Which version should I prepare first for tomorrow?

ophthalmology education AND viva

American Academy Ophthalmology clinical statements preferred practice pattern ophthalmology 2025

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mkdir -p "/tmp/workspace/ophthalmology-viva-pdf/src" "/tmp/workspace/ophthalmology-viva-pdf/output" && python - <<'PY' from pathlib import Path p=Path('/tmp/workspace/ophthalmology-viva-pdf/src/generate.py') p.write_text(r'''from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, PageBreak, Table, TableStyle, KeepTogether from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.lib.colors import HexColor from reportlab.pdfbase.pdfmetrics import stringWidth from pathlib import Path OUT='/tmp/workspace/ophthalmology-viva-pdf/output/Ophthalmology_Postgraduate_VIVA_Rapid_Revision.pdf' navy=HexColor('#12334A'); blue=HexColor('#1976A8'); pale=HexColor('#EAF4F8'); red=HexColor('#A62323'); green=HexColor('#2F6B4F'); grey=HexColor('#555555') styles=getSampleStyleSheet() styles.add(ParagraphStyle(name='CoverTitle', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=27, leading=33, textColor=navy, alignment=TA_CENTER, spaceAfter=14)) styles.add(ParagraphStyle(name='CoverSub', parent=styles['Normal'], fontSize=13, leading=18, textColor=grey, alignment=TA_CENTER)) styles.add(ParagraphStyle(name='H1x', parent=styles['Heading1'], fontName='Helvetica-Bold', fontSize=17, leading=22, textColor=navy, spaceBefore=8, spaceAfter=9, keepWithNext=True)) styles.add(ParagraphStyle(name='H2x', parent=styles['Heading2'], fontName='Helvetica-Bold', fontSize=11.5, leading=15, textColor=blue, spaceBefore=8, spaceAfter=5, keepWithNext=True)) styles.add(ParagraphStyle(name='Bodyx', parent=styles['BodyText'], fontSize=8.75, leading=11.6, spaceAfter=4)) styles.add(ParagraphStyle(name='Small', parent=styles['BodyText'], fontSize=7.7, leading=9.4, textColor=grey)) styles.add(ParagraphStyle(name='QA', parent=styles['BodyText'], fontSize=8.7, leading=11.5, leftIndent=0, spaceAfter=4)) def P(x, sty='Bodyx'): return Paragraph(x,styles[sty]) def bullet(items): return [P('• '+x,'Bodyx') for x in items] def table(headers, rows, widths=None): data=[[P(h,'Small') for h in headers]]+[[P(str(c),'Small') for c in row] for row in rows] t=Table(data, colWidths=widths, repeatRows=1, hAlign='LEFT') t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,0),navy),('TEXTCOLOR',(0,0),(-1,0),colors.white),('FONTNAME',(0,0),(-1,0),'Helvetica-Bold'),('VALIGN',(0,0),(-1,-1),'TOP'),('GRID',(0,0),(-1,-1),0.25,HexColor('#B8CDD7')),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,pale]),('LEFTPADDING',(0,0),(-1,-1),5),('RIGHTPADDING',(0,0),(-1,-1),5),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4)])) return t def section(title, intro=None): S.append(P(title,'H1x')) if intro:S.append(P(intro)) def h(title): S.append(P(title,'H2x')) def q(qn, ans): S.append(P('<b>Q. '+qn+'</b><br/><b>A.</b> '+ans,'QA')) def page(): S.append(PageBreak()) def footer(canvas,doc): canvas.saveState(); canvas.setStrokeColor(HexColor('#C3D8E1'));canvas.line(1.55*cm,1.28*cm,19.45*cm,1.28*cm) canvas.setFont('Helvetica',7.5);canvas.setFillColor(grey);canvas.drawString(1.55*cm,0.87*cm,'Ophthalmology Postgraduate VIVA - rapid revision') canvas.drawRightString(19.45*cm,0.87*cm,f'{doc.page}') canvas.restoreState() S=[] S += [Spacer(1,3.0*cm),P('OPHTHALMOLOGY','CoverTitle'),P('POSTGRADUATE VIVA<br/>RAPID REVISION','CoverTitle'),Spacer(1,0.6*cm),P('Definitions. core examination. differentials. emergencies. rapid-fire answers.','CoverSub'),Spacer(1,1.0*cm),P('<b>How to answer in VIVA:</b> Define -> classify -> give key differentiating signs -> state one urgent exclusion -> outline initial management. Do not give a long list before localizing the problem.','CoverSub'),Spacer(1,2.0*cm),P('Last-night revision aid. Check your institution protocol and current local drug formulations before clinical use.','CoverSub'),page()] section('1. THE OPENING MINUTE: HISTORY AND EXAMINATION','A structured examination earns marks even when the final diagnosis is uncertain.') h('History: use this sequence') S += bullet(['Presenting symptom: loss of vision, pain, redness, photophobia, discharge, diplopia, floaters/flashes, field defect or trauma.', 'Time course: sudden or gradual; constant or episodic; unilateral/bilateral; progression.', 'Vision symptom: central/peripheral, near/distance, monocular/binocular diplopia; positive phenomena such as flashes or halos.', 'Risk factors: diabetes, hypertension, autoimmune disease, tuberculosis/sarcoid risk, atopy, contact lenses, trauma, surgery, topical/systemic drugs and family history.', 'In a painful red eye: ask specifically about contact-lens wear, trauma/foreign body, reduced vision, photophobia, headache/nausea and herpes zoster.']) h('Core examination order') S += bullet(['Visual acuity in each eye separately: unaided, with correction and pinhole. Record CF/HM/PL/PR accurately if very poor.', 'External inspection and ocular motility. Pupils: size, equality, direct/consensual response and RAPD.', 'Confrontation fields; colour vision if optic neuropathy suspected.', 'Slit lamp: lids/lashes -> conjunctiva -> cornea with fluorescein -> anterior chamber -> iris -> lens.', 'IOP, only if open globe is not suspected. Gonioscopy when assessing glaucoma/angle pathology. Dilated fundus: disc, macula, vessels and peripheral retina.']) q('What does pinhole improvement mean?','It usually indicates an optical/refractive contribution to reduced acuity by reducing the blur circle. It does <b>not</b> exclude coexistent pathology; acuity may worsen in macular disease or posterior lens opacity.') q('Define RAPD.','A relative afferent pupillary defect is paradoxical dilation or less constriction when the light is swung to the affected eye. It indicates asymmetric afferent dysfunction, typically optic nerve disease or severe asymmetric retinal disease. It is not caused by cataract alone.') q('List red flags requiring immediate senior/urgent ophthalmic assessment.','Suspected open globe; chemical burn; acute angle closure; microbial keratitis, especially contact-lens wearer; endophthalmitis; retinal detachment symptoms; CRAO; giant-cell arteritis; orbital cellulitis; acute painful loss of vision.') page() section('2. BASIC OPTICS, REFRACTION AND INSTRUMENTS') h('Definitions that are commonly asked') q('Define emmetropia, myopia and hypermetropia.','<b>Emmetropia:</b> parallel rays focus on the retina