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COMPLETE OPHTHALMOLOGY PRACTICAL EXAM REVIEW

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PART 1: ANTI-GLAUCOMA DRUGS (COMPLETE PHARMACOLOGY)

The goal of all anti-glaucoma drugs is to lower intraocular pressure (IOP) - either by reducing aqueous production or increasing aqueous outflow.

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CLASS 1: PROSTAGLANDIN ANALOGUES (PGAs) - FIRST LINE

Agents & Doses:

Indications:

• Primary open-angle glaucoma (POAG) - first-line
• Ocular hypertension

Contraindications:

• Active uveitis / intraocular inflammation
• Herpetic eye disease
• Aphakic patients / history of cystoid macular edema (CME)
• Recent intraocular surgery
• Pregnancy (Pregnancy Category C)
• Do NOT use two PGAs simultaneously (paradoxically raises IOP)

Side Effects:

• Conjunctival hyperaemia (most common)
• Iris hyperpigmentation (irreversible) - highest in green-brown irides
• Eyelash lengthening, thickening, hyperpigmentation (hypertrichosis)
• Periocular skin hyperpigmentation (reversible)
• Periocular fat atrophy/sunken appearance (prostaglandin-associated periorbitopathy)
• Anterior uveitis (rare)
• Cystoid macular edema post-cataract surgery

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CLASS 2: BETA-ADRENERGIC BLOCKERS

Agents & Doses:

Indications:

• POAG, ocular hypertension
• Often used as second-line or in combination

Contraindications (CRITICAL for exam):

• Bronchial asthma / COPD (bronchospasm risk - non-selective > selective)
• Sinus bradycardia / heart block / cardiac failure (systemic absorption causes bradycardia)
• Betaxolol is preferred in mild/moderate asthma (β1-selective, relatively safer)
• Pregnancy (Category C)
• Caution in diabetes (masks hypoglycemia symptoms)
• Depression (CNS side effects)

Side Effects:

Tip: Systemic absorption via nasolacrimal drainage causes systemic effects. Punctal occlusion or eyelid closure for 3 minutes after instillation reduces systemic absorption by ~50%.

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CLASS 3: ALPHA-2 ADRENERGIC AGONISTS

Agents & Doses:

Indications:

• Second/third-line for glaucoma
• Apraclonidine: prevention of post-laser IOP spike (used peri-ALT/YAG)
• Adjunctive therapy

Contraindications:

• Children < 2 years (CNS depression risk - can cause apnea, bradycardia, hypotension)
• Brimonidine contraindicated in children < ~20 kg / infants (CNS penetration)
• MAO inhibitor users (hypertensive crisis)
• Severe cardiovascular disease
• Pregnancy

Side Effects:

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CLASS 4: CARBONIC ANHYDRASE INHIBITORS (CAIs)

A. TOPICAL CAIs

B. SYSTEMIC CAIs

Contraindications:

• Sulfonamide allergy (relative contraindication - cross-reactivity)
• Hypokalemia
• Renal failure / renal stones
• Pregnancy (teratogenicity risk - greatest systemic risk among all glaucoma drugs)
• Sickle cell disease (acidosis risk)
• Hepatic failure

Side Effects (Systemic CAIs - HIGH-YIELD):

• Paraesthesia ("pins and needles" in extremities) - most common
• Hypokalemia (give potassium supplements)
• Malaise, lowered mood, fatigue
• GI symptoms (nausea, vomiting, metallic taste)
• Renal stones (nephrolithiasis)
• Stevens-Johnson syndrome (very rare)
• Aplastic anemia (idiosyncratic, rare, 50% mortality)
• Bone marrow suppression (dose-related)

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CLASS 5: MIOTICS (CHOLINERGIC AGENTS)

Indications:

• Acute angle-closure glaucoma (breaks attack by pulling iris away from angle)
• POAG (now rarely used; fourth-line)
• Pilocarpine also used: before/after goniotomy, iridotomy

Contraindications:

• Active uveitis (worsen inflammation, cause posterior synechiae)
• Neovascular glaucoma
• After penetrating keratoplasty
• Aphakia (risk of retinal detachment)
• Asthma (systemic absorption)

Side Effects:

• Miosis → reduced vision in dim light
• Brow ache / headache (ciliary spasm) - common initially
• Myopia (accommodation spasm)
• Cataract with long-term use (posterior subcapsular)
• Retinal detachment (especially in aphakia/myopia)
• Systemic: SLUDGE syndrome (Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis) with toxicity

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CLASS 6: OSMOTIC AGENTS (for acute IOP reduction)

Contraindications:

• Cardiac failure / severe renal disease (fluid overload risk)
• Diabetics (glycerol only - use isosorbide instead)
• Urinary retention in elderly men (caution)
• Inflammatory glaucoma (blood-aqueous barrier disrupted - limited effect)

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CLASS 7: RHO-KINASE INHIBITORS (ROCK inhibitors) - NEWER CLASS

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COMBINATION DRUGS (HIGH-YIELD):

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DRUG CLASS SUMMARY TABLE (QUICK REVIEW):

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PART 2: OPHTHALMIC INSTRUMENTS

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EYELID INSTRUMENTS

1. Chalazion Clamp (Chalazion Forceps)

• Appearance: Self-retaining instrument with one discoid ring plate on one arm and a solid oval plate on the other
• Size: Multiple sizes available (Lambert: 10 mm/15 mm round; Francis: 16x13 mm oval)
• Use: Applied to evert the eyelid and provide hemostasis during excision of a chalazion (Meibomian cyst)
• Mechanism: The ring end faces outward (toward conjunctival side); scalpel incision made through the ring; the plates clamp the eyelid to prevent bleeding
• Key point: Self-retaining; leaves hands free for surgery

2. Chalazion Scoop / Curette

• Appearance: Small sharp spoon-shaped instrument
• Use: To scrape out granulation tissue from the chalazion cavity after incision
• Sizes: A, B, C, D, E, F (varying cup sizes - 2.2 mm to 5.7 mm)

