ABHINANDAN’S

PRACTICAL
OPHTHALMOLOGY

FOR UNDERGRADUATES

ABHINANDAN JAIN
KESHIKA GUPTA

SECOND EDITION: 2023

 ABHINANDAN’S PRACTICAL OPHTHALMOLOGY

CONTENTS:
1. Template for history and case presentation.
_________________________________ 3-6
2. Drugs. __________________________ 7-9
3. Small incision cataract surgery (SICS). _ 10-12
4. Surgical instruments

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ABHINANDAN’S PRACTICAL OPHTHALMOLOGY
TEMPLATE FOR HISTORY AND CASE PRESENTATION
1) Demographic data
i) Name: ABC
ii) Age: X years
iii) Sex: male
iv) Religion: XYZ
v) Occupation: PQR
vi) Address: BMC, Sagar
2) Chief complaints:
i) Always in patient’s language
ii) No technical terms, Short and concise
iii) Always in chronological order, if same time then in order of severity
How to present?
My patient, ABC, a X years old male, XYZ by religion, PQR by occupation came to the OPD
with complaints of: (chief complaints)

3) History of presenting illness:

i) Details of each complaint
ii) Separate paragraph for each complaint
• Onset (sudden or insidious)
• Progression (progressive, regressive or constant)
• Aggravating/ relieving factors
• Other associations
• Diurnal variations
• Severity of complaint

4) History of past illness:

• Medical history
• Surgical history
5) Family history:
Disease which may have impact over generations.
• DM

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 ABHINANDAN’S PRACTICAL OPHTHALMOLOGY
• HTN
• Colour blindness
• Glaucoma
• High refractive error
• Squint
• Retinopathies etc
6) Personal history:
• Addiction
• Allergies
• Bowel habits
• Sleep
• Food habits

EXAMINATION:
GENERAL PHYSICAL AND SYSTEMIC EXAMINATION:
Orientation, gait, head posture, forehead, facial symmetry
OCCULAR EXAMINATION RIGHT EYE LEFT EYE
VISUAL ACUITY
EYEBROWS
LEVEL (PTOSIS MAY BE PRESENT DUE TO DENERVATION)
CILIA (MADAROSIS IN LEPROSY OR MYXOEDEMA)
ORBIT
INSPECTION (ANY ABNORMALITY)
PALPATION
EYELIDS
POSITION
MOVEMENT
CILIA
LID MARGINS
EYEBALLS
POSITION

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ABHINANDAN’S PRACTICAL OPHTHALMOLOGY
SIZE
MOVEMENT
PALPEBRAL APERTURE
WIDTH
HEIGHT
SHAPE
LACRIMAL APPARATUS
PUNCTA
LACRIMAL SAC AREA
REGURGITATION TEST
LACRIMAL SYRINGING
CONJUNCTIVA
BULBAR
PALPEBRAL
FORNIX
LIMBUS SCLERA
DISCOLOURATION
NODULE
ECTASIA
CORNEA
SIZE
SHAPE
SURFACE
TRANSPARENCY
ULCER
VASCULARIZATION
REFLEX
ANTERIOR CHAMBER
DEPTH
CONTENTS
IRIS
COLOUR
PATTERN
SYNECHIAE
IRIDODONESIS

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 ABHINANDAN’S PRACTICAL OPHTHALMOLOGY
PUPIL
NUMBER
SIZE
SHAPE
REFLEX
LENS
POSITION
COLOUR
INTRAOCCULAR PRESSURE
DIGITAL

DIFFERENTIAL DIAGNOSIS

PROBABLE DIAGNOSIS

HOW TO PRESENT?
HOPI:
The patient was apparently healthy since (time), then he/she started having
symptoms of in patient’s language.
EXAMINATION:
On examination it was found that.
The patient was conscious and well oriented in time, place, and person.
Head posture was….
Try to provide positive findings first and affected side first.