with accommodation relaxed. <b>Myopia:</b> focus lies in front of retina, corrected with a concave (minus) lens. <b>Hypermetropia:</b> focus lies behind retina, corrected with a convex (plus) lens.') q('Define astigmatism.','Unequal refractive power in different meridia, commonly due to toricity of the cornea, producing two focal lines rather than one point focus. Regular astigmatism has perpendicular principal meridia; irregular astigmatism does not.') q('What is presbyopia?','Age-related loss of accommodative amplitude causing impaired near focus. It is corrected with plus near addition.') q('What is anisometropia?','A clinically meaningful difference in refractive state between the eyes. In children it may cause anisometropic amblyopia.') h('Instrument viva') S.append(table(['Instrument','Principle / key answer','Main use'],[ ['Direct ophthalmoscope','Upright virtual magnified image; small field, no stereopsis.','Disc and macula assessment.'], ['Indirect ophthalmoscope','Inverted real aerial image with condensing lens; wide field and stereopsis.','Peripheral retinal examination.'], ['Slit lamp','Focused stereoscopic illumination; optical section localizes corneal/anterior segment lesions.','Anterior segment, with lenses for posterior segment.'], ['Goldmann applanation tonometry','Imbert-Fick principle; force to flatten a standard corneal area.','Reference IOP method; affected by corneal properties.'], ['Gonioscopy','Contact lens overcomes total internal reflection at cornea-air interface.','Angle anatomy, pigmentation, PAS, neovascularization.'], ['OCT','Low-coherence interferometry yielding cross-sectional retinal/optic-nerve images.','Macula, RNFL and glaucoma monitoring.'], ['Fluorescein angiography','IV fluorescein demonstrates retinal circulation and leakage/blockage.','Diabetic retinopathy, macular oedema, vascular lesions.']], [3.1*cm,8.0*cm,6.3*cm])) h('Visual-field language') S += bullet(['<b>Scotoma:</b> localized area of depressed sensitivity within field. <b>Arcuate scotoma:</b> follows retinal nerve-fibre bundles, typical in glaucoma.', '<b>Bitemporal hemianopia:</b> chiasmal lesion. <b>Homonymous hemianopia:</b> retrochiasmal lesion. <b>Altitudinal defect:</b> classically NAION but also other optic nerve/retinal disease.']) page() section('3. RED EYE, CORNEA AND ANTERIOR UVEITIS') h('The painful red eye: differential by danger') S.append(table(['Condition','High-yield clues','First response'],[ ['Conjunctivitis','Diffuse injection, discharge, vision generally normal, no true photophobia.','Exclude corneal disease; hygiene/supportive or targeted treatment.'], ['Keratitis / corneal ulcer','Pain, photophobia, reduced vision, epithelial defect/infiltrate; contact lenses important.','Urgent slit lamp, corneal scrape when indicated, intensive antimicrobial therapy under ophthalmology.'], ['Anterior uveitis','Ciliary flush, consensual photophobia, cells/flare, small/irregular pupil.','Urgent assessment; topical steroid and cycloplegic only after excluding infective keratitis.'], ['Acute angle closure','Severe pain, headache/nausea, halos, cloudy cornea, mid-dilated fixed pupil, high IOP.','Immediate IOP lowering and definitive laser peripheral iridotomy when appropriate.'], ['Scleritis','Deep boring pain, violaceous non-blanching injection, systemic autoimmune association.','Urgent assessment and systemic work-up/treatment.'], ['Episcleritis','Sectoral superficial redness, mild discomfort, blanches with phenylephrine.','Usually benign, but recurrent disease warrants review.']], [3.2*cm,8.5*cm,5.7*cm])) q('Differentiate corneal ulcer from abrasion.','An abrasion is an epithelial defect with fluorescein staining but no stromal infiltrate. An ulcer is an epithelial defect with underlying stromal infiltrate/inflammation and may have anterior chamber reaction or hypopyon. Treat a suspected ulcer as urgent.') q('Define flare and cells in the anterior chamber.','<b>Cells</b> are circulating inflammatory cells seen in the slit beam. <b>Flare</b> is protein in aqueous from breakdown of the blood-aqueous barrier, producing a smoky beam (Tyndall phenomenon).') q('What is hypopyon?','Layered leukocytes in the anterior chamber. Differential includes severe infective keratitis, endophthalmitis, HLA-B27 uveitis and masquerade syndromes.') q('What are posterior synechiae?','Adhesions between posterior iris and anterior lens capsule, commonly after anterior uveitis. They can cause an irregular pupil and, if 360 degrees, pupillary block and iris bombe.') h('Corneal must-knows') S += bullet(['Fluorescein highlights epithelial defects. Herpes simplex epithelial keratitis usually gives branching dendrites with terminal bulbs; avoid topical corticosteroid in active epithelial HSV unless specialist-directed.', 'Herpes zoster ophthalmicus: ophthalmic division rash. Hutchinson sign increases risk of ocular involvement but absence does not exclude it.', 'Keratoconus: progressive corneal ectasia with irregular astigmatism, thinning and protrusion. Think of it in young patients with increasing irregular astigmatism or frequent prescription changes.']) page() section('4. GLAUCOMA') q('Define glaucoma.','A group of optic neuropathies characterized by progressive retinal ganglion-cell loss, optic-disc/RNFL changes and corresponding visual-field loss. IOP is an important, modifiable risk factor but glaucoma may occur at statistically normal IOP.') q('Differentiate ocular hypertension from glaucoma.','Ocular hypertension is raised IOP without characteristic optic neuropathy or field loss. Glaucoma requires structural optic nerve/RNFL damage and/or corresponding functional loss, with appropriate exclusion of mimics.') h('Primary open-angle glaucoma versus angle closure') S.append(table(['Feature','POAG','Acute angle closure'],[ ['Symptoms','Often asymptomatic until late.','Sudden pain, red eye, blurred vision/halos, headache, nausea.'], ['Angle','Open on gonioscopy.','Closed/narrow angle.'], ['Cornea/pupil','Usually clear cornea, normal pupil early.','Corneal oedema, shallow AC, mid-dilated poorly reactive pupil.'], ['Disc/field','Cupping and characteristic RNFL/field loss.','Disc assessment may be secondary acutely.'], ['Priority','Long-term IOP-lowering to target pressure.','Emergency IOP reduction, then eliminate pupillary block such as with LPI.']], [3.2*cm,7.0*cm,7.2*cm])) q('Describe glaucomatous disc changes.','Progressive cupping, vertical cup enlargement, focal rim notching, rim