3. Meibomian Cyst Curette

• Double-ended with two cupped ends
• Used to express and clean out Meibomian cyst contents

4. Entropion Clamp

• Similar to chalazion clamp but larger
• Right and left varieties exist
• Self-retaining with big discoid ends
• Used in entropion surgery

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SCISSORS

5. Corneoscleral Scissors

• Appearance: Spring scissors with curved/straight blades; one blade fits into the anterior chamber
• Use: To extend corneoscleral incision during cataract extraction, penetrating keratoplasty, or evisceration
• Types: Right-cutting and left-cutting varieties (complementary pair)
• Key: The curved blade is inserted into the incision and the scissor cuts along the limbus

6. Conjunctival/Tenotomy Scissors (Westcott/Stevens)

• Fine spring scissors
• Used for conjunctival dissection, undermining, and suture cutting
• Stevens: straight or curved, rounded tips
• Westcott: curved, spring-action, for delicate work

7. Vannas Scissors

• Very fine, small scissors
• Capsulotomy, iris work, fine intraocular cutting

8. Iris Scissors

• Intraocular scissors for iris procedures

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CANNULAE

9. Two-Way (Bi-way) Irrigation-Aspiration Cannula

• Appearance: Two cannulae fitted side by side - one larger (irrigation) and one smaller (aspiration)
• Use: During cataract surgery (ECCE) - one channel infuses BSS (balanced salt solution) to maintain anterior chamber depth; the other aspirates cortical material
• Function: Removes residual lens cortex after nucleus delivery; prevents chamber collapse
• Connected to: I/A machine or two separate syringes

10. Lacrimal Cannula

• Small, curved cannula the size of a syringe needle
• Use:
  • Syringing of nasolacrimal duct (test patency)
  • DCR (dacryocystorhinostomy) surgery
  • Dacryocystography (contrast injection)
  • Drug delivery into nasolacrimal passages
• Types: Straight, angled 45°, angled 90°

11. Irrigating Vectis

• Hollow instrument with a loop at the end
• Use: Introduce fluid into anterior chamber to raise pressure and aid nucleus delivery in cataract surgery; also used to deliver nucleus into anterior chamber

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EVISCERATION INSTRUMENTS

12. Evisceration Spoon (Evisceration Scoop / Mules Scoop)

• Appearance: Spoon-shaped scoop with smooth, blunt edges
• Use: Used in evisceration surgery - to scoop out the intraocular contents (uveal tract, retina, vitreous, lens) after cornea is removed, leaving the scleral shell intact
• Key distinction: Evisceration = removal of intraocular contents; Enucleation = removal of entire eyeball
• After scooping: Implant placed into the scleral shell
• Also used: To place orbital implant into the scleral shell

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FORCEPS

13. Tissue/Fixation Forceps (St Martin's, Lim's)

• Used to fix/hold the globe during surgery

14. Colibri Forceps / Corneal Forceps

• Fine toothed (0.12 mm) or non-toothed
• For holding corneal tissue during suturing

15. Capsule Forceps (Utrata Forceps)

• Fine curved forceps for continuous curvilinear capsulorhexis (CCC) in phacoemulsification

16. MacPherson's Forceps

• Fine, sharp-tipped, untoothed, angulated
• For holding IOL, 10-0 sutures, fine intraocular work

17. Epilation Forceps (Cilia Forceps)

• Stout, flat-ended, blunt forceps with thickened ends
• Use: Remove misdirected eyelashes (trichiasis)

18. Bishop-Harmon Forceps

• General ophthalmic tissue forceps; serrated + 1x2 teeth options

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SPECULA

19. Barraquer Wire Speculum

• Wire loop speculum to hold eyelids apart during surgery
• Minimally obstructs surgical field
• Self-retaining

20. Universal Eye Speculum (Lancaster speculum)

• Blade-type, adjustable, more rigid
• Used for exam or surgery

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NEEDLES & KNIVES

21. Cystotome

• 26-gauge needle bent twice at right angles
• Use: To incise the anterior lens capsule (capsulotomy) in ECCE; also used for can-opener capsulotomy

22. Keratome (Angular Keratotome)

• Angled knife for creating clear corneal incisions

23. Von Graefe's Cataract Knife

• Classic knife for ECCE incision; now largely replaced by phaco needles

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PROBES & DILATORS

24. Bowman's Lacrimal Probe

• Flexible silver probe in graduated sizes
• Use: Probing (syringing) blocked nasolacrimal duct; especially in infants with congenital dacryostenosis

25. Nettleship's Punctum Dilator

• Conical metal dilator
• Use: Dilate the lacrimal punctum before syringing or lacrimal surgery

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MISCELLANEOUS HIGH-YIELD INSTRUMENTS

26. Lens Loop / Vectis (Wire Vectis)

• Loop of wire on a handle
• Use: To extract cataract nucleus during ECCE; slides under the nucleus to deliver it

27. Iris Repositor / Iris Spatula

• Flat, blunt spatula
• Use: To reposition the iris, separate synechiae, protect the iris during surgery

28. Rougine

• Curved, flat, blunt dissector
• Use: Blunt dissection of lacrimal sac during DCR; elevation of periosteum

29. Lang's Lacrimal Dissector with Scoop

• Double-purpose instrument
• Use: Blunt dissection and cleaning during DCR

30. Foreign Body Spud / Needle

• Use: Remove superficial corneal foreign bodies; the spud end for metal particles

31. Callipers

• Measuring instrument for precise distances
• Use: Measuring surgical incision size, IOL positioning, extraocular muscle surgery

32. Retinoscope

• Streak or spot illumination instrument
• Use: Objective refraction to determine refractive error

33. Direct Ophthalmoscope

• Use: Examination of fundus; gives ~15x magnification; monocular image; field of view ~2 disc diameters
• Important: No stereopsis