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ABHINANDAN’S PRACTICAL OPHTHALMOLOGY

DRUGS
ANTIBACTERIALS
CLASS DRUGS MECHANIS TOPICAL USES SYSTEMI ADVERSE
M C EFFECTS
Aminoglycosides Tobramycin Polypeptide 1% eye Pseudomonas Ototoxic
synthesis drops, 2- , and
inhibitors. 4 times a Proteus nephrotoxi
Too toxic for day c
Framycetin systemic 1% skin Pseudomonas
use. cream,
Bactericidal 0.5%
ointment
/ drops
Chloramphenic 0.5% eye Chlamydia,
ol drops Mycoplasma
Fluoroquinolone Ciprofloxacin Inhibit 0.3% Broad Oral –
s bacterial 1 to 4 spectrum for 500 mg
DNA hourly gram positive 12 hourly
synthesis. and negative
Bactericidal I/V-
200mg
12 hourly
Ofloxacin 0.3% Oral –
1 to 4 200-400
hourly mg 12
hourly

I/V-
200mg
12 hourly
Moxifloxacin 0.5% 400mg
1 to 4 OD
hourly

ANTIVIRALS
DRUG DOSE MOA SIDE EFFECT
Acyclovir 0.3 % ointment Inhibits viral DNA Slight punctate
Oral and injectable also available epithelial keratopathy
Valaciclovir Oral 500mg TDS Inhibits viral DNA None

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 ABHINANDAN’S PRACTICAL OPHTHALMOLOGY

ANTI-GLAUCOMA DRUGS
CLASS DRUGS MECHANISM OF OCCULAR S/E SYSTEMIC S/E
ACTION
Prostaglandins Latanoprost Increases Increase pigmentation Flu like symptoms
analogues Travoprost uveoscleral of iris, Trichiasis Joint pain
(PACG) Bimatprost outflow. Distichiasis, Keratitis Headache
(POAG) Tafluprost Reduction in Blurred vision Muscle pain
episcleral venous Hyperaemia
pressure Anterior uveitis
CME
Beta blockers Timolol Decreases Blurred vision Bradycardia
(PACG) Levobunolol aqueous humour Irritation Heart block
(POAG) Metipranolol production Punctate keratopathy Bronchospasm
Allergy CNS depression
Mood swings
Adrenergic Brimonidine Decreases Irritation, Ischaemia Hypotension
agonists Apraclonidine aqueous humour Allergy Vasovagal attack
(PACG) production Conjunctival blanching Dry mouth
(POAG) Follicular conjunctivitis Fatigue
Pruritis Insomnia
Ocular ache Anxiety
Carbonic Acetazolamide Decrease Induced myopia. Acidosis, Malaise
anhydrase Dorzolamide aqueous humour Punctate keratopathy Hirsutism
inhibitors Methazolamide production Conjunctivitis Numbness
(PACG) Brinzolamide Weight loss
(POAG) Loss of libido
Bone marrow depress
Parasympatho Pilocarpine Increases Posterior synechia Increased salivation
mimetic Physostigmine trabecular Keratitis, Myopia Increased secretions
agents Echothiopate outflow Angle closure Abdominal cramps
(miotics) iodide Cataract growth
(PACG) Retinal detachment
Colour vision changes
Hyperosmotic Mannitol Increases the Increased aqueous Urinary retention
agents Glycerol plasma tonicity flare. Headache
(PACG) Isosorbide to create Blurred vision Congestive heart
(POAG) osmotic pressure failure
gradient and Electrolyte disturbance
dehydrates Nausea
vitreous Vomiting
Confusion
Rho kinase Ripasudil Reduction in Conjunctival none
inhibitors Netarsudil episcleral venous hyperaemia
(POAG) pressure Subconjunctival
Increases haemorrhage
trabecular Cornea verticillata
outflow

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ABHINANDAN’S PRACTICAL OPHTHALMOLOGY

ANTIFUNGALS
DRUG SPECTRUM INDICATION ROUTE / DOSE
Amphotericin-B Aspergillus, Blastomyces, Mucormycosis, fungal keratitis, Topical: 0.1-0.25 %
Candida, Coccidiodes, fungal endophthalmitis soln
Cryptococcus, Histoplasma, Subconjunctival:
Leishmania 0.8-1.0mg
Intravitreal: 5 μg
i/v & oral: 0.25-1.0
mg/kg
Natamycin Aspergillus, Candida, Fungal keratitis, fungal Topical: 5% soln
(Pimaricin) Cephalosporium, fusarium, blepharoconjunctivitis, fungal i/v & oral: 50-150
penicillium endophthalmitis mg QD divided in 4