thinning especially inferior/superior, RNFL defects, disc haemorrhage, asymmetry and nasal displacement/bayoneting of vessels. The ISNT rule is supportive, not diagnostic.') q('What is the role of gonioscopy?','It classifies the angle as open, narrow or closed and looks for secondary mechanisms: peripheral anterior synechiae, pigment, pseudoexfoliative material, neovascularization, recession or a plateau iris configuration.') q('Name major topical glaucoma drug classes and key cautions.','Prostaglandin analogues increase uveoscleral outflow. Beta-blockers reduce aqueous production and can worsen asthma/COPD or bradycardia. Alpha-2 agonists reduce production/increase outflow. Carbonic anhydrase inhibitors reduce production. Miotics constrict pupil and increase trabecular outflow but are not appropriate in all mechanisms.') q('What is target IOP?','An individualized pressure at which further glaucomatous damage is unlikely, based on baseline IOP, severity, rate of progression, life expectancy and risk factors. It must be reassessed against disc/OCT/field progression.') page() section('5. LENS, CATARACT AND IOL') q('Define cataract.','Any opacity of the crystalline lens or its capsule that may reduce visual quality or acuity.') q('Classify age-related cataract.','Nuclear sclerosis, cortical cataract and posterior subcapsular cataract (PSC). PSC disproportionately affects near vision and glare, and is associated with steroids, diabetes, uveitis and radiation.') q('What is phacoemulsification?','Ultrasonic emulsification and aspiration of the lens through a small incision followed by posterior-chamber IOL implantation, usually into the capsular bag.') q('What is posterior capsular opacification?','Proliferation/migration of residual lens epithelial cells on the posterior capsule after cataract surgery. It causes gradual visual decline and is treated with Nd:YAG posterior capsulotomy when visually significant.') h('Postoperative cataract complications') S.append(table(['Timing','Complications to mention'],[ ['Early','Wound leak, corneal oedema, raised IOP, retained lens matter, toxic anterior segment syndrome, endophthalmitis.'], ['Intermediate','Cystoid macular oedema, uveitis, IOL decentration.'], ['Late','Posterior capsular opacification, retinal detachment, chronic pseudophakic problems.']], [3.5*cm,13.9*cm])) q('How do you recognize endophthalmitis after surgery/injection?','Pain, reduced vision, red eye, marked anterior chamber/vitreous inflammation and often hypopyon. Treat as an emergency: obtain samples when feasible without delaying prompt intravitreal antimicrobial therapy according to protocol.') q('Define aphakia and pseudophakia.','<b>Aphakia:</b> absence of crystalline lens. <b>Pseudophakia:</b> eye containing an artificial intraocular lens.') page() section('6. RETINA AND VITREOUS') h('Flashes, floaters and curtain: examiner favourite') q('What causes flashes and floaters?','Flashes usually arise from vitreoretinal traction. Floaters may arise from posterior vitreous detachment, vitreous haemorrhage, inflammation or debris. New flashes/floaters require dilated retinal examination to exclude a retinal tear/detachment.') q('Classify retinal detachment.','<b>Rhegmatogenous:</b> full-thickness break allows liquefied vitreous beneath retina. <b>Tractional:</b> fibrovascular membranes pull retina, commonly proliferative diabetic retinopathy. <b>Exudative:</b> subretinal fluid without break/traction due to inflammatory, vascular or neoplastic causes.') q('Macula-on versus macula-off detachment?','Macula-on detachment threatens central vision and needs urgent retinal intervention. In macula-off detachment, central acuity is already affected; urgency remains but timing is individualized by the retinal team.') h('Central retinal vascular occlusions') S.append(table(['Condition','Fundus / presentation','Immediate issue'],[ ['CRAO','Sudden profound painless monocular loss; retinal whitening with cherry-red spot may be seen.','Treat as an ocular stroke: urgent stroke/vascular evaluation and exclude GCA.'], ['CRVO','Painless reduced vision; diffuse retinal haemorrhages, venous tortuosity, disc oedema - “blood and thunder”.','Assess macular oedema, neovascularization and systemic vascular risks.'], ['Branch occlusion','Sectoral haemorrhage/ischemia in vascular territory.','Macular oedema/neovascularization and vascular risk control.']], [3.2*cm,8.3*cm,5.9*cm])) q('Define diabetic retinopathy terms.','<b>NPDR:</b> microaneurysms, haemorrhages, exudates, cotton-wool spots and venous changes without neovascularization. <b>PDR:</b> retinal/disc neovascularization and complications such as vitreous haemorrhage or tractional RD. <b>Diabetic macular oedema:</b> retinal thickening/fluid at macula, often assessed by OCT.') q('What is a cotton-wool spot?','A focal nerve-fibre-layer infarct from precapillary arteriolar occlusion, appearing as a superficial fluffy white lesion. It is not a lipid exudate.') q('Differentiate hard exudates from drusen.','Hard exudates are sharply demarcated yellow lipid deposits in the retina from chronic vascular leakage, often in diabetic disease. Drusen are extracellular deposits beneath the RPE, associated with ageing and AMD.') page() section('7. UVEITIS, SCLERITIS AND SYSTEMIC ASSOCIATIONS') q('Classify uveitis anatomically.','Anterior (iris/ciliary body), intermediate (vitreous/pars plana), posterior (choroid/retina) and panuveitis.') q('What is the difference between granulomatous and non-granulomatous anterior uveitis?','Granulomatous uveitis has large “mutton-fat” keratic precipitates and may occur with sarcoidosis, TB, syphilis and VKH. Non-granulomatous disease commonly has fine KPs and can be acute, recurrent and HLA-B27 associated. These patterns are not absolute.') q('Give systemic associations of acute anterior uveitis.','HLA-B27-associated spondyloarthritis, inflammatory bowel disease, psoriasis, reactive arthritis, sarcoidosis, TB, syphilis, juvenile idiopathic arthritis and infections depending on the presentation.') q('When should you investigate uveitis?','Tailor tests to phenotype, recurrence, severity and systemic clues. Do not order indiscriminate panels. Always consider syphilis and TB testing where clinically relevant, and investigate masquerade/infection before immunosuppression.') q('Differentiate scleritis from episcleritis.','Scleritis causes severe deep boring pain, deeper violaceous injection, possible reduced vision and