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Welcome to Ophthalmology Posting

1. The Ophthalmic History

• Main complaint: onset (sudden vs gradual), severity, duration, frequency
• Past ocular history: prior surgery, trauma, inflammation
• Past medical history: diabetes, hypertension, thyroid disease (all affect the eye)
• Systemic medications: corticosteroids (cause cataracts/glaucoma), tamsulosin (IFIS during cataract surgery), antimalarials (maculopathy)
• Allergies: topical antibiotics, glaucoma drops
• Family history: glaucoma, macular degeneration, inherited retinal disease
• Occupation/hobbies: important for visual demands and injury risk

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2. Core Examination Skills to Master Early

Visual Acuity (VA) — your most important measurement

• Test each eye separately; always test the worse eye first
• Use the patient's glasses/contacts first (corrected VA)
• If VA < 6/6, repeat with a pinhole — improvement suggests a refractive cause
• Know the notation: 6/6 (metric) = 20/20 (imperial) = normal
• For very poor VA: record as Counting Fingers (CF), Hand Movements (HM), Perception of Light (PL), or No Perception of Light (NPL)
• Best-corrected VA (BCVA) is the gold standard for clinical decisions

Slit-Lamp Biomicroscopy

• The workhorse of ophthalmic examination
• Systematically examine: lids → conjunctiva → cornea → anterior chamber (look for cells/flare) → iris → lens
• Learn to adjust illumination: diffuse, direct focal, retro-illumination

Fundus Examination

• Learn indirect ophthalmoscopy (wide field) and direct ophthalmoscopy (disc detail)
• Systematic approach: optic disc → cup:disc ratio → vessels → macula → periphery
• Cup:disc ratio >0.6 or asymmetry >0.2 raises suspicion for glaucoma

Tonometry (IOP measurement)

• Normal: 10–21 mmHg
• Goldmann applanation tonometry is the gold standard
• Remember: corneal thickness affects readings — thin corneas underestimate true IOP

Gonioscopy

• Examines the drainage angle of the eye
• Essential for classifying glaucoma (open-angle vs closed-angle)

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3. Common Presentations You'll Encounter

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4. Key Investigations

• Perimetry (visual fields): Humphrey automated perimetry for glaucoma, neurological lesions
• OCT (Optical Coherence Tomography): Cross-sectional retinal imaging — essential for macula and glaucoma
• Fluorescein Angiography: Vascular diseases, AMD, diabetic retinopathy
• B-scan ultrasound: When fundus is not visible (dense cataract, vitreous haemorrhage)
• Corneal topography: For keratoconus, pre-surgical assessment

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5. Practical Tips for the Ward & OPD

1. Always wash hands and disinfect the slit-lamp chin rest between patients
2. When instilling dilating drops (tropicamide 1% ± phenylephrine 2.5%), warn patients about blurred near vision and photophobia for 4–6 hours; advise them not to drive
3. In any red eye, check IOP before prescribing steroids — steroids in a herpetic corneal ulcer can be catastrophic
4. Never patch a red eye without a diagnosis — you could worsen infectious keratitis
5. Always check the relative afferent pupillary defect (RAPD) with the swinging torch test — it's a critical sign of optic nerve or extensive retinal disease
6. For trauma cases — do not apply pressure to the eye if globe rupture is suspected

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6. Must-Know Emergencies

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7. Your Two Main Reference Books in This Posting

• Kanski's Clinical Ophthalmology (10th ed.) — comprehensive, systematic, excellent for building foundations
• Wills Eye Manual — symptom-based, practical, great for quick OPD/ER reference

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Must-Clerk Cases in Ophthalmology Posting

The 10 Core Case Categories

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Case-by-Case Clerking Checklist

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1. CATARACT

• Age of onset, which eye affected, rate of progression
• Glare worse in sunlight or oncoming headlights? (posterior subcapsular)
• Near vs distance vision — which is worse?
• Systemic: diabetes, steroid use, trauma history
• Family history of early cataract

