Download ICO Handbook for Medical Students Learning Ophthalmology

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)
DearMedicalStudentWelcometoOphthalmology!
Inthisbookletwehaveputtogethertablesofcoreknowledgethatwethinkyouneedtoknowandkey
ophthalmicdisorderswethinkyouneedtohaveseen.
TherearedescriptionsandcolorpicturesofthedifferentcausesofTheRedEyeandthecommoncausesof
acutelossofvision.Thispocketsizedbooksummariesthekeypointsintheophthalmologycurriculum
compliedbytheTaskForceoftheInternationalCouncilofOphthalmologyandisaformatthatisvery
portable!Wehopeyoufindthisuseful.Ophthalmologyisafascinatingdisciplineandyoucanseethe
pathologydirectly.Wehopethatwecanstimulateyourinteresttoreadfurtherandtofurtherdevelopyour
skills.
GoodLuck!!
SueLightmanandPeterMcCluskey
onbehalfoftheInternationalCouncilofOphthalmology2009
Thisdocumentwaseditedandupdated
JuanCarlosGarcíadelaRiva,MD
Contributors:
MaríadelCarmenBerganzaG.,MD
SigfridoRodasDíaz,MD
AlexisCastro,MD
ofthePostgraduateprogramofOphthalmology
InstitutodeCienciasdelaVisión
2015
Page2
Have you seen?
Check
if yes
Remember:
How is it treated?
What are its causes?
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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Supervisor
Have you seen?
Check
if yes
Remember:
How is it treated?
What are its causes?
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
Page4
Supervisor
Check
if yes
Have you seen?
Pupillary responses:
normal and abnormal
Remember:
How is is treated?
What are its causes?
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
Page5
Supervisor
Have you done?
Check
if yes
Points to Remember
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
Page6
Supervisor
ACUTEREDEYE
Therearemanyconditionsthatcanleadtoaredeye,seriousandnotserious.Maybepainfulorpainless
anddetailedexaminationrequiredtosortthemout.
Remember:
Itisrareforapainlessredeyetorequireanurgent(sameday)ophthalmologicalassessment.
Diffuseconjunctivalredness
Blepharitis
Very common non specific generalized inflammation of
the eyelids. Treat with daily lid hygiene, low dose
tetracylines/doxycline, lubrication as required with
routinereferral.
Ectropion
Lidturningoutwardswithexposureofconjunctivalsac.Eye
maybesoreandwatery.Routinereferralandmayrequire
surgery
Entropion
Lidsturninginwardsandeyelashesmayabradecornea-
checkconditionofcorneawithfluorescein.
Ifcornealstaining,tapebackeyelidawayfromthecornea
andrefersameday
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Trichiasis
Ingrowingeyelashes-epilatewhentouchingcornea,
lubricatewithroutinereferral.
Eyelidlesion(chalazionorstye)
Provided there are no overt
eyelidinfectionorinflammation
and no ocular involvement,
routinereferral.
Considertopicalantibiotics.
Pterygium
Araisedwhite/yellowishfleshylesionatthelimbusthatmaybecome
painfulandredifinflamed.Treatment:lubricationandsunglasses.
Routineophthalmologicalreferralforfurthermanagement
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Cornealforeignbodyandoculartrauma
Referforremovalofforeignbody
Check for more severe ocular
trauma such as penetration of the
eye; treat with topical antibiotics if
traumaareaissmall
Beware signs of perforation of the
eye: eye soft, iris protruding, and
irregular pupil Chemical injury copiousirrigationneeded
Cornealerosion
Symptoms:somethingwentintotheeye,verysore,watering++
Signs: eye red and watery, area where corneal epithelium not
intactstainswithfluorescein
Management:checknoforeignbody,topicalantibioticsandcan
padeyealthoughthisdoesnothelphealing.
Seeifpainorvisionworsen
Herpessimplexkeratitis
Symptoms:soreredeye,notsticky
Signs:abnormalcornealepitheliumindendritepatternwhich
stainwithfluorescein
Management:Topicalaciclovir,AVOIDTOPICALSTEROIDS
andseeophthalmologistthefollowingday
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Bacterialcornealinfection
Symptoms:eyesoreandred,oftenincontact
lenswearer,visionmaybeaffectedSigns:white
areaoncornea,maybeperipheralorcentral
Management:urgent(sameday)referralto
ophthalmologist
Marginalkeratitis
Symptoms: sore red eye, may be sticky, may or may not
haveblurryvision
Signs: white areas on periphery of cornea which may be
thinnerthannormalusuallyassociatedwithblepharitis
Management:refertoophthalmologistsameday
Allergicconjunctivitis
Symptoms:eyesitch++andare
redandsore
Signs:swellingandsignsofatopy
e.g.asthma,eczema
Management:Removeallergens
wherepossible,topicalantihistamines,coolcompresses,refer
ifnotbetterin3days
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Viralconjunctivitis
Contacthistorywithrecenteyeorupperrespiratorytract
infectionsymptoms(especiallychildren).Highlycontagious
Symptoms:Burningsensationandwaterydischarge
(differentfrompurulentexudateinbacterialinfections).
