.
d. Optic neuritis: Association with Multiple sclerosis.
e. Vitreous hemorrhage: association with systemic diseases or vascular
occlusion, can cause tractional retinal detachment.
54
THEME 3: A PATIENT WITH A RED EYE
OBJECTIVES:
1. Create a differential for a patient with a red eye, consider associated visual loss/ not!!
a. Keratitis (Infectious, Non-Infectious)
b. Anterior uveitis
c. Acute angle closure
d. Conjunctivitis (Infectious, non-infectious esp. allergic (immune mediated))
e. Dry eye
f. Pterygium
g. Episcleritis, Scleritis
h. Ec- & En-tropion
i. Orbital Cellulitis
j. Steven Johnson syndrome
a. Visual acuity
c. Corneal sensations
d. Corneal staining
e. Pupillary examination
f. Digital tonometery
g. Optic nerve function (VA, Color vision)

a. Keratitis (Infectious, non-Infectious): Infectious or immune-mediated reaction
b. Anterior uveitis: Immune reaction (HLA associated)
c. Acute angle closure: Impeded aqueous access to anterior chamber angle
d. Conjunctivitis (Infectious, non-Infectious): Infectious or immune-mediated
reaction
e. Dry eye: Lid inflammations (blepharitis), nutrient deficiency or immune reaction
f. Pterygium: Exposure to ultra violet light, chronic irritation.
g. Episcleritis & Scleritis: idiopathic/ Autoimmune mediated
h. Ec- & En- tropion: Congenial, traumatic, paralytic/ cicatritial and senile
i. Orbital Cellulitis: Infection (surrounding structures/ immune status)
55
Common: Counseling
Specific:
a. Keratitis: Investigate. Antibiotics, Agent directed chemotherapy/ immune
suppression, cycloplegics. Keratoplasty (key concepts only)
b. Anterior uveitis: Investigate. Immune reaction (HLA associated: Immune
suppression, cycloplegics.
c. Acute angle closure: Acute pressure reduction, prophylactic treatment other
eye. Investigate for cause
d. Conjunctivitis: Investigate, chemotherapy/ immune
suppression
e. Dry eye: Investigate. Lubricants, Immune suppression, lid hygiene, antibiotics,
bandage contact lens.
f. Pterygium: Prevention. Surgery
g. Episcleritis & Scleritis: NSAIDs, lubricants, Immune suppressants
h. Ec- & En- tropion: Epilation. Surgical correction (key
concepts only)
i. Orbital Cellulitis: I/V antibiotics/ Immune status monitoring

a. Keratitis: Corneal scarring & perforation, phthisis bulbi, loss of eye. Side
effects of treatment.
b. Anterior uveitis: Cataracts, glaucoma, corneal opacities. Side effect of
treatment
c. Acute angle closure: Loss of vision in effected or other eye.
Surgery
d. Conjunctivitis: Side effect of treatment (esp. allergic conjunctivitis), esp.
keratoconus & its management
e. Dry eye: Corneal scarring, Side effect of treatment (immune suppression
f. Pterygium: Astigmatism, Corneal obscuration
g. Episcleritis: Dry eyes
h. Ec- & En- tropion: Watering, corneal scarring.
i. Orbital Cellulitis: Optic nerve compression/ Loss of vision
56
THEME 4: A PATIENT WITH AN OCULAR GROWTHS/ OCULAR /
ADNEXA SWELLING
OBJECTIVES:
1A. Create a differential for a swelling on basis of history and examination.
Ocular Adenexa Conjunctival Growths Proptosis
a. Chalazion a. Pterygium, a. Orbit: Cellulitis
b. Stye b. Pingecula, b. Thyroid eye disease
c. Acute/ chronic dacryocystitis c. Conjunctival nevus, c. Orbital / Ocular Tumors
d. Tumors: Basal cell, Squamous d. Conjunctival tumors. - Retinoblastoma (Infants)/
cell Melanoma (elderly)
- Rhabdomyosarcoma (U/L;
Children only)
a. Visual acuity
c. Extra ocular Movements
d. Pupillary reflexes
e. Regurgitation test
f. Digital Tonometry
g Direct & Distant ophthalmoscopy
h. Examination of a swelling

a. Chalazion: Ch. granulomatous inflammation, Obstruction of meibomian gland.
b. Stye: Acute inflammation. Infection of hair follicle gland
c. Acute dacryocystitis: Infection of lacrimal sac, secondary to naso-lacrimal duct
obstruction
d. Tumors: Ultra-violet light, skin pigmentation, age.
e. Pre-septal Cellulitis: Infection anterior to orbital septum.
f. Pterygium: Exposure to ultra violet light, chronic irritation.
g. Orbital Cellulitis: Infection (surrounding structures/ immune status)
h. Thyroid Eye disease: Deposition of glycosaminoglycan, extra ocular muscle
changes, inflammation and fibrosis.
i. Orbital/ Ocular Tumors: Tumors of optic nerve. Mass effect,
Rhabdomyosarcoma (Tumor of mesoderm), Retinoblastoma (primitive retinal
cells), Melanoma (melanocytes, neuroectodermal)
j. Orbital-Cellulitis: Infection of orbital soft tissue, Mass effect.
57
Common: Counseling
Specific:
a. Chalazion: Warm compresses, Intra-lesional steroid, Incision & curettage.
b. Stye: Antibiotics, Analgesics.
c. Acute Dacryocystitis: Antibiotics, analgesics, Dacryo-cysto-rhinostomy.
d. Tumors: Surgical excision with biopsy (frozen section). Reconstruction (key
concepts only).
e. Pre-septal Cellulitis: gram positive antibiotics, anti-inflammatory.
Investigations for Proptosis: Orbit Imaging, Ocular Ultrasound.
f.Thyroid Eye Disease: Medical/ Endo referral, Orbital decompression.
Immunosuppression (threat to vision)
g.Rhabdomyosarcoma: Biopsy, Excision, Radio or Chemo therapy for advanced
tumors
h. Orbital tumors: Slow growing. Surgery/ Monitor
i. Retinoblastoma/ Melanoma: Chemotherapy, Enucleation, Implants for cosmetic
improvement.
j. Orbital-Cellulitis: dual I/V antibiotic therapy, Orbital decompression to reduce
mass effect.
5. Identify Potential complications of Disease & its Management

a. Chalazion: Recurrent Chalazion (rule out: Blepharitis, Tumors, diabetes)
b. Stye: Recurrent Stye (Blepharitis, Diabetes)
c. Acute dacryocystitis: Nasolacrimal fistula, recurrent acute attacks.
d. Tumors: Recurrence. Morbidity (BCC). Mortality (SCC, SGC)
e. Pre-septal Cellulitis: Tissue Necrosis, spread to orbital cellulitis.
f. Thyroid Eye Disease: Loss of vision (optic nerve compression, corneal
scarring, Increased IOP)
g. Rhabdomyosarcoma: Loss of vision.
h. Retinoblastoma/ Melanoma: Loss of vision/ life threatening.
i. Orbital-Cellulitis: Loss of vision, Life threatening complications (meningitis,
brain abscess, cavernous sinus thrombosis)
58
THEME 5: A PATIENT WITH LID MALPOSITION
OBJECTIVES:
1. Create a differential for a patient with lid malposition

a. Congenital ptosis
b. Acquired ptosis
a. Visual acuity
c. Extra-ocular movements
d. Ptosis measurement
3. Propose a mechanism for responsible for the disease (Clinico-Pathological

Correlation) and its natural progression.
a. Congenital ptosis: Levator mal-development, Horner Syndrome
b. Acquired ptosis: Neurogenic, myogenic, senile, mechanical

Common: Counseling
Specific:
a. Congenital ptosis: Surgery (key concepts only)
b. Acquired ptosis: Surgery (key concepts only), Medical treatment for Mysthenia

a. Congenital ptosis: Amblyopia, cosmetics
b. Acquired ptosis: Cosmetics, amblyopia
59
THEME 6: A PATIENT WITH DEVIATION OF EYES
OBJECTIVES:
1. Create a differential for deviation of eyes

a. Comitant Squint: Non-paralytic squint
b. Incomitant squint: Paralytic / Restrictive
a. Visual acuity
d. Corneal reflection test
e. Cover- & Uncover- tests
f. Ophthalmoscopy
3. Propose a mechanism for responsible for the disease (Clinico-Pathological

Correlation) and its natural progression.
a. Commitant/Non-paralytic squint: Eso- and Exo- tropias. Amblyopia,
uncorrected refractive errors, fundus pathology.
b. Paralytic squint: Nerve palsies (CN III, IV, and VI), Mysthenia.
c. EOM fibrosis: Thyroid eye disease, orbital floor fracture with muscle
entrapment

Common: Counseling
Specific:
a. Non-paralytic squint: Refractive error correction, amblyopia treatment, surgery
b. Paralytic squint: Refractory period, muscle transposition (key concepts only)

a. Comitant squint: Amblyopia
b. Restrictive/ Paralytic squint: Diplopia
60
THEME 7: A PATIENT WITH OCULAR, ORBITAL & ADENEXAL
TRAUMA
OBJECTIVES:
1. Create a differential for a patient with ocular trauma

e. Trauma to the eyeball (ocular: Blunt / penetrating)
f. orbit (bony orbit)
g. Trauma to the adenexa
h. Chemical Injury to eye: acid/ alkali burns
a. Visual acuity
d. Pupillary reflexes
e. Eye wash in case of chemical injury
f. Ophthalmoscopy
3. Propose a mechanism for responsible for the symptoms related to ocular trauma.
a. Ocular Trauma: Abrasions, Chemical, corneal foreign-body, corneal perforation,
scleral perforation, subs conjunctival hemorrhage, hyphema, retinal detachment,
optic nerve avulsion
b. Adenexal Trauma: Lid hematoma, lid laceration
c. Orbital Trauma: Loss of eye movements, lower lid anesthesia
d. Chemical Injury: chemical burn to lids, conjunctiva and cornea. Limbal ischemia
leading to corneal problems, deep penetration of chemical burns etc.

Investigations: Orbit Imaging, Ocular Ultrasound.
Common: Counseling
Specific:
a. Ocular Trauma: Prophylactic antibiotics (abrasions), Removal of foreign body,
surgery (perforations, retinal detachment), medical management (hyphema,
subconjunctival hemorrhage), observation
b. Adnexal trauma: Surgery, observation (hematoma)
c. Orbital trauma: Observation, surgery (impaired movements)
61
d. Chemical Injury: copious irrigation (NEVER neutralize acid with alkali or vice
versa), lubricants, Vit C, steroids, surgery; amniotic membrane transplant etc.
etc.
5. Identify Potential complications of trauma

a. Ocular trauma: Loss of vision, endophthalmitis, Siderosis, Chalcosis.
b. Adnexal trauma: Loss of function, impaired vision
c. Orbital trauma: Loss of single vision
d. Chemical Injury: corneal opacity, glaucoma, cataracts, dry eyes, lid and
conjunctival adhesions (ankyloblephron, symblephron)
62
GUIDE TO COURSE CONTENT
THEME 1: A PATIENT WITH GRADUAL PAINLESS DECREASED VISION
 GUIDE TO REFRACTIVE ERRORS
1. DEFINITIONS
a. Myopia
b. Hyperopia
c. Astigmatism
d. Presbyopia
2. CLASSIFICATION
a. Axial
b. Refractive
c. Index
d. Simple & Compound Astigmatism
3. PRESENTATION
a. Gradual painless loss of vision (near or distant)
4. CORRECTION
a. Spectacles
b. Contact Lens
c. Lasers: PRK , LASIK
d. Surgery
5. SPECIAL CASES
a. Keratoconus
i. Definition
ii. Presentation
iii. Correction
1. Glasses
2. Contact Lens: Soft, Rigid
3. Surgery: Collagen crosslinking, Intrastromal rings, Keratoplasty,
b. Pathologic myopia
i. Definition
ii. Presentation
iii. Rule out pathological myopia with high risk retinal degenerations/ Risk of retinal
detachment
iv. Correction
1. Glasses
2. Contact Lens
63
 THEME 1: A PATIENT WITH GRADUAL PAINLESS DECREASED VISION
 GUIDE TO CATARACT ‫سفید موتیا‬

1. DEFINITION & CLASSIFICATION
a. Onset
i. Congenital
ii. Acquired
1. Pre-senile
2. Senile
b. Morphology
i. Cortical
ii. Nuclear
iii. Sub-capsular
iv. Capsular cataracts
c. Opacity
i. Immature
ii. Mature
iii. Hyper-mature
iv. Morgagnian
d. Mode
i. Primary (Age Related)
ii. Secondary
1. Drugs
2. Ocular diseases (Uveitis)
3. Systemic diseases (Diabetes)
e. Terminology
i. Phakic eye
ii. Aphakic eye
iii. Pseudophakic eye
iv. Intra-ocular lens
v. Biometry
2. PRESENTATION
a. Gradual, painless loss of vision, one or both eyes
b. Associated with systemic ailments
c. Associated with ocular ailments (Uveitis)
i. Varying degree of lens opacity
3. EXAMINATION & INVESTIGATIONS

a. Visual Acuity
b. Slit Lamp Examination/ Torch Examination
i. Media Clarity (Cornea, Vitreous)
c. Pupillary reactions
d. Fundus Examination
e. Systemic investigations
i. Blood sugars, Blood Pressure, Hepatitis profile, ECG.
64
4. INTERVENTION
a. When to intervene
i. When activities of daily living affected
ii. Mature cataract leading to complications
b. How to intervene
i. Biometry
1. Axial length
2. Corneal Power
ii. Surgical procedures
1. Anesthesia
a. Local: Topical, Peribulbar, Retro bulbar (old)
b. General
2. Procedure
a. Phacoemulsification with IOL implantation
i. Advantages
1. Early wound healing
2. Lower astigmatism
b. Extra-capsular Cataract Extraction with IOL implantation
c. Intra-capsular Cataract Extraction:
5. COMPLICATIONS
a. Per-operative
i. Bleeding
ii. Iris Prolapse
iii. Posterior Capsule Rupture/ rent/tear
1. Loss of lens fragment
2. Vitreous loss
b. Post-operative
i. Wound leak
ii. Endophthalmitis
1. Warning symptoms
a. Pain
b. Sudden loss of vision
c. Red Eye
2. Management
a. Intra-vitreal antibiotics (Gram +ve and –ve cover), Vitrectomy
3. Prognosis
a. Grave
iii. Posterior Capsular Opacification
a. YAG Laser Posterior Capsulotomy
6. EXAMINATION OF A PATIENT WITH CATARACT SURGERY

a. Pseudophakia
i. Glass like reflex
b. Aphakia
i. Deep AC ii. Iris tremulous iii. Jet black pupil
65
 GUIDE TO OPEN ANGLE GLAUCOMA ‫کاال موتیا‬

a. Optic neuropathy with characteristic VF defects, ONH changes in which IOP is a risk factor
b. Primary & Secondary (only types, not details)
2. PRESENTATION
a. Gradual painless loss of vision, bilateral, “silently” destroys vision
b. Patients usually present with moderate to advanced disease
3. MECHANISM OF IOP GENERATION

a. Aqueous production & outflow
b. Measurement of IOP
i. Digital
ii. Applanation: gold standard
iii. Air puff
4. MECHANISM OF GLAUCOMATOUS DAMAGE

a. ONH Ischemia
i. With Elevated IOP
ii. Without elevated IOP (ischemic or re-perfusion injury; NTG)
b. Destruction of nerve fiber layer
c. Consequent changes in disk and visual field
i. Disk notching (loss of NFL in sup + inf quadrant)
a. higher density of NF entering the disk
ii. Visual Field defects
b. Correspond to areas of NFL loss
c. In Bjerrum’s area (arcuate NFs)
i. Para-central scotoma
ii. Arcuate scotoma
iii. Double arcuate scotoma
iv. Tunnel vision
5. DIAGNOSTICS
a. Evaluation of Visual Field
i. Confrontational
ii. Automated perimeters; gold standard
b. Evaluation of Disk
i. Slit lamp with fundus lens
ii. Automated using OCT/ HRT
a. Cup-Disk Ratio; with notches suspicious
b. Thinning of retinal nerve fiber layer
c. Evaluation of IOP
i. Digital
ii. Applanation (12-21 mm Hg)
d. Evaluation of angle: Gonioscopy
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6. MANAGEMENT
a. Achieve target pressure
i. No further damage occurs
ii. Customized for each patient
iii. Based on VF findings or Disk changes
b. Medical management
i. Aqueous suppressants
ii. Aqueous outflow modifiers
a. Single drug
b. Combination drugs
iii. Adverse effects & contra-indications
a. beta-blockers (asthma, heart blocks)
b. CAI (Sulpha allergy)
c. Prostaglandins (inflammatory/ ACG)
c. Surgery
i. Indications; Failure of medical therapy
a. Compliance (Cost, frequency)
b. Escalating damage
ii. Procedures:
a. Laser Trabeculoplasty
b. Trabeculectomy
c. Trabeculectomy with antimetabolites
d. Glaucoma shunts/ drainage devices
67
 GUIDE TO FUNDUS DYSTROPHIES: ARMD & RETINITIS