systemic autoimmune associations; vessels do not blanch with topical phenylephrine. Episcleritis is usually sectoral, mildly tender and self-limiting.') page() section('8. NEURO-OPHTHALMOLOGY AND PUPILS') q('Define optic neuritis.','Inflammatory optic neuropathy, commonly with subacute unilateral painful visual loss, dyschromatopsia, central scotoma and RAPD. Disc may be normal in retrobulbar neuritis or swollen in papillitis. Atypical features require urgent alternative diagnosis assessment.') q('Differentiate papilloedema from optic disc swelling.','Optic disc swelling is a descriptive sign with many causes. <b>Papilloedema</b> specifically means disc swelling due to raised intracranial pressure, usually bilateral. It needs urgent neurologic evaluation.') q('What symptoms suggest giant-cell arteritis in acute vision loss?','Age usually over 50 plus new temporal headache, scalp tenderness, jaw claudication, polymyalgia symptoms, fever/weight loss or raised inflammatory markers. Suspected GCA with visual symptoms is an emergency: give systemic corticosteroids promptly per protocol while arranging diagnostic work-up.') q('Third-nerve palsy: what is the life-threatening distinction?','A painful third-nerve palsy with pupil involvement may indicate a compressive posterior communicating artery aneurysm until proven otherwise, requiring urgent neurovascular imaging. Do not rely solely on “pupil-sparing” rules.') q('Horner syndrome triad?','Mild ptosis, miosis and facial anhidrosis, with dilation lag in the dark. Localize the sympathetic pathway and consider carotid dissection in acute painful Horner syndrome.') h('Diplopia localization') S += bullet(['Monocular diplopia persists when the fellow eye is covered: usually optical (tear film, cornea, lens, refractive error), rarely cerebral.', 'Binocular diplopia resolves when either eye is covered: due to ocular misalignment. Ask direction of maximum separation and examine motility, cover tests, pupils, ptosis and neurologic signs.']) page() section('9. PAEDIATRICS, STRABISMUS AND LEUKOCORIA') q('Define amblyopia.','Reduced best-corrected visual acuity due to abnormal visual experience during the sensitive period of visual development, without an ocular structural cause sufficient to explain the deficit. Main types: strabismic, anisometropic, deprivation and mixed.') q('Define strabismus, tropia and phoria.','<b>Strabismus:</b> ocular misalignment. <b>Tropia:</b> manifest deviation present with both eyes viewing. <b>Phoria:</b> latent deviation controlled by fusion, revealed on dissociation.') q('What is the cover-uncover test?','It detects a manifest deviation: cover the fixing eye and observe whether the uncovered eye moves to take up fixation. Alternate cover breaks fusion and reveals total deviation.') q('Approach to leukocoria.','Treat as urgent. Main differential: retinoblastoma, congenital cataract, persistent fetal vasculature, Coats disease, retinal detachment, toxocariasis, ROP and coloboma. Examine red reflex and arrange urgent dilated examination/imaging by specialist. Never delay exclusion of retinoblastoma.') q('What are important causes of childhood red reflex abnormality?','Media opacity (cataract, corneal opacity), anisometropia/strabismus, retinal disease and retinoblastoma. Red reflex screening abnormality needs referral.') q('What is congenital nasolacrimal duct obstruction?','Failure of distal nasolacrimal duct canalization, producing epiphora and discharge in infancy with a normal globe and no photophobia. Differentiate from congenital glaucoma, which has photophobia, tearing and blepharospasm.') page() section('10. OCULAR TRAUMA AND EMERGENCIES') h('Open globe: until proven otherwise') q('Signs of open globe injury.','History of high-velocity/sharp trauma, reduced vision, irregular/peaked pupil, shallow or deep AC, prolapsed uvea, positive Seidel test, low IOP, dense subconjunctival haemorrhage or visible wound. Avoid pressure, tonometry, lid retraction and ultrasound if it could apply pressure.') q('Initial management of suspected open globe.','Rigid eye shield, nil by mouth, analgesia/antiemetic, tetanus consideration, systemic antibiotics per local protocol, CT orbit for associated injury/foreign body if appropriate, and urgent ophthalmic surgery. Do not patch or instil unnecessary drops.') q('Chemical injury: immediate first step?','Immediate copious irrigation, before history or detailed examination. Evert lids and remove particulate matter; check pH repeatedly until neutral, then grade injury and commence specialist-directed treatment.') q('What is Seidel test?','Fluorescein test for aqueous leakage: dilute fluorescein streaming from a wound indicates a positive test.') q('Differentiate orbital cellulitis from preseptal cellulitis.','Orbital cellulitis has painful/restricted eye movements, proptosis, chemosis, reduced vision or RAPD and may have systemic toxicity. Preseptal cellulitis does not impair ocular movements, vision or produce proptosis. Suspected orbital cellulitis needs urgent imaging, IV antibiotics and multidisciplinary review.') q('Blow-out fracture signs.','Diplopia/restricted motility from muscle entrapment, infraorbital hypoesthesia, enophthalmos, orbital emphysema and nausea/bradycardia in entrapment. Avoid nose blowing; obtain CT orbit and urgent review when entrapment suspected.') page() section('11. OCULAR DRUGS, LASERS AND IMAGING') h('Rapid pharmacology') S.append(table(['Drug/class','Common use','High-yield adverse effect / caveat'],[ ['Topical corticosteroid','Uveitis, postoperative inflammation, selected surface disease.','Raises IOP, cataract, delayed healing; can worsen untreated HSV/fungal infection.'], ['Cyclopentolate / atropine','Cycloplegia, uveitis comfort and synechiae prevention.','Blurred near vision, photophobia; systemic anticholinergic effects, especially in children.'], ['Phenylephrine','Mydriasis; diagnostic use.','Hypertension/tachycardia risk; does not cycloplege.'], ['Tropicamide','Short-acting diagnostic mydriasis.','May precipitate angle closure in susceptible eyes.'], ['Anti-VEGF intravitreal therapy','Neovascular AMD, DMO, retinal vein occlusion macular oedema.','Endophthalmitis warning: pain, redness, reduced vision after injection.'], ['Acetazolamide','Acute IOP reduction and selected chronic use.','Systemic CAI: electrolyte/renal issues, sulfonamide considerations; check contraindications.']], [3.3*cm,6.5*cm,7.6*cm])) q('Laser peripheral