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Aravind FAQs in Ophthalmology Aravind FAQs in Ophthalmology N Venkatesh Prajna DNB FRCOphth Director-Academics Aravind Eye Hospital Madurai, Tamil Nadu, India ® Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc. 83 Victoria Street London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44-2031708910 Phone: +507-301-0496 Fax: +02-03-0086180 Fax: +507-301-0499 Email: [email protected] Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Shorakhute, Kathmandu Mohammadpur, Dhaka-1207 Nepal Bangladesh Phone: +00977-9841528578 Mobile: +08801912003485 Email: [email protected] Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: [email protected] This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Aravind FAQs in Ophthalmology First Edition: 2013 ISBN: 978-93-5090-183-0 Printed at Preface The specialty of ophthalmology has developed by leaps and bounds in the recent past. Excellent comprehensive books are being brought out at regular intervals, which helps an ophthalmologist to keep abreast with times. In my 15 years experience as a residency director, I have often found the need for a concise, examination oriented ready-reckoner, which would be of use to the postgraduates to answer specifically to the point. This book aims to fill this gap and serves as a compilation of the frequently asked questions (FAQs) and the answers expected in a postgraduate clinical ophthalmology examination. This book should not be misconstrued as a replacement to the existing standard textbooks. These questions have been painstakingly gathered over a 10-year period from the collective experience of several senior teachers at Aravind Eye Hospital, Madurai, Tamil Nadu, India. Apart from the exam-oriented questions, this book also contains examples of case sheet writing and different management scenarios, which will help the students to logically analyze and answer in a coherent manner. I do sincerely hope that this book helps the postgraduate to face his/her examination with confidence. N Venkatesh Prajna Contents 1. Introduction ................................................................. 1 1.1 Visual Acuity 1 1.2 Color Vision 10 1.3 Anatomical Landmarks in Eye 14 1.4 Pharmacology 18 1.5 Slit Lamp Biomicroscope 26 1.6 Direct Ophthalmoscope 33 1.7 Indirect Ophthalmoscopy 36 1.8 X-rays in Ophthalmology 40 1.9 Computed Tomography and Magnetic Resonance Imaging 48 2. Cornea ....................................................................... 55 2.1 Keratometry 55 2.2 Corneal Vascularization 58 2.3 Corneal Anesthesia 60 2.4 Corneal Deposits 63 2.5 Bacterial and Fungal Corneal Ulcer 66 2.6 Acanthamoeba Keratitis 72 2.7 Viral Keratitis 77 2.8 Interstitial Keratitis 80 2.9 Mooren’s Ulcer 82 2.10 Band-Shaped Keratopathy 88 2.11 Adherent Leukoma 91 2.12 Bowen’s Disease 94 2.13 Keratoconus 98 2.14 Stromal Dystrophies—Cornea 107 2.15 Fuch’s Endothelial Dystrophy 117 2.16 Endothelial Disorders and Bullous Keratopathy 121 2.17 Keratoplasty 125 3. Uvea ......................................................................... 134 3.1 Uveitis—History and Clinical Features 134 3.2 Sympathetic Ophthalmia 150 3.3 Fuch’s Heterochromic Iridocyclitis 152 3.4 Vogt Koyanagi Harada Syndrome 154 3.5 Behcet’s Disease 156 3.6 Investigations in Uveitis 158 3.7 Treatment of Uveitis 172 viii ARAVIND FAQs IN OPHTHALMOLOGY 4. Glaucoma ................................................................. 178 4.1 Tonometry 178 4.2 Gonioscopy 186 4.3 Glaucoma Diagnostic with Variable Corneal Compensation (GDx VCC) 192 4.4 Glaucoma Visual Field Defects 194 4.5 Ultrasound Biomicroscopy in Glaucoma 201 4.6 Angle Closure Glaucoma 203 4.7 Management of an Acute Attack of Angle Closure Glaucoma 212 4.8 Primary Open-Angle Glaucoma 213 4.9 Neovascular Glaucoma 220 4.10 Pigmentary Glaucoma 229 4.11 Pseudoexfoliation Glaucoma 233 4.12 Uveitic Glaucoma 239 4.13 Steroid Induced Glaucoma 242 4.14 Lens Induced Glaucoma 245 4.15 Medical Management of Glaucoma 249 4.16 Newer Drugs in Glaucoma 260 4.17 Lasers in Glaucoma 266 4.18 Trabeculectomy 275 4.19 Modulation of Wound Healing in Glaucoma Filtering Surgery 289 4.20 Glaucoma Drainage Devices (GDD) 293 4.21 Cyclodestructive Procedures 302 5. Lens and Cataract .................................................. 308 6. Retina ....................................................................... 