34. Indirect Ophthalmoscope (Binocular Indirect Ophthalmoscope - BIO)

• Head-mounted light source + condensing lens (20D, 28D, 30D)
• Inverted, real image
• Larger field of view (~8 disc diameters with 20D lens)
• Better for peripheral retina, detachments, neonatal exams
• Allows scleral indentation

35. Slit Lamp (Biomicroscope)

• Used with various lenses for anterior and posterior segment examination

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GLAUCOMA-SPECIFIC INSTRUMENTS

36. Goldmann Applanation Tonometer

• Gold standard for IOP measurement
• Uses fluorescein + cobalt blue light
• Measures force needed to flatten (applanate) 3.14 mm area of cornea
• Imbert-Fick law principle

37. Gonioscope (Goldmann, Zeiss, Volk)

• Used with slit lamp to visualize the iridocorneal angle
• Direct gonioscopy (Koeppe) vs indirect (Goldmann 3-mirror)
• Critical for classifying open vs. closed angle glaucoma

38. Pachymeter

• Ultrasonic or optical device
• Measures central corneal thickness (CCT)
• Important in glaucoma risk assessment and tonometry correction

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PART 3: PERIMETRY AND HFA (HUMPHREY FIELD ANALYZER)

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VISUAL FIELD EXAMINATION - OVERVIEW

1. Confrontation visual fields (bedside, clinical screening)
2. Kinetic perimetry (Goldmann)
3. Static automated perimetry (HFA, Octopus) - most used clinically
4. Frequency-doubling technology (FDT) perimetry

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GOLDMANN KINETIC PERIMETRY

• Principle: Uses moving targets of varying size and intensity to map isopters
• Bowl: Hemispherical, white, background illuminance 1000 asb (apostilbs)
• Targets: Circular stimuli varying in size (I-V) and intensity (1-4)
  • Size: I (smallest, 0.25 mm²) to V (largest, 64 mm²)
  • Intensity/Filter: 1 (dimmest) to 4 (brightest)
• Isopter: Line connecting points where target becomes visible as it moves from non-seeing to seeing area
• Named stimuli: Written as e.g., V4e (Roman numeral = size, number = intensity, lowercase letter = filter)
• Advantages: Full field assessment including far periphery; useful in neurological conditions; patient interaction helps reliability
• Disadvantages: Requires skilled perimetrist; time-consuming; not standardized easily

Classic patterns:

• Physiological blind spot: Temporal to fixation (~15° temporal); corresponds to optic disc
• Central scotoma: Optic nerve/macula pathology
• Arcuate scotoma: Glaucoma
• Bitemporal hemianopia: Chiasmal lesion
• Homonymous hemianopia: Post-chiasmal lesion

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STANDARD AUTOMATED PERIMETRY (SAP) - HFA

Humphrey Field Analyzer (HFA) - Carl Zeiss Meditec

• Patient seated at chin rest in center of testing bowl
• Near refractive correction placed in the instrument
• Contralateral eye occluded
• Patient presses button when they see the stimulus
• Background illuminance: 31.5 asb (standard)
• Stimulus size: Goldmann III (most common), 0.43° diameter
• Stimulus duration: 200 milliseconds

Testing Programs:

Threshold Algorithms:

HFA Printout - Key Parameters (MUST KNOW):

• Compares each point to age-matched normals
• Shows total sensitivity loss

• Corrects for generalized depression (e.g., cataract)
• Shows focal defects; more specific for glaucoma
• More reliable for detecting glaucomatous damage

Classic Glaucomatous Visual Field Defects:

1. Nasal step - abrupt step at horizontal meridian in nasal field
2. Paracentral scotoma - near fixation
3. Arcuate (Bjerrum) scotoma - follows nerve fiber layer from blind spot to nasal meridian
4. Double arcuate / ring scotoma - superior + inferior arcuates join
5. Advanced glaucoma: Only central island + temporal island remain
6. End-stage: Total field loss (tunnel vision)

Artifact Recognition:

• Rim artifact: Upper field depression from spectacle frame
• Lens artifact: Central ring of depression
• Ptosis: Superior field depression
• Cataract/media opacity: Generalized depression (Total Deviation affected, Pattern Deviation often normal)

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FREQUENCY-DOUBLING TECHNOLOGY (FDT) PERIMETRY

• Tests magnocellular (M-cell) pathway
• Uses low spatial frequency, high temporal frequency grating
• Detects early glaucomatous loss
• Quick and portable; good screening tool

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PART 4: OPHTHALMIC MEDICATIONS (BROADER REVIEW)

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TOPICAL ANTIBIOTICS

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TOPICAL ANTIVIRALS

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TOPICAL ANTIFUNGALS

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TOPICAL CORTICOSTEROIDS

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TOPICAL NSAIDs

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MYDRIATICS AND CYCLOPLEGICS

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MIOTICS (DIAGNOSTIC)

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LUBRICANTS / ARTIFICIAL TEARS

• Hypromellose (hydroxypropyl methylcellulose) - standard tear substitute
• Carbomer gel (polyacrylic acid) - longer lasting
• Sodium hyaluronate drops - viscous, good retention
• Carmellose (CMC) - common OTC drops
• Lacrilube / Vit-A-Pos ointment - severe dry eye, nocturnal use

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INTRAVITREAL INJECTIONS (ANTI-VEGF)

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PART 5: SYSTEMIC OPHTHALMOLOGY

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DIABETES MELLITUS - Ocular Manifestations

1. Diabetic Retinopathy (DR)

• Mild NPDR: Microaneurysms only
• Moderate NPDR: Microaneurysms + dot-blot hemorrhages + hard exudates + cotton wool spots
• Severe NPDR (4-2-1 Rule):
  • 4 quadrants of retinal hemorrhages, OR
  • 2 quadrants of venous beading, OR
  • 1 quadrant of intraretinal microvascular abnormalities (IRMA)

• New vessels on disc (NVD) or elsewhere (NVE)
• Vitreous hemorrhage
• Tractional retinal detachment
• Neovascular glaucoma (rubeosis iridis)