• Best-corrected VA (both eyes)
• Pinhole improvement?
• Red reflex — asymmetry or absent?
• Slit-lamp: type of cataract (nuclear sclerosis / cortical / posterior subcapsular / anterior subcapsular)
• Pupil dilation for fundus assessment (exclude posterior segment disease)

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2. GLAUCOMA (Primary Open-Angle)

• Family history of glaucoma (first-degree relative = major risk factor)
• Known myopia (risk factor)
• Steroid use (topical/systemic — steroid-induced glaucoma)
• History of ocular hypertension
• Current eye drops — compliance, side effects

• VA (often preserved until late)
• IOP (both eyes) — normal ≠ no glaucoma
• RAPD (if asymmetric damage)
• Slit-lamp: anterior segment, corneal thickness estimate
• Fundus: optic disc — CDR, rim thinning (especially inferior > superior > nasal > temporal = ISNT rule), disc haemorrhages, peripapillary atrophy
• Visual field defects: arcuate scotoma, nasal step, altitudinal defects

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3. DIABETIC RETINOPATHY

• Type and duration of diabetes
• HbA1c — current and trend
• BP and lipid control
• Last retinal screening and result
• Renal involvement (nephropathy correlates with retinopathy severity)
• Pregnancy (accelerates DR)

• VA both eyes
• IOP (neovascular glaucoma risk)
• Dilated fundus: classify — NPDR (mild/moderate/severe) vs PDR
• Macular oedema — clinically significant? (use OCT if available)
• New vessels at disc (NVD) or elsewhere (NVE)?
• Vitreous — haemorrhage, traction?

• Non-proliferative DR: microaneurysms → haemorrhages → hard exudates → cotton wool spots → venous beading → IRMA
• Proliferative DR: new vessel formation → vitreous haemorrhage → traction retinal detachment

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4. CONJUNCTIVITIS

• Discharge type: watery (viral/allergic) vs mucopurulent (bacterial)
• Itching (hallmark of allergic conjunctivitis)
• URTI contact / sick contacts (viral)
• Contact lens wear
• Atopy, hay fever, eczema (allergic)
• Neonatal? (consider gonococcal/chlamydial — important!)
• Any visual blurring? (if yes — not simple conjunctivitis, look further)

• VA — should be normal
• Lid: follicles (viral/chlamydial) vs papillae (bacterial/allergic)?
• Discharge character
• Cornea: clear? (if not, consider keratoconjunctivitis)
• Pre-auricular lymphadenopathy (viral conjunctivitis)

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5. ACUTE ANGLE-CLOSURE GLAUCOMA

• Onset — sudden, unilateral?
• Previous similar attacks (subacute closure)?
• Precipitant: dim lighting, mydriatic drops, emotional stress
• Systemic history: hypermetropia (short axial length = risk)
• Medications that can precipitate: anticholinergics, antihistamines, sympathomimetics

• VA — reduced
• IOP — typically >40 mmHg, rock-hard eye
• Cornea — hazy (epithelial oedema)
• Pupil — mid-dilated, oval, unreactive
• Anterior chamber — very shallow, flare
• Gonioscopy (once acute attack controlled): closed angle
• Check fellow eye — also narrow angle?

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6. ANTERIOR UVEITIS (IRITIS)

• Unilateral or bilateral?
• First episode or recurrent?
• Systemic review: back pain/stiffness (ankylosing spondylitis — most common association), skin rash (psoriasis, sarcoid), bowel symptoms (IBD), joint pain
• STI history (Reiter's, syphilis)
• TB exposure
• Herpetic eye disease history

• VA
• Ciliary flush (limbal injection > peripheral injection)
• Cornea: keratic precipitates (KPs) — fine (non-granulomatous) vs large mutton-fat (granulomatous = TB, sarcoid, syphilis)
• Anterior chamber: cells and flare (grade 0–4)
• Pupil: irregular (posterior synechiae)?
• IOP: may be low (ciliary body suppression) or high (trabeculitis)
• Fundus: vitreous spill-over? (if so, think intermediate/panuveitis)