PIGMENTOSA
ARMD:
1. DEFINITION
a. Age related changes in the macula leading to deterioration of vision
2. PATIENT PRESENTATION
Gradual, painless loss of vision at ages beyond 60.
DRY: Drusens with pigmentary atrophy
WET: CNVM (grayish-green membrane) with or without hge.
3. MECHANISM
a. DRY
i. Concept of Drusen formation
a. Accumulation of lipofuscin like material due to metabolism of photoreceptors
ii. Change in anatomy of fovea
iii. “morphed” appearance of objects
b. WET (concept)
i. Choroidal ischemia
ii. Neo-vessel formation
iii. breakthroughbruch’s membrane (weakened due to age)
iv. Subretinal CNVM
4. INVESTIGATION
a. Amsler grid (take one*)
i. Micropsia
ii. Macropsia
iii. Scotomas
iv. Morphed objects
b. FFA
c. OCT
5. MANAGEMENT
a. DRY
i. Nutrient support
ii. Low vision devices
iii. Avoid UV exposure
b. WET: Anti-VEGF
c. Low vision devices in advanced vision loss
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d. Vocational ad mobility training
RETINITIS PIGMENTOSA:
1. DEFINITION
a. Hereditary disorders that affect the photoreceptors (rods) and retinal pigment epithelium (RPE)
.
a. Night blindness.
b. Visual field constriction
c. Fundus shows RPE hypertrophy as ‘bone spicules’
3. MECHANISM
a. Progressive photoreceptor dysfunction and death
i. Apoptosis
4. INVESTIGATION
a. ERG (Concepts)
b. Fundus Exam
i. Bone spicules
ii. Pale ‘waxy’ disk (photoreceptor death)
iii. Thin vessels (photoreceptor death -> Nutritional requirement)
5. MANAGEMENT
a. Patient Education
b. Low vision devices in advanced vision loss
c. Vocational ad mobility training
69
 GUIDE TO DIABETIC RETINOPATHY
1. DEFINITION
Changes in retina due to microangiopathy of diabetes
a. Usually gradually worsening vision, this is painless, bilateral but can be asymmetrical.
b. At times sudden clouding of vision, which is painless, usually unilateral with objects appearing
“red” (vit. hge)
c. At times as above, with severe visual loss (vascular occlusion)
i. At-least micro-aneurysms
ii. Hard-exudates
iii. dot-blot and flame shaped hges
iv. New vessels, Iris neo-vascularization and NVG
3. MECHANISM & CHAIN OF EVENTS

a. Loss of pericytes -> abnormal dilation of vessels (micro-aneurysms) -> hemorrhage &
transudation (dot+ blot & flame from abnormal vessels) & formation of hard exudates -> Ischemia -
>transient cotton wool spots.
b. exudates cause edema of the retina
i. In macular area affect central vision (CSME)
c. Ischemia causes new vessel formation
i. At disk
ii. Elsewhere
iii. New vessels grow into vitreous with fiber support
d. New vessels bleed -> Vitreous hemorrhage
e. Vitreous hemorrhage can cause traction on retina and detachment
f. detachment can also occur due to fibro-vascular growth in vitreous
4. CLASSIFICATION
a. Non-proliferative diabetic retinopathy
i. At-least micro-aneurysms to less than new vessels
b. Proliferative diabetic retinopathy
i. New vessels at disk or elsewhere
ii. Iris neo-vascularization
5. INVESTIGATIONS
a. Blood glucose levels
b. FFA
i. Concept (retinal blood flow & its changes)
c. OCT (Retinal thickness/ macular edema)
6. MANAGEMENT
a. CONTROL OF DIABETES & RISK FACTORS IS OF PARAMOUNT IMPORTANCE
b. For Diabetic Macular edema
70
i. Intra vitreal Anti VEGF Injections
ii. Laser (focal/ grid)
iii.Intra vitreal steoroid Injections
c. For New Vessels

ii. Laser (PRP)
iii. Anti-VEGF
7. COMPLICATIONS
a. Vitreous hemorrhage
i. from weakened vessel walls due to AS or dilation. Everything seems red
b. Vascular Occlusion
ii. Secondary to AS.
c. NVG
i. Retinal ischemia
d. Tractional Retinal Detachment
71
 GUIDE TO RETINAL DETACHMENT

1. DEFINITION AND CLASSIFICATION
a. Separation of the neural retina from the retinal pigment epithelium
b. Types
a. Rhegmategenous
b. Tractional
c. Exudative
2. ETIOLOGY
Rhegmategenous (tear)
a. Requirements of a Rhegmategenous detachment
i. Tear or hole formation
ii. Fluid to move through the tear (liquefied vitreous)
iii. Separation of retinal layers
b. Tear in the neural retina
i. Usually peripheral (thin retina)
ii. Associated with:
a. PVD (Vitreous traction); Old age (tear)
b. Trauma (tear)
c. Pathologic myopia (thinned retina) (hole)
d. Idiopathic (holes; pre-existing)
e. Systemic diseases (Marfan’s)
i. Conn. Tissue anomalies
c. Liquefied vitreous
i. Pathologic myopia (degeneration of vitreous)
ii. Age related degeneration of vitreous (PVD)
d. Separation
i. Degree of separation dependent on:
a. Location & number of tear(s)/ hole(s)
b. Nature of vitreous
Tractional (less common)
a. Formation of traction bands in the vitreous
i. Vitreous inflammation
ii. Diabetes
b. Bands contract leading to detachment
c. At times bands can cause a tear formation and lead to rhegmatagenous detachment
Exudative (even less common)
a. Accumulation of extensive amount of fluid in sub-retinal space (between neural and pigment retina)
b. Usually associated with long standing malignant HTN
i. Phaeochromocytoma
c. “Shifting” detachment. The detachment shifts as the patient changes posture (movement of fluid)
3. PRESENTATION
Rhegmatagenous
a. Curtain like sudden, painless loss of vision
b. Associated with
i. flashes (vit. traction)
ii. floaters (pigment OR blood)
c. Associated features of trauma
72
Tractional
a. Curtain like loss of vision
b. Associated with findings of systemic disease or pre-existing ocular disease
c. Other presenting features
i. flashes
ii. floaters
Exudative
a. Loss of vision that tends to “shift”
b. Associated symptoms/ signs of systemic ailments
4. PRINCIPLES OF MANAGEMENT
a. Rhegmatagenous (external and internal approaches)
i. Remove fluid
a. Via an external opening
b. Via the hole/ or tear
ii. Seal hole/ tear
a. Externally by cryo
b. Internally by laser
iii. Provide tamponade to healing retina
a. Externally by band/ buckle
b. Internally by gas or fluids
iv. Provide prophylaxis for other eye (pathologic myopia)
a. “barrier” laser at peripheral retina
b. Tractional
i. Release bands
a. Internally by vitrectomy
ii. Rhegmatagenous RD management
c. Exudative
i. Manage underlying condition
5. COMPLICATIONS
a. Loss of vision
b. Loss of eye (phthisis)
73
 GUIDE TO VASUCLAR OCCLUSION

a. Occlusion of central or branch retinal vasculature (arteries and veins)
b. Classification
i. Arterial
a. Central
b. Branch
ii. Venous
a. Central
b. Branch
2. ETIOLOGY
a. Arterial Occlusion (Central or Branch)
i. Atherosclerosis
ii. Embolic
iii. Thrombotic
b. Venous Occlusion
i. Central
a. AS in the Central Artery
b. Malformations (rare)
c. Hypercoagulable states?
d. Thrombus
ii. Branch
a. At Arterio-venous crossing
i. Common adventia
ii. AS in arteries compress veins
b. Local Inflammations (rare)
3. PRESENTATION
a. Central Occlusions
i. Sudden painless loss of vision
a. More in arterial occlusion
b. Varying in venous occlusion
b. Branch Occlusions
i. Sudden painless loss of visual field
ii. Central vision effected if
a. Macular vessels affected
b. fluid accumulation in macula (venous occlusion)
c. SIGNS
a. Central Venous Occlusion
i. “Red” infarct (blood comes in, but can’t be drained)
ii. “Battle field” fundus
a. Scattered hemorrhages all over the retina
b. Hard exudates
iii. Dilated tortuous veins (back pressure)
iv. Cotton-wool spots
b. Branch Vein Occlusion
i. As above but in the quadrant of the occluded vein
c. Central Retinal Artery
74
i. “White” infarct (blood can’t come in)
ii. Pale fundus with thinned arteries and edematous retina (“one” large cotton wool spot)
4. MANAGEMENT
a. Boils down to preventing other eye from going blind.
i. Manage underlying etiology
b. Macular edema in vein occlusion (if affecting central vision)
i. Steroids
ii. Lasers (branch vein only)
iii. Anti-vegf
5. PROGNOSIS
a. Arterial occlusions usually have a grave prognosis
b. Venous occlusion depends on degree of closure and mac. Edema
6. COMPLICATIONS
a. Venous
i. Neo-vascularization of the retina and iris
ii. NVG
b. Arterial
i. Neo-vascularization (rare)
_____________________________________________________________________________
75
 GUIDE TO OPTIC NEURITIS

a. Inflammation of the optic nerve (infectious & non-infectious)
b. Classification
i. Papillitis: Inflammation of the optic nerve head
ii. Retro-bulbar ON: Behind the optic nerve head
2. ETIOLOGY
a. Infectious
i. Viral
b. Non-infectious
i. MS
ii. Optic neuritis can be the first sign of MS
iii. Almost 50% of patients who have optic neuritis go on to develop MS
3. PRESENTATION
a. Sudden painless loss of vision.
b. Visual loss is usually severe down to PL
c. Loss of color vision
d. Loss of contrast sensitivity
e. RAPD
f. Vague complaints of pain on eye movement (retro bulbar type)
g. Examination
i. Papillitis: inflamed, congested optic nerve head
ii. Retro bulbar: Normal looking fundus
4. INVESTIGATIONS:
a. MRI
i. For signs of MS
5. MANAGEMENT
a. Optic Neuritis Treatment Trial (ONTT)
b. 3 days I/V followed by 11 days oral with 3 days taper
c. Alternate: Avonex
d. Attacks can recur and the treatment for recurrence is the same
6. COMPLICATIONS
a. Visual deprivation due to optic atrophy
_____________________________________________________________________________
76
THEME 3: A PATIENT WITH A RED EYE & DECREASED VISION
 GUIDE TO ANGLE CLOSURE

1. DEFINITION
a. Increase in IOP due to aqueous drainage
2. PRESENTATION
a. Sudden, painful loss of vision with a red eye.
b. Hazy/ edematous cornea
c. Shallow AC
d. Mid-dilated non-reactive pupil
e. Circum-corneal congestion
3. MECHANISMS
a. Push factors
i. Phaco morphic glaucoma
ii. Small eye (hypermetropia; Primary ACG)
b. Pull factors
ii. Anterior uveitis (peripheral anterior synechiae)
iii. NVG
4. IMMEDIATE MANAGEMENT
a. Lower IOP
i. Hyper-osmotic agents (Oral, IV; *caution DM; CCF)
ii. Topical pilo, b-blockers, steroids, CAI
iii. Oral analgesics, anti-emetics
iv. Oral CAI
b. Perform PI in BOTH Eyes!
5. LONG TERM MANAGEMENT

a. Monitor IOP after PI
i. If IOP in control, continue monitoring by follow-up
ii. If IOP is high start with medical therapy
a. Pilocarpine = still in use
b. Other drugs
iii. If IOP is refractory do trab
6. SURGERY
a. General concept
i. Filtration surgery
ii. Many complication for a simple procedure
b. Refractory AC; (NVG)
i. Trab might not work
a. Trab with MMC
b. Valves (basic idea)
77
 GUIDE TO KERATITIS
a. Inflammation of the cornea
i. Infectious
ii. Non-infectious (usually near the limbus)
2. PRESENTATION
a. Sudden, painful, loss of vision with a red eye. Usually associated with trauma, CL wear,
Immuno-compromised state
i. Circum-corneal congestion
ii. Corneal ulcer* (none in H’e, Nisseria, H’influenza with infiltration)
iii. Corneal thinning and even perforation
iv. Hypopion
v. Associated signs
a. Decreased sensations (HZO)
b. Pustule lesions on face; CN V (HZO)
3. MECHANISM
a. Invasion of ocular tissue by microbes
4. ETIOLOGICAL AGENTS
a. Bacteria
b. Fungi (h/o trauma with vegetative matter)
c. Viruses (usually HZ; immuno-compromised state)
d. Protozoa (CL use)
5. MANAGEMENT
a. Obvious viral
i. Dendritic ulcer
ii. HZO signs
a. Acyclovir 800mg 5 times a day for 14 days
b. Others
i. Stop all treatment, if any is taken
ii. Scrap and swab
a. Culture
b. Sensitivity
c. KOH for fungi
iii. Start broad spectrum antibiotic & cycloplegic
a. No anti-fungals till proven
iv. Review with C/S report
a. Continue treatment if condition improves
b. Alter if worsening in light of C/S report
v. Continue meds 3 days after infiltration clears
6. COMPLICATIONS
i. Corneal thinning/ perforation
a. Amniotic membrane graft
b. Conjunctival graft
c. Bandage contact lens
ii. Corneal opacity
a. Keratoplasty
78
 GUIDE TO UVEITIS
i. Inflammation of the uveal tract
ii. Divided into 3 entities based on anatomical landmarks
iii. Classified as
a. Granulomatous or Non-granulomatous
b. Acute or Chronic
iv. Strong association with systemic diseases & HLA
a. Ankylosing spondylitis (AS)
b. IBD
c. Arthritis & urethritis (reactive arthritis)
d. Psoriasis
e. Granulomatous type associated with TB; Syphilis
f. CHRONIC: Associated with JIA
v. Most cases are idiopathic
2. PRESENTATION
i. Sudden painful loss of vision with a red eye (Acute)
ii. Chronic presents with gradual loss of vision with minimal symptoms
iii. Presentations:
a. AS presents as unilateral disease which can skip between two eyes
b. IBD, Psoriasis can present with bi-lateral disease
c. JIA usually associated with bilateral disease
d. Co-existing TB; syphilis is a clue to Dx
e. Most cases are idiopathic
iii. ACUTE
a. Circum-corneal congestion
b. Keratic Precipitates KPs (either mutton-fat for granulomatous)
c. Anterior chamber flare and cells (cells indicate active disease)
d. Small, non-reactive & irregular pupil (post. synechiae)
e. Anterior synechiae formation
f. Sterile hypopion in case of severe reaction
g. Rise in IOP depending on degree of CB inflammation vs angle closure
iv. CHRONIC
a. Mild to no symptoms of pain and red eye
b. Might have acute on chronic presentations
c. Patient presents when the vision has deteriorated due to cataract formation
3. MECHANISM
i.Anterior chamber inflammation leading to
ii. Pathological changes in Acute inflammation
a. Cells & flare (exudation
b. Keratic Precipitates (KPs)
c. Sticky iris produces ant. & post. synechiae
d. IOP is interplay between inflammation & angle closure
4. ETIOLOGY
Listed above (mostly idiopathic)
79
5. MANAGEMENT
i.First attack, no investigations only treat (idiopathic)
a. Steroids (or alternate immuno-suppression)
i. Route usually topical
ii. Can be oral or sub. Conjunctival in case of severe infection
b. Cycloplegics
ii. Think of a possible link between a systemic disease and ant. uveitis in case of a first attack
iii. Recurrent attacks. Investigate

a. If symptoms point to a specific etiology:
i. Back ache ->AS -> X-ray cervical and LS-spine
ii. GIT disturbances ->Barium
iii. Infections
a. TB -> CXR; AFB
b. Syphilis -> FTS-AB; VDRL
iv. Young girls with joint pains -> RA factor; X-ray
v. Connective tissue disease ->ANA; ANCA.
6. COMPLICATIONS
a. Therapy
i. Steroids
a. Posterior Sub-capsular cataract
b. Glaucoma (open angle)
b. Disease
i. Cataract (inflammation in the anterior chamber)
ii. Glaucoma (interplay between synechiae and ciliary body involvement & drug use)
80
 GUIDE TO CONJUNCTIVITIS
a. Inflammation of the conjunctiva
i. Non-Infectious
a. Allergic
b. Following chemical trauma
ii. Infectious
a. Bacterial
b. Viral
c. Spirochete (trachoma)
2. PRESENTATION & MANAGEMENT: CONJUNCTIVITIS: ALL TYPES PRESENT WITH A

