International Council of Ophthalmology
Handbook for Medical Students Learning Ophthalmology
2015
Edited and updated by Instituto de Ciencias de la Vision based on Handbook for Medical Students Learning Ophthalmology of the
International Council of Ophthalmology (2009)
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DearMedicalStudentWelcometoOphthalmology!Inthisbookletwehaveputtogethertablesofcoreknowledgethatwethinkyouneedtoknowandkeyophthalmicdisorderswethinkyouneedtohaveseen.TherearedescriptionsandcolorpicturesofthedifferentcausesofTheRedEyeandthecommoncausesofacutelossofvision.ThispocketsizedbooksummariesthekeypointsintheophthalmologycurriculumcompliedbytheTaskForceoftheInternationalCouncilofOphthalmologyandisaformatthatisveryportable!Wehopeyoufindthisuseful.Ophthalmologyisafascinatingdisciplineandyoucanseethepathologydirectly.Wehopethatwecanstimulateyourinteresttoreadfurtherandtofurtherdevelopyourskills.GoodLuck!!
SueLightmanandPeterMcCluskeyonbehalfoftheInternationalCouncilofOphthalmology2009
ThisdocumentwaseditedandupdatedJuanCarlosGarcíadelaRiva,MD
Contributors:
MaríadelCarmenBerganzaG.,MDSigfridoRodasDíaz,MD
AlexisCastro,MD
ofthePostgraduateprogramofOphthalmologyInstitutodeCienciasdelaVisión
2015
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Have you seen? Check if yes
Remember: How is it treated?
What are its causes? Supervisor
Red eye
Dry eye
Dilated pupil
Herpes simplex keratitis
Acute uveitis
Conjunctivitis: viral and bacterial
Conjunctivitis: allergic
Keratoconus
Infective keratitis
Corneal abrasion
Subconjunctival hemorrhage
Lagophthalmos
Chalazion
Blepharitis
Pterygium
Cataract surgery with intraocular lens insertion
Corneal foreign bodies
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Have you seen? Check if yes
Remember: How is it treated?
What are its causes? Supervisor
Normal optic disc
Pale optic disc
Cupped optic disc
Papilledema
Normal fundus
Central and branch retinal vein occlusion
Artery occlusion/ embolus
Diabetic retinopathy
Hypertensive retinopathy
Age Related Macular Degeneration
Toxoplasmosis
Myopia related fundus changes
HIV related fundus manifestations
Retinal Detachment
Glaucoma: Diagnosis and treatment options
Rubeosis Iridis
Scleritis
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Have you seen? Check if yes
Remember: How is is treated?
What are its causes? Supervisor
Pupillary responses: normal and abnormal
Ocular trauma and treatment options
Facial nerve palsies
3rd Cranial nerve palsy
4th Cranial nerve palsy
6th Cranial nerve palsy
Nystagmus
Esodeviations
Exodeviations
Orthoptic assessment
Leucocoria
Refractive errors
Manual refraction
Automated refraction
Presbyopia
Types of lenses used
Visual acuity testing
Low vision evaluation and rehabilitation
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Have you done? Check if yes Points to Remember Supervisor
External examination of a normal eye
Used a Snellen chart
Written visual acuity correctly
Tested color vision
Tested pupillary reflexes
Tested eye movements
Tested visual fields to confrontation
Dilated a pupil
Direct ophthalmoscopy with each hand
Seen the optic disc
Seen the retina and normal blood vessels
Seen a fluorescein angiography
Seen an optical coherence tomography (OCT)
Seen automated visual field tests
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ACUTEREDEYE
Therearemanyconditionsthatcanleadtoaredeye,seriousandnotserious.Maybepainfulorpainlessanddetailedexaminationrequiredtosortthemout.Remember:Itisrareforapainlessredeyetorequireanurgent(sameday)ophthalmologicalassessment.DiffuseconjunctivalrednessBlepharitis
Very common non specific generalized inflammation ofthe eyelids. Treat with daily lid hygiene, low dosetetracylines/doxycline, lubrication as required withroutinereferral.