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7. RETINAL DETACHMENT

• Onset of floaters/flashes vs onset of field defect — gap matters (time-sensitive surgery)
• Which quadrant is the shadow? (superior field defect = inferior retinal detachment — worse prognosis as macula threatened sooner)
• Is the macula on or off? (VA guide)
• High myopia (major risk factor)
• Prior cataract surgery (aphakic/pseudophakic RD)
• Fellow eye — previous RD or lattice degeneration?
• Trauma history

• VA
• Dilated fundus with indirect ophthalmoscopy: location of detachment, find the break, macula status
• IOP: low IOP supports rhegmatogenous RD

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8. CORNEAL ULCER / KERATITIS

• Contact lens wear (Pseudomonas, Acanthamoeba — must ask!)
• Previous herpes labialis or eye disease (HSV keratitis)
• Recent trauma — vegetative matter? (fungal keratitis)
• Immunocompromised state
• Topical steroid use (masks and worsens infection)

• VA
• Slit-lamp:
  • Epithelial defect stained with fluorescein (size, location, margins)
  • Stromal infiltrate
  • Corneal sensation (reduced in HSV — use cotton wisp)
  • Dendrites = HSV keratitis (branching, terminal bulbs)
  • Hypopyon in anterior chamber?
  • Corneal scraping for culture and microscopy (before starting treatment)

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9. PTOSIS

• Unilateral or bilateral?
• Onset — congenital vs acquired; sudden vs progressive?
• Diurnal variation — worse in evening? (myasthenia gravis)
• Diplopia, difficulty chewing/swallowing (myasthenia)
• Headache, dilated pupil (CN III palsy — aneurysm until proven otherwise!)
• Anhidrosis, miosis (Horner syndrome — congenital? carotid/lung pathology?)
• Thymoma, lung cancer (paraneoplastic)

• MRD1 (marginal reflex distance) — normal ~4 mm
• Levator function (lid excursion from downgaze to upgaze)
• Upper lid crease height
• Pupil: dilated (CN III), miotic (Horner), normal (aponeurotic/myasthenic)
• Extraocular movements
• Fatigability test (prolonged upgaze — MG)
• Phenylephrine test for Horner's

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10. AGE-RELATED MACULAR DEGENERATION (AMD)

• Age >50, smoking history (strongest modifiable risk factor)
• Family history of AMD
• Fellow eye involvement?
• Sudden recent worsening? (suggests conversion to wet AMD — subretinal haemorrhage)
• Diet (antioxidant intake) and supplements (AREDS2)

• VA
• Amsler grid — essential in every AMD patient, check for distortion or scotoma
• Dilated fundus:
  • Drusen — size, number, distribution (soft large drusen = high risk)
  • Geographic atrophy (dry AMD)
  • Subretinal fluid, haemorrhage, CNV membrane (wet AMD)
• OCT: gold standard for detecting subretinal/intraretinal fluid

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Quick Summary: What to Always Document in Every Ophthalmic Clerking

□ Presenting complaint + duration
□ VA — each eye separately, with and without correction, pinhole if <6/6
□ RAPD — swinging torch test
□ IOP — both eyes
□ Anterior segment (slit-lamp): lids, conjunctiva, cornea, AC, lens
□ Posterior segment (dilated): disc, macula, vessels, periphery
□ Relevant systemic history (DM, HT, autoimmune, medications)
□ Family history of eye disease
□ Functional impact — driving, work, daily activities

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• The key concept is that RAPD is an afferent problem (optic nerve/retina), not an efferent one (no anisocoria at rest)
• The affected eye's pupil dilates when you swing the light to it — because the brain sees less light coming in from that side
• The classic causes to always remember: optic neuritis, CRAO, severe glaucoma (asymmetric), large retinal detachment
• Dense cataract alone does not cause RAPD — this is a classic exam question

1. A normal corneal optical section (thin slit, oblique beam)
2. Fluorescein staining with cobalt blue filter
3. AC cells and flare grading
4. KPs on retroillumination

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Snellen Chart — What 6/6 Means

So 6/6 means:

The patient reads at 6 metres what a normal eye can read at 6 metres.