DIFFUSELY CONGESTED EYE!
a. Non-infectious Conjunctivitis
i. Allergic
a. Itchy eye
b. Mucoid discharge (eiosinophils)
c. Papillae
d. Seasonal variation OR discrete allergen(s)
i. Anti-histamines with mast cell stabilizers
ii. Steroids for acute exacerbations
a. Counsel steroid use
iii. May lead to keratoconus if excessive rubbing continues from young age
iv. Avoid allergens as much as possible
v. Dark glasses
ii. Chemical trauma

a. Specific history of chemicals
i. Acid
a. Forms a crust, no cornea perforation
ii. Alkali
b. Eats, causes cornea perforation
b. Wash with copious amounts of clean water
c. Refer to an ophthalmologist after washing
b. Infectious
i. Bacterial
a. Neo-natal
i. Neisseria gonorrhoeae
ii. purulent discharge with sticky eye
iii. Can cause extensive damage
iv. Topical antibiotics
v. I/M Cephalosporin + topical drugs
81
b. Children & Adult
i. Purulent discharge
ii. Sticky Eye
iii. Other eye involvement in 2 days
iv. Broad spectrum antibiotic (Chloremphenicol)
v. Avoid Chloremphenicol in children *bone marrow suppression
ii. Viral
a. “Pink” rather than a “red” eye
b. Profuse watery discharge
c. Seasonal out breaks (epidemics)
d. 2nd eye involvement in 5 days
i. Supportive treatment
a. Cold compresses
b. Anti-histamines
c. Decongesents
ii. Bacterial prophylaxis
iii. Spirochete (now rare; once sight threatening)

I. Trachoma: Poor hygiene
i.Chlamydia trachomatis serotypes A-C
ii. Follicular conjunctivitis upper lid
iii. Limbal follicles
iv. Muco-purulent discharge
v. Scarring of cornea, conjunctiva due to entropion formation
vi. Arlt’s line (scarring of lid conjunctiva)
vii. Herbert’s pits (scarring of limbal follicles)
viii. 3- to 4-week course of oral tetracycline
a. Tetracycline 1 g/day OR Doxycycline 100 mg/day OR oral erythromycin.
b. WITH topical tetracycline/ erythromycin ointment, twice daily for 5 days each month for
6 months.
II. Adult Inclusion conjunctivitis
i. Chlamydia trachomatis serotypes D-K
ii. transmitted venereally or from hand-to-eye contact
iii. Chronic follicular conjunctivitis
iv. Muco-purulent discharge
v. Cervicitis (F) or urethritis (M) common
vi. Oral Doxycycline 100 mg twice a day
82
 GUIDE TO EPISCLERITIS& SCLERITIS

1. DEFINITION & CLASSIFICATION:
a. Episcleritis
i. Inflammation of episclera
a. Nodular
b. Diffuse
b. Scleritis
i. Inflammation of sclera (Necrotizing or Non-Necrotizing)
a. Focal (which can be flat or nodular)
b. Diffuse
2. PRESENTATION & MANAGEMENT: EPISCLERITIS

a. Presents as a nodule or diffuse episceral inflammation
i. Conjunctival vessels appear normal
ii. Vessels blanch with vaso-constrictors
a. differentiates from scleritis
iii. Might be associated with
a. Dry eyes/ Blepharitis
b. Systemic connective tissue diseases
b. Idiopathic and self-resolving but resilient

i. Accelerate recovery with
a. Topical steroids
b. Topical NSAIDs
c. Lubricants (co-existing dry eyes)
ii. Look for associated systemic features
3. PRESENTATION & MANAGEMENT: SCLERITIS

a. Presents as U/L, B/L alternating inflammation of sclera
a. Focal (nodular/ flat) or Diffuse
b. Either type can be Necrotizing or Non-Necrotizing
i. Necrotizing -> White areas showing avascularity. Pain ++++
a. EXCEPTION:Scleromalacia perforans is a type of painless necrotizing scleritis
that typically occurs in women with a long-standing history of rheumatoid arthritis
i. Yellow nodules (like rheumatoid nodules)
b. Necrosis -> thinning -> perforation
ii. Non-Necrotizing: Pain ++
i. Deep tissue inflammation (eye is violaceous)

ii. Conjunctival & Episcleral vessels engorged
b. MANAGEMENT:
a. Immune suppression
b. Thinning / Perforation
i. Grafting
83
4. MISCELLANEOUS CONDITIONS
a. Giant papillary conjunctivitis
i. Contact lens wearers
ii. Discontinue wear till resolution
a. Mast cell stabilizers
b. Enzyme system for lens cleaning
b. Toxic follicular conjunctivitis
a. Topical drugs
b. Cosmetics
c. Causes a “trachoma” like reaction minus Herbert’s pits
d. Discontinue use of drugs and/or cosmetics
_______________________________________________________________________
84
THEME 4: A PATIENT WITH AN OCULAR GROWTHS/ OCULAR / ADNEXA
SWELLING
 GUIDE TO OCULAR ADENEXAL SWELLINGS

a. Swelling in the adenexa of the eye
b. Classification
i. Benign
a. Chalazion & Int. Hordeolum
b. Stye
c. Dacryocystitis & its sequelae
d. Congenital NL system block
ii. Malignant
a. Squamous Cell Ca
b. Basal Cell Ca
c. Sebaceous Gland Ca
2. PRESENTAITON
a. Chalazion
i. Painless swelling on the lid
ii. Slow growing
b. Internal hordeolum
i. Painful swelling on the lid
ii. Acute presentation
c. Stye
i. Painful swelling on lid margin
ii. Associated with cellulitis of the lid at times
iii. May also be associated with conjunctivitis if the lash is pulled during infected state
d. Malignant Tumors
i. As a nodule, ulcer or thickening of the lids
ii. Can masquerade as a recurrent Chalazion
iii. Common in Caucasians, old age, UV exposure
e. Acquired Dacryocystitis
i. Painful swelling of the lacrimal sac
ii. Purulent output on regurgitation test
iii. Associated with:
a. Poor hygiene
b. Pre-existing blockage
3. MANAGEMENT
Chalazion
i. Warm compresses
ii. Small lesions: Intra-lesional steroids
ii. Incision and curettage if “i” fails
iv. Rule out tumors in case of recurrent chalazion in the same place
Internal hordeolum & Stye
i. Systemic antibiotics & analgesics
85
ii. Topical antibiotics for conjunctivitis prophylaxis in stye
Tumors
i. Excision biopsy
ii. Radiation
iii. Reconstruction
Acquired Dacryocystitis
a. Managed by oral antibiotics & analgesics

b. Need reconstruction surgery for blocked passage
i. Site of block by
a. Dye disappearance test
b. Regurgitation test
c. Probing &/or syringing
ii. Dacryo-cysto-rhinostomy (DCR)
a. Passage with lacrimal sac and nose
Congential Naso-lacrimal-duct block

i. Failure of the canicular system to form after birth
ii. Watering with occasional episodes of infection
iii. Massage at sac area till one year of age
iv. Reconstruction surgery after that
a. Probing &/ or syringing
b. DCR: Dacryocystorhinostomy
c. Canalicular bypass (in case of canalicular obstruction
_____________________________________________________________________________
86
SWELLING
GUIDE TO THYROID EYE DISEASE

Thyroid orbitopathy (Thyroid Eye Disease), Graves’ disease, is an immunological disorder that
affects the orbital muscles and fat.Hyperthyroidism is seen with orbitopathy at some point in most patients,
although the two are commonly asynchronous. Key features are:
i. Middle-aged adults (30-50 years) are affected most frequently.

ii. The disease is seen in women more commonly than in men, in a ratio of 3-4:1.
iii. It is always a bilateral process but is often asymmetrical.
iv. Multiple muscles are involved simultaneously, most commonly the inferior and medial rectus.
v. Limitation of ocular motility due to:
a. Inflammation.
b. Exophthalmos.
c. Pain.
d. Diplopia.
Classification system (NOSPECS)
Class Signs
0 No signs nor symptoms
1 Only signs are upper eyelid retraction, lid lag, stare
2 Soft tissue signs and symptoms (edema of lids)
3 Proptosis
4 Extra-ocular muscle involvement
5 Corneal involvement secondary to exposure
6 Sight loss secondary to optic nerve compression
2. PRESENTAITON & MANAGEMENT

i. Self-limited.
a. An active phase of inflammation and progression tends to stabilize spontaneously 8–36
months after onset.
b. Produces symmetrical or asymmetrical proptosis
i. Proptosis causes exposure (inability to close eyelids)
b. Symptoms:
i. foreign-body sensation (exposure)
ii. tearing (exposure)
iii. photophobia (exposure)
c. Signs
i. lid retraction (higher lid level; smyph. Activity)
ii .lid lag ( symph. Activity)
iii. Lagophthalmos (incomplete eye closure; proptosis)
iv. Exophthalmos:(proptosis; increase in soft tissue mass)
a. Enlargement of the extra-ocular muscles increased
i. Exophthalmos produces a ‘staring’/ ‘shocked’ gaze
ii. Diplopia (double vision)
b. Orbital fat
i. Exophthalmos produces a ‘staring’/ ‘shocked’ gaze
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c. Proptosis can cause:
i. Optic nerve compression (mass effect)
ii. Dry eyes (improper closure/ exposure)
ii. Diagnosis:
i. Eyelid retraction with objective thyroid dysfunction
a. Thyroid dysfunction is seen in 25-50% patients
b. Thyroid hormone levels may be elevated, normal, or even low.
OR
ii. Either eyelid retraction or objective thyroid dysfunction with:
a. exophthalmos
i. Exophthalmos produces
a. Exposure
b. optic neuropathy
i. Compression of optic nerve produces:
a. Loss of vision/ color sensitivity
b. RAPD
c. extra-ocular muscle involvement
i. fusiform muscles on MRI
ii. Muscle involvement produces
a. Exophthalmos
b. Diplopia
iii. Management
a. A referral to endocrinologist is indicated
b. Short term goals
i. Maintain useful vision
a. For Exposure -> Lubrication; Eye lid closure (tape, Tarsorrhaphy)
b. Optic nerve compression -> 100mg/day Prednisolone until optic nerve
function normalizes. Consider orbital decompression (see below).
c. Diplopia -> Prisms/ Surgery
c. Long term goals
i. Restore Anatomy of orbit
a. Only when disease is stable
b. Orbital decompression
i. Remove orbital boundaries to make way for excess mass
_____________________________________________________________________________
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SWELLING
 GUIDE TO PRE-SEPTAL & ORBITAL CELLULITIS

i. Pre-septal Cellulitis: Inflammation of pre-septal lid tissue (anterior to orbital septum).
a. Etiology: infection of pre-septal lid tissue
i. Source:
a. Ocular, sinus infections
b. Ocular trauma (with infected material)
ii. Common organisms:
a. Staph species
b. Hemophilus Influenzae
ii. Orbital Cellulitis: Inflammation of orbital soft tissue (Vision threatening)

a. Etiology: infection of orbital soft tissue (posterior to orbital septum)
i. Source:
a. Spread of pre-septal cellulitis/ Sinus infections
b. Post orbit surgery
c. Orbital trauma
d. Hematogenous (bacteremia) esp. after dental surgery

i. Pre-septal Cellulitis:
a. Presentation:
i. Pain + (not on eye movement)
ii. Conjunctival congestion
iii. Epiphora (watering)
iv. Lid Edema (Chemosis)
v. Mechanical Ptosis (due to lid edema)
vi. Blurring of vision (Ptosis)
b. Management:
i. Oral antibiotics & NSAIDs
ii. CT-Scan can help differentiate between Pre-septal & Orbital cellulitis
ii. Orbital Cellulitis:

a. Presentation
i. Pain ++++ (also on eye movement)
ii. Decreased vision (ptosis, optic nerve compression)
iii. Loss of optic nerve function
iv. Proptosis
v. Limitation of extra ocular movements
vi. ⁭ IOP
vii. Lid Edema
viii. Mechanical Ptosis

b. Associated features (esp. Bacteremia)
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i. Fever
ii. Malaise
b. Management
i. Hospitalization (till afebrile, return of normal EOM)
ii. Blood works including cultures
iii. I/V antibiotics (1-2 Weeks)
a. Cephalosporin + Metronidazole therapy
b. If suspected fungal etiology add antifungal therapy
iv. Oral antibiotic therapy (2-3 weeks after I/V therapy)
a. Regime as above
v. Supportive therapy
a. Pressure lowering (If IOP is ⁭)
b. NSAIDs
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THEME 5: A PATIENT WITH LID MALPOSITION
 GUIDE TO LID MALPOSITIONS:

a. Ptosis: Abnormally lower position of the upper lid
i. Congential
ii. Acquired
a. Myogenic
b. Neurogenic
c. Mechanical
d. Senile
b. Ectropion: Outward turning of lid margin
i. Congenital
a. Short skin
ii. Acquired
a. Cicatricial
b. Spastic
c. Senile
c. Entropion: Inward turning of lid margin
i. Congenital
a. Short lower lid retractor defect
ii. Acquired
a. Cicatricial
b. Paralytic
c. Senile
d. Chalazion: Non-infectious granulomatous swelling of meibomian gland
e. Internal hordeolum: Infection of meibomian gland
f. Stye: Infection of hair follicle
g. Malignant tumors: BCC, SCC, SGC
2. PRESENTAITON
Ptosis
a. Complete or partial obscuration of the palpebral fissure
b. Amblyopia in congenital ptosis
i. Lack of lid crease
ii. Poor levator function
c. High arched brow in senile ptosis
d. Associated CN III palsy signs in paralytic ptosis
e. Associated signs of MG in myogenic ptosis
Ectropion
a. Out turned lower lid –varying degrees
b. Congested palpebral conjunctiva
c. Watering
d. symptoms of dry eyes
i. Poor blink action
ii. Gritty sensation
Entropion
a. Inward turned lower lid margin –varying degrees
b. Trichiasis
c. Watering and conjunctival congestion
d. Corneal ulcers and opacities
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3. INVESTIGATIONS & MANAGEMENT
Ptosis
i. Levator function
ii. Amount of ptosis
iii. Surgical correction
i. Some levator function
a. Levator resection
ii. Poor levator function
a. Frontalis sling
Ectropion
i. Identify the cause
a. Paralytic
i. Give time with supportive therapy
b. Senile
ii. Shorten the inner layers of the lid
Entropion
i. Identify the cause
a. Spastic
i. Release spasm or its cause
b. Senile
ii. Shorten out layers of the lids
_____________________________________________________________________________
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THEME 6: A PATIENT WITH DEVIATION OF EYES ‫بھینگا پن‬/ ‫آنکھ کا ٹیڑھا پن‬
 GUIDE TO SQUINT/ OCULAR DEVIATION:

• SQUINT: Misalignment of visual axis.