Ectropion
Lidturningoutwardswithexposureofconjunctivalsac.Eyemaybesoreandwatery.Routinereferralandmayrequire
surgeryEntropion
Lidsturninginwardsandeyelashesmayabradecornea-checkconditionofcorneawithfluorescein.Ifcornealstaining,tapebackeyelidawayfromthecorneaandrefersameday
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TrichiasisIngrowingeyelashes-epilatewhentouchingcornea,lubricatewithroutinereferral.Eyelidlesion(chalazionorstye)
Provided there are no overteyelidinfectionorinflammationand no ocular involvement,routinereferral.Considertopicalantibiotics.
PterygiumAraisedwhite/yellowishfleshylesionatthelimbusthatmaybecomepainfulandredifinflamed.Treatment:lubricationandsunglasses.Routineophthalmologicalreferralforfurthermanagement
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CornealforeignbodyandoculartraumaReferforremovalofforeignbodyCheck for more severe oculartrauma such as penetration of theeye; treat with topical antibiotics iftraumaareaissmallBeware signs of perforation of theeye: eye soft, iris protruding, andirregular pupil Chemical injury -copiousirrigationneeded
CornealerosionSymptoms:somethingwentintotheeye,verysore,watering++Signs: eye red and watery, area where corneal epithelium notintactstainswithfluoresceinManagement:checknoforeignbody,topicalantibioticsandcanpadeyealthoughthisdoesnothelphealing.Seeifpainorvisionworsen
Herpessimplexkeratitis
Symptoms:soreredeye,notstickySigns:abnormalcornealepitheliumindendritepatternwhichstainwithfluoresceinManagement:Topicalaciclovir,AVOIDTOPICALSTEROIDSandseeophthalmologistthefollowingday
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BacterialcornealinfectionSymptoms:eyesoreandred,oftenincontactlenswearer,visionmaybeaffectedSigns:whiteareaoncornea,maybeperipheralorcentralManagement:urgent(sameday)referraltoophthalmologist
Marginalkeratitis
Symptoms: sore red eye,maybe sticky,mayormaynothaveblurryvisionSigns:white areas on periphery of corneawhichmay bethinnerthannormalusuallyassociatedwithblepharitisManagement:refertoophthalmologistsameday
Allergicconjunctivitis
Symptoms:eyesitch++andareredandsoreSigns:swellingandsignsofatopye.g.asthma,eczemaManagement:Removeallergenswherepossible,topicalanti-histamines,coolcompresses,referifnotbetterin3days
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Viralconjunctivitis
Contacthistorywithrecenteyeorupperrespiratorytractinfectionsymptoms(especiallychildren).HighlycontagiousSymptoms:Burningsensationandwaterydischarge(differentfrompurulentexudateinbacterialinfections).Classicallybeginsinoneeyewithrapidspreadtotheother,oftenpre-auricularlymphadenopathySigns:eyeredandwatery.SwollenconjunctivaparticularlyinlidsManagement:Willresolveonownandtreatmentaimedatcomfort.Coolcompresses,regularlubricants(withoutpreservative).Antibioticdropsifindicated.Resolutionmaytakeweeks.Referifphotophobiaanddecreaseinvisualacuity,severediseaselastinglongerthan3weeks.Subconjunctivalhemorrhage
Blood under the conjunctiva - usually unilateral, localizedandsharplycircumscribed.Underlyingscleranotvisible.No inflammation, pain or discharge. Vision unchanged.Possibleassociationwithminor injuries including rubbing.Common with use of anti-platelet agents andanticoagulants.Management: reassure. Check BP, blood coagulationstudies or INR if indicated. Routine referral only ifconditionworsensorpaindevelops.
Painful-mostcasesofconjunctivitisarepainfulbutthereareothercausesaswell.
HyphemaSymptoms:eyeisredandseverelossofvisionfollowingtrauma-considernon-accidentalinjuryinchildrenandblooddyscrasias.Signs:eyehasvisiblebloodinsideandcorneamayalsobestained.EyemaybeverysoreifintraocularpressureisraisedManagement:Bedrest,eyepad.Urgent(sameday)assessmentbyophthalmologist.
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BacterialconjunctivitisSymptoms:eyeredandsticky,oftenbilateralSigns:redeyeswithpurulentdischargeNocornealoranteriorchamberInvolvement.Systemicallywell.Management:regularhygienetominimizesecretionbuildup,topicalantibioticsfor5days.Referifvisionisaffected,ifdoesnotimprovewithtreatmentafter2daysorworsensandifaftertreatmentfor5days.