2. Other Ocular Manifestations of DM:

• Cataract: Earlier onset "snowflake" (sorbitol accumulation); more common posterior subcapsular
• Cranial nerve palsies: III (with pupil sparing - diabetic mononeuropathy), IV, VI
• Refractive changes: Hyperglycemia → myopia (lens swelling); hyperopia when glucose drops
• Rubeosis iridis (NVI): Neovascularization of iris → neovascular glaucoma
• Increased susceptibility to infections: Orbital cellulitis, mucormycosis

Treatment of DR:

• Control of systemic risk factors (HbA1c, BP, lipids)
• Laser photocoagulation: Pan-retinal photocoagulation (PRP) for high-risk PDR/severe NPDR
• Anti-VEGF intravitreal (ranibizumab, bevacizumab, aflibercept): DME, proliferative DR
• Vitrectomy: Vitreous hemorrhage not clearing, tractional detachment

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HYPERTENSION - Ocular Manifestations

Hypertensive Retinopathy (Keith-Wagener-Barker Classification):

• Central/branch retinal artery occlusion (CRAO/BRAO)
• Central/branch retinal vein occlusion (CRVO/BRVO)
• Accelerated/malignant hypertension → choroidal ischemia (Elschnig's spots)

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THYROID EYE DISEASE (Graves' Ophthalmopathy / TED)

Clinical Features (NOSPECS / CAS classification):

• Dalrymple's sign - lid retraction
• Von Graefe's sign - lid lag on downgaze
• Stellwag's sign - infrequent blinking
• Joffroy's sign - no wrinkling on upgaze
• Moebius sign - convergence weakness

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RHEUMATOID ARTHRITIS

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SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

• Dry eye (similar to RA)
• Retinal vasculitis - cotton wool spots from ischemia (lupus retinopathy)
• Retinal vein/artery occlusions
• Scleritis, episcleritis
• Hydroxychloroquine toxicity (bull's-eye maculopathy) - screening needed

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SARCOIDOSIS

• Anterior uveitis (most common ocular manifestation)
• Posterior uveitis: "candle-wax drippings" (periphlebitis)
• Conjunctival nodules (biopsy diagnostic)
• Lacrimal gland involvement (dry eye)
• Optic nerve granuloma
• Band keratopathy (chronic hypercalcemia)

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HIV/AIDS

• CMV retinitis (most common serious ocular manifestation in AIDS)
  • CD4 < 50 cells/μL
  • "Pizza-pie / tomato-ketchup" appearance (hemorrhagic necrosis)
  • Treatment: Ganciclovir IV/oral, valganciclovir, foscarnet, cidofovir
• HIV retinopathy: Cotton wool spots (most common)
• Toxoplasma chorioretinitis ("headlight in fog")
• Pneumocystis choroidopathy
• Herpes zoster ophthalmicus (HZO)
• Molluscum contagiosum eyelids

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TUBERCULOSIS

• Choroiditis / subretinal granuloma (tuberculoma)
• Anterior uveitis (granulomatous)
• Optic neuritis
• Interstitial keratitis (Cogan's syndrome - actually syphilis but TB can cause IK too)
• Scleritis, episcleritis

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MULTIPLE SCLEROSIS

• Optic neuritis - most common presentation; unilateral vision loss, RAPD, pain on eye movement
• Internuclear ophthalmoplegia (INO) - MLF lesion; adduction failure + contralateral nystagmus
• Uveitis (rare)
• Nystagmus

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DRUG-INDUCED OCULAR TOXICITY (HIGH-YIELD)

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PART 6: COMMUNITY OPHTHALMOLOGY

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DEFINITIONS (KEY TERMS)

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GLOBAL BURDEN OF BLINDNESS

• ~43 million people blind worldwide (2020)
• ~295 million with moderate/severe visual impairment
• >80% of blindness is avoidable (preventable or treatable)
• >90% of blind people live in low/middle-income countries (LMICs)

Main Causes of Blindness (Global):

1. Cataract - ~47-51% (leading cause; treatable)
2. Glaucoma - ~12% (preventable/treatable)
3. Age-related macular degeneration - ~8-9%
4. Corneal opacity - ~5%
5. Diabetic retinopathy - ~4-5%
6. Childhood blindness - ~4%
7. Trachoma - ~3-4% (infectious; preventable)
8. Onchocerciasis (river blindness) - ~1%
9. Vitamin A deficiency - declining due to supplementation programs

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VISION 2020 - THE RIGHT TO SIGHT

• Launched: 1999 jointly by WHO + IAPB (International Agency for Prevention of Blindness)
• Goal: Eliminate avoidable blindness by year 2020
• Target diseases: Cataract, trachoma, onchocerciasis, childhood blindness, refractive errors, low vision
• Later additions: Glaucoma, diabetic retinopathy
• Three pillars: Disease control, human resource development, infrastructure/technology

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TRACHOMA

• Cause: Chlamydia trachomatis (serovars A, B, C) - obligate intracellular organism
• Most common infectious cause of blindness globally
• Transmission: Direct contact (eye-to-eye), flies, fomites
• Reservoir: Children (active infection); adults suffer from scarring complications

WHO/FWHO Grading (MacCallan Classification):

SAFE Strategy (WHO):

• S - Surgery (trichiasis correction - bilamellar tarsal rotation)
• A - Antibiotics (azithromycin single dose 20 mg/kg OR tetracycline ointment 6 weeks)
• F - Facial cleanliness
• E - Environmental improvement (sanitation, water)

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VITAMIN A DEFICIENCY (VAD)

• Leading cause of preventable blindness in children
• Sequence: Night blindness → Xerophthalmia → Corneal ulcer → Keratomalacia → blindness/death

Xerophthalmia Classification (WHO):

Treatment:

• < 6 months: 50,000 IU Vitamin A orally on Days 1, 2, and 14
• 6-12 months: 100,000 IU same schedule
• > 12 months: 200,000 IU same schedule
• Treat underlying malnutrition, measles