• ORTHOPHORIA: Normal ocular alignment.
– Visual axis of both eyes are parallel with eyes in primary position (i.e. looking at
6m or beyond)
• Visual axis: Line of vision extending from point of fixation to fovea.
• Squint will not be bilateral, one eye is fixating and other is deviated with respect to the
fixating eye,
– However it can be alternating between two eyes, i.e. when one eye fixates other
eye deviates
• CLASSIFICATION:
– Tropia: Manifest/ visible
• Commitant/ non-paralytic
• Deviation between two eyes remain within 5 in different position
of gaze.
• Non commitant: Deviation changes in different position of gaze.
• Paralytic
• Fibrosis of muscles: Thyroid eye disease
• Trauma: orbital floor fracture
– Phoria: hidden/ latent
• Becomes evident when fusion is not maintained. e.g fatigue, cover/
uncover test.
• TERMINOLOGY
– Named according to the deviation of eye
• Eso: inward deviation of eye ball
• Exo: Outward deviation
• Hyper: upward deviation
• Hypo: downward deviation
• Cyclo: inward or outward cyclodeviations.
• All of the deviations can be manifest/ tropia or hidden/ phoria.
LAWS FOR OCULAR MOTILITY

• Herring’s Law: Equal innervation of yoke muscles
• Sherrington Law: Reciprocal inhibition of antagonists
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2. PRESENTAITON:
• INFANTILE ESOTROPIA: Alternate esotropia, presents around 6 months of age
• ACCOMMODATIVE ESOTROPIA: Uncorrected hypermetropia
• SENSORY ESOTROPIA/ EXOTROPIA: Stimulus deprivation e.g. cataract
• INTERMITTENT EXOTROPIA: Phoria dissociates into tropia
• PARALYTIC SQUINTS: sudden onset of diplopia
3. MANAGEMENT
- Rule out any media opacity, fundus pathology or neurological cause of squint.
a. Non-paralytic squint:
1. Check and correct Refractive error: (Cycloplegic refraction),
– Fully refractive accommodative esotropia.
• Treatment: full cycloplegic correction.
– Partially refractive accommodative esotropia.
• Treatment: i. Refractive error correction
– ii. Reassess with glasses
– iii. Surgery on residual squint only
2. Amblyopia treatment:
- Patching/ Atropinization
- Amblyopia becomes refractory if treatment is delayed
3. Surgery:
- Recession to weaken a muscle/
- Resection to strengthen a muscle
b. Paralytic squint:
- To avoid diplopia:
- Occlusion
- Prismatic glassess
- Surgery: Refractory period, muscle transposition (key concepts only)
Aim for straight eyes in primary and / reading position
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THEME 7: A PATIENT WITH OCULAR/ ORBITAL INJURY
 GUIDE TO OCULAR TRUAMA

Damage to the ocular structures with or without visual implications
b. Classification
i. Ocular
a. Foreign body
b. Chemical
c. Perforation
d. Hemorrhages
i. Subconjunctival
ii. Anterior chamber (Hyphema)
e. Optic nerve avulsion
ii. Adnexal
a. Lid hemorrhage (bruise; “black” eye, “shiner”)
b. Lid laceration with or without damage to lacrimal system
iii. Orbital
a. Fracture of orbital bones
iv. Sympathetic Ophthalmitis

OCULAR
i. Foreign body
a. Presents with a red, itchy & usually watery eye. Fluorescein staining might reveal
corneal abrasion or ulcer
b. Foreign body origin

i. Metal workers
ii. Airborne
a. Dust
b. Insects
c. Remove superficial foreign body & prescribe a broad spectrum antibiotic. If there is a
corneal abrasion, patching maybe beneficial
ii. Chemical
a. Presents with an intensely red eye with corneal opacification or even perforation if the
chemical is strong enough (usually strong alkalis; acids form slough which prevent
perforation. Pain can be present and range from mild to severe, again depending on
nature of chemical.
b. Chemical origin
i. Industrial
ii. Household
a. Toilet/ floor cleaners
b. Cooking (Vinegar, hot oil etc)
c. Wash continuously with clean water and call in a specialist. DO NOT STOP WASHING
till he arrives.
iii. Perforation
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a. Presents with as a painful red eye usually with varying amount of loss of vision,
depending on route of entry and final resting place
b. Perforation origin
i. Metal workers, shrapnel
a. Siderosis
b. Chalcosis
ii. Household items
a. Knives
b. Pencils, esp. children
iii. Bullets.
c. After an eye exam, start oral antibiotics and analgesics. Order an X-ray or CT (NO MRI
for magnetic objects). Prepare for surgery.
iv. Hemorrhages
a. Usually associated with blunt trauma, though can accompany other types of trauma as
well.
b. Origin
i. Subconjunctival
ii. Anterior chamber (hyphema)
c. Subconjunctival hemorrhages self-resolve. They might be a sign of retro-bulbar

hemorrhage (hemorrhage behind the eyeball). It is thus essential to find the posterior limit
of the hemorrhage by asking the patient to move the eye
d. Hyphema. Bed rest, with IOP reduction (topical and systemic).May cause very high
IOP and subsequent optic nerve damage. Non-clearing hyphema might require surgery.
v. Optic nerve avulsion

a. Rare, secondary to acceleration-deceleration trauma to the face. Presents as sudden
loss of vision which can be total blindness (PL-) at presentation.
b. Orbital imaging to visualize extent of damage.
ADENEXAL
i. Lid Hemorrhage
a. Presents with a black eye, if large enough can cause mechanical ptosis. Also called a
“shiner”. Technical term is ecchymosis
b. Origin
i. Blunt trauma
c. Self-resolving. Get orbital imaging to rule out secondary fracture of the orbit. If eyeball
can be seen, examine for damage as well as extra-ocular movements (to rule out orbital
fractures).
ii. Lid Laceration

a. Presents with pain and damage to lids. If it involves medial end of the lids the lacrimal
system might be damaged (canaliculi)
b. Origin
i. Trauma with sharp objects
c. Surgical repair with reconstruction of the lacrimal system if damaged.
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ORBITAL
i. Fracture of orbital bones
a. Presents with facial trauma with large objects (like cricket balls), as compared to ocular
trauma which occurs with small objects (like golf balls). May have varying signs of all
forms of trauma listed above, esp. hemorrhages. Specific signs include diplopia (double
vision, muscle entrapment), sunken eye (enophtalmos; fat herniation from fractured
walls) and lower lid anesthesia (damage to Infra-orbital nerve)
b. Origin
i. Ploy trauma, facial trauma
c. Get orbital imaging to look for fractures.

i. No fractures: look for other forms of damage to the eye
ii. Fracture seen
a. No sunken eye and no diplopia: observe
b. Sunken eye or diplopia: Surgical repair
SYMPATHETIC OPHTHALMITIS:
- Rare disease, can be potentially blinding
- Bilateral, granulomatous uveitis
- Caused by exposure of previously immune-privileged ocular antigens from trauma or surgery
with a subsequent bilateral autoimmune response to this tissue.
- The injured or operated eye is the exciting eye and the contralateral eye is the sympathizing
eye.
- Vision is lost in one eye due to trauma , and in other eye due to granulomatous panuveitis.
97
SECTION IV:
Ophthalmology Clinical Skills
98
HISTORY TAKING
Key Objectives: History Taking
1. Frame concise presenting complaints, focusing on:

a. Duration (Sudden Vs Gradual)
b. Uni- or Bi- Laterality
c. Association with pain
2. Biopsychosocial profiling:
How are the patients symptoms related to his residence, surroundings & other people?
3. Asking the right question:
“What brings you to the eye OPD today?”

‫آج آپ آنکھوں کی کس بیماری کے لیے اسپتال آے ہیں‬
4. Framing the Presenting complaint:

Most of the time, ocular complaints revolve around fairly common presentations (as listed
in objectives). The most common presentation is that of deteriorating vision (to various
extents). This is followed by watering (including other forms of discharge), itching,
redness and ocular misalignment (squint). To help make it easier for yourself it is
important to frame your presenting complaint in a manner that helps narrow down the
differential diagnosis.
Once the patient tells you of the presenting complaint you can qualify it using the
adjectives below:
ONSET PAIN INVOLVEMENT

Sudden OR Gradual Present OR Absent One or Both eyes
For example, if your patient complains of decreased vision, you can qualify this as
(depending on what the patient says)
1. Sudden & painless decreased vision Right Eye -1 day

2. Gradual & painless decreased Both Eyes – 6months
3. Sudden & painful loss of vision Left Eye - 6hrs
*Common sense dictates that gradual loss of vision should not be associated with pain.
Most, but not all systemic diseases tend to affect both eyes symmetrically or
asymmetrically.
99
The advantage of qualifying presenting complaint helps narrow the differential. If the
patient has Sudden & painless loss of vision, you are thinking of only 4 major entities
(Retinal Detachment, Vascular obstruction, Optic nerve inflammation, vitreous
hemorrhage), rather than more than 10 for just loss of vision (Refractive errors, Cataract,
Open angle glaucoma, Macular degeneration, Diabetic retinopathy, Keratitis, Angle
closure, Uveitis, Presbyopia and the three mentioned before).
Age can also help you narrow down the differential even further. A young patient
presenting with gradual painless loss of vision in both eyes probably has a refractive error,
while an elderly with similar complaints can have cataract, open angle glaucoma and/ or
macular degeneration (ARMD) as major differentials.
Environmental factors can also give a clue with regards to a diagnosis. A chemical factory
worker is likely to suffer from allergies, while an elderly male from northern Pakistan and
lid swelling might have a malignant tumor.
The table on the following page lists some of the most common ocular presentations. You
can use this as a ‘guide line’ to think about the ‘correct’ differentials. Try and place all
symptoms into a single disease category, rather than coming up with a different disease
for every symptom the patient presents with.
100
# PRESENTATION COMMON DIFFERENTIALS
1. Refractive errors
2. Cataract ( age)
1 Painless loss of vision 3. Diabetic retinopathy
(GRADUAL) 4. Macular degeneration ( age)
6. Open Angle Glaucoma
7. Amblyopia (related to #1); ( age)
8. Retinitis Pigmentosa ( loss of night vision)
9. Retinoblastoma (Children)
10. Vit A. Deficiency
1. Retinal detachment
2 Painless loss of vision 2. Retinal vascular obstruction (CRAO/CRVO)
(SUDDEN) 3. Optic neuritis
4. Vitreous hemorrhage
1. Keratitis/ Corneal Ulcer/ Corneal Erosion
3 Painful loss of vision 2. Uveitis (Anterior)
(RED EYE D/D) 3. Angle closure
4. Episcleritis & Scleritis
1. Infectious conjunctivitis
4 Watery eye 2. Allergic conjunctivitis* (++ itching)
(& OTHER TYPES OF 3. Foreign body in the eye
DISCHARGE) 4. Tear film disturbance (incl. Vit A )
5. Blepharitis (related to #4)
6. Lid margin abnormalities
5 Ocular misalignment including 1. Non-paralytic squint/ ptosis
lids 2. Paralytic squint/ ptosis
LIDS:
1. Chalazion
2. Stye
6 Swellings & Growths 3. Tumors ( age, sun exposure, skin color)
4. Pre septal Cellulitis
ADENEXA:
1. Dacryocystitis(leading to #2)
2.Naso-lacrimal passage obstruction (occupation,
hygiene)
CONJUNCTIVA:
1. Pterygium (sun exposure)
2. Pengicula
PROPTOSIS:
1. Thyroid Eye disease
2. Orbital tumors
3. Rhabdomyosarcoma (Children)
4. Orbital Cellulitis
1 Orbital injury/fracture
7 Ocular trauma 2. Blunt ocular trauma
3. Penetrating injury
4. Chemical injury
101
You can use this sample form to take an ophthalmic history:
NAME: AGE:/ GENDER OCCUPATION:
MARRIED: ROUTE: Outpatient (OPD)/ In patient (IPD/

RESIDENCE
admitted) or Emergency
PRESENTING COMPLAINT: This lists, in chronological order (newest first), the main complaint(s)
(symptoms) that the patient comes to a hospital on a particular day.
Mention unilateral/ bilateral, painful or painless, sudden or gradual, and associated with decreased vision
or not etc. etc.
HISTORY OF PRESENTING COMPLAINT: This part explains the events that led up to the time the
symptoms showed up.
REVIEW OF SYSTEMS: This is a brief over-view of other associated problem the patient might have.
PAST MEICAL/ SURGICAL HISTORY: Any significant history of illness that the patient might have
experienced. This might or might not be related to the current illness. Especially ask about ocular
disease/ surgery/ trauma etc. etc.
FAMILY HISTORY: Details about the patient’s family, their state of health (or illness). Especially ask
about family history of eye disease e.g. congenital cataract, glaucoma, night blindness, retinal
detachment etc. etc.
PERSONAL HISTORY: This, as the name states, lists personal information about the patient. His
occupation, income, addictions (smoking).
MEDICATIONS: This lists the medicines that the patient has used in the recent past or is still continuing
to use. Especially ask about anti-tuberculosis treatment, steroids ocular medications, injections or lasers
etc.
EXAMINATION RIGHT EYE LEFT EYE
Visual Acuity
Refraction
Near Acuity
Torch Exam:
Brows
Lids/ lashes
Conjunctiva
Cornea
Iris
Lens
AC Depth
Tonometry
Visual Field
EOM/ Ocular Alignment
Regurgitation
Ophthalmoscopy
Direct
Distant
Pupillary Reactions
Squint*
Corneal Reflection
Cover-Uncover
Alternate Cover
PTOSIS
INVESTIGATIONS: This part lists the investigations that have been done so far relating to the presenting
complaint.
102
 GENERAL OCULAR EXAMINATION
The examination of the ocular structures will help you pick up signs that will aid you in
diagnosing patient’s state of disease. General ocular examination is a series of tests that
should be done in all patients coming to the eye clinic
Objectives
1.Perform a thorough basic eye examination
a. Greet.Consent. Explain.Command.Procedure. Thank
2. Infer the results of the test
Clinical Methods
1. Record Visual acuity
a. Distant acuity with Snellen’s chart, pin hole at 6 meters
b. Near acuity with Reading chart
2. External Inspection with a torch

a. Adenexa
Brows
Lids
Naso-lacrimal area
b. External eye
Cornea
Sclera
3. Pupillary reactions
a.Direct
b. Indirect
c. Consensual
d. Swinging light
4. Distant &direct ophthalmoscopy

a. Principles of pupillary dilation
b.Dilated fundus examination via distant and direct techniques
103
 SPECIAL OCULAR EXAMINATION
If your differential leads you towards a specific disease you can choose from these
“special” examination techniques to establish or dismiss your diagnosis.
Clinical Methods
1. Squint: Check ocular alignment
a. Corneal reflection test
b. Cover &Un –Cover tests
2. Ptosis
a. Ptosis measurement
i. Amount of ptosis
ii. Levator function
b. Associated phenomena
i. Bell’s phenomena
ii. Jaw winking
3. Examination of a swelling
a. Site
b. Size
c. Shape
d. Surface temperatures
e. Skin changes
f. Surrounding skin temperature & changes
g.Spread (superficial & deep attachments)
h. Sides (distinct or diffuse)
4. Corneal staining
a. Use of fluorescein dye
5. Regurgitation& Dye Disappearance Tests
6. Digital Tonometery
7. Visual fields
a. Confrontation visual field
8. Extra-ocular movements
a. Nine diagnostic position of gaze (6 cardinal positions + primary position+
midline up and down position).
104
 COUNSELLING:
For all patient presentations the essential step in management is counseling.