DryEyeCommonchronicocularconditionthatisoftencausedby,orcoexistswithotheroculardiseases.Symptoms:soreness,grittinessoftenworsensintheevening.Signs:dependsondegreeofdryness.Ifnotsevere,eyeinjectedwithpoortearfilm.FluoresceinstainingofcornealepitheliumManagement:Usuallygoodreliefwithlubricants-putinasoftenasnecessarytorelievesymptoms-usepreservativefreedropsif>x4perdayandointmentoneyeballbeforesleep.Routinereferralifsymptomsnotimproved.
Acuteangleclosureglaucoma
Symptoms:Painfuleyewithsystemicsymptomsincludingheadache,nauseaandvomitingSigns:MorecommoninAsianraces,eyered,verytenderandfeelshardonpalpation,corneausuallyhashazyappearance,andanteriorchamberisshallowwithirregularsemidilatedpupil.Management:Urgent(sameday)referraltoophthalmologist.
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Ciliaryinjection/scleralinvolvementScleritis
Diffuse Nodular Necrotizing
Symptoms:eyepainwhichradiatestoheadandwakesthematnightSigns:Eyeisred,mayhavenodulesandnecroticpatch,scleramaybediscoloredandistendertopalpation.Associatedhistoryofrheumatoidarthritis,vascularorconnectivetissuediseaseManagement:Urgent(sameday)referraltoophthalmologistAcuteAnteriorUveitis(Iritis)Symptoms:photophobia,eyeredandsore,visionmayormaynotbeaffectedSigns:redeyewithciliaryinjectionaroundiris,anteriorchamberappearscloudyfromcellsandflare.Management:urgent(sameday)referraltoophthalmologist
HypopyonVisibleaccumulationofwhitecellsinferiorlyseeninsevereuveitis.Urgent(sameday)referralforinvestigationofinfection,inflammationorocularmalignancy
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Acutevisualdisturbance/SuddenlossofvisionTransientIschemicAttack(AmaurosisFugax)
Symptoms:Monocularvisual loss thatusually lasts seconds tominutes,butmaylast1-2hours.Visionreturnstonormal.Signs: Essentially normal fundus exam (an embolus within aretinal arteriole is only occasionally seen. Other neurologicalsignsassociatedwithischemiaofcerebralhemispheres.Investigation and management: Assessment of cardiovascularrisk factors, blood count, electrolytes, lipids, fasting bloodsugar, thrombophilia screen. Echocardiogram.Carotiddoppler
studies.Startaspirin,referraltoneurology/cardiologyorvascularsurgeryasappropriate.Patientswithrecurrentepisodesofamaurosisfugaxrequireimmediatediagnosticandtherapeuticintervention.CentralRetinalVeinOcclusion
Symptoms:Suddenandpainlesslossofvision.Signs:dilatedtortuousveins,cottonwoolspots,opticdiscswelling,retinalhemorrhagevisibleinallfourquadrantswhichmayobscuremuchoffundusdetail.Predisposingfactors:increasingage,hypertension,anddiabetes.
InvestigationandManagement:Screenfordiabetesandhypertension,excludeglaucoma.Routinereferralforanophthalmologicalopinion.CentralRetinalArteryOcclusion
Symptoms:Suddenandpainlesslossofvision.Signs:Visualacuity<6/60,RelativeAfferentPupillaryDefect(RAPD)Fundusexamination:paleretinal(abnormalandasymmetricalredreflex)cherryredspot-areaofcilioretinalsparingInvestigationandManagement:Urgent(sameday)ESRandCRPtoexcludeGiantCellArteritis.,urgent(sameday)referraltoophthalmologisttoseewhetheranyimmediatetreatmentispossible.TIAworkup
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OpticneuritisSymptoms:Painlesslossofvisionoverhourstodays.Visionlosscanbesubtleorprofound.Orbitalpainusuallyassociatedwitheyemovement.Signs:Usuallyfemalesaged18-45,mayhaveotherfocalneurologicalsigns,reducedvisualacuityandcolorvision.RelativeAfferentPupillaryDefect(RAPD),centralscotoma,opticdiscmaylooknormal(retrobulbarneuritis)orbeswollen.InvestigationandManagement:Completeophthalmicandneurologicalexamination.Bloodcount,ErythrocyteSedimentationRate(ESR),urgent(sameday)referraltoophthalmologistmaybeindicatedforfurtherMRIinvestigationandintravenoussteroidtreatmentmayberequired.ThereareNOindicationsfororalcorticosteroidsasinitialtreatment.IschemicOpticNeuropathy(AION)/GiantCellArteritis
Transient visual loss may precede an ischemic opticneuropathyorcentralretinalarteryocclusion.Symptoms: Temporal headache. scalp tenderness, jawclaudication, fever and night sweats, generalized musclepainandweakness.Signs: Typically affects patients greater than 50 years.Mayinclude the following: Afferent pupillary defect, poor visualacuity, often count fingers only, palpable and tender non-pulsatiletemporalartery,swollenpaleopticdisc.
