Study Guide The and Disorders

STUDY GUIDE VISUAL SYSTEM

Udayana University Faculty of Medicine, DME 1

Study Guide The Visual System and Disorders

TABLE OF CONTENTS

Page CONTENT 1

LEARNING OUTCOMES 2

BLOK TEAM 4

FASILITATORS 5

CORE CURICULUM 6

TIME TABLE 9

TIME TABLE CLINICAL SKILL 11

MEETING OF STUDENT REPRESENTATIVES 13

FORMAT OF ARTICLE REVIEW 13

TOPICS OF ARTICLE REVIEW 14

LEARNING PROGRAM 16

PRACTICUM AND BASIC CLINICAL SKILL GUIDES 45

CURRICULUM MAP 61

Udayana University Faculty of Medicine, DME 2

Study Guide The Visual System and Disorders

LEARNING OUTCOMES

THE AIMS 1. Comprehend the underlying normal structure and function of the visual system and its practical or clinical implications. 2. Understanding the pharmacology and pharmacokinetic of the ocular medicines. 3. Able to manage common eye and visual disorders and refer of high risks patient with visual disorders for further investigation and management. 4. Awareness and responsiveness to the community aspects of health care, needs, education and promotion.

LEARNING OUTCOMES

1. Able to know and understand anatomy of the eye structures 2. Able to know and understand Histology of the eye structures 3. Able to know and understand Physiology of the eye, and Physiology of vision 4. Able to know and understand the pharmacology and pharmacokinetic of the ocular medicines 5. Able to establish diagnosis and management patient with Refraction disorders such as Mild Hipermetropia, mild , mild and . 6. Able to initially diagnose, manage and later refer patient with Refraction disorders such as and contact problems. 7. Able to establish diagnosis and management patient with external eye diseases such us , , , Hordeolum, and 8. Able to initially diagnose, manage and later refer patient with external eye diseases such as , , , , and 9. Able to initially diagnose and later refer patient with external eye diseases such as keratokonjungtivitis sicca and . 10. Able to initially diagnose, manage and later refer patient with disorders. 11. Able to establish diagnosis and management patient with ocular injuries such as foreign bodies in the and subconjunctival 12. Able to manage and initially diagnose and later refer patient with ocular injuries such as and lacerations. 13. Able to initially diagnose and later refer patient with ocular injuries such as corneal erosion, foreign bodies on the , thermal corneal burn and lacrimal duct lacerations. 14. Able to establish diagnosis and management patient with eyelids and lacrimal

Udayana University Faculty of Medicine, DME 3

Study Guide The Visual System and Disorders

system disorders such us . 15. Able to initially diagnose, manage and later refer patient with eyelids and lacrimal systems disorders such as dacrioadenitis and dacriocystitis 16. Able to initially diagnose and later refer patient with eyelids and lacrimal sytems disorders such as , lagophthalmus, epichantus, , eyelids retraction and 17. Able to initially diagnose and later refer patient with , lens dislocation and corneal disorders such as and . 18. Able to initially diagnose and later refer patient with retinal disorders . 19. Able to initially diagnose and later refer patient with neuro & disorders including and binocular . 20. Able to establish diagnosis and management patient with community ophthalmology disorders such as night blindness 21. Able to initially diagnose, manage and later refer patient with community ophthalmology disorders such as 22. Able to initially diagnose and later refer patient with community ophthalmology disorders such as blindness due to 5 most common eye disorders (Cataract, Glaucoma, refractive errors, infection and immunology eye diseases and disorders)

CURRICULUM CONTENT 1. Anatomy, histology and physiology of the eye. 2. Pharmacology of the eye medicines. 3. Refractive Errors. 4. Infection & Immunologic Eye Diseases. 5. Glaucoma disorders 6. Eyelids and Lacrimal systems disorders 7. Ocular Injuries 8. Cataract, corneal and lens disorders. 9. Vitreous and Retinal disorders 10. Neuro Ophthalmology & strabismus disorders.

Udayana University Faculty of Medicine, DME 4

Study Guide The Visual System and Disorders

BLOCK VISUAL SYSTEM AND DISORDERS

COORDINATOR : dr. Putu Budhiastra, SpM(K) SECRETARY : dr. I Wyn Eka Sutyawan Sp.M TIME : 21 June 2016 – 20 July 2016

Block Team

No Name

1 dr. Yuliana,MBiomed 2 dr. Putu Budhiastra, Sp.M (K) 3 dr. Ni Made Ayu Surasmiati, M. Biomed , Sp.M 4 dr. AAA Sukartini Djelantik, Sp.M (K) 5 Prof.dr.I Dewa Putu Sutjana,PFK,M.Erg 6 dr. W.G Jayanegara, Sp.M (K) 7 Dr. dr. AAA Mas Putrawati T, Sp.M(K) 8 dr. I.G.A.Dewi Ratnayanti 9 dr. Ariesanti Tri Handayani, Sp.M(K) 10 Dr. dr. Made Jawi

Lectures No Name Dept No Telp

1 dr. Putu Budhiastra, Sp.M (K) Ophtalmology 085238238999 2 Prof.dr.NK Niti Susila,SpM (K) Ophtalmology 08123643816 3 dr. Ni Made Ayu Surasmiati, M. Biomed, Sp.M Ophtalmology 081338341860 4 dr. AAA Sukartini Djelantik, Sp.M (K) Ophtalmology 081337314911 5 dr. Made Agus Kusumadjaja, Sp.M (K) Ophtalmology 08123981349 6 dr. W.G Jayanegara, Sp.M (K) Ophtalmology 0818909147 7 Dr. dr. AAA Mas Putrawati T, Sp.M(K) Ophtalmology 08123846995 8 dr. Ariesanti Tri Handayani, Sp.M(K) Ophtalmology 0818375611 9 dr. Yuliana,M.Biomed Anatomy 085792652363 10 Prof.dr.I Dewa Putu Sutjana,PFK,M.Erg Physiology 08123924477 11 dr. I.G.A.Dewi Ratnayanti, m.Biomed Histology 03618550344 12 Dr. dr. Made Jawi, M.Kes Pharmacology 08179787972 13 dr. Ni Made Ari Suryathi, M. Biomed, Sp.M Ophthalmology 085253651928 14 dr. Ni Made Laksmi Utari, M.Biomed, Sp.M Ophthalmology 082340393727 15 dr. IGAM Juliari,Sp.M Ophthalmology 08123615625 16 dr. Wayan Eka Sutyawan,Sp.M Ophthalmology 081338538499 17 dr. Ari Andayani,Sp.M Ophthalmology 08113803666 18 dr. I Made Krisna Dinata, M.Erg Physiology 08174742566