iridotomy: indication and principle.','Used to relieve/prevent pupillary block in angle-closure disease by making a full-thickness iris opening that equalizes pressure between posterior and anterior chambers.') q('Panretinal photocoagulation: purpose?','Ablates peripheral ischemic retina to reduce angiogenic drive and regression of neovascularization, principally in proliferative retinopathy. It can reduce peripheral field and night vision.') q('When do you use OCT, FA and B-scan?','<b>OCT:</b> retinal layers, fluid, macula and RNFL. <b>FA:</b> leakage, perfusion, blockage and neovascular patterns. <b>B-scan ultrasound:</b> posterior segment when fundus view is obscured, for example vitreous haemorrhage, while respecting open-globe precautions.') page() section('12. RAPID-FIRE DIFFERENTIALS') S.append(table(['Presentation','Must state in a VIVA'],[ ['Sudden painless monocular vision loss','CRAO, retinal detachment, vitreous haemorrhage, retinal vein occlusion, ischaemic optic neuropathy. Exclude GCA in appropriate patient.'], ['Painful loss of vision','Optic neuritis, acute angle closure, keratitis/uveitis, scleritis, endophthalmitis.'], ['Painful red eye + photophobia','Keratitis or anterior uveitis until proven otherwise; check VA, fluorescein, AC, IOP if safe.'], ['White pupil in child','Retinoblastoma first exclusion; also cataract, PFV, Coats, ROP, toxocariasis, RD.'], ['Proptosis','Thyroid eye disease, orbital cellulitis, tumour, vascular lesion, inflammatory orbitopathy. Distinguish axial/non-axial and acute/chronic.'], ['Disc swelling','Papilloedema, optic neuritis, NAION, infiltrative/infective optic neuropathy, diabetic papillopathy, pseudopapilloedema/drusen.'], ['Anisocoria','Physiological, Horner, third-nerve palsy, tonic pupil, pharmacologic, traumatic iris injury. Determine whether greater in dark or light.'], ['Corneal oedema','High IOP, endothelial dysfunction, inflammation, trauma, postoperative state.'], ['Hyphema','Trauma, rubeosis, bleeding disorder. Check IOP and exclude open globe; rebleed risk.'], ['Vitreous haemorrhage','PDR, retinal tear/detachment, trauma, retinal vascular occlusion. B-scan if no fundus view and globe closed.']], [4.5*cm,12.9*cm])) h('Ten final VIVA habits') S += bullet(['Always report VA first and specify each eye.', 'In red eye, say whether vision is reduced and whether there is photophobia.', 'In suspected retinal pathology, state “I will dilate and examine the peripheral retina.”', 'In suspected glaucoma, state “I will assess disc, fields/OCT and perform gonioscopy.”', 'In acute vision loss over age 50, explicitly say “I will exclude giant-cell arteritis.”', 'In trauma, state whether you suspect an open globe before touching the eye.', 'In child with leukocoria, say “urgent retinoblastoma exclusion.”', 'Do not call every white retinal lesion an exudate. Localize it: nerve fibre layer, retina or sub-RPE.', 'For management questions: stabilize, investigate only if it does not delay treatment, and name the definitive treatment.', 'Use “consistent with” rather than overclaiming when you have incomplete data.']) h('Sources and scope') S.append(P('Prepared as a rapid oral-exam framework using standard ophthalmic concepts. Core examination concepts including visual-acuity and pinhole testing are aligned with <i>Kanski’s Clinical Ophthalmology: A Systematic Approach, 10th ed.</i>, Examination Techniques. For patient care, follow local protocols and current specialty guidelines. The American Academy of Ophthalmology describes its Preferred Practice Patterns as guidance for practice rather than rules for every individual patient.')) doc=SimpleDocTemplate(OUT,pagesize=A4,rightMargin=1.55*cm,leftMargin=1.55*cm,topMargin=1.45*cm,bottomMargin=1.6*cm,title='Ophthalmology Postgraduate VIVA Rapid Revision',author='Orris') doc.build(S,onFirstPage=footer,onLaterPages=footer) print(OUT) ''') PY python "/tmp/workspace/ophthalmology-viva-pdf/src/generate.py" python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/ophthalmology-viva-pdf/output/Ophthalmology_Postgraduate_VIVA_Rapid_Revision.pdf' r=PdfReader(p) print('pages',len(r.pages),'size',__import__('os').path.getsize(p)) print(r.pages[1].extract_text()[:300]) PY

acute vision loss AND diagnosis

AAO acute vision loss red eye differential diagnosis ophthalmology

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python - <<'PY' from pathlib import Path p=Path('/tmp/workspace/ophthalmology-viva-pdf/src/generate_supplement.py') p.write_text(r'''from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.colors import HexColor from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, PageBreak, Table, TableStyle from pypdf import PdfReader OUT='/tmp/workspace/ophthalmology-viva-pdf/output/Ophthalmology_VIVA_Causes_Differentials_Orbit_Anatomy.pdf' navy=HexColor('#12334A'); blue=HexColor('#1976A8'); pale=HexColor('#EAF4F8'); grey=HexColor('#555555'); alert=HexColor('#8C1D1D') st=getSampleStyleSheet() st.add(ParagraphStyle(name='CT',parent=st['Title'],fontName='Helvetica-Bold',fontSize=25,leading=30,textColor=navy,alignment=TA_CENTER,spaceAfter=14)) st.add(ParagraphStyle(name='CS',parent=st['Normal'],fontSize=12,leading=16,textColor=grey,alignment=TA_CENTER)) st.add(ParagraphStyle(name='H1',parent=st['Heading1'],fontName='Helvetica-Bold',fontSize=16,leading=20,textColor=navy,spaceBefore=7,spaceAfter=8,keepWithNext=True)) st.add(ParagraphStyle(name='H2',parent=st['Heading2'],fontName='Helvetica-Bold',fontSize=11,leading=14,textColor=blue,spaceBefore=6,spaceAfter=4,keepWithNext=True)) st.add(ParagraphStyle(name='B',parent=st['BodyText'],fontSize=8.55,leading=11.25,spaceAfter=3)) st.add(ParagraphStyle(name='S',parent=st['BodyText'],fontSize=7.5,leading=9.1,textColor=grey)) def P(x,style='B'): return Paragraph(x,st[style]) def T(head, rows, widths): data=[[P(x,'S') for x in head]]+[[P(x,'S') for x in r] for r in rows] t=Table(data,colWidths=widths,repeatRows=1,hAlign='LEFT') t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,0),navy),('TEXTCOLOR',(0,0),(-1,0),colors.white),('FONTNAME',(0,0),(-1,0),'Helvetica-Bold'),('VALIGN',(0,0),(-1,-1),'TOP'),('GRID',(0,0),(-1,-1),.25,HexColor('#B8CDD7')),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,pale]),('LEFTPADDING',(0,0),(-1,-1),4),('RIGHTPADDING',(0,0),(-1,-1),4),('TOPPADDING',(0,0),(-1,-1),3),('BOTTOMPADDING',(0,0),(-1,-1),3)]));return t S=[] def sec(x, intro=''): S.append(P(x,'H1')) if intro:S.append(P(intro)) def h(x):S.append(P(x,'H2')) def