314 6.1 Fundus Fluorescein Angiography (FFA) 314 6.2 Ultrasonography (USG) 325 6.3 Diabetic Retinopathy (DR) 330 6.4 Lasers in Diabetic Retinopathy 338 6.5 Hypertensive Retinopathy (HTN Retinopathy) 349 6.6 Central Retinal Vein Occlusion (CRVO) 355 6.7 Central Retinal Artery Occlusion (CRAO) 363 6.8 Retinal Detachment (RD) 368 6.9 Endophthalmitis 390 6.10 Retinitis Pigmentosa 398 6.11 Retinoblastoma (RB) 407 6.12 Age-Related Macular Degeneration (ARMD) 414 6.13 Vitrectomy 422 6.14 Central Serous Chorioretinopathy (CSCR) 426 6.15 Angiogenesis 428 CONTENTS ix 7. Neuro-Ophthalmology ............................................ 430 7.1 The Normal Pupil 430 7.2 Optic Nerve Head 435 7.3 Optic Neuritis 442 7.4 Papilledema 449 7.5 Optic Atrophy 464 7.6 Optic Disk Anomalies 474 7.7 Anterior Ischemic Optic Neuropathy 480 7.8 Oculomotor Nerve 485 7.9 Fourth Nerve Palsy 496 7.10 Abducens Nerve Palsy 500 7.11 Myasthenia Gravis 505 7.12 Nystagmus 513 7.13 Visual Fields in Neuro-Ophthalmology 519 7.14 Cavernous Sinus Thrombosis 523 7.15 Carotico-Cavernous Fistulas 530 7.16 Carotid Artery Occlusion 532 7.17 Ophthalmoplegia 537 7.18 Malingering 543 8. Orbit .......................................................................... 548 8.1 Ectropion 548 8.2 Entropion 557 8.3 Ptosis 562 8.4 Eyelid Reconstruction 568 8.5 Blepharophimosis Syndrome 576 8.6 Thyroid-Related Orbitopathy (TRO) and Proptosis 577 8.7 Blowout Fractures of the Orbit 597 8.8 Orbitotomies 602 8.9 Botulinum Toxin 606 8.10 Dacryocystorhinostomy 608 9. Pediatric Ophthalmology and Strabismus............ 610 9.1 Diplopia Charting 619 9.2 Hess Charting 621 10. Miscellaneous.......................................................... 626 10.1 Vitamin A Deficiency 626 10.2 Localization of Intraocular Foreign Bodies (IOFB) 631 10.3 Community Ophthalmology 641 Case Sheet Writing .......................................................... 649 Index ................................................................................ 669 1 Introduction CHAPTER 1.1. VISUAL ACUITY 1. Define visual acuity. Visual acuity is defined as the reciprocal of the minimum resolvable angle measured in minutes of arc for a standard test pattern. 2. Define visual angle. It is the angle subtended at the nodal point of the eye by the physical dimensions of an object in the visual field. 3. What are the components of visual acuity? Visual acuity has three components. i. Minimum visible: Detection of presence or absence of stimulus. ii. Minimum separable: Judgment of location of a visual target relative to another element of the same target. iii. Minimum resolvable: Ability to distinguish between more than one identifying feature in a visible target. Threshold is between 30 sec and 1 minute of arc. 4. What are the components of measurement of vision? i. Visual acuity ii. Field of vision iii. Color vision and iv. Binocular single vision. 5. Who developed classic test chart? Professor Hermann Snellen in 1863. 6. What is the testing distance? Why do we check at that distance? The testing is done 6 m (20 ft) away from the target. At this distance, divergence of rays that enters the pupil is so small that rays are considered parallel. Hence, accommodation is eliminated at this distance. 2 ARAVIND FAQs IN OPHTHALMOLOGY 7. Describe about the Snellen’s chart. The letters are: i. It consists of series of black capital letters on a white board arranged in lines, each progressively diminishing in size. ii. Lines comprising letters have such a breadth that they will subtend at an angle of 1 minute at the nodal point of the eye at a particular distance. iii. Each letter is designed such that it fits in a square. iv. The sides of the letter are 5 times the breadth of constituent lines. v. At given distance, each letter subtends at an angle of 5 minutes at the nodal point of the eye. 8. What does normal 6/6 visual acuity represent? It represents the ability to see 1 min of arc which is close to theoretical diffraction limits. 9. Explain LogMAR charts. i. Used for academic and research purposes. ii. This is a modification of Snellen’s chart, where each subsequent line differs by 0.1 log unit in the minimum angle of resolution (MAR) required for that line. iii. They have equal number of letters in each line. iv. Used at a distance of 4 meters. 10. What is the procedure of testing visual acuity (VA) using Snellen’s chart? i. Patient is seated at a distance of 6 m from the Snellen’s chart because at this distance the rays of light are practically parallel and patient exerts minimal accommodation.
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