Classicallybeginsinoneeyewithrapidspreadtotheother,
oftenpre-auricularlymphadenopathy
Signs:eyeredandwatery.Swollenconjunctivaparticularly
inlids
Management:Willresolveonownandtreatmentaimedatcomfort.Coolcompresses,regularlubricants
(withoutpreservative).Antibioticdropsifindicated.Resolutionmaytakeweeks.Referifphotophobia
anddecreaseinvisualacuity,severediseaselastinglongerthan3weeks.
Subconjunctivalhemorrhage
Blood under the conjunctiva - usually unilateral, localized
andsharplycircumscribed.Underlyingscleranotvisible.
No inflammation, pain or discharge. Vision unchanged.
Possible association with minor injuries including rubbing.
Common with use of anti-platelet agents and
anticoagulants.
Management: reassure. Check BP, blood coagulation
studies or INR if indicated. Routine referral only if
conditionworsensorpaindevelops.
Painful-mostcasesofconjunctivitisarepainfulbutthereareothercausesaswell.
Hyphema
Symptoms:eyeisredandseverelossofvisionfollowing
trauma-considernon-accidentalinjuryinchildrenand
blooddyscrasias.
Signs:eyehasvisiblebloodinsideandcorneamayalso
bestained.Eyemaybeverysoreifintraocularpressureis
raised
Management:Bedrest,eyepad.Urgent(sameday)
assessmentbyophthalmologist.
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Bacterialconjunctivitis
Symptoms:eyeredandsticky,oftenbilateral
Signs:redeyeswithpurulentdischargeNocornealor
anteriorchamberInvolvement.Systemicallywell.
Management:regularhygienetominimizesecretion
buildup,topicalantibioticsfor5days.Referifvisionis
affected,ifdoesnotimprovewithtreatmentafter2days
orworsensandifaftertreatmentfor5days.
DryEye
Commonchronicocularconditionthatisoftencausedby,or
coexistswithotheroculardiseases.
Symptoms:soreness,grittinessoftenworsensintheevening.
Signs:dependsondegreeofdryness.Ifnotsevere,eye
injectedwithpoortearfilm.Fluoresceinstainingofcorneal
epithelium
Management:Usuallygoodreliefwithlubricants-putinas
oftenasnecessarytorelievesymptoms-usepreservative
freedropsif>x4perdayandointmentoneyeballbefore
sleep.Routinereferralifsymptomsnotimproved.
Acuteangleclosureglaucoma
Symptoms:Painfuleyewithsystemicsymptomsincluding
headache,nauseaandvomiting
Signs:MorecommoninAsianraces,eyered,verytenderand
feelshardonpalpation,corneausuallyhashazyappearance,
andanteriorchamberisshallowwithirregularsemidilated
pupil.
Management:Urgent(sameday)referraltoophthalmologist.
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Ciliaryinjection/scleralinvolvement
Scleritis
Diffuse
Nodular
Necrotizing
Symptoms:eyepainwhichradiatestoheadandwakesthematnight
Signs:Eyeisred,mayhavenodulesandnecroticpatch,scleramaybediscoloredandistenderto
palpation.Associatedhistoryofrheumatoidarthritis,vascularorconnectivetissuedisease
Management:Urgent(sameday)referraltoophthalmologist
AcuteAnteriorUveitis(Iritis)
Symptoms:photophobia,eyeredandsore,visionmayor
maynotbeaffected
Signs:redeyewithciliaryinjectionaroundiris,anterior
chamberappearscloudyfromcellsandflare.
Management:urgent(sameday)referraltoophthalmologist
Hypopyon
Visibleaccumulationofwhitecellsinferiorlyseeninsevere
uveitis.
Urgent(sameday)referralforinvestigationofinfection,
inflammationorocularmalignancy
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Acutevisualdisturbance/Suddenlossofvision
TransientIschemicAttack(AmaurosisFugax)
Symptoms: Monocular visual loss that usually lasts seconds to
minutes,butmaylast1-2hours.Visionreturnstonormal.
Signs: Essentially normal fundus exam (an embolus within a
retinal arteriole is only occasionally seen. Other neurological
signsassociatedwithischemiaofcerebralhemispheres.
Investigation and management: Assessment of cardiovascular
risk factors, blood count, electrolytes, lipids, fasting blood
sugar, thrombophilia screen. Echocardiogram. Carotid doppler
studies.Startaspirin,referraltoneurology/cardiologyorvascularsurgeryasappropriate.Patientswith
recurrentepisodesofamaurosisfugaxrequireimmediatediagnosticandtherapeuticintervention.
CentralRetinalVeinOcclusion
Symptoms:Suddenand
painlesslossofvision.
Signs:dilatedtortuousveins,
cottonwoolspots,opticdisc
swelling,retinal
hemorrhagevisibleinallfour
quadrantswhichmayobscure
muchoffundusdetail.
Predisposingfactors:
increasingage,hypertension,
anddiabetes.