pg():S.append(PageBreak()) def bullets(a):S.extend(P('• '+x) for x in a) def foot(c,d): c.saveState();c.setStrokeColor(HexColor('#C3D8E1'));c.line(1.55*cm,1.25*cm,19.45*cm,1.25*cm);c.setFont('Helvetica',7.5);c.setFillColor(grey);c.drawString(1.55*cm,.84*cm,'Ophthalmology VIVA: causes, differentials and orbit anatomy');c.drawRightString(19.45*cm,.84*cm,str(d.page));c.restoreState() S += [Spacer(1,2.6*cm),P('OPHTHALMOLOGY VIVA','CT'),P('CAUSES, DIFFERENTIALS<br/>AND ORBIT ANATOMY','CT'),Spacer(1,.6*cm),P('A symptom-first booklet for rapid oral answers. Use a three-part response: <b>time course -> pain -> site of lesion</b>.','CS'),Spacer(1,.8*cm),P('<b>Emergency rule:</b> sudden vision loss, red eye with reduced vision/photophobia, trauma, or child with leukocoria needs urgent ophthalmic assessment. This booklet is for VIVA revision, not self-management.','CS'),pg()] sec('1. LOSS OF VISION VS DIMINUTION OF VISION') h('Basic distinction') S.append(T(['Term','VIVA definition / how to say it'],[ ['Loss of vision','A severe reduction or absence of useful vision. Describe precisely: no perception of light (NPL), perception of light (PL) with/without accurate projection, hand movements (HM), counting fingers (CF), or measured acuity.'], ['Diminution of vision','Any subjective or measured reduction from previous visual function. It may be mild, partial, central, peripheral, transient, unilateral or bilateral.'], ['Transient visual loss','A reversible episode of visual impairment. Determine monocular vs binocular, duration, positive visual phenomena and vascular risk.'], ['Monocular loss','Usually lesion anterior to optic chiasm: media, retina or optic nerve.'], ['Binocular/homonymous loss','Think visual pathways posterior to chiasm, but bilateral ocular causes can occur.']], [4.4*cm,13.0*cm])) h('One-line VIVA approach') bullets(['“First I will confirm whether it is monocular or binocular, sudden or gradual, painful or painless, transient or persistent, and whether the defect is central or peripheral.”','“I will document VA, pupils including RAPD, colour vision, fields, anterior segment, IOP if safe, and dilated fundus examination.”','“In anyone aged over 50 with acute optic/retinal ischaemia, I will urgently exclude giant-cell arteritis.”']) h('Why the distinction matters') bullets(['<b>Acute profound loss</b> suggests vascular occlusion, retinal detachment, vitreous haemorrhage, acute glaucoma, optic neuropathy or trauma.', '<b>Mild diminution</b> may be refractive, tear-film/corneal, early cataract, macular disease or early optic neuropathy.', '<b>Central loss</b> points to macula or papillomacular bundle. <b>Peripheral constriction</b> suggests glaucoma, retinitis pigmentosa, chiasmal/retrochiasmal disorders or functional causes.']) pg() sec('2. SUDDEN VISION LOSS: PAINFUL OR PAINLESS') h('Sudden painful loss of vision') S.append(T(['Cause','Clues that win marks','Immediate concern'],[ ['Acute primary angle closure','Severe pain, headache/nausea, halos, corneal oedema, shallow AC, mid-dilated sluggish pupil, very high IOP.','Ophthalmic emergency: lower IOP and definitive angle treatment.'], ['Microbial keratitis / corneal ulcer','Pain, photophobia, red eye, reduced VA, epithelial defect plus stromal infiltrate; contact-lens history.','Urgent antimicrobial treatment; risk of perforation/scarring.'], ['Anterior uveitis','Aching pain, ciliary flush, consensual photophobia, cells/flare, small or irregular pupil.','Exclude infective keratitis before steroid.'], ['Scleritis','Severe deep boring pain, violaceous deep injection, tenderness; autoimmune association.','May threaten globe; evaluate systemic disease.'], ['Optic neuritis','Subacute rather than instantaneous, pain on eye movement, dyschromatopsia, RAPD, central scotoma.','Assess atypical features and neuro-inflammatory cause.'], ['Endophthalmitis','Pain and marked vision reduction after surgery, injection, penetrating trauma or endogenous infection; hypopyon/vitritis.','Immediate intravitreal-treatment pathway.'], ['Orbital cellulitis / orbital apex disease','Painful restricted motility, proptosis, chemosis, vision/RAPD possible, fever may occur.','Imaging, IV antibiotics and urgent multidisciplinary care.']], [4.1*cm,8.1*cm,5.2*cm])) h('Sudden painless loss of vision') S.append(T(['Cause','Clues that win marks','Do not miss'],[ ['Central retinal artery occlusion','Profound sudden monocular loss; pale retina and cherry-red spot may appear later.','Ocular stroke and GCA exclusion.'], ['Amaurosis fugax','Transient curtain/shade, typically monocular, often embolic.','TIA/stroke pathway.'], ['Retinal detachment','Flashes, floaters then curtain/shadow; detached corrugated retina.','Macula-on RD needs urgent retinal review.'], ['Vitreous haemorrhage','Floaters/haze/cobwebs, poor fundus view; PDR, retinal tear or trauma causes.','Exclude retinal tear/detachment with B-scan if globe closed.'], ['Retinal vein occlusion','Painless variable loss, venous dilation/tortuosity, widespread or sectoral haemorrhages.','Macular oedema and neovascular complications.'], ['NAION','Acute painless monocular loss, often on awakening, altitudinal defect and disc oedema.','Differentiate arteritic AION due to GCA.'], ['Macular haemorrhage / wet AMD event','Sudden central distortion or loss in older patient.','Macular neovascularization assessment.'], ['Occipital stroke','Homonymous field loss, often perceived as bilateral visual loss.','Acute stroke evaluation.']], [4.1*cm,8.1*cm,5.2*cm])) pg() sec('3. GRADUAL AND INSIDIOUS DIMINUTION OF VISION') h('Use “media, retina/macula, optic nerve, pathway, refractive”') S.append(T(['Pattern','Common causes','VIVA discriminator'],[ ['Gradual painless central blur','Refractive error, cataract, dry/wet AMD, diabetic macular oedema, epiretinal membrane, macular hole, optic neuropathy.','Pinhole, slit lamp and macular/optic-nerve assessment; ask metamorphopsia.'], ['Gradual glare/halos','Cataract, corneal oedema/irregularity, dry eye, uncorrected refractive error.','Glare with good chart acuity is common in early cataract.'], ['Gradual peripheral loss','Primary open-angle glaucoma, retinitis pigmentosa, chronic retinal detachment, chiasmal lesion.','Field testing and disc/RNFL evaluation.'], ['Night blindness','Vitamin A deficiency, retinitis pigmentosa, congenital stationary night blindness, high myopia.','Ask childhood onset and family history; examine peripheral retina.'], ['Progressive painless