Udayana University Faculty of Medicine, DME 5

Study Guide The Visual System and Disorders

FACILITATORS

Regular Class (Class A) No Name Group Department Phone Room dr. Pande Made Wisnu 3rd floor: 1 A1 Urology 082111133211 Tirtayasa, Sp.U R.3.09 dr. Made Bramantya Karna, 0817300133 3rd floor: 2 A2 Orthopaedi Sp.OT R.3.10 dr. I Made Suka Adnyana, 081236288975 3rd floor: 3 A3 Surgery Sp.BP-RE R.3.11 dr. I G N Mahaalit Arimbawa, 0811396811 3rd floor: 4 Anasthesi Sp.An KIC A4 R.3.12 dr. Muliani, M.Biomed 085103043575 3rd floor: 5 A5 Anatomy R.3.13 dr. I Wayan Sugiritama, M.Kes 08164732743 3rd floor: 6 A6 Histology R.3.14 dr. I Made Agus Kresna 081805470888 3rd floor: 7 A7 Anasthesi Sucandra, Sp.An R.3.15 dr. I Gede Budhi Setiawan, 08123923956 3rd floor: 8 A8 Surgery Sp.B (K) Onk R.3.16 dr. I Putu Bayu Mayura, S.Ked 3rd floor: 9 A9 Microbiology 082236165801 R.3.17 Putu Gede Sudira, Sp.S 3rd floor: 10 A10 DME 081805633997 R.3.19

English Class (Class B) No Name Group Department Phone Room

dr. I Made Mahayasa, Sp.B- 08123990624 3rd floor: 1 B1 Surgery KBD R.3.09 dr.Tjokorda Gde Dharmayuda, 0811394108 3rd floor: 2 B2 Interna Sp.PD -KHOM R.3.10 Dr.dr. I Made Muliarta, M.Kes 081338505350 3rd floor: 3 B3 Fisiology R.3.11 dr. Ida Ayu Dewi Wiryanthini, M 081239990399 3rd floor: 4 Biochemistry Biomed B4 R.3.12 dr. Ni Made Ari Suryathi, Ophthalmology 085253651928 3rd floor: 5 B5 M.Biomed, Sp.M R.3.13 Prof. dr. I Gusti Made Aman, 3rd floor: 6 B6 Pharmacology 081338770650 Sp.FK R.3.14 dr. Ketut Suardamana, Sp.PD- 08123985811 3rd floor: 7 B7 Interna KAI R.3.15 dr. Wayan Eka Sutyawan,Sp.M 3rd floor: 8 B8 Ophthalmology 081338538499 R.3.16 Dr.dr. Dyah Kanya Wati, Sp.A 085737046003 3rd floor: 9 B9 Pediatric (K) R.3.17 dr. I Gede Ketut Sajinadiyasa, 085237068670 3rd floor: 10 B10 Interna Sp.PD R.3.19

Udayana University Faculty of Medicine, DME 6

Study Guide The Visual System and Disorders

CORE CURRICULUM

BLOCK : VISUAL SYSTEM AND DISORDER SEMESTER : IV SKS : 2 NO DAY LEARNING OUTCOME EDUCATIONAL LEARNING METHOD OF STRATEGIES SITUATION ASSESMENT 1 1 Able to know and Independent learning Introductory lecture MCQ understand the Integrated learning Student Project Anatomy of the eye Problem based learning SGD Practicum 2 2 Able to know and Independent learning Introductory lecture MCQ understand the Integrated learning Student Project Histology of the eye Problem based learning SGD Practicum 3 3 Able to know and Integrated learning Introductory lecture MCQ understand the Integrated learning Student Project Physiology of the eye Problem based learning SGD Practicum 4 4 Able to know and Problem based learning Introductory lecture MCQ understand the Integrated learning Student Project Pharmacology and Problem based learning SGD Pharmacokinetic of the Practicum eye medicines 5 5 Able to establish Independent learning Introductory lecture MCQ diagnosis and manage Integrated learning Student Project OSCE patient with Problem based learning SGD INFECTION & BCS IMMUNOLOGIC EYE DISEASES such as : - Conjunctivitis, blepharitis, hordeoulum, chalazion and dry eye syndrome - Scleritis, episcleritis - Keratitis,uveitis - Kerato-conjunctivi. sicca - Iridocyclitis, Iritis - Endoftalmitis 6 6 Able to establish Integrated learning Introductory lecture MCQ diagnosis and manage Integrated learning Student Project OSCE patient with OCULAR Problem based learning SGD INJURY such as: BCS - Conjunctiva & cornea foreign body,corneal erosion, thermal /burn injury - Sub conjunctiva Haemorrhage, hyphema - laceration, lacrimal duct laceration

Udayana University Faculty of Medicine, DME 7

Study Guide The Visual System and Disorders

7 7 Able to establish Problem based learning Introductory lecture MCQ diagnosis and manage Integrated learning Student Project OSCE patient with Problem based learning SGD GLAUCOMA BCS DISORDERS such as : - Acute glaucoma - Chronic glaucoma - Secondary glaucoma - Congenital glaucoma 8 8 Able to establish Independent learning Introductory lecture MCQ diagnosis and manage Integrated learning SGD patient with CORNEA & Problem based learning BCS LENS DISORDERS such as : - Cataract - Lens dislocation - Keratokonus

9 8 Able to establish Integrated learning Introductory lecture MCQ diagnosis and manage Integrated learning Student Project OSCE patient with VITREO Problem based learning SGD RETINAL DISORDERS BCS such as : - - Retinal vessel occlusion - Degeneration macula - Diabetic - 10 9 Able to establish Problem based learning Introductory lecture MCQ diagnosis and manage Integrated learning SGD patient with NEURO Problem based learning OPHTHALMOLOGY - Papilloedema - - - Optic atrophy Introductory lecture & STRABISMUS Student Project MCQ EXAMINATION AND SGD DISORDERS such as : - diplopia - amblyopia - - 11 10 Able to establish Independent learning Introductory lecture MCQ diagnosis and manage Integrated learning SGD OSCE patient with Problem based learning BCS REFRACTIVE DISORDERS such as : - Myopia - Hypermetropia - Astigmatism - Presbiopia - Anisometropia