CYCLOPLEGICS
DRUG INDICATION DOSAGE PEAK DURATION TONUS
EFFECT OF ACTION ALLOWANCE
Atropine sulphate <5 years old TDS x 3days 2-3 days 10-20 days 1D
(1% ointment)
Homatropine 5-8 years One drop every 10 60- 90 48-72 hours 0.5 D
hydrobromide mins x 6 mins
(2% drops)
Cyclopentolate 8-20 years One drop every 15 80-90 6-18 hours 0.75 D
hydrochloride mins x 3 mins
(1% drops)
Tropicamide Not used as One drop every 15 20-40 4-6 hours 0.5 D
(0.5%, 1 % drops) cycloplegic for mins 3 to 4 times mins
retinoscopy; used
only as mydriatic
Phenylephrine` Used as mydriatic One drop every 15 30-40 After 1 day nil
(5%, 10% Drops) alone or in mins 3 to 4 times mins
combination with
tropicamide

ANTI ALLERGIC AND VASOCONSTRICTORS

CLASS EXAMPLES
H1 receptor antagonist Levocabastine, emidastine difumarate
Mast cell stabilizers Cromolyn sodium, nedocromil sodium
H1ϴ with mast cell stabilizing activity Olapatadine, bepotastine, ketotifen fumarate
Topical NSAIDs Flurbiprofen, ketorolac, nepafenac, bromofenac
Vasoconstrictors Naphazoline/pheniramine, antazoline
Weak corticosteroids Loteprednol, fluorometholone, rimexolone
Oral antihistamines Fexofenadine, cetirizine, ebastine
Immunomodulators Tacrolimus, cyclosporine

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 ABHINANDAN’S PRACTICAL OPHTHALMOLOGY

SICS (Small Incision Cataract Surgery)

Preparation
The patient is given anaesthesia in the block room and then taken to the operating theatre.
Types:
1. Subconjunctival Anaesthesia
2. Sub-Tenon Anaesthesia
3. Topical Ocular Anaesthesia
4. Peribulbar Anaesthesia
5. Retrobulbar Anaesthesia
6. Intracameral Anaesthesia

Technique
1) Draping and painting with 5% betadine solution.
2) Superior rectus bridle suture
3) Conjunctival flap and exposure of sclera.
It is performed with the help of tipped scissors along the limbus from 10 to 2 ‘o’ clock
position.
4) Haemostasis
cotton wisp or gentle wet field cautery may be used.
5) Sclerocorneal Tunnel Construction
The concept of a sclerocorneal tunnel is based on three planar tunnel.
The first is a perpendicular scleral incision (external scleral incision), (15 blade is used)
the second is a horizontal incision through the sclera and cornea (sclerocorneal tunnel)
(crescent knife), and
The third is a bevelled incision in the anterior chamber (internal corneal incision)
(keratome).
The inner corneal has the self-sealing property.
6) Anterior Chamber Entry
This approach is made with the help of a 3.2 mm angled keratome.

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ABHINANDAN’S PRACTICAL OPHTHALMOLOGY
7) Paracentesis (Side Port Incision)
The paracentesis incision is placed at 9 ‘o’ clock position with a 15-degree blade.
8) Staining Technique
After injecting the air bubble, the dye is injected with a tuberculin syringe from the
paracentesis or main port. The air bubble prevents the dye from getting diluted and
prevents endothelial staining. The air bubble is then replaced with the help of
viscoelastic.
9) Anterior Capsulotomy:
a. Envelope Capsulotomy
b. Can Opener Capsulotomy
c. Continuous Curvilinear Capsulorrhexis (CCC)
d. Linear Capsulotomy.
10) Hydro dissection
separate corticonuclear mass from posterior capsule
11) Nuclear extraction
phacosandwich technique
fishhook technique
phacofracture technique
12) Aspiration of cortex
using two-way irrigation aspiration (Simcoe’s) cannula
13) IOL implantation
done in posterior capsular bag.
14) Removal of viscoelastic material
15) Wound closure
anterior chamber is deepened with balanced salt solution (BSS), ringer lactate through
side port, it seals the tunnel due to valve effect.

TYPES OF CATARACT SURGERY

1) Couching
lens was pushed into vitreous cavity
2) Crude capsular extraction
3) Intracapsular cataract extraction (ICCE).
entire cataractous lens with intact capsule is removed. Weak and degenerated zonules
are a prerequisite.

