OPHTHALMOLOGY

Semester 7 & 8
Guide Book

Year Four
MED 4068 Class 2007

Course Coordinator
Dr Wahid Abdullah Salem Wajih
 OPHTHALMOLOGY
Ophthalmology employs preventive, medical, and surgical means to maintain visual health
and function and to evaluate and treat disorders of the eye, orbit, and ocular adnexae (eyelids,
lacrimal apparatus, etc). The principals if ophthalmic practice rest on the foundations of visual
science, ocular physiology and biochemistry, and the empirical findings of clinical research
and clinical experience.

Medical student teaching in ophthalmology is provided in a four-week clerkship shared with

another special posting for the fourth year medical students. The aim of the clerkship is to
familiarize the student with common ocular problems, including those caused by infection,
trauma, hereditary disorders, cataracts, glaucoma and retinal abnormalities. Also included is
instruction in the medical and surgical approaches to these disorders.

Students are assigned to a full-time faculty member. Students interact with patients in an
outpatients setting, observe ocular surgery in the operating room, attend teaching rounds, and
interactive presentations and departmental conferences.

Additional elective in ophthalmology may be arranged individually by the final year students.
Students with particular interest in ophthalmology may apply for this elective.

AIMS:

1. To develop an understanding of the disorders of the visual system in terms of the

anatomy, physiology and pathology of the eye, its adnexae, and the higher visual
pathways.

2. To facilitate a problem-oriented approach to understanding the management of eye

diseases in the hospital and the community setting.

OBJECTIVES:

By the end of the ophthalmology attachment students will be expected to:

• be familiar with the general architecture and function of the eye, its adnexae and the
sensory and the motor pathways associated with the eye.

• be able to assess clinically the important parameters of the visual function; visual
acuity, visual field, colour vision.
• be able to perform a competent clinical examination of the eye and adnexae with the
aid of pen torch and an ophthalmoscope and be able to interpret his/her findings.

• recognize common disorders of the eye and ocular function and understand their
treatment.

• appreciate the value of an ophthalmological examination in patients with systemic or

neurological disease.

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TEACHING METHODS:
• Interactive lectures preceded by a relevant TBL session.
• Clinical skills Sessions and demonstrations.
• Directed clinical exposure to patients through bedside teaching and clinic attendance.
• Student seminars sessions.
• Assigned reading sessions

INTERACTIVE LECTURES

There will be five interactive lectures in ophthalmology preceded with a relevant TBL
session. Students are expected to attend all these session and prepare and participate in the
TBL sessions. Attendance will be monitored regularly.

Session 1: Anatomy and physiology of the Eye and adnexa.

Session 2: The Red Eye
Session 3: Diabetic retinopathy
Session 4: Refractive Errors of the Eye
Session 5: Ocular trauma
Session 6: Ocular Motility and Neuro-ophthalmology

CLINICAL SKILLS SESSIONS

Session 1: History taking of an ophthalmic case

Session 2: Eye Examination: will include:
A) Visual acuity and Pupil examination
B) Ophthalmoscopy and Confrontation Visual field
C) Eye Movement and extraocular muscle function assessment.
Session 3: Ocular Surgery, Video session.

STUDENT SEMINARS SESSIONS:

• Group A: Cataract and
• Group B: Glaucoma

ASSIGNED READING:
• Central retinal artery occlusion
• Central retinal vein occlusion
• Age related macular degeneration

CLINICAL TEACHING:
• Outpatient clinic:
• Optometry:
• Minor OT:
• Bedside teaching and ward clerking:

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 INTERACTIVE LECTURES

Session 1: Anatomy and physiology of the Eye and adnexa

Objectives:
By the end of the lecture the student should be able to:
1. Identify various parts of the eye and orbit
2. Understand the important systems in close proximity to the eye
3. Describe the course of the cranial nerves especially the 2nd to the 7th CN
4. Describe the layers of :
• Eye lid • Retina
• Tear film • Choroid
• Cornea • Crystalline Lens
5. Describe the boundaries of the anterior and the posterior chambers
6. Describe the function of the tear film and aqueous humour
7. Define accommodation and list its components
8. Describe the light reflex