InvestigationandManagement:ImmediateESR/CRP(NBclassicallybutnotalwaysraisedinGCA),referraltoophthalmologistforurgent(sameday)(sameday)steroidtreatmentandtemporalarterybiopsy.
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Theeyeinsystemichypertension(reproducedwithpermissionWongTY,MitchellP.Hypertensiveretinopathy.NEJM2004Nov25;351(22):2310-7)
Mildhypertensiveretinopathy
Generalizedarteriolarnarrowing,focalarteriolarnarrowing,a-vnicking,opacityofarteriolarwall
(copperwiring)systemicassociations:OR1-2stroke,coronaryheartdiseaseanddeath
Moderatehypertensiveretinopathy
Anytypeofhemorrhage,microaneurysm,CWS,exudatesorcombinationSystemicassociation:OR>2stroke,cognitivedecline,deathfromcardiovascularcauses
Severehypertensiveretinopathy
Signsofmoderateretinopathyplusopticdiscswelling.Strongassociationwithdeath
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Theeyeindiabetes
Classicfeaturesofbackgroundretinopathywithafewexudates(leftpicture)andmoresevere(rightpicture)withhemorrhages,venousbeadingandcottonwoolspot
Severediabeticmaculopathywithexudatesandclinicallysignificantmacularedema(leftpicture)and
anothereyeaftermacularlaser(rightpicture)showinglaserburnsSevereproliferativeretinopathy(leftpicture)withnewvesselsarisingfromopticdiscandrightpictureshowslotsoflaserburnsusedtodestroytheperipheralischemicretinaandcausethenewvesselsto
regress
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RetinalDetachment
RetinalDetachmentoccurswhenthereisseparationofsensoryretinafromtheretinalpigmentepithelium.Mostcommonetiologyisapredisposingretinalholetear,oftenassociatedwithmyopiabutmayfollowtraumaSymptoms:painlesslossofvision.Thepatientmayhaveencounteredarecenthistoryofincreasednumberofvisualfloatersandorvisualflashes.Theremaybea“darkshadow”inthevisionoftheaffectedeye.Signs:greyareaofretinawhichiswhereitisdetached,visionreducedifretinadetachesandinvolvesthemacula.Management:urgent(sameday)referraltoophthalmologist
AgeRelatedMacularDegeneration
ChangesinAgeRelatedMacularDegenerationdryform(left)andneovascularmembranewetform(right).
AgeRelatedMacularDegeneration(ARMD)isacommoneyeconditionandaleadingcauseofvisionlossamongpeopleage50andolder.Itcausesdamagetothemacula.RiskfactorsincludeSmoking,FamilyhistoryandGenetics.Theearlyandintermediatestagesofthediseaseusuallystartwithoutsymptoms.Theeyeexammayincludethefollowing:Visualacuitytest,dilatedeyeexam,Amslergrid,Fluoresceinangiogram.Opticalcoherencetomography(OCT).
Toxoplasmosis
AccordingtotheCenterforDiseaseControl(CDC),Toxoplasmosisisoneofthemostcommonhumaninfectionsthroughouttheworld.Eyedisease(mostfrequentlyretinochoroiditis)leadstoanacuteinflammatorylesionoftheretina,whichresolvesleavingretinochoroidalscarring.Symptomsofacutediseaseincludeeyepain,photophobia,tearingoftheeyes,blurredvisionPersonswithcompromisedimmunesystemsmayexperienceseveresymptomsthatincludefever,confusion,headache,seizures,nausea,andpoorcoordination.