Udayana University Faculty of Medicine, DME 8

Study Guide The Visual System and Disorders

12 10 Able to know about: Integrated learning Introductory lecture MCQ COMMUNITY Integrated learning SGD OPHTHALMOLOGY Problem based learning PROBLEM such as: - Blindness, Loss of vision - Community ophthalmology

Udayana University Faculty of Medicine, DME 9

Study Guide The Visual System and Disorders

TIME TABLE

Study load : 2 SKS = 10 days

DAY PROGRAMME LEARNING ACTIVITIES CLASS B CLASS A PIC

I LEARNING INTRODUCTION 08.00 - 08.15 09.00 - 09.15 Budi 21/6/16 OUTCOME 1 LECTURE : Yuliana - Anatomy of the 08.15 - 09.00 09.15 - 10.00 Eye Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Plenary session 14.00 -15.00 15.00 -16.00 Yuliana II LEARNING LECTURE: 22/6/16 OUTCOME 2,3 - Histology of the 08.00-09.00 09.00-10.00 Ratna/Mayun eye Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Plenary session 14.00-15.00 15.00-16.00 Ratna/Mayun III LEARNING LECTURE : 23/6/16 OUTCOME 3 - Physiology of the 08.00-09.00 09.00-10.00 Sutjana/ eye Krisna Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Sutjana/ Plenary session 14.00-15.00 15.00-16.00 Krisna IV LEARNING LECTURE : 27/6/16 OUTCOME 3,4 - Physiology of the 08.00 - 08.30 09.00 - 09.30 Krisna eye - Pharmacology of 08.30-09.00 09.30-10.00 Jawi the ocular medicine Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Plenary session 14.00-15.00 15.00-16.00 Krisna, Jawi V LEARNING LECTURE: 28/6/16 OUTCOME - Visus and 08.00-08.30 09.00-09.30 Ariesanti 5,6,22 Refraction Eka - Refraction 08.30-09.00 09.30-10.00 disorders Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Ariesanti, Plenary session 14.00-15.00 15.00-16.00 Eka

Udayana University Faculty of Medicine, DME 10

Study Guide The Visual System and Disorders

VI LEARNING LECTURE: 30/6/16 OUTCOME - Infection eye 08.00-08.30 09.00-09.30 Niti 7,8,9,21,22 disorders - Imunologic eye 08.30-09.00 09.30-10.00 Juliari disorders Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Plenary session 14.00 -15.00 15.00 -16.00 Niti, Juliari VII LEARNING LECTURE: 01/7/16 OUTCOME - Congenital and 08.00-08.30 09.00-09.30 Agus 10,22 Chronic Glaucoma - Acute and 08.30 -09.00 09.30 -10.00 Ari Surya Secondary Glaucoma Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Agus, Plenary session 14.00-15.00 15.00-16.00 Ari Surya VIII LEARNING LECTURE: 11/7/16 OUTCOME - Ocular Injuries 08.00-08.30 09.00-09.30 Sukartini 11,12,13,14,15 - Eyelids and 08.30-09.00 09.30-10.00 Laksmi U ,16 Lacrimal Disorders Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Sukartini, Plenary session 14.00-15.00 15.00-16.00 Laksmi U IX LEARNING LECTURE : 12/7/16 OUTCOME - Cornea and Lens 08.00-08.30 09.00-09.30 Jaya 17,18,22 disorder - Retina 08.30-09.00 09.30-10.00 Ari Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Student Project 12.30-14.00 10.00-11.30 Plenary session 14.00-15.00 15.00-16.00 Jaya, Ari X LEARNING LECTURE : 13/7/16 OUTCOME - Neuro 08.00-08.30 09.00-09.30 Mas 19,20 Ophthalmology - Strabismus 08.30-09.00 08.30-09.00 Surasmiati Independent Learning 09.00-10.30 12.00-13.30 SGD 10.30-12.00 13.30-15.00 Break 12.00-12.30 11.30-12.00 Juliari Student Project 12.30-14.00 10.00-11.30 Mas, Plenary session 14.00-15.00 15.00-16.00 Surasmiati

Udayana University Faculty of Medicine, DME 11

Study Guide The Visual System and Disorders

XI ARTICLE REVIEW PRESENTATION TEAM 13- 19/7/16 XII PRAKTIKUM / BASIC CLINICAL SKILL TEAM 14- (Histology, Physiology, Ophthalmology) 20/7/16 XIII PRE-EVALUATION BREAK TEAM 21/7/16 XIII FINAL ASSESSMENT TEAM 22/7/16

Note. • Lecture: at class room (4.01), 4 rd floor start on time • Class will be locked while the lecture begin, please do not late for the class • Student Presentation: at class room (4.01)

TIME TABLE BASIC CLINICAL SKILL

Study load : 1 SKS = 5 days DATE : 14 July 2016 – 20 July 2016

DAY LEARNING ACTIVITY CLASS B CLASS A PIC

I LECTURE: 08.00 – 09.00 09.00 – 10.00 Laksmi Utari 14/7/16 VISUAL ACUITY EXAMINATION BCS Visual Acuity Exam 09.30-11.30 13.00-15.00 TEAM + Anterior segmen Break 11.30-12.00 12.30-13.00 Student Project Presentation 12.00-14.00 10.30-12.30 Eka II LECTURE : 08.00-09.00 09.00-10.00 Mas Putrawati 15/7/16 - TONOMETRY - VISUAL FIELD/KONFRONTASI - AMSLER GRID BCS Tonometry + 09.30-11.30 13.00-15.00 TEAM Konfrontasi + Amsler Grid Break 11.30-12.00 12.30-13.00 Student Project Presentation 12.00-14.00 10.30-12.30 Surasmiati III LECTURE : 18/7/16 - POST SEGMENT 08.00-09.00 09.00-10.00 Surasmiati EXAMINATION BCS Post Segment Exam 09.30-11.30 13.00-15.00 TEAM Break 11.30-12.00 12.30-13.00 Student Project presentation 12.00-14.00 10.30-12.30 Budi/Ari IV LECTURE : 19/7/16 - Anterior Segment 08.00-08.30 09.00-09.30 Ari Suryathi Examination - Therapeutic Instillation 08.30-09.00 09.30-10.00 & Drug Prescription BCS Ant Segment Exam+ 09.30-11.30 13.00-15.00 TEAM Terupeutis Break 11.30-12.00 12.30-13.00 Student Project 12.00 -14.0 0 10.30 -12.30 Laksmi Utari

