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5th year Course Book/Ophthalmology

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  • 1. University of Sulaimani<br />College of Medicine<br />Department of Surgery<br />Ophthalmology Unit<br />(Ophthalmology Course Book)<br /> Ophthalmology Syllabus for Fifth Year Med Students (2010-2011) <br />Course Information:<br /> <br />Course Title: Ophthalmology Credit Hours : 72hours.(27hours theoretical lectures&45hours practical cessions)Theoretical: Practical: 1 Lecture per week 1-2p.m (Monday)(27 lectures)9a.m-12.00p.m for 3 weeksLocation Theoretical: college halls(3) Practical: Shahid Dr.Aso Teaching Eye Hospital Head of Unit: Dr. Tara Mahmood HassanCoordinator: Dr. Ali KamalUnit Location: Department of Surgery Email Address of unit :anwar772000@yahoo.com Tel..+96407702171917. Course coordinator link: alikamal22@yahoo.comTel. +9647705449905List of teachers on this course:Dr. Khaled Saeed Abd AlmajeedDr. Ali Abdullah TaqiDr. Bakhtiar Qadir HamasallehDr. Tara Mahmood Hassan<br />Course Description <br />The class of Ophthalmology includes series of theoretical lectures in the following titles <br />1.Anatomy & Embryology of the eye <br />2. physiology and function of the eye<br />3. Orbit <br />4. Eye lids diseases <br />5. Lacrimal apparatus <br />6. Conjunctiva <br />7. Cornea <br />8. Sclera <br />9. Lens and its diseases (cataract) <br />10. Refractive errors<br />11. Glaucoma <br />12. Uveitis<br />13. Retina &Optic nerve<br />14. Ocular motility & Strabismus <br />15. Systemic diseases and the eye <br />16. Eye emergencies and trauma <br />17. Neurophthalmology<br />The practical part of the course includes daily 3 hours practical training on ophthalmic <br />history taking, uses of ophthalmic instruments (slitlamp, magnifying aiding lenses, direct and indirect ophthalmoscope, retinoscope, tonometers,snellen chart & perimeters) <br />Also examining with students different clinical cases and we concentrate on clinical cases of eye emergencies, eye trauma, differential diagnosis of red eye <br />Class objectives: <br />1. Train the students how they can obtain a detailed ophthalmic history and examination technique of different eye diseases and concentrating on special practical points. <br />2. How to use different ophthalmic instruments <br />3. Diagnosis and management of different eye diseases <br />4. How they can manage eye trauma and emergencies <br />5. The differential diagnosis of different eye diseases for example red eye<br />Materials and Resources <br />Material Required Readings Lecture notes In ophthalmology( text book), Parsons disease of eye (text book) Recommended Readings Clinical Ophthalmology Kanski (text book)Related Resources American Academy of Ophthalmology series web site www.aao.org <br />Expectations and Policies <br />Our policy in this course is to encourage the students to share in the theoretical and practical knowledge of Ophthalmology by building a strong relation between the students and their teachers based on friendship and respect and training them to use the basic instruments especially the direct ophthalmoscope & slit-lamp & how they can manage general ophthamological problems and emergencies and when they have to refer the patient to the specialist, all the above done with regular monitoring of class performance by assessment and personal evaluation at the end of the practical course.<br />Academic Honesty Plagiarism. In speaking or writing, plagiarism is the act of passing someone else’s work off as one’s own. In addition, plagiarism is defined as using the essential style and manner of expression of a source as if it were one’s own. If there is any doubt, the student should consult his/her instructor or any manual of term paper or report writing. Violations of academic honesty include: 1. Presenting the exact words of a source without quotation marks; 2. Using another student’s computer source code or algorithm or copying a laboratory report; or 3. Presenting information, judgments, ideas, or facts summarized from a source without giving credit. Cheating. Cheating includes using or relying on the work of someone else in an inappropriate manner. It includes, but is not limited to, those activities where a student: 1. Obtains or attempts to obtain unauthorized knowledge of an examination’s contents prior to the time of that examination. 