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Reading the Fraction

Note: Normal corrected VA in young adults is often better than 6/6 (e.g. 6/5 or 6/4) — meaning they can read at 6 m what a standard normal eye would need to be at 5 or 4 m to read.

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The US / Imperial Equivalent

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Why Letters Get Smaller Down the Chart

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Practical Tip in Clinic

• Always record which eye (R/L), whether it is aided or unaided, and whether pinhole was used
• Example: R VA: 6/18 (unaided) → 6/6 (pinhole) tells you the problem is refractive — correctable with glasses
• Example: R VA: 6/18 (unaided) → 6/18 (pinhole) tells you there is pathology — pinhole did not help

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Ophthalmic Drops & Ointments — Practical Guide

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PART 1 — FOR EXAMINATION / DIAGNOSTIC USE

1. Mydriatics (Pupil Dilating Drops)

Drugs in Detail

In your OPD: You will most commonly use Tropicamide 1% alone or combined with Phenylephrine 2.5% for fundus exam.

What to Tell Every Patient Before Dilating

• Vision will be blurred for near for 4–6 hours (tropicamide)
• Eyes will be sensitive to light (photophobia) — bring sunglasses
• Do not drive after dilation
• Warn any patient with narrow angles — dilation can precipitate acute angle-closure glaucoma

Before You Dilate — Always Check

• Is the anterior chamber deep or shallow? (Torch light from temporal side — check for shadow on nasal iris)
• Any history of angle-closure glaucoma?
• Is it a head injury patient whose pupils need monitoring? → Do NOT dilate

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2. Topical Anaesthetics

• Tonometry (IOP measurement)
• Corneal foreign body removal
• Gonioscopy / contact lens examination
• Corneal scraping for culture

Important: Topical anaesthetics are for in-clinic use only. Never give a patient a bottle to take home — they mask pain that protects the cornea, and repeated use is toxic to the corneal epithelium.

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3. Fluorescein (Diagnostic Dye)

• Corneal abrasion → uniform green patch
• Corneal ulcer → green-staining epithelial defect with edges
• Dendritic ulcer (HSV) → branching tree pattern with terminal bulbs
• Seidel's sign → aqueous leaking from a wound dilutes fluorescein → streaming dark "waterfall" on blue light = open globe
• Tear film — fluorescein used to measure tear break-up time (TBUT) in dry eye assessment

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4. Rose Bengal / Lissamine Green

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PART 2 — FOR TREATMENT / MEDICATION USE

5. Antibiotic Drops and Ointments

Ointment vs drops: Ointments have longer contact time, useful at night or for lids (blepharitis). Drops are preferred during the day as they don't blur vision.

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6. Anti-inflammatory Drops

Topical Steroids

Never start topical steroids without a diagnosis. Steroids on an undiagnosed herpetic ulcer → corneal melt. Steroids can raise IOP (steroid-induced glaucoma) and accelerate cataract formation.