Udayana University Faculty of Medicine, DME 12

Study Guide The Visual System and Disorders

V LECTURE : 20/7/16 - Histology Examination 08.00-08.30 09.00-09.30 Ratna - Physiology Practice Lecture : Ishihara 08.30-09.00 09.30 -10.00 Krisna Plucido Kampimetri Practicum Histology 09.30-11.30 13.00-15.00 Histology team Break 11.30-12.00 12.30-13.00 Practicum Physiology 12.00-14.00 10.30-12.30 PHYSIOLOGY TEAM

Note: Lecture for BCS Ophthalmology, Histology and Physiology will be held at Class Room (R.4.01) BCS Ophthalmology will be held at Skill Lab. Histology Practicum will be demonstrated in classroom. Physiology Practicum will be held in Physiology Dept. Each BCS will be divided into 4 small groups: ENGLISH CLASS (CLASS B): Group A Group B Group C Group D REGULAR CLASS (CLASS A): Group A Group B Group C Group D

Udayana University Faculty of Medicine, DME 13

Study Guide The Visual System and Disorders

MID BLOCK MEETING

The meeting between block planner team, facilitators and the student group representatives will be held on 28 Juni 2016 at classroom (4.01) if necessary. In this meeting all the facilitator and student group representative are expected to give suggestion and input as an evaluation to improve the study guide and educational process of visual system and disorder. Because of the important of this meeting, all the facilitators and student group representative are strongly expected to attend the meeting. All of student group representatives (approximately 10 students) are expected to give suggestion and input or complain to the team planner for improvement. For this purpose, every student group must choice one student as their representative to attend the meeting.

PLENARY SESSION For each learning task, the student is requested to prepare a group report. The report will be presented in plenary session. Lecturer in charge will choose the group randomly. The aim of this presentation is to make similar perception about the topic that has been given.

ASSESSMENT METHOD Assessment will be held on Monday, 27 Juli 2016 . The Final examination will be held with the format of Computer Based Test. There are 100 questions for the examination that consist out Multiple Choice Questions (MCQ). The time provision is 100 minutes. The number of MCQ is 100. The minimal passing score for the assessment is 70. The proportions of examination score are: Small Group Discussion : 5% Article Review (Student Project) : 15% Final assessment (MCQ) : 80% The Prerequisites of Final Examination: - Attend 75% of total student activities - Uniform for Examination: white shirt, black trouser/ skirt, shoes. NO SANDALS ALLOWED to be wear at the class - Bring Student ID card with photo - Be present 15 minute before the examination starting time

Other than the examination score, the student performance and attitude during group discussion and all block activities will be considered for the average final score.

Article Review Students have to write an Article Review with topics that has not been given by lecturer. The topic will be chosen randomly on day one. Each small group discussion is going to write one Article Review with different tittle. One topic shall be wroten by 10-12 students with the direction from facilitator. Students make one review as student project and will be presented in front of the class and scored by respective facilitators and evaluators.

Format of Article Review

1. Cover:  Title Article Review writed at top left corner Udayana Symbol Name Student Registration Number Udayana University, School of Medicine, 2015 2. Introduction 3. Content: From Definition to Treatment 4. Summary 5. Reference (minimal 10 references)  Vancouver

Udayana University Faculty of Medicine, DME 14

Study Guide The Visual System and Disorders

Example: Journal. John L, Kaplan El. Nonparametric estimation from incomplete observations. J Am Stat Assoc 2008;45:456-481.

Tex book Rootman J, Lapointe JS: Masenchymal Tumor. In Rootman J (ed): Diseases of the . Philadelphia: JB Lippincott CO, 2000,pp 455-469.

Note: 8-10 pages, 1.5 space, Time New Roman 12, page at right bottom.

Supervisor (Facilitator) Score with 60% qualification, while Evaluator Score the Presentation with 40% qualification.

TOPIC OF ARTICLE REVIEW English Class Date SGD Presentation Title Evaluator Time 13/7/16 B1 10.00-10.30 Corneal Ulcer Niti/Juliari B2 10.30-11.00 Endophthalmitis Niti/Juiari

14/7/16 B3 10.00-10.30 Eka S B4 10.30-11.00 ROP Eka S

15/7/16 B5 10.00-10.30 Congenital Esotropia Surasmiati B6 10.30-11.00 Eksotropia Intermitten Surasmiati

18/7/16 B7 10.00-10.30 Central Serous Chorioretinopathy Budiastra/Ari A B8 10.30-11.00 Central Retinal Artery Oclusion Budiastra/Ari A

B9 10.00-10.30 Basal Cell Carcinoma Laksmi Utari 19/7/16 B10 10.30 -11.00 Squamous Cell Carcinoma Laksmi Utari

Note. Student presentation: at class room (4.01)

Regular Class Date SGD Presentation Title Evaluator Time 13/7/16 A10 12.30-13.00 Endofthalmitis Niti/Juliari A9 13.00-13.30 Corneal Ulcer Niti/Juliari

14/7/16 A8 13.00-13.30 ROP Eka S A7 13.00-13.30 Congenital Cataract Eka S

15/7/16 A6 12.30 -13.00 Eksotropia Intermitten Surasmiati A5 13.00-13.30 Congentital Esotropia Surasmiati

18/7/16 A4 12.30-13.00 Central Retinal Artery Oclusion Budiastra/ Ari A A3 13.00-13.30 Central Serous Chorioretinopathy Budiastra/Ari A

19/7/16 A2 12.30 -13.00 Squamous Cell Carcinoma Laksmi Utari A1 13.00-13.30 Basal Cell Carcinoma Laksmi Utari

Note. Student presentation: at class room (4.01)

Udayana University Faculty of Medicine, DME 15

Study Guide The Visual System and Disorders

Article Review Assessments Form Block of Visual system and disorders

Name :………………………………………….. Student Reg. Number :………………………………………….. Facilitator :………………………………………….. Title :…………………………………………..