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ONCHOCERCIASIS (River Blindness)

• Cause: Onchocerca volvulus (filarial worm); transmitted by Simulium blackflies
• Ocular features: Punctate keratitis → sclerosing keratitis; anterior uveitis; chorioretinitis; optic atrophy
• Treatment: Ivermectin (kills microfilariae; does not kill adult worms)
• Control: Vector control (insecticides in rivers) + mass drug administration

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DIABETIC RETINOPATHY SCREENING

• Screen all type 2 diabetics at diagnosis; type 1 diabetics after 5 years
• Annual dilated fundal examination
• National Diabetic Retinopathy screening programs in many countries

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REFRACTIVE ERRORS

• Most common cause of visual impairment worldwide (easily correctable)
• Uncorrected refractive error: Major public health problem
• School eye health programs: Vision screening for children
• Myopia epidemic: Major concern, especially in East Asia

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CATARACT - PUBLIC HEALTH ASPECTS

• Leading cause of blindness globally and in most developing countries including India
• Cataract Surgical Rate (CSR): Number of cataract operations per million population per year
  • Target: >3000/million/year for reducing cataract blindness
  • India: varies by state; national average improving
• Barriers to uptake: Cost, lack of awareness, no perceived need, transport, fear of surgery, poor quality outcomes

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NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS (NPCB) - INDIA

• Launched: 1976 (7th Five-Year Plan)
• Later renamed: National Programme for Control of Blindness and Visual Impairment (NPCBVI)
• Target: Reduce prevalence of blindness from 1.4% to 0.3%
• Activities:
  • Cataract surgery (free of cost at government centers)
  • School eye health screening
  • Corrective glasses for school children
  • Vitamin A supplementation
  • Trachoma control
  • Diabetic retinopathy management
  • Low vision services

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SCHOOL EYE HEALTH PROGRAM

• Vision screening for myopia (most common refractive error in children)
• Use of Snellen chart / "E" chart for illiterates
• Referral for glasses or further evaluation
• Screening tests: Visual acuity 6/6, cover test, color vision (Ishihara)

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NATIONAL BLINDNESS SURVEY - INDIA

• Rapid Assessment of Avoidable Blindness (RAAB) surveys
• Prevalence of blindness in India: ~1.1-1.4%
• Leading causes in India: Cataract (~66%), refractive errors, glaucoma, corneal blindness

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QUICK REVISION CHEAT SHEET

Anti-Glaucoma Drug Mnemonics:

• First line: Prostaglandin (once at night) → Beta-blocker → Add CAI → Add Alpha-2 agonist → Add Pilocarpine
• Acute angle-closure: Pilocarpine 2% + Acetazolamide IV + Timolol + IV/Oral Mannitol → Definitive: Laser PI
• Never use 2 PGAs together (paradoxical IOP rise)
• Beta-blocker contraindicated in: Asthma, heart block, bradycardia
• Brimonidine contraindicated in: Infants/children (CNS apnea)
• CAI (systemic) side effect: "Pins and needles" (paraesthesia) - most common

HFA Key Numbers:

• MD < -6 dB = Early glaucoma
• MD -6 to -12 dB = Moderate glaucoma
• MD > -12 dB = Advanced glaucoma
• Fixation loss < 20% = Reliable
• False positive < 15% = Reliable

Instruments 5-Second ID:

• Chalazion clamp = Ring + plate → chalazion surgery
• Evisceration scoop = Blunt spoon → scoops intraocular contents
• Corneoscleral scissors = Spring scissors → extends corneoscleral incision
• Two-way cannula = Double lumen → irrigation + aspiration in cataract surgery
• Lacrimal cannula = Curved needle-sized → NLD syringing

Community Ophthalmology Numbers:

• Blindness: < 3/60 BCVA (WHO)
• 80% blindness avoidable
• SAFE = trachoma strategy
• First cause blindness globally: Cataract (47%)
• VISION 2020: WHO + IAPB; 1999; eliminate avoidable blindness

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What's Included (6 Major Sections):

• 7 drug classes: Prostaglandins, Beta-blockers, Alpha-2 agonists, CAIs (topical + systemic), Miotics, Osmotics, ROCK inhibitors
• Each drug: Class, MOA, specific agents + doses, indications, contraindications, side effects
• Combination drugs table (Cosopt, Combigan, Simbrinza, etc.)

• Chalazion clamp, Evisceration scoop (Mules), Corneoscleral scissors, Two-way irrigation-aspiration cannula, Lacrimal cannula, Chalazion scoop, Wire vectis, Cystotome, Bowman's probe, Rougine, and many more
• Each: appearance, use, key distinguishing feature

• Goldmann kinetic perimetry (principles, isopters, stimuli naming)
• HFA - testing programs (24-2, 30-2, 10-2), SITA algorithms
• Printout interpretation: MD, PSD, GHT, VFI, total/pattern deviation maps, reliability indices
• Glaucomatous field defect patterns

• Antibiotics, antivirals, antifungals, steroids, NSAIDs, mydriatics/cycloplegics, anti-VEGF agents, lubricants

• Diabetic retinopathy (NPDR/PDR grading), hypertensive retinopathy (KWB grades), thyroid eye disease, RA, SLE, sarcoidosis, HIV, TB, MS
• Drug-induced ocular toxicity table

• WHO blindness definitions, global burden, VISION 2020, trachoma (SAFE strategy), Vitamin A deficiency/xerophthalmia grading, onchocerciasis, NPCB India

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OPHTHALMOLOGY PRACTICAL EXAM

Complete Case Presentations: Cataract | Mature Senile Cataract | Pseudophakia | Aphakia

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HOW TO APPROACH ANY CASE AT THE STATION

"On examination of this patient..."