monocular loss','Cataract, optic-nerve sheath meningioma, compressive optic neuropathy, chronic maculopathy, tumour.','RAPD, colour deficit, disc and imaging where indicated.'], ['Progressive bilateral loss','Cataract, refractive error, diabetic maculopathy, glaucoma, toxic/nutritional optic neuropathy, cortical disease.','Assess symmetry, fields, colour and systemic/medicine history.']], [4.2*cm,7.6*cm,5.6*cm])) h('Insidious onset: must-mention causes') bullets(['<b>Refractive/optical:</b> uncorrected myopia, hypermetropia, astigmatism, presbyopia, dry eye, contact-lens problems.', '<b>Media:</b> cataract, corneal degeneration/dystrophy, chronic corneal oedema, vitreous opacities.', '<b>Macular:</b> AMD, diabetic macular oedema, epiretinal membrane, macular hole, inherited macular dystrophy.', '<b>Optic nerve:</b> glaucoma, compressive optic neuropathy, toxic/nutritional optic neuropathy, hereditary optic neuropathy.', '<b>Field/pathway:</b> pituitary/chiasmal compression, retrochiasmal tumour or chronic stroke.', '<b>Functional:</b> non-organic visual loss is a diagnosis of positive inconsistency after excluding organic disease.']) h('“Sudden” versus “gradual” caveat') S.append(P('Patients may only <i>notice</i> chronic disease suddenly. Ask when vision was last definitely normal. Cataract, glaucoma and diabetic retinopathy can be advanced at first presentation.')) pg() sec('4. RED EYE: DIFFERENTIAL DIAGNOSIS') h('First classify: benign-looking or sight-threatening?') S.append(T(['Diagnosis','Pain / vision / photophobia','Key signs'],[ ['Conjunctivitis','Grittiness or mild discomfort; vision usually normal; photophobia absent.','Diffuse conjunctival injection; watery, mucopurulent or allergic discharge; follicles/papillae depending cause.'], ['Subconjunctival haemorrhage','Painless; vision normal.','Sharply demarcated red patch; no discharge. Check trauma, anticoagulation or hypertension when relevant.'], ['Dry eye / blepharitis','Burning, fluctuating blur; mild photophobia possible.','Lid-margin disease, tear-film instability, punctate epithelial staining.'], ['Episcleritis','Mild discomfort; vision normal.','Sectoral superficial injection that typically blanches with phenylephrine.'], ['Scleritis','Severe boring pain, may reduce vision.','Deep violaceous non-blanching injection; tenderness; systemic association.'], ['Keratitis / ulcer','Pain, reduced vision, photophobia.','Fluorescein epithelial defect; infiltrate/ulcer, AC reaction ± hypopyon.'], ['Anterior uveitis','Aching, photophobia especially consensual, blurred vision.','Ciliary flush, cells/flare, KPs, small/irregular pupil.'], ['Acute angle closure','Severe pain, blur/halos, nausea/vomiting.','Corneal oedema, shallow AC, high IOP, mid-dilated pupil.'], ['Endophthalmitis','Severe pain and marked visual loss.','Postoperative/post-injection setting; AC/vitreous inflammation.'], ['Orbital cellulitis','Painful eye movements; vision can decrease.','Proptosis, restricted motility, chemosis, fever/systemic illness possible.']], [4.2*cm,6.4*cm,6.8*cm])) h('VIVA red-eye answer') bullets(['“I will check visual acuity first. Reduced VA, true photophobia, corneal staining/infiltrate, ciliary injection, abnormal pupil, high IOP or proptosis makes this potentially sight-threatening.”','“In a contact-lens wearer with a painful red eye, I will assume microbial keratitis until excluded.”','“I will not label it simple conjunctivitis if VA is reduced, there is significant pain/photophobia, or the cornea is abnormal.”']) pg() sec('5. BASIC ARTERIAL SUPPLY OF EYE AND ORBIT') h('One sentence') S.append(P('<b>The ophthalmic artery</b>, usually the first intracranial branch of the internal carotid artery, enters the orbit through the optic canal and gives branches to the globe and orbit. Kanski notes that it runs inferior to the optic nerve in the optic canal.')) S.append(T(['Vessel','Territory / oral-exam point'],[ ['Ophthalmic artery','Main orbital artery from internal carotid system. Major branches include central retinal artery, posterior ciliary arteries, lacrimal, muscular, supraorbital, ethmoidal, medial palpebral, dorsal nasal and supratrochlear arteries.'], ['Central retinal artery (CRA)','Enters optic nerve about 8-12 mm behind globe. End-arterial supply to <b>inner retina</b>. Occlusion causes CRAO. A cilioretinal artery, if present, arises from ciliary circulation and can spare central retina.'], ['Short posterior ciliary arteries','Multiple branches that supply choroid and much of optic nerve head via peripapillary circle of Zinn-Haller. Thus posterior ciliary circulation supplies <b>outer retina indirectly via choroid</b>.'], ['Long posterior ciliary arteries','Usually medial and lateral; run forward to anterior uvea and contribute to major arterial circle of iris.'], ['Anterior ciliary arteries','From muscular branches, accompanying recti. Supply anterior sclera/conjunctiva and contribute to anterior segment and major iris circle. Important in anterior-segment ischaemia after multiple rectus surgery.'], ['Muscular branches','Supply extraocular muscles; give anterior ciliary arteries.'], ['Lacrimal artery','Lacrimal gland and lateral eyelids/conjunctiva.']], [4.8*cm,12.6*cm])) h('High-yield retina statement') S.append(P('<b>Inner retina = central retinal artery.</b> <b>Outer retina and RPE = choriocapillaris supplied by posterior ciliary circulation.</b> This dual supply explains some retinal ischaemic patterns.')) pg() sec('6. VENOUS DRAINAGE OF EYE AND ORBIT') S.append(T(['Vein','Drainage / VIVA point'],[ ['Central retinal vein','Drains retina; exits within or near optic nerve and drains to ophthalmic venous system/cavernous sinus. It is the vessel involved in CRVO.'], ['Vortex veins','Usually 4-6 veins draining choroid, ciliary body and iris. They leave globe posterior to equator and drain into superior or inferior ophthalmic vein.'], ['Superior ophthalmic vein','Formed near medial orbit; exits through superior orbital fissure to cavernous sinus. Communicates anteriorly with facial/angular veins.'], ['Inferior ophthalmic vein','Drains inferior orbit; communicates with superior ophthalmic vein and may drain to cavernous sinus and/or pterygoid plexus through inferior orbital fissure.'], ['Clinical relevance','Facial infection can spread through valveless facial/angular and ophthalmic veins to cavernous sinus. A carotid-cavernous fistula can cause an enlarged superior ophthalmic vein, proptosis, chemosis and raised