This will be an active learning process tailored for discrete patient
presentations, but will be based on the following template:
1. Introductions and greeting
2. Exploring patients knowledge about his (or her) condition
3. Adding to or correcting patient’s perception about his (or her) condition in

everyday language that the patient understands
4. Offering patient viable, management options based on best applicable

evidence that is in line with patient’s beliefs and biopsychosocial standing
5. Offer the patient to ask more questions
6. Ends the interview
105
CLINICAL SKILLS
• All Clinical Methods have 7 components
1. Pre-requisites
2. Greeting & Consent
3. Explanations
4. Command
5. Performing clinical skill (procedure)
6. Interpretation
7. Conclusion
1: PRE-REQUISITES:
What are prerequisites to perform the skill
– Location
– Lighting
– Instruments
– Seating arrangement
– Skill
2: GREETING & CONSENT:
• Plain language that the patient can understand
• Can combine Greeting & Consent with Explanation
3: EXPLANATION:
Broad outline as to what you are going to do
– If you need to palpate the patient, make sure you tell him (her) where and how and what
to expect.
106
– If you are going to use an instrument, show the instrument to the patient and explain how
you are going to use it.
– If you are going to do a procedure that is potentially painful, reassure and tell the patient
what to expect.
4: COMMAND:
Tell the patient what to do at the start of an examination
– Posture (Please sit , please stand)
– Gaze (Please look down, please look straight)
– Follow an object (Please follow my pen with your eyes)
5: PERFORM (PROCEDURE):
Perform the clinical skill
– It is better to tell the patient what you are doing, while you are doing it, but it is not
necessary
– DO NOT un-necessarily repeat procedures that potentially cause pain. Make sure you get
it right and pick up clinical findings the first time.
– Make sure you warm your hands if you are to palpate the patient and your nails are
properly clipped
6: INTERPRETATION:
Make a mental note of your findings.
– You can jot them down on paper once the examination is done
– Tell the patient in plain language your findings
– Tell the examiner/ or note down the results in a technically “correct” manner
7: CONCLUSION:
Thank the patient
107
To illustrate this, let’s take the example of the Visual Acuity Clinical skill. This example will help
you understand how to use plain language to communicate with the patient.
1: PRE-REQUISITES:
• Room: 6 meters in length, or 3 meters if a mirror is used.
• Illumination: Well lit room/ Equivalent of a mid-day sun in Northern hemisphere
• Snellen’s Visual Acuity Chart (in a language the patient can understand), Level chart
with patient’s gaze
• Pin-hole
2& 3 GREETING, CONSENT & EXPLANATION:
‫ اسالم علیکم‬-
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
.‫ آج مجھے آپ کی آنکھ کا معائنہ کرنا ہوگا‬-
.‫ اس کے لئے آپ کو سامنے بورڈ پر لکھے گئے الفاظ کو پڑھنا ہوگا‬-

‫ کیا آپ اس کے لئے اجازت دیتے ہیں؟‬-
.‫ اگر معائنے کے دوران آپ کو درد یا تکلیف ہو تو براہ کرم مجھے بتائیں‬-
4: COMMAND & PERFORM PROCEDURE
‫ آپ اردو یا انگریزی میں سے کیا پڑھنا‬/ ‫ آپ اردو یا انگریزی پڑھ سکتے ہیں؟‬-
‫چاہیں گے؟‬
.‫ اگر آپ دور کی عینک لگاتے ہیں تو پہن لیں‬-
‫ یا لفظ ”نون یا‬/‫ کیا آپ سامنے بورڈ پر یا آئینے کے پر سب سے اوپر والی الئن‬-
‫“دیکھ سکتے ہیں؟‬T
108
. ‫ اپنے بائیں ہاتھ کی ہتھیلی کے ساتھ اپنی بائیں آنکھ کو ڈھانپ لیں‬-
‫ اور اس الئن تک پڑھیں جہاں تک آپ‬، ‫“ سے پڑھنا شروع کریں‬T ‫ اب “نون یا‬-
. ‫دیکھ سکتے ہیں‬
‫ اب اپنی دوسری آنکھ کے لئے بھی یہی طریقہ کار دہرائیں۔‬-
- If the patient cannot read up to 6/6 line from the right eye, ask him to use a pinhole, while
keeping the left eye covered.
. ‫بائیں آنکھ کو اپنی ہتھیلی کے ساتھ ڈھانپ لیں‬ -
.‫ اب اس سوراخ کو دائیں آنکھ کے سامنے رکھ کر پڑھیں‬-
5: PERFORM (PROCEDURE):
• If the patient uses glasses for distant vision, ask him to put them on. Select a language he
is comfortable with or use tumbling E’s if the patient is illiterate
• Ask patient with both eyes open if he can see the top letter. If he can’t move the patient to
5m and ask again. Keep doing this till you are a meter away from the chart. If the patient
still can’t read, skip testing with Snellen’s chart.
• Ask the patient to close the Left eye with the palm and read the chart as far as possible.
Repeat with the right eye
• Note down VA for both eyes, use pinhole if needed
6: INTERPRETATION:
• If the patient is 6/6 both eyes, his vision is equal to normal population
• If he is 6/6 with a pinhole in both eyes, he has some form of refractive error
• If his vision is less than 6/6 and doesn’t improve with pin-hole, he probably has a
pathologic process other than a refractive error. Pin hole testing may not improve VA by
109
using a pin hole if the magnitude of refractive error is greater than +5 or less than -5, though
it might improve VA to some extent (e.g. from 6/36 to pinhole 6/18).
7: CONCLUSION:
 Explain your findings to the patient and/or the examiner
 Thank the patient
110
CLINICAL SKILLS DETAILS
Practice exercises are given at the end of some skills. These will help you in self-assessment!
I: VISUAL ACUITY
1. Prerequisites
• Room: 6 meters in length, or 3 meters if a mirror is used.
• Illumination: Well lit room/ Equivalent of a mid-day sun in Northern hemisphere
• Snellen’s Visual Acuity Chart (in a language the patient can understand), Level chart
with patient’s gaze
• Pin-hole
2& 3. Greeting /Consent& Explanation

‫اسالم علیکم‬ -
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
.‫ آج مجھے آپ کی دور کی نظر کی کا معائنہ کرنا ہوگا‬-
.‫ اس کے لئے آپ کو سامنے بورڈ پر لکھے گئے الفاظ کو پڑھنا ہوگا‬-
4. Command
a. Sit the patient down at 6 meters, level with an illuminated Snellen’s chart in a well lit room
b. Ask him if he can read English (preferred) and/ or Urdu. Use the “E” chart if the patient is
illiterate. Use a stick to point to letters on the chart.
c. If the patient wears distance vision glasses ask him to put those on.
5. Procedure
a. Stand at the right side of the patient & ask him to identify the top letter of the language he can
understand. If he can’t skip to step #j
b. Ask the patient to close the left eye with the palm of his left hand
c. Now ask him to read as far down as he can with the right eye.
111
d. Note down the number associated with the last line the patient could read. If he reads less than
half the letters in the line also note the numbers of letters read.
e. Now ask the patient to close the right eye with the palm of his right hand
f. Now ask him to read as far down as he can with the left eye
. Note down the number associated with the last line the patient could read. If he reads less than
half the letters in the line also note the numbers of letters read.
h. If the patient can’t read all the way to the line associated with the number “6” continue to the
next step otherwise skip to #6: Interpretation
i. Ask the patient to hold the pinhole and show him the little opening in its center. Some pinholes
might have more than one opening. Repeat steps #b-g but this time with the pinhole in front of the
eye or distant vision glasses that the patient might be wearing.
j. If the patient can’t identify the top letter of the language he can understand continue to calculate
the visual acuity by: (one eye at a time for all the following steps i-v, the fellow eye MUST be
occluded as described above)
i. Reduce the distance 1 meter at a time. Ask him to identify the top letter at each 1-meter
reduction. Remember once the reading distance is less than 6 meters, the patient must only
be able to identify the top letter. If he can read more than the top letter, take him a meter
back. He should be able to read the top letter from there as well. Do this up to 1 meter. Skip
to #6: Interpretation
ii. If the patient can’t read the top letter at 1 meter, then show him either 1,3or 5 fingers at
two feet and ask him to identify the number of fingers you are holding up (one eye at a
time). If he can’t identify them at two feet, repeat at one foot. Skip to #6: Interpretation
iii. If the patient can’t count fingers at one foot, ask him to identify your moving hand (one
eye at a time). DO NOT ASK HIM EVERY TIME YOU MOVE YOUR HAND. Give the
command once and see if he can pick up the times you move your hand. If you must give
a verbal clue give it in a negative way. E.g. do not wave your hand and ask him if he can
see it moving. Also perform step #v if the vision is hand movements. Skip to #6:
Interpretation
iv. If the patient can’t see your hand moving, use a brightly illuminated torch and ask him
if he can see the light. If the patient confuses room lights with your torch’s, dim the room’s
lights. Again as before, give the command once only. Give verbal clues in a negative
manner (i.e. do not shine the torch in the patient’s eye and ask him if can hesee the light).
This is the LIGHT PERCEPTION. Move on to step v.
v. Shine the light from the top, bottom, left and right each time asking the patient to ‘catch’
the light. This is LIGHT PROJECTION. Do this one eye at a time.
112
6. Interpretation
a. Note down the visual acuity. If the patient can read the chart while sitting at 6 meters, the
visual acuity (VA) is notified as:
6/n +ph 6/n´ (or niph)
VA
6/p +ph 6/p´ (or niph)
Where
*n / p= the number of the line read with a naked eye or patient’s glasses
*n´ / p´= the number of the line read with a naked eye or patient’s glasses + pinhole (ph = pinhole)
*niph= If the vision does not improve with a pinhole
If the visual acuity was taken with the patient wearing his distance correction add the letter “cc”
below VA to indicate this.
Note:
*The vision in the right eye is written at the top
*If the vision is 6/6 (normal VA) there is no need to do pinhole testing!
*If the patient reads less than half the letters in a line, put a ‘p’ next to the visual acuity of that eye
to indicate that the patient read the line partially
b. If the patient was not able to read the chart at 6 meters, the visual acuity is noted as:
N/60 ph N´/n´ (or niph)

VA
P/60 ph P´/p´ (or niph)
Where
N and P = The distance (in meters) the patient is standing from the chart
N´ and P´ = The distance (in meters) the patient is standing from the chart with an added pinhole
n´ and p´= The number of the line read with a naked eye or patient’s glasses + pinhole (ph =
pinhole). Remember if N´ or P´ is less than 6, n´ or p´ can’t be more than 60!
Note:
113
If the distance at which the patient stands while reading the chart is less than 6, the denominator
(the lower number) in the VA fraction can’t be anything else than 60!
c. For Counting Fingers use “CF” followed by 1’ or 2’ to indicate the distance
d. For Hand Movements use the notation “HM”
e. For Light Perception use the notation “LP”
f. For Light Projection use the following notation
S ±
T N ± ±
I ±
Where
S= Superior Retina I= Inferior Retina T= Temporal Retina N= Nasal Retina
+ = Light ‘caught’ by the patient
- = Light not ‘caught’ by the patient
When shining the light from top the bottom retina is illuminated and tested. If the patient can
‘catch’ the light put a “+” at the bottom of the “X” (which corresponds to ‘I’). Do this for all 4
quadrants.
g. If the patient has negative LP and no projection in ANY quadrant, note down the vision as
“NLP” (No Light Perception/ Projection)
7. Conclusion
a. Describe patient’s visual acuity& its implications to him and/ or the examiner
b. Thank the patient
8. Exercises
Describe the visual acuity for the following:
1: 2: 3:
6/18pph 6/6 4/60 ph 6/60 CF 2’ ph 6/60
VA VA - + + VA
HM - NLP
114
II: NEAR ACUITY:
1. Prerequisites
a. Near Vision Chart
b. Well lit room
c. Patient MUST already be corrected for distance vision if required!
2& 3. Greeting /Consent & Explanation
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
.‫آج مجھے آپ کی قر یب کی نظر کی کا معائنہ کرنا ہوگا‬ -

.‫– اس کے لئے آپ کو چارٹ پر لکھے گئے الفاظ کو پڑھنا ہوگا‬

4. Command
a. Make sure the patient is comfortably seated.
b. If the patient wears near vision correction, ask him to put that on
5. Procedure
a. Stand at the right side of the patient
b. Give him the near vision chart and ask him to hold it WHERE HE WANTS TO READ FROM
(& NOT WHERE HE CAN READ FROM!)
c. Now ask him to read the smallest print (in his preferred language, if he is bilingual ask him to
read the English text) that he easily can. Note the number of the line (usually written as Nx, where
‘x’ is a number) that he can read easily.
d. If the patient can’t read any of the lines ask him if he wears a distance correction. If he does, ask
him to put that one and make him read the text again.
e. If he is still unable to read the text, correct the patient for distance vision before proceeding
any further.
115
6. Interpretation
a. Near Vision (N or NV) is notified as
Nx
N Ny
Where
Nx = the number of the line the patient can read from the right eye
Ny = the number of the line that patient can read from the left eye
Note:
*There is no pinhole testing for near vision, nor any distance adjustment
*A normal individual reads up to the N6 line
*Near vision can be checked binocularly, because you are checking accommodation!!
7. Conclusion
a. Describe patient’s near vision & its implications to him and/ or the examiner
8. Exercises
Describe the near vision for the following:

1: 2: 3:
N6 N12 N6/6
N N18 N N6 N N36
116
III: TORCH EXAMINATION (ADNEXA)
1. Prerequisites
a. Torch
b. Well lit room

.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-

‫ آج مجھے آپ اس ٹارچ کی روشنی سے آپ کی آنکھ کا معائنہ کرنا ہوگا‬-

4. Command
a. Make sure the patient is seated comfortably
b. Ask him to look at a distant target.

5. Procedure
a. Stand at one side of the patient and shine the light so it is centered on the bridge of the nose
b. Examine the following structures:
I. The Brows:
i. Symmetry between the two brows (the level of the two brows)
ii. Hair distribution
iii. Any Scars/ discolorations
iv. Any Swellings (see below describing a swelling)
II. The Lids (Lids open):
i. Symmetry between the two upper lids

ii. The level of the two upper lids (should cover upper 2mm of the cornea)
iii. The direction and distribution of eye lashes in both upper and lower lids
117
iv. The position of the two lower lids especially the position of the puncta
v. Any accumulated discharge/ crusts on lashes
Ask the patient to close his eyes and examine the lids again
III. The Lids (Lids Closed):
i. The lid crease line

ii. Any scars/ discolorations
iii. Any swellings on the lid or at the lid margin
iv. The closure of the lids (see if they cover the eye ball completely)
v. Any accumulated discharge/ crusts on lashes
IV. The Lacrimal Area: Shine the light on the medial side of the eye lids illuminating the side
of the nose adjacent to the eye lids. Look for
i. Any scars/ discolorations

ii. Any accumulated discharge at the medial end of the eye lids
iii. Any swellings
c. If you locate any swellings, describe them by:
S: Site (Location)
S: Size (Pea, Almond, Lentil)
S: Shape (Round, Oval)
S: Surface (Ulcerated, Excoriated, Congested)
S: Skin (Skin Temperature as compared to surrounding skin)
S: Surroundings (Relationship of the swelling to surrounding including deeper structures
as well as its extent and margins; E.g. fixed to deeper tissue, indistinct margins etc)
6. Interpretation
a. Either draw your findings (see below) or list them down.
I. The Brows:
i. Asymmetrical brows might indicate that the patient is using the frontalis muscle to elevate the
upper lid
ii. Any changes in hair distribution might indicate prior surgery
118
iii. Scars indicate surgery or trauma as do discolorations which might indicate tumors as well
iv. Swellings can be because of a number of causes depending on the presentation (infections,
benign or malignant tumors, edema, or blood)
II. The Lids (Lids open):
i. Asymmetrical lids might indicate ptosis, swellings on lids
ii. A difference in resting position of upper lids can indicate any of the causes listed above
iii. Direction of eye lashes indicates the position of lid margin. Normally they are directed outwards
and upwards (upper lid) or downwards (lower lid). Any change might indicate abnormal lid margin
position
iv. Lower lids rest at the level of the limbus. Punctii at the medial end of lower lids usually about
the eye ball.
v. Discharge on the lids might indicate Conjunctivitis. Crusting indicates Blepharitis
III. The Lids (Lids Closed):
i. Absence of lid crease line is seen in congenital ptosis
ii. Scars indicate trauma or surgery as do discolorations which might indicate tumors as well
iii. Swellings can be because of a number of causes depending on the presentation (infections,
benign or malignant tumors, edema, or blood)
iv. Abnormal lid closure can be seen after ptosis surgery or thyroid eye disease
v. Discharge on the lids might indicate Conjunctivitis. Crusting indicates Blepharitis
iv. The Lacrimal Area:
i. Scars indicate surgery or trauma (rare in this area). Discolorations indicate surgery or tumors
ii. Discharge indicates a fistula formation after dacryocystitis
iii. Swellings in this area are most likely due to chronic naso-lacrimal duct obstruction or acute
dacryocystitis
b. Illustrating your findings: Draw a picture as shown below and illustrate your adnexa findings
on it.
119
7. Conclusion
a. Describe patient’s findings& its implications to him and/ or the examiner
120
IV: TORCH EXAMINATION (EYE BALL)
1. Prerequisites
a. Torch
b. Well lit room
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-