Topics to be covered:
1. The eye location between important structures
2. The bony orbit
3. Cranial nerves 2-7
4. Anatomy of the extraocular muscles
5. Anatomy of the eyelid
6. Anatomy of the globe
7. Physiology of the eye (selected topics)
• Tear film
• Aqueous humour
• Accommodation
• Light reflex

Session 2: The Red Eye

Objectives:
By the end of the lecture the student should be able to:
1. List the differential diagnosis of a red eye
2. Recognize the presentation of the following conditions:
a. Bacterial and viral conjunctivitis
b. Acute angle closure glaucoma
c. Anterior uveitis
d. Allergic conjunctivitis
e. Infective keratitis
3. Understand the principles of the management of the above conditions

Topics to be covered:

1. Differential diagnosis of red eye

2. Infective conjunctivitis
3. Allergic conjunctivitis
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 4. Acute angle closure glaucoma
5. Anterior uveitis
6. Infective keratitis
7. Miscellaneous conditions: subconjunctival haemorrhage, episcleritis, scleritis,
Stevens-Johnson syndrome, blepharitis

Session 3: Diabetic retinopathy

Objectives:
By the end of the lecture the student should be able to:
1. Understand the impact of diabetic retinopathy as a major cause of blindness
2. Recognize the fundus findings of diabetic retinopathy
3. Understand the importance of fundus examinationin all patients with diabetes mellitus.

Topics to be covered:
1. Review of diabetes mellitus complications
2. Classification of diabetic retinopathy
• Non-proliferative diabetic retinopathy
• Proliferative diabetic retinopathy
• Diabetic maculopathy
3. Management of diabetic retinopathy

Session 4: Refractive Errors of the Eye

Objectives:
By the end of the lecture the student should be able to:
1. Define the following terms:
• Myopia • Astigmatism
• Hypermetropia • Presbyopia
2. Describe how an image is perceived by the human eye
3. Recognize various types of lenses used to correct refractive
errors, namely; convex lens, concave and cylindrical lenses.
4. Understand the principles of correcting various types of
refractive errors

Topics to be covered:

1. Image formation on the retina

2. Myopia, Hypermetropia, Astigmatism and Prebyopia

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Session 5: Ocular Trauma
Objectives:
By the end of the lecture the student should be able to:
1. Recognize the types of the ocular trauma
2. How to handle the case of ocular trauma according the types
3. What they should do
4. What they should not to do

Topics to be covered;
1. MECHANICAL INJURIES
• _ Extraocular foreign bodies
• _ Blunt trauma
• _ Perforating injuries

2. NON-MECHANICAL INJURIES
• Chemical injuries
o Acid burns
o Alkali burns
• Thermal injuries
• Electrical injuries
• Radiational injuries
o Ultraviolet radiations
o Infrared radiations
o Ionizing radiational injuries

Session 6: Ocular Motility and Neuro-ophthalmology

Objectives:
By the end of the lecture the student should be able to:

1. Recognize the span of normal eye movements

2. Understand the principles of Hirschberg’s test and cover tests
3. State the definition and main types of squint
4. Recognize abnormal eye movements due to 3rd, 4th and 6th cranial nerve palsies
5. Recognize visual field defects due to lesions along the visual pathway

Topics to be covered:
Extraocular muscles:
1. Action of extraocular muscles
2. Assessment of ocular deviations:
• Hirschberg’s test • Cover test

Strabismus:
1. Definitions and clinical appearance
• Phoria Tropia

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 2. Principles of management
• Correction of refractive • Orthoptics
errors • Surgery
• Occlusion

Cranial nerve palsies:

1. Oculomotor nerve palsy
2. Trochlear nerve palsy
3. Abducens nerve palsy

Visual pathway
1. Normal visual pathway
2. Visual field defects due to lesions along the pathway

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 CLINICAL SKILLS SESSIONS
Session 1: History taking of an ophthalmic case
Session 2: Eye Examination: will include:
A) Visual acuity and Pupil examination
B) Ophthalmoscopy and Confrontation Visual field
C) Eye Movement and extraocular muscle function assessment.
Session 3: Ocular Surgery, Video session.