IOP.']], [4.8*cm,12.6*cm])) h('Cavernous sinus: what can be affected?') bullets(['Within/related to cavernous sinus: CN III, IV, V1, V2 (lateral wall), CN VI and internal carotid artery. In cavernous sinus thrombosis, expect fever, proptosis, chemosis, painful ophthalmoplegia and sensory loss in V1/V2 distribution.', 'CN VI is particularly vulnerable because it runs more medially within the sinus adjacent to the internal carotid artery.']) pg() sec('7. NERVE SUPPLY OF EYE AND ORBIT') h('Motor: extraocular muscles') S.append(T(['Nerve','Muscles / action','VIVA phrase'],[ ['CN III: oculomotor','SR, IR, MR, IO, levator palpebrae; parasympathetic to sphincter pupillae and ciliary muscle.','“All extraocular muscles except LR and SO.”'], ['CN IV: trochlear','Superior oblique: intorsion, depression in adduction, abduction.','“SO4.”'], ['CN VI: abducens','Lateral rectus: abduction.','“LR6.”'], ['Facial nerve VII','Orbicularis oculi closes lids; parasympathetic secretomotor supply to lacrimal gland via greater petrosal pathway.','Facial palsy risks exposure keratopathy.']], [3.8*cm,9.0*cm,4.6*cm])) h('Sensory: trigeminal nerve') bullets(['<b>V1 ophthalmic division</b> enters orbit via superior orbital fissure. Its branches are lacrimal, frontal and nasociliary.', '<b>Nasociliary</b> gives long ciliary nerves (corneal sensation and sympathetic supply), posterior ethmoidal, anterior ethmoidal and infratrochlear branches. It is the sensory root for the corneal reflex.', '<b>V2 maxillary division</b> reaches orbit through inferior orbital fissure as infraorbital and zygomatic nerves. Infraorbital nerve supplies lower lid, cheek, lateral nose and upper lip.']) h('Autonomic supply') S.append(T(['System','Pathway and action'],[ ['Parasympathetic','Edinger-Westphal nucleus -> CN III -> ciliary ganglion -> short ciliary nerves. Causes pupillary constriction (sphincter pupillae) and accommodation (ciliary muscle).'], ['Sympathetic','Hypothalamus -> ciliospinal centre -> superior cervical ganglion -> carotid plexus -> long ciliary nerves. Causes pupillary dilation (dilator pupillae); supplies Müller muscle and ocular vessels.'], ['Corneal reflex','Afferent: V1 nasociliary. Efferent: VII to orbicularis oculi.']], [4.3*cm,13.1*cm])) pg() sec('8. BONES OF ORBIT, FISSURES AND FORAMINA') h('Orbit shape') S.append(P('The orbit is a four-sided pyramidal cavity: base anteriorly and apex posteromedially. It has <b>seven bones</b>: frontal, sphenoid, zygomatic, maxilla, palatine, ethmoid and lacrimal.')) S.append(T(['Wall','Bones','Clinical correlation'],[ ['Roof','Frontal bone and lesser wing of sphenoid.','Frontal sinus/cranial fossa proximity.'], ['Lateral wall','Zygomatic bone and greater wing of sphenoid.','Strongest wall; lateral orbitotomy approach.'], ['Floor','Maxilla chiefly, plus zygomatic and small palatine contribution.','Thin: blow-out fracture, infraorbital nerve injury.'], ['Medial wall','Ethmoid chiefly, plus lacrimal, frontal process of maxilla and body of sphenoid.','Very thin lamina papyracea; ethmoid sinus disease can spread to orbit.']], [3.4*cm,7.8*cm,6.2*cm])) h('Openings and contents') S.append(T(['Opening','Major contents'],[ ['Optic canal','Optic nerve (CN II) and ophthalmic artery.'], ['Superior orbital fissure','CN III, IV, V1, VI, superior ophthalmic vein and sympathetic fibres. Structures within annulus of Zinn include CN III divisions, nasociliary nerve and CN VI; IV, frontal, lacrimal and superior ophthalmic vein lie outside it.'], ['Inferior orbital fissure','Infraorbital nerve and vessels, zygomatic nerve, inferior ophthalmic vein communication with pterygoid plexus.'], ['Anterior/posterior ethmoidal foramina','Ethmoidal nerves and vessels.'], ['Infraorbital canal/foramen','Infraorbital nerve and vessels.']], [4.4*cm,13.0*cm])) h('Apex syndrome versus superior orbital fissure syndrome') bullets(['<b>Orbital apex syndrome:</b> optic nerve plus multiple ocular motor/sensory nerves: visual loss/RAPD plus ophthalmoplegia and V1 involvement.', '<b>Superior orbital fissure syndrome:</b> CN III, IV, V1, VI dysfunction with ophthalmoplegia and forehead sensory loss, but optic nerve function is relatively spared.']) pg() sec('9. LAST PAGE: EXAMINER-STYLE RAPID RESPONSE') for q,a in [ ('Patient says “I cannot see” - first question?','“Is it one eye or both, sudden or gradual, and is there pain?” Then document VA and pupils.'), ('Most dangerous painful red-eye diagnoses?','Microbial keratitis, acute angle closure, anterior uveitis, scleritis, endophthalmitis and orbital cellulitis.'), ('Most dangerous painless sudden visual-loss diagnoses?','CRAO/ocular stroke, retinal detachment, arteritic AION due to GCA and occipital stroke.'), ('Which retinal supply is end arterial?','Central retinal artery supplies inner retina and behaves as an end artery.'), ('Which nerve carries corneal sensation?','Ophthalmic division of trigeminal, chiefly nasociliary via long ciliary nerves.'), ('Which nerves move the eye?','III, IV and VI. LR6 SO4, all others III.'), ('Seven orbital bones?','Frontal, sphenoid, zygomatic, maxilla, palatine, ethmoid and lacrimal.'), ('Thin orbital wall?','Medial wall: lamina papyracea of ethmoid. Floor is also thin and commonly blows out.'), ('Optic canal contents?','Optic nerve and ophthalmic artery.'), ('What is the key danger in child with white pupil?','Retinoblastoma until proven otherwise.')]: S.append(P('<b>Q. '+q+'</b><br/><b>A.</b> '+a)) h('Sources') S.append(P('Anatomy and ophthalmic examination facts are based on <i>Kanski’s Clinical Ophthalmology: A Systematic Approach, 10th ed.</i>, including its optic-nerve circulation section (p. 778 in the indexed text) and angle-closure clinical features section. Current care should follow local protocols and specialty guidelines.')) doc=SimpleDocTemplate(OUT,pagesize=A4,leftMargin=1.55*cm,rightMargin=1.55*cm,topMargin=1.45*cm,bottomMargin=1.6*cm,title='Ophthalmology VIVA Causes Differentials and Orbit Anatomy',author='Orris') doc.build(S,onFirstPage=foot,onLaterPages=foot) r=PdfReader(OUT); print(OUT, len(r.pages)) ''') PY python "/tmp/workspace/ophthalmology-viva-pdf/src/generate_supplement.py" python - <<'PY' from pypdf import PdfReader from pathlib import Path p=Path('/tmp/workspace/ophthalmology-viva-pdf/output/Ophthalmology_VIVA_Causes_Differentials_Orbit_Anatomy.pdf') r=PdfReader(str(p)); print('pages',len(r.pages),'bytes',p.stat().st_size); print('last-page-text',r.pages[-1].extract_text()[:200]) PY