2. Copies another student’s work or intentionally allows others to copy assignments, examinations, source codes or designs; 3. Works in a group when she/he has been told to work individually; 4. Uses unauthorized reference material during an examination; or 5. Have someone else take an examination or takes the examination for another <br />Instruction methodology: <br />We use data show, different slides , white board , medical instruments, patients <br />Theoretical Lectures Outline<br />No.TopicsLecturer1Introduction to ophthalmology& Embryology,Dr.Bakhtiar2Anatomy& Physiology of the eyeDr.Bakhtiar3OrbitDr. Tara4OrbitDr. Tara5EyelidsDr. Khaled6Lacrimal apparatusDr. Khaled7ConjunctivaDr.Ali8ConjunctivaDr.Ali9Cornea & ScleraDr. Bakhtiar10Cornea & ScleraDr.Bakhtiar11Lens & CataractDr.Khaled12Lens & CataractDr.Khaled13GlaucomaDr.Ali14GlaucomaDr.Ali15Optics & Refractive errors Dr.Tara16Optics & Refractive errorsDr.Tara17UveitisDr.Khaled18UveitisDr.Khaled19Retina & Optic nerveDr.Bakhtiar20Retina & Optic nerveDr.Bakhtiar21Ocular Motility & strabismusDr.Tara22Ocular Motility & strabismusDr.Tara23Systemic diseases & eyeDr.Khaled24Ocular Emergencies & TraumaDr.Ali25Laser in OphthalmologyDr.Tara26NeurophthalmologyDr.Bakhtiar27Differential Diagnosis of the Eye conditionsDr.Ali<br />Practical Course Outline<br />
    • DATE Topics Sat. Ophthalmic case history,slitlamp&fundus examination lenses 2. Sun. V.A. & Perimetry Mon. Patients examinations,red eye,corneal ulcer,uveitisTues. Direct & indirect ophthalmoscope Wed Review of instruments Sat. Refraction &lenses Sun. Trauma &Chemical burns Mon. Patients examinationsTues. Lid problems &masses ,Corneal lesions Wed. Eye Emergencies Sat.CataractSun.GlaucomaMon.Patients examinationsTues.ReviewWed.Assessment & clinical Exam.
    Grading<br />Assessment methods: Theoretical Mid-Year Exam 20% Clinical exam 20% Final exam 50% Attendence & medical ethics 10%Theoretical Lectures&5% for practical Grading scale: 90% to 100% = EXCELLENT 80% to 89% = VERY GOOD 70% to 79% = GOOD 60% to 69% = MEDIUM 50% to 59% = FAIR < 50 % = FAIL <br />Introduction to ophthalmologyThe eyeball, or globe, sits in a protective bony structure known as the orbit. Lined with muscle, connective and adipose tissues, the orbit is about 4 cm in height, width, and depth and is shaped roughly like a four-sided pyramid, surrounded on three sides by the sinuses: The ethmoid (medially), the frontal (superiorly), and the maxillary (inferiorly). The optic nerve and the ophthalmic artery enter the orbit at its apex through the optic foramen. The anterior portion of the eye is protected by the eyelids, composed of thin elastic skin that covers striated and smooth muscles. Tears are vitally important to the health of the anterior segment of the eye. They are formed by the lacrimal gland and the accessory lacrimal glands. The conjunctiva, a mucous membrane, provides a barrier to the external environment and nourishes the eye. The sclera, commonly known as the " white of the eye," is a dense fibrous structure that composes the posterior five sixths of the eyeThe cornea a transparent avascular domelike structure, forms the most anterior portion of the eyeball and is the main refracting surface of the eye. Behind the cornea lies the anterior chamber, filled with a continually replenished supply of clear aqueous humor, which nourishes the cornea. The uvea consists of the iris, the ciliary body, and the choroid. The iris, or colored part of the eye, is a highly vascularized, pigmented collection of fibers surrounding the pupil. The pupil is a space that dilates and constricts in response to light. Directly behind the pupil and iris lies the lens, a colorless and almost completely transparent biconvex structure held in position by zonular fibers. It is avascular and has no nerve or pain fibers. The lens is suspended behind the iris by the zonules and is connected to the ciliary body. The ciliary body controls accommodation through the zonular fibers and the ciliary muscles. The posterior chamber is a small space between the vitreous and the iris. Aqueous fluid is manufactured in the posterior chamber by the ciliary body <br />The choroid is layered between the retina and the sclera and is a vascular tissue, supplying blood to the portion of the sensory retina closest to it.<br />The ocular fundus is the largest chamber of the eye and contains the vitreous humor, a clear gelatinous substance, mostly water, encapsulated by a hyaloid membrane, the vitreous humor.<br />Good visual acuity is not dependent solely on a healthy functioning eyeball but also on an intact visual pathway. This pathway is made up of the retina, optic nerve, optic chiasma, optic tracts, lateral geniculate bodies, optic radiations, and the visual cortex of the brain. The pathway is an extension of the central nervous system. The optic nerve is innervated by the second cranial nerve. Its purpose is to transmit impulses from the retina to the occipital lobe of the brain. <br />The Ocular Examination Visual AcuityAfter the patient's chief complaint and history have been established, visual acuity should be assessed. This is an essential part of the eye examination and a measure against which all therapeutic outcomes are based Most health care providers are familiar with the standard Snellen chart. This chart is composed of a series of progressively smaller rows of letters and is used to test distance vision. The fraction 6/6 