4. Command
b. Ask him to look at a distant target
5. Procedure
*Some of the interpretation findings are given here to keep the text coherent
A. Stand at one side of the patient which corresponds to the eye being examined. Though it is
possible to examine both eyes standing on one side.
B. Shine the light from the front to illuminate the entire eye ball. Examine the eye ball as follows
I. Conjunctiva
i. Ask the patient to look up, down, left and right while you examine the conjunctiva. You can
gently pull the upper lids upwards to inspect the superior conjunctiva. Make sure you let the
patient know what you are about to do! Look for:
ii. Discharge. Note the type (watery, mucoid, purulent)
iii. Congestion/ Hemorrhages. Conjunctiva has fine blood vessels only.
For hemorrhages it is essential that you ask the patient to move the eyeball to find its
(hemorrhages) posterior limit
121
iv. Swellings or growths. Describe swellings as given in ‘Adnexa Examination’ and growths as
given below
v. Pull the lower lid down with the pulp of your thumb and examine the palpebral conjunctiva.
II. Cornea
The Cornea is examined first by shining the light from the front (direct) and then the same steps
are carried out by shining the light from about 60 degrees (oblique) to your viewing angle (as
shown below)
i. Examine the cornea for clarity. Note any faint opacities.
Grade opacities as given below
ii. Examine the limbus for a white band. This is usually present
in the elderly and is due to deposition of cholesterol (arcus
senilis)
iii. Cornea is devoid of blood vessels. Look for any aberrant
blood vessels.
III. Iris
The iris is examined the same way as above. Using both direct and oblique illumination.
i. Look at the shape and size of the pupil.
ii. Look at the color of iris and any sectoral changes in its color. Compare the color of the two
irises
IV. The Lens
The lens is best examined by using oblique illumination technique. Make sure the reflex of the
bulb of the torch falls within the pupil to get the best view. Describe the status of the patient as
follows
i. Phakic:
The reflex of the normal lens is grayish green. It appears to be like a grey cloud. If the lens has a
cataract it will take a white tinge. If the cataract is dense or mature enough, the entire lens might
be white
ii. Aphakic:
When there is no lens present, the reflex is jet black. If the patient moves his eye slightly the iris
seems to shake (i.e. has tremors). This is because it has lost its posterior lens support
iii. Pseudophakic:
When an artificial lens is implanted the reflex is like that of a piece of glass in the eye.
122
V. The Anterior Chamber depth
To examine the depth of the anterior chamber the torch is placed in line with the lateral canthus
(as shown below). You should be standing at the front and the patient should be looking straight
as was commanded at the beginning of the procedure
i. Shine the light into the anterior chamber from the position
shown
ii. Look for a crescentic shadow at the medial end of the eye ball.
If you see this than the anterior chamber is shallow
C. If you see any growths on the Conjunctiva describe them as:
i. The Starting point: Nasal, Temporal, Superior or Inferior Conjunctiva
ii. The End point: On the limbus, encroaches on the cornea
iii. The nature of growth: Fibrous, Fibro-vascular, Vascular, Pigmented.
D. Grade Corneal Opacities as:
i. Nebular: Faint opacities that don’t impede visualization of the iris
ii. Macular: Denser opacities that do impede visualization of the iris
iii. Leucomal: Very dense opacities that do not allow visualization of the iris
6. Interpretation
a. Either draw (see below) your findings or note them down
I. Conjunctiva
i. The type of discharge can help diagnose the type of conjunctivitis:

a. Mucoid: Allergic, especially if it forms a wire if touched and pulled
b. Purulent: Bacterial
c. Watery: Allergic
ii. Congestion indicates conjunctivitis. Hemorrhages can be associated with type of conjunctivitis
or trauma. If they are traumatic find its posterior limit! If you can’t find it, it probably means the
blood is coming from behind the orbit. This can be an ophthalmic emergency!
iii. Most conjunctival swellings are Pterygium (esp. on the medial side) or Pengicula (again on
the medial side)
123
II. Cornea
i. Note down any opacities and grade them as describe above

ii. Note down any aberrant blood vessels
III. Iris
i. Describe the shape of pupil. It is normally round. It might be small (miosed) and irregular in
uveitis, mid dilated and round in acute angle closure.
ii. Any differences in the color of the two irises might be because of uveitis
IV. The Lens
The findings of the lens have already been described above

V. The Anterior Chamber depth
The anterior chamber is shallow in acute angle closure or hypermetropia and might lead to angle
closure
b. Illustrating your findings:
Draw a picture as shown below and illustrate your eye ball findings on it.
7. Conclusion
124
V: PUPILLARY REACTIONS
1. Prerequisites
a. 2 Torches (preferably one stronger at illuminating than the other)
b. A dimly lit or (preferably) a dark room

.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-

‫ دوران معائنہ کمرے کی روشنی بند ہو گی‬-
‫ اگر معائنے کے دوران آپ کو درد یا تکلیف ہو تو براہ کرم مجھے بتائیں‬-
4. Command
a. Make sure that the patient is seated comfortably
b. Ask the patient to look at a distant object
5. Procedure
All the steps are performed while standing at the side of the patient
a. Note the size of the pupils in a brightly lit room. Any difference of 2mm or greater between the
two pupils in is called anisocoria (an= not iso = same coria = pupil size)
b. Turn the room lights off (or make the room as dim as possible).
c. Note the size of pupils in the dark room by shining the light from below and just illuminating
the eyes
d. Illuminate the eyeball, one at a time, and notice the behavior of the pupil. Note its shape, its
reaction (Does all of the pupil react or does it react partially? Does it react to light at all). This is
the DIRECT PUPILLARY REACTION.
125
e. To check CONSENSUAL REACTION you will require two torches. Place the weaker of the
two illuminators below the eye and shine light on it so that it only allows you to see the pupil.
While keeping your eye on this pupil, use the other illuminator to shine light on the other eye
making sure the light does not spill over onto the opposite eye. Test both eyes.
f. To check for a Relative Afferent Pupillary Defect (RAPD), illuminate one eye and note its
pupillary reaction. Now quickly swing the light over to the other eye and see how it reacts.
g. To check for near (accommodation) response tell the patient to keep focusing at a distance until
you tell him to look at a near object like a pen. Illuminate both pupils from below (so that you just
see them). Ask the patient to look at the pen which is held about 20 cms from the patient in line
with the bridge of the nose.
6. Interpretation
a. Anisocoria: If there is a difference of > 2mm between the two pupils than anisocoria is present.
Anisocoria can be more in dark or light.
i. Anisocoria More in Dark:
If pupillary sizes exhibit a greater difference in dark (with the smaller pupil being defective as in
the dark pupils should dilate), it is called ‘anisocoria more in dark’. This is due to a defect in the
dilator muscle or its innervation of the smaller pupils.
ii. Anisocoria More in Light:
If anisocoria is more in light (with thelarger pupil being defective as in the light pupils should
constrict) it is called ‘anisocoria in light’. This is due to a defect in the constrictor muscle or its
innervation of the larger pupil.
b. Pupillary Reactions: Note the behavior of the pupils to various types of illumination. Pupillary
reactions are described by any of the following two methods:
i. Method I: Round/ Regular / Reacting (Both eyes direct, consensual & to accommodation).
Round: Describes the shape of the pupil
Regular: Describes that all of the pupil reacts
Reacting: Describes that pupil reacts to light
ii. Method II: PERRRLA.
P= Pupils
E= Equal (i.e. both eyes behave alike)
RRR = Round/ Regular/ Reacting (as above)
L= Light
A= Accommodation i.e. Near Reflex
Any oddity of this behavior is described by altering the three characteristics of the pupil (Round/
Regular / Reacting)
126
If the pupils are not Round: They can be oval, oblique. This usually indicates either uveitis (Iritis)
or pupillary trauma. Label them according to their shape.
If the pupils react irregularly (i.e. only a part of the pupil reacts): This can be due to trauma, effect
of dilating drugs, damage due to recurrent angle closure attacks. Label these pupil as ‘irregularly
reacting’
If the pupils do not react: This can be due to drugs, trauma, acute angle closure (mid-dilated), iritis
(constricted). Label these pupils as ‘Non-reacting’.
i. Direct Pupillary Reactions:
Label the pupil as described above
ii. Consensual Pupillary Reactions:
Label this reaction as described above
iii. Test for RAPD:
If an RAPD is detected label that eye as ‘RAPD+’. Remember that one optic nerve should
perform relatively better than the other for this test to be positive!
iv. Reaction to Accommodation i.e. Near Reflex:
Label this reaction as described above. It is possible for Accommodation reflex to be intact
in absence of light reactions (the pathway for both is different).
Note:
*The most important cause of a non-reacting pupil in a normal looking eye is drugs
*The most common cause of a mid-dilated and non-reacting pupil in a ‘red’ and ‘painful’ eye is
acute angle closure
*The most common cause of a constricted and non-reactive pupil in a ‘red’ and ‘painful’ eye is
iritis
7. Conclusion
127
VI: VISUAL FIELDS (CONFRONTATION)
1. Prerequisites
a. Ability to sit at level with the patient
b. Well lit room
c. Visual field testing targets (preferable)
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
‫ آج مجھے کی آنکھ کا معائنہ کرنا ہوگا‬-
‫ آج میں آپ کی نظر کے دائرہ کا جائزہ لوں گا‬-
- ‫اگر معائنے کے دوران آپ کو درد یا تکلیف ہو تو براہ کرم مجھے بتائیں‬-
4. Command
b. Sit about a meter away from the patient making sure that you sit level with him
c. Show the patient your test target (top of a pen, wiggling finger) and ask him if he can see it with
his eyes (cover one eye while asking him to make sure he can see with both eyes independently).
d. Tell the patient you will either show the test target or wiggle your finger expecting him (the
patient) to tell you when he is able to see the target or your finger wiggling.
e. During the examination tell the patient to keep looking into your eye and not towards your hand!
5. Procedure
During the procedure you will measure the perimeter of the visual field followed by the area inside
the perimeter noting the defects in both
Spectacles can affect the size of the visual field. Either test without spectacles (for you and the
patient), or mention in your notes that the test was done with spectacles on (for you and/ or the
patient)
a. Testing the Perimeter:
128
i. Ask the patient to close his left eye with the palm of his hand. You should close your right eye
(by the palm of your hand). The corresponding eyes now should be open
ii. Extend your left hand mid-way between yourself and the patient towards the left (temporarily)
in plane of the patient’s eyes. Wiggle your finger (or show the test target) asking the patient to tell
you if he can see the target. If he can’t move the target inwards until he can see it. You only need
to remember how the patient’s field in this quadrant compares to yours.
iii. Repeat this process (using the left hand) testing the superior (up), inferior (down) and nasal
(towards the right) quadrants (by extending your hand midway between yourself and the patient
in these quadrants, always in the plane of patient’s eyes). Keep in mind how the patient’s field
compares to yours in each of these quadrants.
iv. Repeat this process for the other eye, this time using your right hand. Again note how the
patient’s field compares to yours in the 4 quadrants.
v. Draw the perimeter of the visual fields as shown in #6 Interpretation
b. Testing inside the Perimeter:
i. Ask the patient to close his left eye with the palm of his hand. You should close your right eye
ii. Ask the patient to tell you when he is unable to see the top of your finger (or the test target) as
you move it towards the center.
iii. Extend your left handmid way between yourself and the patient towards the left (temporarily)
in plane of the patient’s eyes. Place your finger (or show the test target) at approximately the point
where the patient was able to see it before. Now move it towards the center (in a straight line)
reminding the patient to tell you if he sees it disappearing (as described above). If at any point he
sees it disappear make a mental note of that position within the perimeter and ask the patient to
tell you when he can see the finger again. This will help demarcate the scotoma.
iv. Repeat this process (using the lefthand) testing the superior (up), inferior (down) and nasal
(towards the right) quadrants.
v. Repeat this process for the other eye, this time using your righthand. Again note how the
patient’s field compares to yours in the 4 quadrants.
vi. Draw any defects that were observed within the perimeter that you drew before (as shown in
#6 interpretation)
c. Locating the blind spot:
i. The blind spot cannot be tested by using your finger as the target falls outside the boundaries of
the scotoma created by the blind spot. Use the tip of the ball point pen as your target
ii. Ask the patient if he can see the tip of a ball point pen individually with both eyes.
129
iii. Ask the patient to close his left eye with the palm of his hand. You should close your right eye
iv. Extend your left handmid way between yourself and the patient towards the left (temporarily)
while holding the pen in the plane of patient’s eyes.
v. Ask the patient to tell you when he can’t see the tip of the ball point pen
vi. Slowly move the ball point pen towards the center in a straight line, like you moved your finger
in testing within the perimeter (described above)
vii. The tip of the ball point pen should disappear for both you and the patient in the temporal field.
If it disappears for the patient before it disappears for you make a mental note. Do the same if it
disappears for the patient after it disappears for you. This demarcates the beginning of the blind
spot.
viii. Now ask the patient to tell you when it reappears. This marks the end of the blind spot.
ix. Repeat this procedure for the other eye
x. Note down the size of the blind spot on the same diagram as before
6. Interpretation
This test relies on you having a normal visual field and a blind spot. If you know yourself to have
a defective field take that into account
a. If the patient visual field perimeter compares to yours simply draw to round circles indicating
the perimeter of the field (for the right and left eyes). The figure below shows how the circle
represents the four quadrants of the visual field.
S S
T N N T
I I
Left Right
Normal Visual Fields
S = Superior Quadrant T = Temporal Quadrant
N = Nasal Quadrant I = Inferior Quadrant
130
b. If the patient visual field is defective as compared to yours, draw a constriction in the field in
the quadrant that you observed the defect in.
Defective Visual Fields
1. Superior quadrant left eye constriction 2. Inferior quadrant right eye constriction
c. If there was any scotoma (other than the blind spot), approximately draw it within the perimeter
(as solid circles). It is not necessary to show the blind spot, unless its size was bigger than your
own blind spot.
Scotoma in inferior quadrant Scotoma in nasal quadrant eye
7. Conclusion
131
VII: REGURGITATION TEST
1. Prerequisites
a. Clipped fingers nails
b. Well lit room
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
‫آج میں آپ کی آنکھ کے آنسوؤں کے نکاس کے راستے کا معائنہ کروں گا‬ -
‫ اس کےلئے میں آپ کو تکلیف دیئے بغیرآپ کی آنکھ کی اندرونی طرف انگلی سے‬-
‫ گی‬/‫دباؤ ڈالوں گا‬
‫اگر معائنے کے دوران آپ کو درد یا تکلیف ہو تو براہ کرم مجھے بتائیں‬- -
4. Command
b. Ask the patient to look at a distant target
c. Ask the patient if he has had a bad cold recently.
5. Procedure
a. For performing regurgitation test on the right, stand on the patient’s right side. Conversely stand
on the left side if the test is to be performed on the patient’s left naso-lacrimal system
b. Make sure your finger nails are clipped, especially the nail on the little finger
c. Warm the little finger of your right hand (if you are left handed you can use your left hand as
well)
d. Observe the naso-lacrimal area of the patient. If you see a ‘hot’ swelling, ask the patient if it
hurts when he touches the swelling. DO NOT proceed without the consent of a doctor, if there is
such a swelling.
e. Observe the nasal bridge for any obvious deflection.
f. Look for any discharge in the area. You might want to clear the discharge to get a better view of
the area. Use gloves and a sterile cotton gauze. Tell the patient you are going to use the gauze to
clean his eye. If the discharge was on the side of the nose near the lacrimal sac area chances are it
was coming from a fistula.
132
g. Gently put the pulp of your little finger over the area of the lacrimal sac. To locate the lacrimal
sac follow the two eyelids as they converge medially. They end up is a cord like tendon which
runs medially to the nose. The lacrimal sac lies below this tendon. Now press the sac against the
side of the nose.
h. While you press over the lacrimal sac observe the punctii (on the medial end of the eye lids).
Look for discharge coming out of the punctii
i. Note the nature of discharge. It can be mucoid (white), purulent (yellow-white) or clear watery.
j. Repeat the procedure on the other eye (if required)
6. Interpretation
If upon pressing the lacrimal sac discharge regurgitates out of the punctii it implies an obstruction
of the lacrimal drainage system beyond the lacrimal sac.
a. If the discharge is mucoid, the obstruction is probably due to an old dacryocystitis
b. If the discharge is purulent, there is probably an element of dacryocystitis (most likely to be
chronic)
c. If the discharge is clear and watery the obstruction is most likely to be not very long standing
d. At times a nasal obstruction (due to deflected septum, hypertrophied mucosa or severe rhinitis)
can also produce a positive regurgitation test
7. Conclusion
133
VIII: DIGITAL TONOMETRY
1. Prerequisites
a. Clipped fingers nails
b. Well lit room
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
‫آج میں کاال موتیا کےلئے آپ کی آنکھوں کے دباؤ کا معائنہ کروں گا‬ -
‫اس کےلئے میں آپ کو تکلیف دیئے بغیرآپ کی آنکھوں کو انگلیوں سے دباؤں گا‬ -
‫اگر معائنے کے دوران آپ کو درد یا تکلیف ہو تو براہ کرم مجھے بتائیں‬-
4. Command
a. Make sure the patient is comfortably seated
b. After you have completed your observation (see step #a below) ask the patient to look down
towards his feet, but keep his head straight
5. Procedure
a. Start by telling the patient to fixate on a distant target. Observe the eye lids for any obvious
swelling (especially ‘hot’ swelling) or conjunctiva for severe congestion. If you see any swelling,
ask the patient if it hurtswhen he touches it. DO NOT proceed if there is such a swelling (or
conjunctival congestion) without the consent of the doctor.
b. Make sure your nails are clipped (all fingers, both hands) and your hands are warm (if they are
not, simply rub them together)
c. Stand on one side of the patient that is to be examined.
d. Once the patient is looking down place the pulp of the index fingers of both hands on the inner
and outer quadrants of the upper lid (as shown below) respectively.
e. Spread the rest of the fingers of both hands on the forehead for support.
134
f. Gently press on the eye lid with one of the fingers. Make a mental note of the feedback you get
from pressing on the globe. Also make a note of the feedback you get in the other finger. This is a
result of the vitreous/ aqueous in the eye shifting due to the initial pressure application.
g. Repeat the procedure in the other eye. THIS MUST BE DONE! Digital tonometery relies on
comparing the results obtained from both the eyes!
6. Interpretation
Digital tonometry is a qualitative assessment of Intra-ocular pressure. The results depend on the
tactile feedback obtained from pressing the eye
a. The feedback can be compared to the following:
i. Touching your finger nail with the pulp of your index finger
ii. Touching your palm with the pulp of the index finger
iii. Feedback sensation that is in between the two
Compare the difference in feedback between the two eyes.
b. If the feedback was like pressing your nail, the pressure in that eye is ‘high’
c. If the feedback was like pressing your palm, the pressure in that eye is ‘normal’
d. If both eyes ‘feel’ the same, qualify the pressures based on feedback (i.e. both eyes have ‘high’
pressures if it felt like pressing your finger nail)
e. If the feedback was somewhere in between it can be difficult to assess on digital tonometery if
these pressures are high or normal
NOTE:
*High and Normal here are qualitatively used. You can’t say if the ‘high’ pressure is higher than
normal, it is higher as compared to the fellow eye.
7. Conclusion
135
IX: EXTRA OCULAR MOVEMENTS
1. Prerequisites
a. Target (a ball point pen would do)