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 ABHINANDAN’S PRACTICAL OPHTHALMOLOGY
4) Extracapsular cataract extraction (ECCE)
major portion of the anterior capsule with epithelium, nucleus and cortex are removed.
Posterior capsule is left intact.
Types:
1. Conventional ECCE
2. Manual SICS
3. Phacoemulsification
4. Femtosecond laser assisted cataract surgery (FLACS)

REFERENCES:
1. COMPREHENSIVE OPHTHALMOLOGY BY AK KHURANA

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Bone punch
It is used to enlarge the
bony opening during DCR
operation
Artery (haemostatic) forceps:
1. To catch bleeding vessels during
operation of the lids and lacrimal
sac.
2. To hold the skin and muscle stay
sutures
3. To hold small peanut gauze

IIIIIIIIIII.
pellets for blunt dissection in
lacrimal sac surgery.
4. To hold gauze pieces while packing
the socket after enucleation or
exenteration.

5) to hold lacrimal sac prior to

excision in DCT
 Universal wire speculum:
Used to keep lids apart during:
• Intraocular operations
• Extraocular surgery e.g.,
squint, pterygium
• Enucleation and evisceration
operation
• Removal of conjunctival and
corneal foreign bodies.
• Cauterization of corneal
ulcers
• Examination of the eye in
patients with blepharospasm

Self-retaining
lacrimal wound
retractor (muller’s):
It is used to retract the skin
during surgery on lacrimal
sac (e.g., DCR or DCT)
 Corneal scissors or
D section enlarging
I scissors:
I
Straight

Curved

Uses:
• Used to enlarge corneal or
corneoscleral incision for
conventional ICCE and ECCE.
• To enlarge corneal incision in
keratoplasty operation
• To cut the scleral and
trabecular tissue in
trabeculectomy
• It can also be used for cutting
and undermine conjunctiva in
various operations.
De wecker’s scissors:
It is used to perform iridectomy, iridotomy and to cut
the prolapsed form vitreous and pupillary membrane
Cheatle forceps:
It is used to remove
sterilized instruments from
boilers and formalin
cabinets. The forceps are
placed in a container of
methylated spirits when not
in use.
 ⑰

Spring action (barraquer’s type) needle holder:

Used for passing sutures in the conjunctiva, cornea, sclera
and extraocular muscles
-

Castroviejo’s needle holder:

It is generally used in extraocular surgery, e.g.,
conjunctival suturing, squint surgery. It can also be
used in for intraocular surgery
Simcoe’s two-way irrigation & aspiration cannula:
Uses:
• For irrigation and aspiration of the lens matter in
ECCE.
• Aspiration of hyphaema
 Cystotome or capsulotome:
It is used for doing anterior
capsulotomy or capsulorrhexis during
ECCE.

Fishhook:
It is used for nuclear extraction
during ECCE & SICS

Hydro dissection
cannula:
It is used to perform hydro
dissection and hydro delineation
in phacoemulsification and SICS.

Hydro dissection versus hydro delineation the hydro

dissection is separating the nucleus from the capsule
whereas hydro delineation is separating one part of
the nucleus from other such as epinucleus to the
cortical nucleus
 Bulldog clamp
It is used to secure sutures and prevent
entangling other sutures.

sharp Frobbed
-
0
Muscle (strabismus) hook:
Uses:
• it is used to engage the extraocular muscles
during surgery for squint, enucleation and
retinal detachment.
• It may be used in place of lens expressor

Allis forceps (clamp):

Used to hold the lacrimal sac and
helps complete removal of sac in DCT
 '

atooMM
I
free

Superior rectus holding forceps:

It is used to hold the superior rectus muscle while
passing the bridle suture under it. It is used to
stabilize the eyeball during any operation such as
cataract surgery, glaucoma surgery, corneal
surgery.
·

syeball fixed downwards.