is considered the standard of normal vision. Most people can see the letters on the line designated as 6/6 from a distance of 6 meters. The External Eye ExaminationAfter the visual acuity has been recorded, an external eye examination is performedDIAGNOSTIC EVALUATION DIRECT OPHTHALMOSCOPY Is a hand-held instrument with varying plus and minus lenses. The lenses can be rotated into place, enabling the examiner to bring the cornea, lens, and retina into focusIndirect Ophthalmoscopy Is an instrument commonly used by the ophthalmologist. It produces a bright and intense light. The light source is fixed with a pair of binocular lenses, which are mounted on the examiner's head. The ophthalmoscope is used in conjunction with a hand-held 20-dioptcr lens. This instrument enables the examiner to see larger areas of the retina, although in an unmagnified state. Slit-Lamp ExaminationIs a binocular microscope mounted on a table. This instrument enabls the user to examine the eye with magnification of 10 to 40 times the real image. Color Vision TestingBecause alteration in color vision is sometimes indicative of optic nerve problems, color vision testing is often performed in a neuro-ophthalmologic workup. UltrasonographyLesions in the globe or the orbit may not be directly visible and are evaluated by ultrasound.Color Fundus PhotographyFundus photography is a technique used to detect and document retinal lesions. The patient's pupils are widely dilated during the procedure, and visual acuity is diminished for about 30 minutes due to retinal " bleaching" by the intense flashing lights. Tonometry <br />Tonometry is used to measure IOP by determining the amount of force necessary to indent or flatten (applanate) a small anterior area of the globe of the eye.<br />GonioscopyGonioscopy is used to visualize the angle of the anterior chamber to identify abnormalities in appearance and measurements.<br />Perimetry Testing<br />Perimetry testing is used to evaluate the field of vision. A visual field is the area or extent of physical space visible to an eye in a given position. Its average extent is 65 degrees upward, 75 degrees downward, 60 degrees inward, and 95 degrees outward when the eye is in the primary gaze.<br />IMPAIRED VISION <br />REFRACTIVE ERRORS <br />In refractive errors, vision is impaired because a shortened or elongated eyeball prevents light rays from focusing sharply on the retina. Blurred vision due to refractive error can be corrected with eyeglasses and contact lenses.<br />GLAUCOMAGlaucoma is the term used to describe a group of ocular conditions characterized by optic nerve damage, high intraocular pressure and visual field deffect. CLASSIFICATION OF GLAUCOMAGlaucoma can be open angle or angle closure, depending on which mechanisms cause the impairment of the aqueous outflow. Glaucoma can also be primary or secondary, depending on whether associated factors contribute to the rise in IOP. CATARCTA cataract is a lens opacity or cloudinessClinical ManifestationsPainless blurring of vision is characteristic of cataracts. Commonly Used Ocular MedicationsTopical AnestheticsOne to two drops of proparacaine hydrochloride and tetracaine hydrochlorid are instilled before diagnostic procedures such as tonometry and gonioscopy and in minor ocular procedures such as removal of sutures or conjunctival or corneal scrapings.Mydriatics and CycloplegicsMydriasis, or pupil dilation, is the main objective of the administration of mydriatics and cycloplegicsAnti-lnfectivesAnti-infective medications include antibiotics, antifungals, and antivirals. Most are available as drops, ointments, or subconjunctival or intravitreal injections. Antibiotics include penicillin, the cephalosporins, aminoglycosides, and fluoroquinolones. The main antifungal agent is amphotericin B. Antivirals include acyclovir and ganciclovir. Corticosteroids and Nonsteroidal Anti-Inflammatory Drugs <br />The topical preparations of corticosteroids are commonly used in inflammatory conditions of the eyelids, conjunctiva, cornea, anterior chamber, lens, and uvea. In posterior segment diseases that involve the posterior sclera, retina, and optic nerve, the topical agents are less effective; hence, the parenteral and oral routes are preferred.<br /> Examinations.<br /> Types of questions: <br />1. Short essay.<br />2. Long essay.<br />3. Multiple choice questions.<br />4. Blankets<br />5. True & false<br />Time of exam. <br />3 Three hours.<br />The number of questions and marks are divided as follows:<br />20 Marks for long essays.<br />20 Marks for short essays.<br />40 Marks for MCQs.<br />10 Marks for T&F<br />10 Marks for Blankets<br />The methods of correction of answers depend on key answers and key for multiple choice questions and correction and marks are given accordingly.<br />Advices and directions for all students before and during exams.<br />
    • Read the question twice before answering.