NSAIDs (Topical)

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7. Anti-allergic Drops

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8. Glaucoma Drops (IOP-Lowering)

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9. Lubricants / Artificial Tears

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10. Other Commonly Seen Drops

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Quick Reference Summary Card

DILATION (fundus exam):   Tropicamide 1% ± Phenylephrine 2.5%
CYCLOPLEGIA (refraction): Cyclopentolate 1% (children), Atropine 1%
ANAESTHESIA (before IOP): Proxymetacaine 0.5% or Tetracaine 0.5%
STAINING (ulcer/abrasion): Fluorescein strip + cobalt blue light
BACTERIAL CONJUNCTIVITIS: Chloramphenicol drops/ointment
HSV KERATITIS:            Aciclovir 3% ointment — NEVER steroids
UVEITIS:                  Steroid drops + Cycloplegic (homatropine/atropine)
GLAUCOMA (1st line):      Prostaglandin analogue (latanoprost, night)
ACUTE ANGLE CLOSURE:      IV Acetazolamide + Pilocarpine drops + Timolol
DRY EYE:                  Hypromellose / Sodium hyaluronate drops; ointment at night

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Definition of Blindness

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1. WHO / International Classification (ICD-11)

The key cut-off: < 3/60 BCVA in the better eye = WHO blind

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2. Legal Blindness

Best-corrected VA of 6/60 (20/200) or worse in the better eye OR a visual field of 20° or less (even if central VA is preserved)

• It is based on the better eye — if one eye is normal, a person is not legally blind
• Visual field counts — someone with 6/6 vision but severe tunnel vision (e.g. end-stage glaucoma, retinitis pigmentosa) can still qualify as legally blind if their field is ≤ 20°
• Loss of vision in one eye only does not constitute legal blindness

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3. Practical Levels of Vision — What Each Means

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4. Low Vision vs Blindness

Low vision means the person still has some usable vision and can benefit from visual rehabilitation (magnifiers, large print, etc.).

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5. Quick Summary Table

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6. Common Causes of Blindness Globally (WHO)

1. Uncorrected refractive error — most common cause of visual impairment worldwide (preventable)
2. Cataract — most common cause of treatable blindness globally
3. Glaucoma — most common cause of irreversible blindness
4. Age-related macular degeneration (AMD)
5. Diabetic retinopathy
6. Trachoma — most common infectious cause of blindness globally
7. Onchocerciasis (river blindness) — in endemic areas

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In your exam/OSCE: If asked "define blindness" — the expected answer is the WHO definition: BCVA < 3/60 in the better eye, OR visual field < 10°. Also know that legal blindness = < 6/60.

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Near Vision — Complete Guide

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1. The Physiology — Why We Need Near Vision Testing

Accommodation

• Mechanism: Parasympathetic signal (CN III) → ciliary muscle contracts → zonules relax → lens becomes rounder/thicker → focal point moves closer
• Accommodation is measured in diopters (D) — the reciprocal of the near point distance in metres

Presbyopia — The Key Condition

Presbyopia = age-related loss of accommodation due to progressive hardening and enlargement of the lens (denaturation of lens proteins → lens loses elasticity)

• Onset typically age 40–45
• Presents as difficulty reading or needing to hold things further away ("arms not long enough")
• Not a disease — a normal ageing process
• Corrected with reading glasses (plus lenses) — or bifocals if the patient also has a distance refractive error

By age 70, the power of accommodation falls to essentially 0 diopters — the lens remains at a fixed focal length permanently. — Guyton & Hall, Medical Physiology

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2. Near Vision Charts — The Notation Systems

a) Jaeger (J) Notation

• The original near vision system — still widely used in clinical practice
• Consists of paragraphs of text in decreasing print sizes, numbered J1 to J14+
• J1 = smallest (finest) print = equivalent to good near vision
• J14+ = largest print = very poor near vision

b) N (Newspaper) Notation

• Print size measured in point size — labelled N5, N6, N8, N10, N12, N18, N36, N48
• N5 = smallest (newsprint-sized text) = normal near vision
• N8 = average newspaper body text
• This system is intuitive — "N5" means the patient can read 5-point print

c) Rosenbaum Pocket Card (Bedside)

• A pocket-sized card held at 14 inches (35 cm) — equivalent to the Snellen chart at distance
• Results expressed as distance Snellen equivalents (e.g. 20/20, 20/40)
• Extremely useful at the bedside, in ED, and for quick assessments
• Patient must wear their reading glasses if they use them