Corneo - scleral forceps (pierse

hoshkin forceps):
These are used to hold the cornea or scleral edge (of
incision)I for suturing during cataract, glaucoma, repair
of corneal or scleral tears and keratoplasty
operations.
To hold
eteygium during
·
excision
Capsulorrhexis
Kelman-McPherson di
forceps:
Used to hold
anterior capsule forceps:
during continuous Uses:
curvilinear • To hold superior haptic of IOL
capsulorrhexis. during its placement
• To tear off anterior capsular flap
in ECCE
• Can be used for suture tying

Wire Vectis:
It is used to remove subluxated lens and anteriorly
dislocated lens in ICCE technique and the nucleus in
ECCE technique.

hand
Sinskey hook or IOL dialer:
-left
Uses:
• To dial the PMMA non foldable IOL for
proper positioning in capsular bag
• It can also be used to manipulate nucleus in
phacoemulsification surgery.
Spring scissors (Westcott’s):
They are used as handy alternatives to ringed
scissors for cutting and undermining conjunctiva
in various operations and to cut sutures

Freer’s periosteum elevator:

• Blunt debulking and lifting periosteum
from bones in confined areas
• It is used in endoscopic septoplasty and
DCR
• Any procedure that involves dissecting
soft tissue cartilage or bone
 to
curved
are
it
of globe.

Tenotomy / strabismus Plain curved scissors:

scissors: Used to cut and
• To cut extraocular undermine conjunctiva in
muscles various operations.
• To separate delicate
tissues

Killian nasal speculum

 ·
unciva
Tar
I

Skin I
surface
Chalazion clamp:
To fix the chalazion and achieve
haemostasis during the incision and
curettage operation

·
ostatic, self retaining.

Chalazion scoop:
To scoop out contents of chalazion the
chalazion during incision and curettage
itand left
side are different.
·
Todix lid
entropion
during
operation
skin E
· hemostatic.
surface. -> tasal
conjunctia.
Lid clamp or entropion clamp

Optic nerve guide (enucleation spoon)

· used for endeation aftering severing all recti mudes

·
passed from lateral side.

below spoon cut optic Nerve

passed
to
· Scissor is

Desmarre’s retractor:
used to retract lids during examination of the eyeball in
cases of blepharospasm in children, in cases with marked
-

swelling and ecchymosis,

-
corneoscleral sutures, removal
of corneal foreign body and for double eversion of upper
lid to examine superior fornix.
 Lacrimal cannula:
• For syringing the
lacrimal passages
• As AC cannula for
putting air

Nettleship’s punctum dilator:

To dilate the punctum and canaliculus
 Bone gouge:
To smooth the irregularly cut margins of the
bone by nibbling small projecting bone and in
DCR operation and in orbitotomy operation

Cat’s paw lacrimal wound retractor:

It is used to retract the skin during lacrimal sac lid

Cutaneous
surgery

tissue t
 Evisceration spatula:
To separate out the uveal tissue from the
sclera during evisceration spatula

Bard parker’s handle: (BP handle).

Blade of different sizes can be fitted onto a
groove at the tip of the handle for making the
desired incision
Trabeculectory
- -

eles -
- &
Scheral incision
&
-

Cataract Sx.

· Skin incision ->

DCR.

·
Chalazion
 Castroviejo calliper:
Used to take measurements during squint, ptosis,
retinal detachment and pars plana vitrectomy
surgery. It is also used to measure corneal
diameter and visible horizontal iris diameter

Needle holder:
It is generally used in extraocular surgery, e.g.,
conjunctival suturing, squint surgery. It can also be
used in for intraocular surgery
 Lacrimal probes (bowman’s):
• To probe nasolacrimal duct
• To identify the lacrimal sac during DCT
and DCR operations
·

congenital Dacycystitis -
probing
·congenital functal stenosis.

Plain toothed forceps

Plain forceps:
• To hold conjunctiva during any surgical procedure
• To hold scleral flap in trabeculectomy
• To tie sutures
• To hold skin during eyelid surgery
• To hold nasal mucosal flaps and lacrimal sac flaps in
DCR operation
 Chisel:
To cut the bone during DCR and orbitotomy
operations

Foreign body spud:

It is used to remove corneal foreign body
 Keratome:
Keratomes are used to make valvular
corneal incisions for entry into the
-
& anterior chamber for all modern
techniques of cataract extraction.

other Keratomes be used to

·

tunnel.
may
enlarge

of
rangulationany setonallel
Crescent knife:
• To make tunnel incision in the sclera and cornea for
phacoemulsification and manual SICS
• To separate conjunctiva and subconjunctival tissue
from sclera and limbus
• To prepare partial thickness lamellae of sclera
• To separate pterygium
· Lamellar Keratoplasty-
15° side port entry blade:
It is used to make small valvular clear corneal
incision (side port incision)
·
Paracentesis.

staining ofAnesorcalatethe
·