Time Table of Consultation

No Point of Discussion Date Supervisor Sign 1 Outline of Paper 2 Final Discussion

No Item Assessment Range Score (%) Score 1 Ability to find the literature 0-20 2 Communication/attitude/presentation 0-30 3 Quality of material (SOAP) 0-40 4 Student interest and motivation 0-10 TOTAL 100 Facilitator,

(………………………………………) NIP

No Item Assessment Range Score (%) Score 1 Quality of material 0-60 2 Capability of Information Searching 0-10 3 Critical Thinking 0-30 TOTAL 100 Evaluator/Supervisor,

(………………………………………) NIP

Udayana University Faculty of Medicine, DME 16

Study Guide The Visual System and Disorders

LEARNING PROGRAM Day 1 MODULE 1 ANATOMY OF THE EYE By dr. Yuliana, M.Biomed

SUMMARY The eyes lie within two bony orbits, located on either side of the root of the nose. The medial walls of the orbits are almost parallel. They border the nasal cavity anteriorly and the ethmoidal air cell and the sphenoid sinus posteriorly. The lateral walls border the middle cranial, temporal, and pterygopalatine fossae. Superior to the orbit is the anterior cranial fossa and the frontal and supraorbital sinus. The maxillary sinus and the palatine air cell are located inferiorly. Seven bones make up the bony orbit such as frontal, zygomatic, maxillary, ethmoidal, sphenoid, lacrimal, and palatine. The four rectus muscles insert anteriorly on the along the Spiral of Tillaux. Two oblique muscles are superior and inferior oblique muscle.Six of the twelve cranial nerves (CV II-VII) directly innervates the eye and periocular tissue. The principal arterial supply of the orbit and its structures derives from the ophthalmic artery, the first major branch of the intracranial portion of the internal carotid artery.

LEARNING TASK: 1. Describe four walls of orbit and the bones that construct the walls. 2. Describe blood supply of the eye 3. Describe about components 4. Describe about orbit muscles 5. Describe about layers of eyeball 6. Describe about nerve supply of the eyes

SELF ASSESSMENT: 1. Describe about the position of bones that construct the walls 2. Describe about the position of lacrimal apparatus

LEARNING RESOURSES: 1. Moore.K.L, Agar A.M.R : Essensial Clinical Anatomy, Second Edition, Lippincott Williams & Wilkins. 1995, USA

Day 2 MODULE 2 Title of Lecture HISTOLOGY OF THE EYE DR. RATNAYANTI

Abstract Like any other senses, eye is our window to the external world. Eye captures image continuously and transmits it to the brain for next processing and understanding. The structure of the eye is perfectly designed to perform its course. The light reflected by object enters the eye through cornea and . The amount of light permitted is regulated by by dilating or constricting the pupil. Then, the refractive structures, lens and vitreous body, directing the light to the retina where it translated to a signal the brain can understand and perceived as an image. The shape and structure of the other eye walls support the photoreceptor function of the eye. The rigid and opaque protects the eye and maintains the spherical shape needed for precise image in the back of the eye. The provides nutrition and its melanin blocks lights from other angles, thus, only light comes

Udayana University Faculty of Medicine, DME 17

Study Guide The Visual System and Disorders from cornea is received. The accessory structures of the eye also support and protect the eye. It is consist of lacrimal gland, which produce tears; conjunctiva, covered the anterior part of the eye; and eye lids, the “on and off button” of the eye.

Vignette A 25 year old woman came to your private practice with a symptom of pink eye. She already had it since 2 days ago and it getting worse by now. It also followed by a yellowish secret which usually noticed when she got up from sleeping in the morning. She also felt pain and her eyes felt watery. From the examination you found redness in the white area of both eyes and also on the inside of the eyelids.

Learning Task: 1. What histologic structure mainly affected in the case? 2. Describe that histologic structure involve in the case above!

A 89 year old man came to a private practice due to dryness in the eye. He often felt itchy, gritty, and sometime burning. After the feeling he was tearing then when the tearing stopped he felt the symptoms again. It became worst if he read, watched television or went out especially in a windy day. He was in regular use of beta blocker because of heart problem. The doctor took Schimer’s test and found the result was minimal wetting of the paper.

Learning Task: 1. What is the main structure disturbed in the case above? 2. Describe about the structure, which layer is mainly affected in the case above? 3. Describe all of the accessory structures that contributing in the formation of the structure mentioned!

Self Assessment: 1. Describe in detail about the accessory structure involve in the case above 2. Describe the accessory structures that contributing in the formation of tear film! 3. Describe about the circulation and function of aqueous humor and tears! 3. Describe about the refractive media of the eye: 1. Cornea 2. Aqueous humor 3. Lens 4. Vitreous humor 4. Describe in detail about the histologic structure of the eye’s wall: 1. Sclera 2. 3. Retina 5. Describe about the structure that holds the lens, including the choroid body! 6. What fluid drains from the eye to the canal of Schlemm? 7. What structures absorb the light that enters the eye? 8. The area in the retina that contains no photoreceptor cells is called…. 9. What is the sclera made of? 10. What cells in the conjunctiva which produce substance that constitute the tear film?

References: 1. Gartner, L. P. & Hiatt, J. L. 2011. Color Textbook of Histology. 3 rd Ed. Philadelphia: Saunders Elsevier. Pp. 514-526. 2. Fawcett, D. W. & Jensh, R. P. 2002. Concise Histology. 2 nd Ed. London: Arnold. Pp.301-313.

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DAY 3 Module 3 Title of Lecture PHYSIOLOGY OF THE EYE By Prof.dr.I Dewa Putu Sutjana, PFK,M.Erg

INTRODUCTION The human know the environment because they had special senses, such as visual system, auditory, smell, taste, tactile which are call five senses. The visual system was control around 90% of the daily activity. The visual system detects and interprets light stimulations. The light stimulations are in form of electromagnetic waves of lengths between 400 to 700 nm, which make up visible light. The human can be known the environment because they had: 1. The optic system, for reflected the light enters the eye and focuses it on the retina 2. The retina as photoreceptors transducer light energy into an nerves impulses 3. The optical neural, Neural pathways from the retina to the visual cortex at occipital lob of brain. 4. The visual cortex of the brain process nerve impulses into visual images.