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3. How to Test Near Vision — Step by Step

Setup

1. Good lighting — natural light or a bright lamp
2. Patient holds the near vision chart at their comfortable reading distance (usually 33–40 cm) — measure and record this distance
3. Test each eye separately — cover the other eye
4. Patient wears their reading glasses if they use them (especially for presbyopia patients — you must test with their correction to get best-corrected near VA)

Procedure

Step 1: Cover left eye
Step 2: Patient holds near chart at comfortable reading distance
Step 3: Ask patient to read smallest line they can see clearly
Step 4: Record: e.g. J2 or N6 at 33 cm, right eye
Step 5: Repeat for left eye
Step 6: Then test binocularly (both eyes open)

What to Record

Example: R near VA: N6 @ 33 cm (with reading glasses)

• Which eye (R/L/binocular)
• The notation result (J or N)
• The distance it was held at
• Whether reading glasses were worn

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4. Near Vision vs Distance Vision — Clinical Correlation

"Near vision testing can be a sensitive indicator of the presence of macular disease." — Kanski's Clinical Ophthalmology, 10th ed.

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5. Special Situations

Traumatic Mydriasis

• Trauma can paralyse the iris sphincter → fixed dilated pupil → reduced depth of focus → blurred near vision even in a young patient
• Always test near VA in eye trauma cases

After Dilation Drops

• Tropicamide/cyclopentolate paralyse the ciliary muscle → no accommodation → near vision blurred
• Always warn patients before dilating: "You will not be able to read clearly for a few hours"
• Test near VA before dilating if relevant

Malingering / Non-organic Visual Loss

• If a patient claims they cannot see but near VA is intact or inconsistent, consider non-organic loss
• Use optokinetic nystagmus (OKN) test: pass a striped drum/tape in front of the eye — involuntary tracking movements (nystagmus) indicate an intact visual pathway even if the patient claims blindness

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6. Amsler Grid — Near Vision + Macular Function Test

• A grid of fine squares with a central dot
• Patient fixates on the central dot and reports any distortion (wavy lines = metamorphopsia) or missing areas (scotoma)
• Standard test for AMD monitoring — patients can use it at home daily
• If lines appear wavy or a patch is missing → wet AMD, macular oedema → refer urgently

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7. Summary Card

Standard near vision testing distance:   33–40 cm
Normal near vision:                       J1 or N5
Notation systems:                         J (Jaeger), N (newsprint), Snellen equivalent
Always test WITH reading glasses          (if patient uses them)
Test BEFORE dilating drops                (dilation removes accommodation)
Near VA reduced + distance VA normal:     Think PRESBYOPIA
Both near + distance reduced:             Think MACULA or OPTIC NERVE
Macular function test:                    Amsler grid at 33 cm

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Ophthalmoscopy / Fundoscopy — Complete Guide

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1. Why It Matters

• Eye diseases: glaucoma, retinal detachment, diabetic retinopathy, AMD, CRAO, CRVO
• Systemic diseases: hypertension, diabetes, raised intracranial pressure, leukaemia, sickle cell, endocarditis

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2. Types of Ophthalmoscopy

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3. Direct Ophthalmoscopy — The Bedside Skill

The Instrument

• A handheld device with a light source and a rotating lens wheel
• Lens wheel corrects for refractive error of both examiner and patient
• Apertures: large (dilated pupil), small (undilated), red-free (green filter for vessels), cobalt blue (with fluorescein)

Before You Start

• Darken the room — essential for an undilated pupil
• Dilate if possible (tropicamide 1%) — gives a far better view
• Ask patient to fixate on a distant target on the wall (reduces accommodation and pupil constriction)
• Remove your own glasses if you have mild refractive error (correct with the lens wheel instead)
• Check the battery and light intensity