InvestigationandManagement:Screenfordiabetesandhypertension,excludeglaucoma.Routine
referralforanophthalmologicalopinion.
CentralRetinalArteryOcclusion
Symptoms:Suddenandpainlesslossofvision.
Signs:Visualacuity<6/60,RelativeAfferentPupillary
Defect(RAPD)Fundusexamination:paleretinal(abnormal
andasymmetricalredreflex)cherryredspot-areaof
cilioretinalsparing
InvestigationandManagement:Urgent(sameday)ESRand
CRPtoexcludeGiantCellArteritis.,urgent(sameday)
referraltoophthalmologisttoseewhetheranyimmediate
treatmentispossible.TIAworkup
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Opticneuritis
Symptoms:Painlesslossofvisionoverhourstodays.Visionloss
canbesubtleorprofound.Orbitalpainusuallyassociatedwitheye
movement.
Signs:Usuallyfemalesaged18-45,mayhaveotherfocal
neurologicalsigns,reducedvisualacuityandcolorvision.Relative
AfferentPupillaryDefect(RAPD),centralscotoma,opticdiscmay
looknormal(retrobulbarneuritis)orbeswollen.
InvestigationandManagement:Completeophthalmicand
neurologicalexamination.Bloodcount,ErythrocyteSedimentation
Rate(ESR),urgent(sameday)referraltoophthalmologistmaybe
indicatedforfurtherMRIinvestigationandintravenoussteroidtreatmentmayberequired.Thereare
NOindicationsfororalcorticosteroidsasinitialtreatment.
IschemicOpticNeuropathy(AION)/GiantCellArteritis
Transient visual loss may precede an ischemic optic
neuropathyorcentralretinalarteryocclusion.
Symptoms: Temporal headache. scalp tenderness, jaw
claudication, fever and night sweats, generalized muscle
painandweakness.
Signs: Typically affects patients greater than 50 years. May
include the following: Afferent pupillary defect, poor visual
acuity, often count fingers only, palpable and tender nonpulsatiletemporalartery,swollenpaleopticdisc.
InvestigationandManagement:ImmediateESR/CRP(NBclassicallybutnotalwaysraisedinGCA),
referraltoophthalmologistforurgent(sameday)(sameday)steroidtreatmentandtemporalartery
biopsy.
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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,exudatesorcombination
Systemicassociation:OR>2stroke,cognitivedecline,deathfromcardiovascularcauses
Severehypertensiveretinopathy
Signsofmoderateretinopathyplusopticdiscswelling.Strongassociationwithdeath
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Theeyeindiabetes
Classicfeaturesofbackgroundretinopathywithafewexudates(leftpicture)and
moresevere(rightpicture)withhemorrhages,venousbeadingandcottonwoolspot
Severediabeticmaculopathywithexudatesandclinicallysignificantmacularedema(leftpicture)and
anothereyeaftermacularlaser(rightpicture)showinglaserburns
Severeproliferativeretinopathy(leftpicture)withnewvesselsarisingfromopticdiscandrightpicture
showslotsoflaserburnsusedtodestroytheperipheralischemicretinaandcausethenewvesselsto
regress
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RetinalDetachment
RetinalDetachmentoccurswhenthereisseparationofsensory
retinafromtheretinalpigmentepithelium.Mostcommon
etiologyisapredisposingretinalholetear,oftenassociatedwith
myopiabutmayfollowtrauma
Symptoms:painlesslossofvision.Thepatientmayhave
encounteredarecenthistoryofincreasednumberofvisual
floatersandorvisualflashes.Theremaybea“darkshadow”inthe
visionoftheaffectedeye.
Signs:greyareaofretinawhichiswhereitisdetached,vision
reducedifretinadetachesandinvolvesthemacula.
Management:urgent(sameday)referraltoophthalmologist
AgeRelatedMacularDegeneration
ChangesinAgeRelatedMacularDegenerationdryform(left)andneovascularmembrane
wetform(right).
AgeRelatedMacularDegeneration(ARMD)isacommoneyeconditionandaleadingcauseofvision
lossamongpeopleage50andolder.Itcausesdamagetothemacula.RiskfactorsincludeSmoking,
FamilyhistoryandGenetics.
Theearlyandintermediatestagesofthediseaseusuallystartwithoutsymptoms.Theeyeexammay
includethefollowing:Visualacuitytest,dilatedeyeexam,Amslergrid,Fluoresceinangiogram.Optical
coherencetomography(OCT).
Toxoplasmosis
AccordingtotheCenterforDiseaseControl(CDC),
Toxoplasmosisisoneofthemostcommonhumaninfections
throughouttheworld.Eyedisease(mostfrequently
retinochoroiditis)leadstoanacuteinflammatorylesionofthe
retina,whichresolvesleavingretinochoroidalscarring.
Symptomsofacutediseaseincludeeyepain,photophobia,
tearingoftheeyes,blurredvision
Personswithcompromisedimmunesystemsmayexperience
severesymptomsthatincludefever,confusion,headache,
seizures,nausea,andpoorcoordination.
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