Session 1: History taking of an ophthalmic case.

Objectives:
By the end of the lecture the student should be able to:
1. List various components of a history
2. List common ocular complaints
• Alteration of visual acuity
• Pain or discomfort in or around the eyes
• Abnormal eye secretions
3. List common ocular sings
4. Take a history of a patient with an eye problem
5. Describe common eye signs
6. List various steps of complete eye examination

Topics to be covered:
1. The eye as an integral part of the human body
2. History taking:
• Chief complaint
• History of present illness
• Past ocular history
• Eye medications
• General medical/surgical history
• Systemic medications
• Allergies
• Family history
3. Important recognizable conditions and syndromes
4. Examination of the eye
• Visual acuity
• External examination
• Ocular motility
• Pupils
• Visual fields
• Fundus examination

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Session 2: Eye Examination

A) Visual acuity and Pupil examination

Objectives:
By the end of the tutorial the student should be able to:
1. Describe the principles of the Snelen’s chart
2. Assess the visual acuity for far and near vision
3. Assess the visual acuity for an illiterate person
4. Describe the neuronal connections of the light reflex
5. Describe the sympathetic and parasympathetic nerve supply to the iris
6. Conduct a competent pupil examination
7. Recognize normal and abnormal pupil reaction

Topics to be covered:
1. Principles of the Snelen’s chart
2. Far and near visual acuity
3. Illiterate E test
4. Light reflex
8. Sympathetic and parasympathetic nerve supply to the iris
5. Abnormal pupils:
• The Mrcus Gunn pupil
• Argyl Robertson pupil
• Adie’s pupil
• Horner’s syndrome
6. Hands on training on pupil examination

(The students can examine each other during the hands on training)

B) Ophthalmoscopy and confrontation visual field examination

Objectives:
By the end of the tutorial the student should be able to:
1. Operate the ophthalmoscope competently
2. Use the ophthalmoscope to elicit the red reflex
3. Use the ophthalmoscope to visualize the fundus occuli
4. Recognize the normal structures of the fundus
5. Conduct a confrontation visual field test
6. Understand the visual pathway
7. Understand the principles of various visual field defects due to
visual pathway defects

Topics to be covered:
1. The ophthalmoscope instrument
2. Ophthalmoscopy techniques
3. Ophthalmoscopy hands-on-training
4. Visual pathway

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 5. Visual field defects due to visual pathway
lesions
6. Hands-on training on confrontation visual
field testing
• The students can examine each other during the hands on training
• The lecturer should try to arrange for a case

C) Eye Movement and extraocular muscle function assessment.

Objectives:
By the end of the tutorial the student should be able to:
1. Competently examine the eye movements
2. Examine the eye lid and recognize lid lag, lid retraction and ptosis
3. Recognize abnormal eye movements due to 3rd,4th and 6th cranial nerve palsies
4. Assess the amount of ocular deviation using the Hirschberg’s test
5. Assess the basic type of strabismus using the cover test

Topics to be covered:
1. Review the actions of the extraocular muscles
2. Normal lid position, lid lag and ptosis
3. Review of abnormal eye movements
4. Review of ocular deviations
5. Hands on training :
• Eye movements
• Hirschberg’s test
• Cover test

• The students can examine each other during the hands on training
• The lecturer should try to arrange for a case

SESSION 3: Ocular Surgery, Video session.

Objectives:
By the end of the tutorial the student should be able to:
1. List the indications for cataract surgery
2. Understand the basic principles of cataract surgery
3. List the indications for drainage surgery
2. Understand the basic principles of trabeculectomy surgery

Topics to be covered:
1. Cataract surgery
• ECCE with IOL (video)
• Phacoemulsification (video)
2. Trabeculectomy surgery (video)
3. Refractive surgery: LASIK
4. Minor surgery: Chalazion, Pterygium

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STUDENT SEMINARS SESSIONS:

• Group A: Cataract and

• Group B: Glaucoma
• Group A&B: Drugs in Ophthalmology

Each subgroup will take one subject (e.g. cataract) to be presented with this
subgroup with any number of students in that group.