Technique — Step by Step

1. Start with lens wheel at "0"
2. Right eye of patient → use YOUR right eye, hold scope in right hand, stand on patient's right
3. Left eye of patient  → use YOUR left eye, hold scope in left hand, stand on patient's left
   (Same-side rule: avoids nose-to-nose contact)

4. Rest your free hand on patient's FOREHEAD — stabilises your position

5. From arm's length, shine light at pupil → look for the RED REFLEX first
   (dull/absent reflex = cataract, vitreous haemorrhage, retinoblastoma)

6. Approach slowly from the TEMPORAL SIDE at a slight angle (~15°)

7. Come in close — ideally 3–4 cm from the eye
   (Most students stay too far away — this is the most common mistake)

8. When close, the OPTIC DISC should come into view
   If blurry → rotate lens wheel until disc is sharp

9. Correct for refractive error:
   - Hypermetrope (far-sighted patient/examiner) → plus lenses (GREEN numbers)
   - Myope (short-sighted) → minus lenses (RED numbers)

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4. What You See — The Normal Fundus

Systematic Examination — Always in This Order

Step 1: Optic Disc

Step 2: Cup:Disc Ratio (CDR)

      ___________
     |           |       = Disc (whole disc diameter)
     |   _____   |
     |  |cup  |  |       = Cup (central pale area — no neural tissue)
     |  |_____|  |
     |___________|

CDR = Diameter of cup ÷ Diameter of disc

Inferior > Superior > Nasal > Temporal Any violation of this rule = suspicious for glaucomatous damage

Step 3: Blood Vessels

• Follow vessels out from the disc in all 4 quadrants (superior, inferior, nasal, temporal)
• Arteries = narrower, brighter red, have a light reflex
• Veins = wider, darker red, no light reflex
• Normal artery:vein ratio = 2:3

Step 4: Macula

Focus on the disc, then move the light 2 disc diameters temporally — or ask the patient to look directly at the light

• Appears slightly darker than surrounding retina
• Foveal reflex = bright central pinpoint light reflection (present in young people; reduced with macular disease)
• The macula has no large vessels — only capillaries

Step 5: Peripheral Retina

• Look for: retinal tears, detachment, pigment changes, laser scars, lattice degeneration
• Retinal detachment appears as elevated, grey, corrugated retina that billows with eye movement

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5. Red Reflex — Never Skip This

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6. Direct vs Indirect — Key Differences

Retinal detachment CANNOT be ruled out by direct ophthalmoscopy alone — indirect ophthalmoscopy is needed to view the peripheral retina where most breaks occur. — Rosen's Emergency Medicine

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7. Common Mistakes to Avoid

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8. Quick Revision Card

Instrument used:     Direct ophthalmoscope
Magnification:       15x
Starting lens:       0 (adjust for patient's refraction)
Approach:            Temporal side, ~15° angle, ~3–4 cm final distance
Same-side rule:      Right eye → your right eye; Left → your left eye
Exam order:          Red reflex → Disc → CDR → Vessels → Macula → Periphery
Find macula:         2 disc diameters temporal to disc
Normal CDR:          ≤ 0.5 (suspicious if > 0.6 or asymmetry > 0.2)
Normal AV ratio:     Artery:Vein = 2:3

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Uveitis — Complete Guide

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1. What Is Uveitis?

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2. Anatomical Classification (SUN / IUSG)

Anterior uveitis is the most common form and the one you will see most in OPD.

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3. Aetiological Classification

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4. Course Classification

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5. Anterior Uveitis — The Must-Know Type

Symptoms

• Pain (deep, aching) — due to ciliary spasm
• Photophobia — often severe
• Lacrimation (watering)
• Blurred vision — from cells/flare in AC + corneal oedema
• Ciliary flush — limbal injection (circumcorneal violet-red ring)

Onset is typically sudden in HLA-B27-related disease and insidious in JIA and Fuchs uveitis syndrome.