I.OPTIC SYSTEM OF THE EYE The optics system of the eye is equivalent to the usually photographic camera. It has a lens system, aperture system (call pupil) and retina that correspond to the film. The lens system of the eye is composed of four refractive interfaces. If all the refractive surfaces of the eye are added together and considered to be one single lens known as reduced eye. In reduced eye total refractive power 59 diopters when the eye accommodated for distant vision. FORMATION OF AN IMAGE ON THE RETINA The light from the objects refracted and focused by the optics system of the eye on the retina. The image is inverted and reversed with respect to the object. However, the mind perceives objects in the upright position. PUPILLARY DIAMETER Like in the camera the eye had the pupil which is formed by the iris. The major function of the iris is to control the diameter of the pupil. The diameter of the pupil is control the amount of light enters the eye. The stimulation of the parasympathetic nerve increases the diameter of pupil. The change of pupil diameter followed the ACCOMODATION The eye can be adjusted automatically the vision changes from the near to par objects, by changes the refractive power of the eye which is known as accommodation. In human eye the accommodation is due to change the refractive power of the lens (from 20 diopters to about 34 diopters), especially in children or the young person. The ability of eye accommodation (lens refractive power) is reduced with increased of age, and than followed by presbyopia. NORMAL VISION AND ERROR OF REFACTION Normal vision known as an emmetropic eye, if parallel light rays from distant objects are in sharp focus on the retina, when ciliary muscle completely relaxed. If the parallel light rays are focus behind the retina is known as hyperopia, if parallel light rays focus in the front of retina known as myopia, but if the different of the curvature of the cornea is known as astigmatism. The correction of is use of lens, concave spherical lens for myopia, convex lens for hyperopia and cylindrical lens for astigmatism. VISUAL ACUITY Visual acuity is the ability of the person to distinguished two bright pin point spots of light 10 meters away can barely distinguished the spots as separate entities when they are 1.5 to 2 millimeters apart. Clinical method to tested the visual acuity use the Snellen’s chart,

Udayana University Faculty of Medicine, DME 19

Study Guide The Visual System and Disorders consist of letter of different sizes placed 20 feet away from the person being tested, with the formula: V = d/D V= visual acuity, d = distant of the person can read the letter, and D=distant of normal vision can read that letter. FLUID SYSTEM OF THE EYE For normal vision, the eye filled with intraocular fluid, which maintains sufficient pressure in the eyeball to keep it distended. The fluid can be divided into two portions: aqueous humor, which lies in front of the lens and vitreous humor, which is between the posterior surface of the lens and the retina. The aqueous humor is a freely flowing fluid, whereas the vitreous humor sometimes called the vitreous body, is gelatinous mass. Both water and dissolved substances can diffuse slowly in the vitreous humor but there is little flow of fluid. Aqueous humor is continually being formed and reabsorbed. The balance between formation and reabsorption of aqueous humor regulates the total volume and pressure of intra ocular fluid. RECEPTOR AND NEURAL FUNCTION OF THE RETINA Retina is the light sensitive portion of the eye, contain 9 layers from outside to inside as follows (1) pigmented layer, (2) layer of rods and cones, (3) outer nuclear layer, (4) outer plexiform layer, (5) inner nuclear layer, (6) inner plexiform layer, (7) ganglionic layer, (8) layer of fiber, (9) inner limiting membrane. After the light passes through the lens system of the eye and then through the vitreous humor, it enters the retina from the inside layer and then finally reaches the layer of rods and cones. Cones located at the central fovea, a minute area in the center of retina occupying a total area around 1 square millimeter. The central fovea only 0.3 millimeters in diameter is composed almost entirely of cones. Outer of the center fovea located by rods. PHOTORECEPTOR RHODOPSIN-RETINAL VISUAL CYCLE AND EXCITATION OF THE RODS When light energy is absorbed by rhodopsin the rhodopsin begins to decompose within a very small fraction, cause photoactivation of electron, and then re-formation of rhodopsin again, which is call rhodopsin-retinal cycle. In that cycle vitamin A more important for normal vision, but if vitamin A is not enough, the night blindness occurs. PHOTOCHEMISTRY OF COLOR VISION BY CONES Photo chemicals in the cones have almost same to the rhodopsin at the rods. The difference is the protein portions, call the opsins (photopsins). According to the Young- Helmholtz theory, there are three type of color pigment in the cones cells (blue, green, red): blue sensitive pigment, green sensitive pigment, and red sensitive pigment. So different cones (three type of cone) are sensitive to different colors of light. . When a single group of color-receptive cones is missing from the eye, the person is unable to distinguish some colors from others, call color blindness. If the person loss of red cones it is called a protanope, if lacks of green called deuteranope. Red green color blindness is a genetic disorders, that at the female X chromosome. So that the color blindness almost in males. NEURAL FUNCTION OF THE RETINA Neural organization at the retina is more complex. The function of the neural pathways is to transmit the neural impulse from the retina (rods and cone) through the optic nerve to the brain. It is different at the peripheral retina and in the center foveal retina. That is way the center foveal retina for detail and color vision

LEARNING TASK 1. Describe the equivalent and the different optic system of the human eye to the photographic camera. 2. Describe the optic system of the eye 3. Describe the different of emmetropia, hyperopia and myopia. 4. What is accommodation, and in the human eyes which part of the optic system most important.

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5. Describe the circulation of the eye fluid 6. Describe the different of rods and cones in the vision perception 7. Describe the rhodopsin-retinal cycle, during light exposure to the rod 8. Describe the role of vitamin A in rhodopsin retinal cycle 9. Describe the Young-Helmholtz theory of the color vision 10. Describe many kind of color blindness

SELF ASSESSMENT 1. Can you mention the part of optic system 2. What is mean by presbyopia and why it is occur in the human? 3. Can you explain the role of cilliary muscle during accommodation? 4. Can you explain why color blindness almost occur in males. 5. Can you explain the neural function of the retina 6. Can you explain why the niktalopia person difficult to see in the afternoon but not problem at the morning?