Objectives:
By the end of the lecture the student should be able to:
1. Define chronic visual loss
2. Recognize the presentation of various types of chronic visual loss
3. List the differential diagnosis of a case of chronic visual loss
4. Understand the principles of management of various conditions causing chronic visual
loss
5. Recognize the ocular medications
Topics to be covered:
1. Cataract:
• Aetiology
• Clinical picture
• Types
• management
2. Glaucoma:
• Primary
• Secondary
• Medical and surgical management
3. Drug in ophthalmology:
• Mydriatics
• Miotics
• Drugs used in glaucoma
• Antibiotics
• Steroid treatment
• Antiallergic agents
• Tear substitutes
• Diagnostic agents
• Drugs and contact lenses
• Systemic drugs and the eye
• Corneal protection in patients who are unconscious or have exposed eyes

ASSIGNED READING:
• Central retinal artery occlusion
• Central retinal vein occlusion

Objectives:
By the end of the lecture the student should be able to:
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 1. List various causes of acute visual loss
2. Identify conditions requiring urgent management
3. Recognize the presentation of various conditions
4. Recognize fundus changes in various conditions
5. Be aware of mistaking longstanding poor vision for acute visual loss
6. Be aware of functional disorders

Topics to be covered:
1. Nature of acute visual loss
2. Assessment of acute visual loss
3. Causes of acute visual loss
4. Comprehensive discussion of selected topics:
• CRAO & BRAO
• CRVO &BRVO
• Angle closure glaucoma
• Optic neuritis

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CLINICAL TEACHING:
A minimum attendance is required from each student as follows:
Outpatient clinic: 2 sessions
Optopetry: 1 session (observe at least 2 cases)
Minor OT: Observe a Chalazion and/or a Pterygium excision
Bedside teaching: 2 sessions
Ward clerking: Minimum of one case

REFLECTION: One hour session every two weeks

CONSULTATION: One hour session a week

EQUIPMENT:

Medical students are requested to present themselves at the clinics equipped with the
following items:
• Fixation target
• 6” plastic ruler
• Small (pen) torch
• Ophthalmoscope

CLINICAL SKILLS TO BE ACQUIRED

• Pupil examination
• Visual acuity assessment
• Confrontation Visual field assessment
• Funduscopy examination
• Eye movement and extraocular muscle function assessment.

EACH STUDENT WILL HAVE SEEN AND ABLE TO RECOGNIZE THE

FOLLOWING:

• Normal fundus - especially optic disc and macula

• Diabetic retinopathy - different types
• Glaucoma - chronic simple - optic disc cupping
• Cataract
• The red eye –conjunctivitis/iritis/corneal abrasion/corneal FB/keratitis
• Squint
• Macular degeneration

EACH STUDENT MUST ENSURE HE/SHE HAS SEEN

• At least 2 cataract patients
• At least 2 diabetic retinopathy patients
• At least 2 red eye patients
(These cases should be clearly logged in the relevant spaces in the logbook)

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ASSESSMENT:
1. Logbook
The student logbook will be used to assess the standard of clinical skills obtained.
Attendance and clinical exposure are used to partly determine this standard. Failure to
meet the set criteria will normally result in Failure of the course. Therefore, each student
should complete his or her logbook fully.

2. Examination

Assessment Criteria Continuous assessment (40%):

Satisfactory completion and reflection on patient, 10%

procedural skills and other clinical tasks (log book):

Group assignments (oral presentation/ written) 10%

(TBL/seminar/outpatient clinic postings/bedside
teaching/ patient clerking/ referral letter analysis)

Clinical skill evolution 10%

Total 30%
End-of –posting examination* (70%):

1. Written Assessment
(40%)
A combination of various types of questions
• SAQ
• EMQ
• Best answer questions
2. Clinical Assessment (30 %)
The clinical assessment will be at the end of 2 rotations
during the examination week and will be in the form of
OSCE + case presentation

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