1. History (brief, relevant) - chief complaint, duration, relevant history
2. Visual Acuity - distance, near, with and without correction
3. Torch/Penlight examination - external eye, cornea, pupil, iris, red reflex
4. Slit Lamp Examination (anterior segment - systematic)
5. Posterior Segment - fundus, if applicable
6. Special Tests / Investigations
7. Diagnosis
8. Management

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CASE 1: MATURE SENILE CATARACT

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PRESENTING HISTORY (to tell the examiner)

• Gradual, painless diminution of vision in [right/left/both eyes] for [duration]
• Patient was initially able to see but vision has been progressively worsening
• Patient complains of:
  • Difficulty in daily activities (reading, recognizing faces)
  • Glare from headlights and sunlight
  • Difficulty seeing in low-light conditions
  • Initially had frequent change of spectacle prescription
  • No pain, no redness, no discharge
• No history of trauma, diabetes, steroids use (or if present, note it)"*

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VISUAL ACUITY

Key for examiner: "The visual acuity is markedly reduced to perception of light with accurate projection of rays in all four quadrants, confirming the retina is functioning - this is essential before planning surgery."

Inaccurate projection of rays = contraindication to surgery (suggests posterior segment pathology)

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TORCH/PENLIGHT EXAMINATION

• Cornea: Clear, transparent - no vascularization, no edema
• Anterior chamber: Deep (in most cases), no cells or flare visible
• Pupil: Round, regular, reacting to light (direct and consensual - check!)
• RAPD: Absent (if present, suggests posterior segment disease)
• Iris: Normal architecture; no neovascularization
• Lens: "The lens appears completely white/opaque on torch examination"
  • Leukocoria visible - white pupil reflex
  • No fundal glow (absent red reflex) - because the mature cataract completely blocks the red reflex

KEY CLINICAL FINDING to say loudly: "There is absent red reflex in this eye, and the pupillary area appears white - consistent with a mature cataract."

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SLIT LAMP EXAMINATION (Anterior Segment)

• Clear, transparent
• No Descemet's folds, no bullae
• No corneal guttae
• Normal thickness (confirm with Van Herick: anterior chamber angle appears open)

• Deep and quiet
• No cells, no flare (grade 0)
• In phacomorphic glaucoma: AC would be shallow due to swollen lens

• Normal architecture, regular pupil margin
• No rubeosis (neovascularization of iris)
• No posterior synechiae

"On slit lamp examination with a narrow slit beam directed at the lens, the entire lens appears uniformly white and opaque, consistent with a MATURE SENILE CATARACT."

• Entire lens is opacified - no clear zones visible
• No shadows on transillumination (compare with immature cataract where you get a shadow of the iris on the opaque lens)
• Shadow test (Oblique illumination test):
  • Shine torch obliquely from the temporal side
  • Immature cataract → crescent-shaped iris shadow visible on the lens
  • Mature cataract → NO shadow (lens uniformly opaque; shadow absent)
• Lens surface may appear somewhat wrinkled in hypermature cataract

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SPECIAL TESTS

• Shine penlight from the side at 45°
• Mature cataract → No shadow (the iris shadow does not fall on the lens because the lens is completely white - the shadow cannot be seen)
• Immature: shadow present (clear cortex remains)

• Using direct ophthalmoscope at arm's length
• Mature cataract → Absent red reflex (the opaque lens blocks fundal reflection)

• Test in 4 quadrants (UP, DOWN, TEMPORAL, NASAL)
• Ask patient: "From which direction is light coming?"
• Must be positive in all 4 quadrants before surgery
• Absent projection → retinal dysfunction → modify surgical planning / prognosis

• Performed when fundus cannot be visualized
• Checks: posterior vitreous detachment, retinal detachment, vitreous opacities, posterior staphyloma, intraocular foreign body
• Normal B-scan = proceed with surgery

• For IOL power calculation
• Using SRK-T formula (most common), Holladay, Haigis formula
• Target: emmetropia or slight myopia

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DIAGNOSIS

• Gradual painless diminution of vision
• Absent red reflex
• Completely opaque, white lens on slit lamp examination
• Absent shadow on oblique illumination
• Positive projection of rays in all four quadrants

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DIFFERENTIAL DIAGNOSIS

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MORPHOLOGICAL STAGES OF SENILE CATARACT (MUST KNOW):

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TYPES OF SENILE CATARACT:

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MANAGEMENT

• Visual acuity, PL/PR, color perception
• Keratometry + biometry (IOL power calculation - SRK-T formula)
• B-scan (if fundus not visible)
• Corneal endothelial cell count (specular microscopy)
• Blood sugar, BP, CBC (if GA needed)
• Dilated fundus examination of fellow eye

• Topical antibiotic + steroid combination (e.g., moxifloxacin + dexamethasone TDS for 4 weeks)
• NSAID drops (prevent CME)
• Review at 1 day, 1 week, 4 weeks
• Refraction and glasses at 6-8 weeks

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CASE 2: PSEUDOPHAKIA (Patient who had cataract surgery with IOL implant)

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DEFINITION

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HISTORY

• Patient reports improved vision post-surgery
• May complain of: glare, halos, dysphotopsia (especially at night)
• OR: gradual re-blurring of vision (posterior capsule opacification)
• No pain, no discharge"

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VISUAL ACUITY

Key point for examiner: "The patient will require reading glasses as the IOL is monofocal and does not accommodate."