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Slit-Lamp Signs — What to Look For

A. Keratic Precipitates (KPs)

B. Anterior Chamber Cells — SUN Grading

C. Anterior Chamber Flare — SUN Grading

D. Posterior Synechiae (PS)

• Iris adhesed to anterior lens capsule due to inflammation
• Cause: irregular pupil shape
• If 360° = seclusio pupillae → aqueous cannot flow → iris bombé → angle-closure glaucoma
• Prevention: cycloplegics (dilate pupil, prevent adhesion)
• Breaking fresh PS: phenylephrine + cycloplegic; subconjunctival Mydricaine if drops fail

E. IOP Changes in Uveitis

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6. Systemic Associations — Must Know

HLA-B27 Associated (Most Common Non-Infectious Cause)

Mnemonic: ARPI or remember "HLA-B27 = Back, Bowel, Behave (behave badly — recurs)"

• Unilateral, alternating
• Acute onset, recurrent episodes
• Non-granulomatous (fine KPs)
• Responds well to topical steroids
• Ask about: lower back pain/stiffness (worse in morning, better with activity), skin rash, bowel symptoms, urethritis

Other HLA Associations

Other Key Systemic Associations

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7. Investigations for Uveitis

First-Line (All Cases)

• FBC — leucocytosis (infection), eosinophilia (parasites)
• ESR / CRP — non-specific inflammation marker
• HLA-B27 — seronegative spondyloarthropathy
• Serum ACE + lysozyme — sarcoidosis (ACE elevated in ~80% acute sarcoid)
• VDRL/RPR + TPHA — syphilis serology (both tests needed)
• QuantiFERON-TB Gold / Mantoux — tuberculosis
• ANA — JIA (especially in children with CAU)
• CXR — sarcoidosis, TB

Additional (Selected Cases)

• ANCA — if associated scleritis (GPA/Wegener's)
• HIV serology — opportunistic infections
• Toxoplasma IgG — posterior uveitis
• Lyme serology — if endemic area

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8. Complications of Uveitis

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9. Treatment

Acute Anterior Uveitis (AAU) — Standard Regimen

Typical tapering regimen:
Week 1: hourly (or every 2 hours)
Week 2: 4x daily
Week 3: 3x daily
Week 4: 2x daily
Week 5: 1x daily → stop
(Total ~5–6 weeks; adjust based on response)

• Cyclopentolate 1% — mild/moderate cases (lasts 12–24 hrs)
• Homatropine 5% — moderate disease (lasts 3 days)
• Atropine 1% — severe disease (lasts 7–10 days)

• Phenylephrine 2.5–10% + cycloplegic drops
• If drops fail → subconjunctival Mydricaine (atropine + adrenaline + procaine injection)
• If dense fibrin → intracameral TPA (tissue plasminogen activator) 12.5–25 μg

Chronic Anterior Uveitis (CAU)

• Target: complete suppression — zero cells AND zero flare
• Even low-grade activity causes complications
• May need long-term maintenance drops
• Steroid-sparing agents (methotrexate, mycophenolate) for refractory cases

Complications of Topical Steroids to Monitor

• IOP rise (steroid responders) — check IOP at every visit
• Cataract — posterior subcapsular
• Secondary infection (bacterial, fungal, HSV reactivation)
• Corneal melting — rare

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10. Quick Summary

Most common type:     Anterior uveitis (iritis/iridocyclitis)
Classic triad:        Pain + Photophobia + Ciliary flush
Key slit-lamp signs:  KPs, AC cells/flare, posterior synechiae
KP type matters:      Fine = non-granulomatous; Mutton-fat = granulomatous
Most common RF:       HLA-B27 (ankylosing spondylitis, IBD, psoriatic, Reiter's)
Granulomatous causes: TB, Sarcoid, Syphilis, VKH, Sympathetic ophthalmia
Most common complication causing blindness: Cystoid macular oedema
Treatment pillars:    Topical steroid (taper) + Cycloplegic
Never steroid without diagnosis — exclude herpetic keratitis first

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