    • 2. Think of the answer before writing.
    • 3. Plan your answer in a separate page before writing it down on the answer paper.
    • 4. Arrange the answer in the form of introduction, contents and the final part so that the student organizes his/her answer
    • 5. Sample of MCQ and long and short essays
    Chose the most appropriate answer(single choice) <br />1. Pigmented Layer of the Retina which is not true<br /> a. consists of a single layer of cells. <br /> b. these cells have a secretory function.<br /> c. absorption of light is one of there functions.<br /> d. consists of multiple layers of cells. <br />2. Adverse Risk Factors for diabetic retinopathy; all true except<br /> a. poor metabolic control.<br /> b. myopia.<br /> c. obesity<br /> d. smoking<br />3. Obstruction of the central retinal artery; the false answer is <br /> a. mostly occur at the lamina cribrosa.<br /> b. giant-cell arteritis.<br /> c. subacute bacterial endocarditis.<br /> d. cause reversible visual loss. <br />Put (T) in front the true one and (F) for false one and (D) if you don’t know <br /> 1. Keratic precipitates are inflammatory cell deposition over corneal endothelium.<br />Photophobia is one of the signs of acute iridocyclitis.<br />Answer by true(T) and false (F) (10 M)<br /> 1. Causes of ptosis could be:-<br />
    • ( )a. senile aponeurotic.
    • 6. ( )b. vascular .
    • 7. ( )c. mechanical.
    • 8. ( )d. self induced.
    • 9. 2. Epiphora caused by:-
    • 10. ( )a. aqueous humor leakage.
    • 11. ( )b. hyposecretion of tears.
    • 12. ( )c. block of nasolacrimal duct.
    • 13. ( )d. parasympathetic stimulation of lacrimal gland.
    Chose the appropriate answer for each blanket (8 M)<br />Mature cataract……………………………………<br />Congenital cataract ………………………………<br />Hypermature cataract…………………………….<br />mitotics<br />corticosteroids<br />diabetes mellitus<br />lamellar or zonular cataract <br />Assay questions<br />
    • 1. Enumerate the possible the nerve affected & the muscles involved paralytic squint? Answer
    • 14. 1. Oculomotor nerve (3rd cranial nerve)palsy, it affects the following extraocular muscles:-
    • 15. i-medial rectus.
    • 16. ii-superior rectus.
    • 17. iii-inferior rectus.
    • 18. iv-inferior oblique.
    • 19. Abducent nerve (6th cranial nerve)palsy, it affects the:-
    • 20. lateral rectus muscle.
    • 21. Trochlear nerve (4th cranial nerve )palsy it affects the :-
    • 22. superior oblique muscle.
    Student feedback for the subject of a lecture<br />Date: course: year: lecturer: title:<br />No.Evaluation QuestionsScore(1-5)Subjective Remarks1The objectives and key messages of the subject were clear2The contents of the subject were useful and related to the main objectives of the course3The materials were prepared carefully as needed4The lecturer/ tutor while lecturing tried to analyze the principles, contents and the important points of the subject simply and properly.5The lecturer/ tutor while lecturing kept my attention.6The lecturer/ tutor came into the classroom on time and was committed to the duration of the lecture.7The lecturer's behavior in the classroom was calm and respectful8The slides used in the lecture were clear and attractive.9At the end of the lecture, the lecturer gave the students a chance for questions and comments. His/ her answers were complete. 10The reading sources are new and compatible with the subject.Total score<br />1-very bad 2–bad 3–medium 4- good 5-verygood<br />