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TORCH EXAMINATION

• Cornea: Scar/wound at limbus (temporal clear corneal incision - barely visible) or superior corneal scar if ECCE
• Anterior Chamber: Deep and quiet
• Pupil: Round, reacting to light; may be slightly irregular if synechiae present
• RAPD: Absent (should be)
• Red Reflex:

  "On torch examination, a BRIGHT RED REFLEX is present, indicating a clear optical media"

  • The red reflex is markedly brighter and clearer than a normal phakic eye
  • The IOL has no accommodation, so there is no "accommodative darkening" of the reflex
• IOL reflexes (Purkinje images):
  • 4th Purkinje image from the anterior face of the lens is absent in pseudophakia (the IOL's anterior surface gives a different reflex pattern)

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SLIT LAMP EXAMINATION

• Clear; may see a small, self-sealing wound scar at limbus (temporal or superior)
• Wound is sutured (ECCE) or sutureless (phaco/SICS)
• No corneal edema in uncomplicated cases
• If corneal edema present: suspect bullous keratopathy (Pseudophakic Bullous Keratopathy - PBK)

• Deep and quiet - usually deeper than a phakic eye (IOL is thinner than natural lens)
• No cells or flare
• Angle is typically open

• May show peripheral iridotomy (PI) if performed previously
• Gentle tremulousness (mild iridodonesis) may be present if zonular dehiscence occurred during surgery

"On slit lamp examination, the lens capsule is present (as the surgery was extracapsular - ECCE or phacoemulsification). Within the capsular bag, a clear artificial intraocular lens is visible."

• Position: In the capsular bag (most common) or in the sulcus / anterior chamber
• Optic: Clear, round
• Haptics: May be visible at the edge of the pupil (curved, flexible haptics)
• IOL markings: Some IOLs have manufacturer's markings
• Reflections: Two bright reflections (from anterior and posterior surface of IOL) seen with slit lamp
• IOL type:
  • Posterior chamber IOL (PCIOL) in capsular bag - standard
  • Sulcus IOL - sits in the ciliary sulcus
  • Anterior chamber IOL (ACIOL) - in anterior chamber, supported by angle (older type)

"The posterior capsule appears [clear / hazy with Elschnig's pearls / fibrotic]."

• Clear posterior capsule = uncomplicated pseudophakia
• Posterior Capsule Opacification (PCO) = the most common late complication of cataract surgery
  • White pearl-like opacities (Elschnig's pearls) on the posterior capsule
  • Results from proliferation of residual lens epithelial cells
  • Occurs in 10-50% of patients within 3-5 years
  • Causes: gradually worsening vision, glare
  • "The posterior capsule shows Elschnig's pearls / fibrotic changes, consistent with posterior capsule opacification (PCO)."

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SPECIAL TESTS FOR PSEUDOPHAKIA

• Bright and uniform in uncomplicated pseudophakia
• Reduced or absent if PCO present

• Performed with slit lamp
• PCO: opaque areas visible on retroillumination against the red reflex

• Treatment: Nd:YAG laser posterior capsulotomy
• Creates a central opening in the opaque posterior capsule
• Immediate restoration of vision
• Risk: elevated IOP, CME, IOL damage, rare retinal detachment

• Dilated fundoscopy to rule out:
  • CME (cystoid macular edema)
  • Retinal detachment (risk is higher post-cataract surgery)
  • Diabetic maculopathy (if diabetic)

• If patient has unexpected refractive error post-surgery

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DIAGNOSIS

• History of cataract surgery
• Bright red reflex on torch examination
• Corneal wound scar at limbus
• Deep, quiet anterior chamber
• Clear intraocular lens visible within the capsular bag on slit lamp examination
• [Clear / Hazy] posterior capsule

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COMPLICATIONS OF CATARACT SURGERY (TO KNOW FOR VIVA):

• Posterior capsule rupture with vitreous loss
• Expulsive choroidal hemorrhage (rare but catastrophic)
• Dropped nucleus

• Corneal edema
• Striate keratopathy
• Anterior uveitis
• Elevated IOP (viscoelastic retained)
• Wound leak (Seidel test positive)
• Hyphema

• PCO - most common (Nd:YAG laser capsulotomy)
• Pseudophakic bullous keratopathy (PBK)
• Cystoid macular edema (Irvine-Gass syndrome)
• IOL dislocation / decentration
• Retinal detachment (especially in high myopes)
• Endophthalmitis (rare but vision-threatening)
• Glaucoma (secondary)

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CASE 3: APHAKIA (Lens absent - No IOL implanted)

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DEFINITION

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CAUSES OF APHAKIA

1. Post-surgical - ICCE (old technique where entire lens + capsule was removed), or ECCE/phaco complicated by posterior capsule rupture without IOL implantation
2. Traumatic - lens expelled through a penetrating wound
3. Congenital - primary (lens never formed) or secondary (absorption)
4. Spontaneous subluxation/dislocation - Marfan's, homocystinuria

In your exam, it is most likely a post-surgical aphakia (elderly patient who had ICCE done many years ago before IOL era)

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HISTORY

• Has markedly reduced vision without glasses
• Wears thick aphakic spectacles / contact lenses
• Complains of 'Jack-in-the-box phenomenon' (ring scotoma with aphakic glasses)
• May complain of difficulty with spatial perception"

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VISUAL ACUITY

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TORCH EXAMINATION

• Cornea: Scar at limbus
  • If ICCE: large superior limbal scar (corneoscleral incision)
  • If ECCE without IOL: similar limbal scar
  • Sutures may still be visible (interrupted or continuous nylon sutures)
• Anterior Chamber: Typically DEEP (without a lens, the AC is much deeper than normal)
• Iris:
  • IRIDODONESIS - characteristic trembling/quivering of the iris on eye movement
  • Normally, the lens supports the iris; without the lens, the iris wobbles
  • Ask the patient to move their eyes quickly - observe iris trembling
  • "On asking the patient to make rapid saccadic eye movements, trembling of the iris is noted - this is called IRIDODONESIS and is a sign of aphakia."
• Pupil: Round; may have a surgical peripheral iridectomy (PI) visible - small notch in the iris at the limbus (done in ICCE to prevent pupillary block)
• Red Reflex:

  "On torch/direct ophthalmoscope examination, there is a BRIGHTLY ENHANCED RED REFLEX - much brighter than normal, because there is no lens to attenuate the fundal reflection."