RESOURCES: 1. Guyton, A. The Textbook of Medical Physiology 2. Silverthorn, D.U. 2010. Human physiology. An Integrated Approach.Fifth Ed. Pearson. San Fransisco.

DAY 4 Module 3 Title of Lecture PHYSIOLOGY OF THE EYE – Visual Pathways dr. I Made Krisna Dinata, M.Erg

Abstract The Visual Pathways The visualnerve signals leave the through the opticnerves. At the optic chiasm, the optic nerve fibersfrom the nasal halves of the retinas cross to theopposite sides, where they join the fibers from theopposite temporal retinas to form the optic tracts. The fibers of each optic tractthen synapse in the dorsal lateral geniculate nucleus of the thalamus , and fromthere, geniculocalcarine fibers pass by way of the optic radiation (also called the geniculocalcarine tract ) to the primary visual cortex in the calcarine fissure areaof the medial occipital lobe. Visual fibers also pass to several older areas of the brain: 1. From the optic tracts to the suprachiasmatic nucleus of the hypothalamus, presumably tocontrol circadian rhythms that synchronize various physiologic changes of the body with night and day 2. Into the pretectal nuclei in the midbrain , to elicit reflex movements of the eyes to focus on objects of importance and to activate the pupillary light reflex 3. Into the superior colliculus, to control rapid directional movements of the two eyes 4. Into the ventral lateral geniculate nucleus of the thalamus and surrounding basal regions of the brain, presumably to help control some of the body’s behavioral functions. The visual pathways can be divided roughly into an old system to the midbrain and base of the forebrain and a new system for direct transmissionof visual signals into the visual cortex located in the occipital lobes. Inhuman beings, the new system is responsible for perception of virtually allaspects of visual form, colors, and other conscious vision.

Function of the Dorsal Lateral Geniculate Nucleusof the Thalamus The optic nerve fibers of the new visual system terminate in the dorsal lateralgeniculate nucleus, located at the dorsal end of the thalamus and also calledsimply the lateral geniculate body, as shown in Figure 51–1. The dorsal lateralgeniculate nucleus serves two principal functions: First, it relays visual informationfrom the optic tract to the

Udayana University Faculty of Medicine, DME 21

Study Guide The Visual System and Disorders visual cortex by way of the optic radiation (also called the geniculocalcarine tract ). This relay function is so accurate thatthere is exact point-to-point transmission with a high degree of spatial fidelityall the way from the retina to the visual cortex.

Visual Field The field of vision is the visual area seen by an eye at agiven instant. The area seen to the nasal side is calledthe nasal field of vision, and the area seen to the lateralside is called the temporal field of vision. Each called monocular visual field. The area which are seen by two eyes is called binocular visual field

Fusion of the Visual Images From the Two Eye To make the visual perceptions more meaningful, thevisual images in the two eyes normally fuse with eachother on “corresponding points” of the two retinas.The visual cortex plays an important role in fusion. It was pointed out earlier in the chapter that correspondingpoints of the two retinas transmit visual signals todifferent neuronal layers of the lateral geniculatebody, and these signals in turn are relayed to parallelneurons in the visual cortex. Interactions occurbetween these cortical neurons to cause interference excitation in specific neurons when the two visualimages are not “in register” — that is, are not precisely “fused.”

Case A woman, 65 yo, came to physician with complainthat hervisual doesn’t work properly. The examination found that she had bipolar hemianopia.

Learning Task 1. Which area in visual pathways had been damage in that patient? 2. Describe the transmit of visual impulse from retina to the brain 3. What is called the monocular and binocular visual field 4. Differentiate the nasal and temporal visual field, and what tool for evaluation of the visual field 5. Describe how the visual image can be fusion

Self Assessment 1. Explain the different of visual field from left and right visual field 2. What is called the monocular and binocular visual field 3. Discribe the neural pathways to control pupillary light reflex 4. Describe the neural pathways to the optic nerve to form the consensual reflex

Refferences 1. Medical Physiology eleventh edition, Guyton & Hall. 2. Physiology fifth edition, Linda S. Costanzo. 3. Silvertharn, D.U. 2010. Human Physiology. An Integrated Approach. Fifth Ed. Pearson. San Fransisco

Udayana University Faculty of Medicine, DME 22

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DAY 4 MODULE 4 Title of lecture OCULAR PHARMACOLOGY By Dr. dr. I Made Jawi, M.Kes

Abstract Various pharmacologic agents are used for the treatment of eye disorders. The major challenge faced by today’s pharmacologist and formulation scientist is ocular drug delivery. Topical eye drop is the most convenient and patient compliant route of drug administration, especially for the treatment of anterior segment diseases. Delivery of drugs to the targeted ocular tissues is restricted by various precorneal, dynamic and static ocular barriers. Also, therapeutic drug levels are not maintained for longer duration in target tissues. In the past two decades, ocular drug delivery research acceleratedly advanced towards developing a novel, safe and patient compliant formulation and drug delivery devices/techniques, which may surpass these barriers and maintain drug levels in tissues. Anterior segment drug delivery advances are witnessed by modulation of conventional topical solutions with permeation and viscosity enhancers. Also, it includes development of conventional topical formulations such as suspensions, emulsions and ointments. Various nanoformulations have also been introduced for anterior segment ocular drug delivery. On the other hand, for posterior ocular delivery, research has been immensely focused towards development of drug releasing devices and nanoformulations for treating chronic vitreoretinal diseases. These novel devices and/or formulations may help to surpass ocular barriers and associated side effects with conventional topical drops. Also, these novel devices and/or formulations are easy to formulate, no/negligibly irritating, possess high precorneal residence time, sustain the drug release, and enhance ocular bioavailability of therapeutics. An update of current research advancement in ocular drug delivery necessitates and helps drug delivery scientists to modulate their think process and develop novel and safe drug delivery strategies. Systemic administration of a drug to treat would require a high concentration of circulating drug in the plasma to achieve therapeutic quantities in the aqueous humours, with the increased risk of side effect. Three important factors have to be considered when attempting drug delivery to the eye: (1) how the blood-eye barrier (systemic to ocular) or cornea (external to ocular) is crossed to reach the site of action; (2) how to localize the pharmacodynamic action at the eye and minimize drug action on other tissues; (3) how to prolong the duration of drug action so that the frequency of drug administration can be reduced. Many of the pharmacological agents commonly used for the treatment of eye disorders have been discussed in other blocks, such as anti bacterial, anti viral, anti allergy and anti inflammation agents. A number of antibacterial antibiotics have been formulated for topical ocular use. Natamycin is the only ophthalmic antifungal in use. Autonomic agents have several uses in ophthalmology, including diagnostic evaluation of , as adjunctive therapy in laser and incisional surgeries, and in the treatment of glaucoma. Glaucoma is a condition of the eye in which there is an increase in the intraocular pressure (IOP), causing progressive atrophy of the optic nerve with deterioration of vision. Drugs reduce IOP either by increasing outflow of aqueous humour, by decreasing aqueous production (beta-adrenergic blocking drugs, alpha-adrenergic agonists, and carbonic anhydrase inhibitors), or transiently reducing the volume of intraocular fluids (osmotic agents). SELF-DIRECTED LEARNING 1. Basic principles of drug that affect outonomic nervus system 2. Pharmacokinetic and pharmacodynamic of some drugs that use in visual system 3. Important side effects of drugs that use in visual system 4. Important drug for glaucoma treatment, cycloplegic and antibiotic.