b. Well lit room
c. Ability to sit at level with the patient
d. Familiarity with eye movement terminology
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
. ‫آج میں آپ کی آنکھ کے پٹھوں کا معائنہ کروں گا‬ -
- ‫اگر معائنے کے دوران آپ کو درد یا تکلیف ہو تو براہ کرم مجھے بتائیں‬-
4. Command
a. Show the target you are going to use to perform the test and ask the patient to identify it with
both of his eyes individually. The target can be the tip of a pen. The light from a torch is NOT a
suitable target as it has no boundaries
5. Procedure
a. Make sure you are seated about a meter from the patient and on level with him
2 different tests of eye movements will be performed namely:

i. Pursuits. ii. Saccades
b. Testing Pursuits:
If you are asked to test pursuits in one eye (Ductions), ask the patient to close the other eye with
the palm of his hand. Testing procedure is the same for Ductions and testing both eyes together
(versions)
i. Ask the patient to follow your target with his eyes only and not move his head. If the patient
moves his head during testing ask him not to. If he continues to do so, tell the patient you are going
to hold his head with your hand in order to stabilize it in central position.
136
ii. Place the target midway between yourself and the patient in the midline at the level of the bridge
of the nose.
iii. Move your target in front of the patient in an “H” pattern with an extra central limb as shown
below (“the modified H”). You can test the muscles in any order
iv. As the patient moves his eyes notice if they reach the end point of movements in each position.
The end points for different position are approximated as follows:
a. Elevation: The eyes should move up so that about 3mm of clear sclera can be seen below
the limbus
b. Depression: The eyes should move down so that about half the cornea is covered by the
lower lid. Lift the upper lids to get a better look view
c. Abduction: The temporal limbus should reach the lateral canthus
d. Adduction: The nasal limbus should be inside the puncta on the lower lid
v. Once you are done with the modified “H” movements perform tests for convergence and
divergence
a. Convergence Testing: To test convergence move your target from about half meter out,
level with the bridge of the nose, towards the patient and notice both eyes moving inwards
b. Divergence Testing: To test divergence simply move the target back from the position
at the end of step #a above. Notice both eyes moving outwards.
If you were asked to perform Ductions, repeat the procedure in the other eye.
SR IO+SR IO SR IO+SR IO
LR MR MR LR
IR IR+SO SO SO IR+SO IR
RIGHT EYE LEFT EYE
THE MODIFIED “H”
vi. Draw the Extra ocular movement chart as shown above. Indicate any deficit by marking the
approximate movement of the eye in that gaze. E.g. the figure below shows abduction deficit in
the right eye. The eye only moves about half way out from the midpoint (indicated by) Put a “√”
against all movement that are ‘full’ (i.e. the eye reaches the end point)
137
√SR IR+IO√ IO√
LR MR √
√IR √IR+SO SO√
The √ indicates that the eye

The indicates that the moved normally in this
abduction is limited. direction (adduction)
NOTE:
*Sometime you can induce a nystagmus as the eye reaches its end point
c. Testing Saccades
i. Place both of hands in the horizontal plane, fisted, midway between yourself and the patient
spreading them so they are lie just outside the facial outline of the patient as shown below.
ii. Ask the patient to quickly look towards the hand with the open palm without moving his head.
iii. Randomly open and close the fists between the two hands and notice if the patient is able to
rapidly switch between the hands and gaze towards the one with the open fist
iv. Repeat the procedure by keeping your hands in the vertical plane, just outside the outline of the
patient (as shown below).
138
6. Interpretation
Defects in extra-ocular movements could be due to neurologic, muscular or orbital causes. The
most common cause of defective movement is neurologic (nerve palsies)
a. Associate defective movement with its muscle and the nerve. It is possible to have multiple
muscular deficits. As CN III supplies more than a single muscle its palsy will affect more than one
extra ocular movement
b. Abnormal saccades are due to lesion in the control center for saccades which lies in the
cerebrum
7. Conclusion
139
X: OPHTHALMOSCOPY
1. Prerequisites
a. Ophthalmoscope
b. Dark Room
c. Your own refractive error
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
‫ آج مجھے اس خصوصی آلے * کی روشنی مدد سے آپ کی آنکھ کا معائنہ کرنا ہوگا‬-
*Point to the ophthalmoscope in your hand
4. Command
b. Ask him to focus on a distant object
c. Before turning the lights off, tell the patient you are going to do so
d. Ask the patient if he wears distance vision correction. If he does ask he knows the number of
his correction. If he does not look at his glasses and find out if they are correcting hypermetropia
or myopia. Make a mental note of this. You only need to note the spherical correction.
5. Procedure
Two different types of examination are performed with the ophthalmoscope
a. Distant Ophthalmoscopy (also called Distant-Direct Ophthalmoscopy)
b. Direct Ophthalmoscopy
Make sure you are familiar with the equipment before beginning the examination.
You should learn to do this test without wearing your distance correction spectacles. Contact
lenses are okay. Remember to dial in your correction in the instrument before doing direct
ophthalmoscopy. Again only take into account the spherical correction
140
a. Distant Ophthalmoscopy:
i. Stand at the side of and about a meter away from the patient
ii. Turn the instrument on to full illumination
iii. Point the instrument towards a wall and make sure the largest white light circular illumination
is selected. If not select it
iv. Now shine the light at the patient centering it on the bridge of the nose
v. Bring your eye to viewing hole of the instrument
vi. Observe the nature of the reflex coming from the eyes
vii. You might want to dial in a +10 lens to magnify small opacities (obstruction in the red reflex)
b. Direct Ophthalmoscopy:
i. Hold the instrument in the same hand as the eye of the patient you want to examine and stand
about a meter away on the side of the patient (the side which corresponds to the eye being
examined).
ii. Tell the patient you are going to approach him with the ophthalmoscope during the examination
and might need to put your hand on his head. Tell him that you are going to be really close to him
during the examination
iii. If the patient’s pupils are dilated turn the instrument on and select the largest white light circular
illumination, otherwise select the smaller white light circular illumination.
iv. Dial in an appropriate correction which is the algebraic sum of your correction and the patient’s
correction (E.g. If you wear -3 and the patient wears +1, the correction to dial in is -3+(+1) = -2)
iv. Center the light in the patient’s eye to be examined. Now bring your eye (the same as the one
as you are examining. E.g. If you are examining the patient’s right eye, use your right eye) to the
viewing hole
v. Follow the red reflex in towards the patient.
vi. The top of the instrument should be adjacent to the patient’s brow. At this point the retina
should be in focus.
vii. Twist the instrument medially to locate the optic disk. Notice its margins, color, size of cup
viii. Follow any of the 4 large blood vessels into their respective quadrants. Look for hemorrhages,
exudates in those quadrants
ix. Finally tell the patient to look into the light. Be quick and try and locate the fovea reflex (a
small bulb like reflex just on top of the fovea). Also try and look for patches of pigmentation or
degeneration (white areas). DO NOT spend too much time looking at the fovea! The bright light
will hurt the patient!
141
6. Interpretation
a. Distant Direct Ophthalmoscopy:
i. A ‘full’ red reflex in both eyes indicates a normal finding. Notice that the ‘red’ might not be
uniform in its entirety. The bottom half might be slightly duller than the top and may even appear
to be nearly black. Do not confuse this with the ‘black’ of an opacity
ii. If you find an obstruction in the way of the red reflex (which always appears as ‘jet’ black) try
and localize it. The opacities can only exist in the transparent media of the eye (cornea, lens and
vitreous).
a. Any opacities in the cornea should be detected during torch examination of the eye ball
b. Any vitreous opacity should move as the patient moves his eyes.
c. Opacities most commonly detected by the ophthalmoscope are from the lens (cataract)
b: Direct Ophthalmoscopy:
It is a very difficult task to be able to learn retinal and optic disk examination during a 4 week
rotation. Try and concentrate on honing your skill. The findings that you should try and look for
are
i. Hemorrhages: They appear red
ii. Exudates: They appear yellow
7. Conclusion
142
XI: PTOSIS EXAMINATION
1. Prerequisites
a. A millimeter rule (scale)
b. Torch
c. Well lit room
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
‫ آج مجھے اس اسکیل اور ٹارچ کی روشنی مدد سے آپ کی آنکھ کا معائنہ کرنا ہوگا‬-
4. Command
a. Make sure the patient is comfortably seated
b. Ask the patient to look straight at the beginning of the examination
c. Sit just to the side of the patient so that you can easily reach his eyes with your hands
5. Procedure
Ptosis examination has the following components:
*Amount of Ptosis
*Levator function
*Checking Bell’s phenomena
*Corneal sensations
*Jaw Winking
DO NOT PROCEED IF YOU OBSERVE ANY ‘HOT SWELLINGS’ ON THE PATIENTS
LIDS! Take the consent of a doctor first!
a. Amount of Ptosis:
143
i. While the patient is looking straight note the level of upper lid resting position in BOTH the
eyes. Make a note of thelevel of the highest point on upper lid in relation to the center of the pupil
(see diagram below).
ii. If it is difficult for you to assess the position of the upper lid in relation to the pupil, center the
light of a pen torch on the eye. Note the distance between the reflection of the bulb in the cornea
to the position of the highest point on the upper lid (see diagram below). Do this for both eyes
The interpretation section (#6) explains these measurements)
b. Levator function:
i. Tell the patient you are going to hold his brow with the thumb of your hand
ii. Warm your hands
iii. Place your thumb (firmly, but gently) horizontally over the brow of the eye with ptosis
iv. Tell the patient you are going to bring the rule (scale) to the front of his eye
v. Tell the patient to look down with his eyes, keeping his head straight
vi. Place the rule (scale) in front of the patient’s eye, millimeter side on the front.
vii. Align the lowest point on the upper lid with any printed number on the millimeter side of the
scale (This value will be referred to as ‘x’).
viii. Tell the patient to look up as far as he can while you hold his brow and the scale in front of
his eye. This movement of the lid is defined as ‘excursion’
ix. Notice the position of the upper lid relative to the scale when the patient is looking up. Note
this reading on the scale. (This value will be referred to as ‘y’)
x. Subtract ‘y’ from ‘x’ (y-x). This is the levator function. Note this down
c: Bell’s Phenomena:
i. Ask the patient to firmly close his eyes (both of them!)
144
ii. Tell him that you will try to open his eyes with your hands and he should offer some gentle
resistance to your efforts
iii. Gently place the pulp of your thumbs on the upper lids of the patient’s closed eyes
iv. Now gently open the patient’s eyes by apply upward force from your thumbs. Note if the eye
ball has rotated upwards. This will be evident by the cornea having moved upwards underneath
the upper lid. Note how much of the cornea is visible when you open his eyes
d: Corneal Sensations:
i. Make a thin wisp out of a tissue paper
ii. Show this wisp to the patient telling him that you will use this to assess the cornea of the patient
iii. Hold the wisp in your right hand if examining the right eye ptosis and vice versa
iv. Hold out your left hand, as far to the left of the patient as possible, and instruct the patient to
turn his eyes towards your hand without turning his head
v. Bring the wisp from the right side outside of the patient’s gaze. If he sees the wisp approaching
his eyes he will close them before the wisp can touch the cornea
vi. Note if the patient reflexley closes his eye when the wisp touches the cornea
e: Jaw Winking:
i. Ask the patient to imagine as if he is chewing a gum
ii. Notice if his eyes ‘wink’ as he chews
iii. It is easier if you offer children a biscuit (after taking permission from their guardian).
6. Interpretation
Always compare the two eyes before commenting on ptosis. Congential ptosis can be bilateral and
asymmetrical. Some races have shorter palpebral fissure heights that might simulate ptosis
a. Amount of Ptosis:
145
i. The horizontal corneal diameter is 12mm, thus the radius is 6mm. The upper 2mm is normally
covered by the upper lid
ii. The normal distance between the highest point on the upper lid and the center of the pupil (which
corresponds to the center of the cornea in almost all normal eye balls) is thus 6-2mm (= 4mm).
iii. In ptosis this distance is reduced. At times the ptosis can be severe enough to completely cover
the pupil. In these cases measure the visible cornea from below and subtract that from the corneal
radius (6mm). For example if only 2 mm of cornea can be seen; 2-6 = -4mm of ptosis.
b. Levator function:
Levator function provides an insight into the ability of the levator palpebrae superioris muscle to
elevate the upper lid. Depending on the value obtained, levator function is described as:
i. Poor (Upper lid excursion of 0-5 mm)
ii. Moderate (Upper lid excursion of 5-10 mm)
iii. Good (Upper lid excursion of ≥ 11 mm).
It might be possible to operate on the levator muscle if its function is moderate. If the function of
the muscle is poor, it is usually advisable to perform a sling surgery
c. Bells’ phenomena:
Good Bell’s phenomena (cornea completely covered by upper lid) indicates that the cornea will
be protected if ptosis is over corrected
d. Corneal sensations:
Intact corneal sensations will ensure that if ptosis is over corrected, the corneal blink reflex will
prevent (to an extent) corneal exposure damage
e. Jaw Winking:
Jaw winking occurs due to a misdirection of cranial nerves. If jaw winking is positive it indicates
ptosis is not caused by a defective levator muscle
7. Conclusion
146
XII: OCULAR ALIGNMENT
1. Prerequisites
a. Torch
b. Occluder (Can be made out of paper folded into a triangle)
c. Well lit room
*Ocular alignment & its examination is a challenge not only for graduates but even trained
ophthalmologist! Do not be discouraged if you have trouble getting into grips with its finer points!
*The technical term for ‘squint’ is strabismus
.‫ ہے‬--------------------- ‫ میرا نام ڈاکٹر‬-
.‫ آج میں ٹارچ کی مدد سے آپ کی آنکھ کا معائنہ کروں گا‬-
.‫ اس دوران میں آپ کی آنکھ کو سامنے سے بند کروں گا‬-
4. Command
a. Make sure he is seated comfortably
b. Ask the patient to look at a distance target
c. Also ask the patient if he has any diplopia (double vision)
5. Procedure
Two tests of ocular alignment will be performed.
a. Corneal reflection test (Hirschberg’s test)
b. Cover & Un-cover test
a. Corneal reflection test:
i. Shine the light, centered at the bridge of the nose of the patient
147
ii. Notice the location of the reflection of the light in the cornea in relation to the center of the
pupil. (See figure below).
iii. If no squint is present the reflection will be centered on the pupil. If squint is present the
reflection will be off-set from the center of the pupil.
iv. Make a mental note of the distance between the off-set light reflex and center of the pupil (see
the figure below).
v. Repeat the test by asking the patient to look at an object about a foot from the bridge of the
nose of the patient.
b. Cover & Un-Cover tests:

Cover Test:
i. Tell the patient that you are going to cover the ‘good’ eye (the non-squinting eye) of the patient.
If none of the eyes appear to squint, cover the right eye first
ii. Cover the eye with an occluder COMPLETELY! Make sure the patient cannot peek from behind
the occluder.
iii. Observe the behavior of the other eye. If there was apparent (manifest squint) in the un-covered
eye, note how it responds to covering the fellow eye
iv. Keep the cover on the eye for at least 10 seconds
Uncover Tests:
i. Now remove the cover from the eye and notice its behavior
ii. The eye behind the cover might make a ‘corrective’ movement or not move at all.
148
Repeat this test by covering the other eye
6. Interpretation
a. Corneal Reflection Test:
*Terminology used to describe the position of the deviated eye:

a. Eye turned outwards = Exotropia
b. Eye turned inwards = Esotropia
c. Eye turned upwards = Hypertropia
d. Eye turned downwards = Hypotropia
i. Each millimeter of light off-set from the center of the pupil equates to a squint of 7 degrees
ii. If the light falls on the edge of the pupil and the light is deflected inwards. The amount of squint
is 7x2 = 14 degrees. As the light is deflected inwards, the eye must have turned outwards. Thus
this is 14 degrees of ‘Exotropia’
b. Cover & Uncover Tests:
Cover Test
i. If the uncovered eye has an obvious squint at the start of an examination (i.e. the uncovered eye
was not straight), notice how it responds to covering the ‘good’ eye
i. If the eye moves, it is said to take ‘fixation’ (i.e. starts looking again)
This implies that:
a. This eye has some visual capacity AND
149
b. The ptosis is not due to a problem with muscle or nerve defect
ii. If the eye does not move, it implies that:
a. This eye has poor visual capacity (unless the patient also complained of diplopia, see below).
AND/ OR
b. This eye is squinting due to a defect in nerve and/ or muscle function.
The uncover part of the test will help you figure this out
iii. If the uncovered eye has no obvious squint, proceed to uncover part of the test
iv. If the patient complains of diplopia with both eyes open and has an obvious (manifest) squint
it almost always implies that the squint is due to a muscle and/or nerve defect
Uncover Test:
i. Notice the behavior of the occluded eye as the cover is removed.
ii. The eye does not move at all. This implies the eye did not have any hidden (latent) squint
iii. The eye makes a ‘corrective’ movement medially. This implies that behind the cover the eye
had moved laterally and had to ‘correct’ its alignment by moving medially. This shows a latent
squint (Exophoria)
iv. Please read the Interpretation of Cover test #ii (the eye does not move). Assume this to be the
case in this instance. The eye behind the cover will:
a. Deviate in the direction of the squint (in the squinting eye). This is called ‘secondary’ deviation
b. This deviation will be more than the deviation of the squinting eye.
c. This is a typical appearance of a paralytic squint.
Try and figure out why this happens, keeping in mind the neural control of eye movements.
Performing extra-ocular movements (with the permission of the examiner) in patients of squint
can also identify muscular deficits. But they can be misleading in long standing squints. (Again
try and figure this out, considering what happens to muscles that remain in a contracted state for
long periods of time)
Terminology related to Latent (hidden) squint:
1. Eye behind the cover turned laterally = Exophoria
2. Eye behind the cover turned medially = Esophoria
3. Eye behind the cover turned upwards = Hyperphoria
4. Eye behind the cover turned downwards = Hypphoria
150
Note the phrasing. The positions referred to are the positions of the eye, not the corrective (see #iii
Uncover test) movement they make!
7. Conclusion
151
CHECK LISTS FOR CLINICAL SKILLS
I. CHECK LIST FOR DISTANCE VISUAL ACUITY
Sr No Item Yes No
– Examinee Greets and introduces him/ herself to patient.
– Takes consent
– Gives clear commands to the patient
– Makes patient sit at 6 meters.
– Asks if patient to put on distance vision glasses (if any).
– Asks if the patient can see Snellen’s chart in patient

preferred language (or English)
– Moves patient to appropriate distance if he can’t see the

chart at 6meters
– Asks the patient to properly close one eye at a time
– Checks VA in both eyes one at a time
– Uses pinhole at 6m (if required)
– Checks Hand movements perception (HM) or Light

Perception (PL) [if required]
– Checks Light projection with vision HM +ve or PL +ve

vision
– Explains findings /Documents visual acuity properly
– Demonstrates professionalism & empathic attitude toward

Patient.
– Thanks the patient
152
II. CHECK LIST FOR NEAR ACUITY
Sr No Item Yes No
– Takes consent
– Asks if patient is already wearing any distance/ near vision

glasses, if yes ask patient to put them on.
– Give him the near vision chart and ask him to hold it
WHERE HE WANTS TO READ FROM (& NOT WHERE
HE CAN READ FROM!)
– Ask to read (in his preferred language or English) the

smallest print as far down as possible both eyes at time.
– Explains findings / Documents near acuity in prescribed

format

Patient.
153
III& IV: CHECK LIST FOR EYE EXAMINATION WITH A TORCH
Sr No Item Yes No
– Takes consent
– Instructs the patient to gaze at a distant target
– Stands at the side of the patient
– Examines brows
– Examines lids (open and closed)
– Examines naso-lacrimal area
– Examines conjunctiva by moving the eye ball in 4 quadrants;
proper command and exposure
– Examines cornea
– Examines Anterior chamber/ depth
– Examines shape of pupil
– Examines status of Lens/ pseudophakia/ aphakia
– Uses hand sanitizer before and after touching the patient
– Explains findings in a systematic way

Patient.
154
V: CHECK LIST FOR PUPILLARY EXAMINATION
Sr # Item Yes No
- Greeting & Introduction
- Consent & Explain patient what he/ she is going to check
- Instructs patient to look at a distance
- Stands at the side
- Inspects the pupil in light
- Asks to dim the lights
- Performs pupillary reaction in dim light / dark room
- Checks
1. Direct reflex in both eyes separately
2. Consensual or both eyes (uses dim torch at chin and bright
torch for eye)
3. Relative afferent pupillary defect (RAPD)
4. Near reflex
- Describes correct findings
- Shows professional and empathic attitude towards patient
- Thanks the patient
155
VI: CHECK LIST FOR CONFRONTATION VISUAL FIELDS
Sr # Item Yes No
1 – Greets and introduces him/ herself to patient.
2 – Takes consent
3 – Sits at appropriate distance: adjusts the arm’s length
4 – Adjusts for the height
5 – Not sitting cross legged with the patient
5 – Asks the patient if he/ she can see the target prior to beginning of test.
– Uses the appropriate side of eye (right for right and vice versa.)
6 – Checks the visual field perimeter and area.
– During testing asks if patient can see the target.
– Makes sure that patient keeps gaze fixed.
10 – Locates blind spot if command was given.
11 – Describes (Interprets and concludes ) findings
12 – Demonstrates professionalism & empathic attitude toward Patient.
156
VII: CHECK LIST FOR REGURGITATION TEST
Sr # Item Yes No
- Examinee Greets and introduces him/ herself to patient.
- Takes proper consent, Explains to the patient what he is about

to do
- Nails are clipped
- Warms hands if its winter
- Uses hand sanitizer before examination
- Observes area
- Uses the little finger
- Presses in the right area
- Does not use excessive force
- Uses hand sanitizer after touching the patient
- Describes findings
157
VIII: CHECK LIST FOR DIGITAL TONOMETRY
Sr # Item Yes No
- Examinee Greets and introduces him/ herself to patient.
- Takes proper consent, Explains to the patient what he is about to

do
- Nails are clipped
- Warms hands if its winter
- Uses hand sanitizer before and after touching the patient
- Observes area
- Instructs patient to look down (and not to close eyes)
- Uses the index fingers of both hands correctly for palpation

and rests other fingers on forehead
- Palpates above the tarsal plate area (not over that)
- Does not use excessive force
- Compares with the other eye
- Describes findings
158
IX: CHECK LIST FOR EXTRA-OCULAR MOVEMENTS
Sr # Item Yes No
– Greets and introduces him/ herself to patient.
– Takes consent
– Gives clear commands to the patient to follow the specific point on the
target.
– Do not use finger as a target.
– Shows target at or beyond 33cm./ Sits at appropriate distance
– Makes sure patient is not moving his head.
– Checks Versions in 9 diagnostic positions of gaze.
- Horizontal movements
- Vertical movements
- Oblique movements
– Checks convergence and divergence
– Checks saccades if asked to (horizontal and vertical)
– Checks Ductions| if asked to

– Describes (Interprets and concludes ) findings
– Demonstrates professionalism and empathic attitude toward patient
159
X: CHECK LIST FOR DISTANT-DIRECT AND DIRECT OPHTHALMOSCOPY
Sr # Item Yes No
– Takes consent especially mentions about dim light
– Identifies and uses the correct instrument
– Gives clear commands to the patient to look at the distance.
– Asks to dim the lights
– Starts at an arm’s length

FOR DISTANT-DIRECT/ RED GLOW EXAMINATION:
– Shines light at the bridge of the nose
– Both eyes fall in the illumination field
DIRECT OPHTHALMOSCOPY:
– Asks and corrects for patient’s / own distant refractive correction in
Ophthalmoscope (if required).
– Uses the appropriate side/ hand/ eye
– Follows the light into the eye
– Gets close enough to get a view
– Focuses separately for disc and macula
– Uses hand sanitizer before and after touching the patient/ instrument
– Describes (Interprets and concludes ) findings

160
XI: CHECK LIST PTOSIS EXAMINATION
Sr # Item Yes No
– Takes consent
– Gives clear commands to the patient to follow the specific
point on the target.
– Sits at the appropriate distance
– Observes both eyes(for assessing eye(s) that is ptotic
– Checks amount of ptosis i.e. Margin Reflex Distance
– Checks Levator function: proper position of scale
– Checks Bells phenomena: proper command and method
– Checks corneal sensations: proper command and method
– Checks jaw winking: proper command and method
– Uses hand sanitizer before and after touching the patient
– Demonstrates professionalism and empathic attitude toward
patient
161
XII: CHECK LIST OCULAR ALIGNMENT
Sr # Item Yes No
– Takes consent
– Gives clear commands to the patient to look at either near or far target.
– Does not use finger as a target.
– Sits at the level of the Patient
– Performs corneal reflection test / Hirschberg test, examines and
compares both eyes simultaneously
• Performs cover test on right eye (observing left eye)
• Performs cover test on left eye (observing right eye)
– Performs uncover/ alternate cover test
– Observes movements in appropriate eye
– Describes (Interprets and concludes) findings of Hirschberg test and
cover/uncover test separately.
162
APPENDIX I
Fundus Angiogram
Optical Coherence Tomography (OCT) of Macula
163
A Scan of Eye
B Scan Ultrasound
164
Humphrey Visual Fields
Corneal Topograph
165

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CLINICAL ROTATIONS &

Google drive link for Ophthalmology resources:

Contributions & Revision 2021 Dr Ayisha Kausar

3rd year case scenarios Dr Imran Janjua

Acknowledgment Prof Dr Ali Tayyab

In Shifa College of medicine, Ophthalmology themes are introduced during 2 nd year of

The clerkship program focuses on basic competencies (outcomes) that an undergraduate

1. Identify prevalent ophthalmic pathologies.

# Outcome Competency Objectives* Teaching strategy Assessment tool

*Highlighted areas show minimum objectives required in third year

Highlighted areas show minimum objectives required in third year

Highlighted areas show minimum objectives required in third year

Highlighted areas show minimum objectives required in third year

TIME SLOT MAJOR ACTIVITIES (LOCATION)

THEMES & SKILLS FOR 3rd YEAR ROTATION

THEME I: GRADUAL PAINLESS DECREASED VISION

THEME II: RED EYE/ SUDDEN PAINFUL DECREASED VISION

THEME III: OCULAR GROWTHS & SWELLINGS

THEME IV: TRAUMA/ OCULAR EMERGENCIES

Past Ocular History: Not significant

Ocular Medications: None

Past Medical History: Not significant

Surgical History: Not significant

Past Family Ocular History: Not significant

Social History: Belongs to a middle class family

Review of systems: Not significant

OD/ Right eye OS/ Left eye

IOP (Goldman applanation) 14 mmHg 14mmHg

Pupils Round, regular, reactive Round, regular, reactive

Extraocular Movements Normal. Normal

Confrontational V.F OD Normal OS Normal

OD/ Right eye OS/ Left eye

Rlevant Pictures: Right Eye Rlevant Pictures: Left Eye

2. What are various mechanisms of lens opacification?

3. What are different types of cataract and classification (congenital /acquired) ?

4. What are the different methods to treat cataract?

Past Ocular History: Not significant

Ocular Medications: None

Past Medical History: Not significant

Surgical History: Not significant

Past Family Ocular History: Not significant

Social History: Not significant

Review of systems: Not significant

Right Eye Left Eye

Visual acuity 6/36 6/24

What is myopia? What are the different options to treat myopia?

Ocular Medications: None

Past Medical History: Not significant

Surgical History: Not significant

Past Family Ocular History: Not significant

Social History: Not significant

Review of systems: Not significant

Right Eye Left Eye

Visual acuity 6/24 6/24

Lens Clear Clear

What is hypermetropia? What are the different options to treat hypermetropia?

Past Ocular History: He was previously diagnosed with astigmatism.

Ocular Medications: None

Past Medical History: Not significant

Surgical History: Not significant

Past Family Ocular History: Not significant

Social History: Not significant