  • The red reflex in aphakia is very bright and uniform
  • This is opposite to cataract (where red reflex is absent)

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SLIT LAMP EXAMINATION

• Old limbal scar (superior in ICCE)
• May have interrupted nylon sutures if old ECCE
• Clear cornea in center typically
• Check for: bullous keratopathy (PBK - can occur after ICCE)

• DEEP ANTERIOR CHAMBER - the AC is noticeably deeper without the lens occupying posterior chamber
• Quiet - no cells or flare (if no inflammation)

• May have a peripheral iridectomy (small pie-shaped notch at superior limbus)
  • PI was routinely done with ICCE to prevent pupillary block glaucoma
• Iridodonesis (trembling) with slit lamp visible
• Normal vasculature, no rubeosis

"On slit lamp examination with the narrow slit beam directed into the pupillary area, there is a complete absence of the crystalline lens. The posterior capsule is also absent (in ICCE, entire lens including capsule was removed). The vitreous face is visible anteriorly."

• No lens material visible in any plane
• No capsular bag visible
• Vitreous can be seen bulging forward (anterior hyaloid face)
• In ECCE without IOL: Posterior capsule remnant may still be present; it differentiates from ICCE

• Anterior hyaloid face visible through the pupil
• Vitreous herniation into AC may occur (can cause corneal touch)

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SPECIAL TESTS

• Ask patient to make quick horizontal eye movements
• Positive iridodonesis = aphakia (or subluxated lens)

• Normal phakic eye: 4 Purkinje images (reflections from corneal surfaces and both lens surfaces)
• Aphakia: Only 2 Purkinje images (from cornea only; lens images absent)
• Pseudophakia: 3-4 images (depends on IOL type)
• Examiner's test: shine penlight toward patient's eye and count reflections

• Brighter than normal in aphakia

• Reflex moves "with" the streak in high degrees (high hypermetropia +10 to +14 D)

• If media is clear, do dilated fundoscopy
• Look for: retinal detachment (higher risk after ICCE), macular degeneration, optic nerve changes

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REFRACTIVE CORRECTION IN APHAKIA

"Jack-in-the-box phenomenon": Objects suddenly appear as they enter through the ring scotoma of aphakic glasses - disturbing and disorienting for patients.

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DIAGNOSIS

• History of cataract surgery (ICCE) [X years ago]
• Poor unaided vision correctable with +10 to +12D convex lens
• Limbal scar with peripheral iridectomy
• Deep anterior chamber
• Iridodonesis
• Brilliant, enhanced red reflex
• Complete absence of lens and posterior capsule on slit lamp
• Only 2 Purkinje images

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QUICK COMPARISON TABLE: CATARACT vs PSEUDOPHAKIA vs APHAKIA

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VIVA QUESTIONS AND ANSWERS (MOST COMMONLY ASKED)

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Iridodonesis = trembling of the iris due to loss of support (aphakia, subluxated lens). Phacodonesis = trembling of the lens due to zonular weakness (subluxation). Both seen on rapid eye movements.

Penlight shone from temporal side at 45°. Crescent-shaped shadow seen on lens in IMMATURE cataract (clear cortex between iris and opacity reflects light). MATURE cataract: no shadow - the whole lens is opaque, no clear cortex to cast a shadow from the iris.

In hypermature cataract: the anterior capsule is wrinkled and shrunken due to leakage of water out. The lens may appear smaller. In Morgagnian cataract: cortex is completely liquefied and the brown/black nucleus sinks to the bottom - visible on slit lamp.

In nuclear sclerotic cataract, increased refractive index of the nucleus causes myopic shift, allowing elderly patients (previously hypermetropic) to read without glasses again temporarily.

Posterior Capsule Opacification (PCO) - occurs in 10-50% of patients over 3-5 years. Treated with Nd:YAG laser capsulotomy.

ECCE: Only nucleus and cortex removed; posterior capsule left intact; IOL placed in capsular bag. ICCE: Entire lens including capsule removed; IOL cannot be placed in capsular bag (must use ACIOL or scleral-fixated IOL); results in aphakia if no IOL.

SRK-T formula (most common for eyes of normal axial length). For very short eyes (<22 mm): Hoffer Q. For very long eyes (>26 mm): Haigis, SRK-T. Biometry performed using A-scan ultrasound or optical biometry (IOLMaster).

Occurs in patients on systemic alpha-1 blockers (e.g., tamsulosin for BPH). The iris is flaccid, billows under irrigation, and may prolapse through incision. The pupil also constricts intraoperatively. Must inform surgeon preoperatively.

A-scan biometry for axial length + Keratometry for corneal curvature. Power = A constant - (2.5 × axial length) - (0.9 × K reading). For emmetropia, target = 0 D.

In aphakic spectacle correction: due to the strong convex lens and ring scotoma, objects suddenly "pop into" view as they enter the visual field through the ring scotoma - disorienting for the patient. Not seen with contact lenses or IOLs.

Clear IOL in capsular bag, bright red reflex, deep quiet anterior chamber, small limbal scar, possibly PCO, IOL haptics visible at pupil margin.

Purkinje I: Corneal anterior surface (upright); Purkinje II: Corneal posterior surface (upright, dimmer); Purkinje III: Lens anterior surface (upright); Purkinje IV: Lens posterior surface (inverted, brightest, used for gonioscopy lenses). Aphakia: Only P-I and P-II (2 images). Pseudophakia: Depends on IOL (usually 3 images).

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HOW TO PRESENT AT THE STATION - SCRIPT

For MATURE SENILE CATARACT:

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Summary of What's in This Guide

1. Mature Senile Cataract - the full workup including shadow test, absent red reflex, B-scan, IOL calculation, surgical options (phaco vs ECCE vs SICS)
2. Pseudophakia - signs of IOL in situ, posterior capsule assessment, PCO, YAG capsulotomy, complications
3. Aphakia - iridodonesis, brilliant red reflex, deep AC, 2 Purkinje images, limbal scar + PI, aphakic correction (+10-12D), Jack-in-the-box phenomenon
4. Cataract types - PSC vs Nuclear vs Cortical vs mature/hypermature/Morgagnian with distinguishing features

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The 3 Most Exam-Critical Points to Memorize Right Now