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SCENARIO

Vignette Nyoman Dewi,70 y.o, is diagnosed by an ophthalmologist as having glaucoma. Your initial assessment reveals that she has high blood pressure and appears to have difficulty in following instructions. Please discuss the following issues.

Learning Tasks 1. Which anti-glaucoma will you give to the patient according to the patient condition? Explain your answer. 2. What is the mechanism of action on the muscle of the iris and cilia? 3. What receptor mediates the action? 4. List parts of the eyes that are innervated by the autonomic nervous system and explain the effects of sympathetic and parasympathetic drugs to those parts. 5. List the drugs that can be used to treat glaucoma and explain their mechanism of action to reduce the intraocular pressure 6. Please explain, why topical application sometimes has systemic effect? 7. List the important side effects of anti-glaucoma agents. 8. Which drug can produce ? Explain the mechanism of action of this drug. 9. Please compare the advantages and disadvantages between eye drops and eye ointments.

Self Assessments 1. Please explain the factors that determine the rate and the extent of absorption of the drug after topical application to the eye. 2. Please explain the possible absorption pathways of an ophthalmic drug following topical application to the eye. Which routes are desired to localize ocular drug effects? 3. Please explain, why topical eye can cause systemic side effects? 4. Please explain how to apply eye drop to the eye to get optimal effect. 5. Please explain the characteristics of cholinoceptors in the peripheral nervous system. 6. Please explain the characteristic of adrenoceptors in the ANS. 7. Please explain the effects of sympathetic and parasympathetic drugs on the eye. 8. Please list some drugs used in glaucoma and explain their mechanisms of action. 9. Please list important side effects of drugs used in glaucoma. 10. Please list some drugs used in ophthalmology diagnostic.

RESOURCES Standard textbook 1. Trevor AJ, Katzung BG, and Masters SB. Katzung & Trevor’s Pharmacology Examination & Board Review. Seventh Ed. Singapore: McGraw Hill 2005.

Additional Readings 1. Moroi SE, Lichter PR. Ocular Pharmacology in Goodman & Gillman’s: The Pharmacology Basis of Therapeutics. 10th Ed. New York: McGraw Hill. 2001.

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DAY 5TH MODULE 5 Title of lecture REFRACTION DISORDERS By Ariesanti TH, MD, Eka Sutyawan

AIMS: Describe the Signs, Symptoms, Patophysiology and Management of refractive errors

LEARNING OUTCOMES: Can describe the Signs, Symptoms, Patophysiology and Management of: 1. Myopia 2. Hyperopia 3. Astigmatism 4. Presbyopia 5. Anisometropia

CURRICULUM CONTENTS 1. Optics and Refraction 2. Refraction examination 3. Emetropia and Ametropia / Refractive Errors 4.

ABSTRACT / SUMMARY OF LECTURE The eye change refractive power to focus on near object by a process call it accommodation. Emetropia is absence of refractive errors and ammetropia is the present of refractive errors. Light rays are focused on the retina to create sharp image. The light has to pass trough refractive media of the eye such as cornea, lens and vitreous body to reach retina. Some equipment are needed to examine refraction as follows Snellen chart, Trial lenses, trial frame, pupil distance ruler, lensometer, astigmatism chart, streak retinoscopy and autorefractor. The technique used in subjective refraction is trial and errors technique, while Astigmatic Clock Dial technique and Jackson Cross Cylinder technique were used to find astigmatism of the patient. Emmetropia is term used for eye with parallel light from distant object focused on retisna without accommodation of the eye. Ametropia is condition where parallel light is not focused on retina without eye accommodation. Classification of ammetropia is myopia, hypermetropia and astigmatism. Miopia is a refractive error in which focus for light rays from a distant object is anterior to the retina. Hypermetropia is a refractive error in which the focus of light rays from a distant object is behind the retina. Astigmatism is a refractive error that prevents the light rays from coming to a point focus on the retina because of different degrees of refraction in the various meridians of the cornea or crystalline lens. Presbyopia (“old sight”) is a physiologically blurred near vision, commonly evident soon after age 40, due to reduction in the power of accommodation. The management of refractive errors could be glasses, contact lens and refractive surgery. Contact lens could be used to treat refractive errors, theraphy for some ocular pathologies as well as cosmetic or prosthetic use. Some could be developed regarding the inappropriate handle and use of contact lens, such as allergic, Keratitis and corneal ulcer.

SELF DIRECTING LEARNING (in depth learning of above lecture) 1. Physiology of Optics and refraction 2. Definition of Emetropia and Ametropia 3. Refraction examination 4. Refractive error: Myopia

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5. Refractive Error: Hyperopia 6. Refractive Error: Astigmatism 7. Refractive Error: Presbyopia 8. Anisometropia 9. Managements of refractive errors 10. Benefits and complications of Contact lens use

SCENARIO 1. A 8 years old boy complain about intermittent blurred vision and headache at the frontal region. Everyday, the patient spent his time in front of his gadget all day. From physical examination found that he able to read all the letters from the Snellen chart. After given mydriatic drops and done the refraction, he can read all the letters with correction of S+2.00 D in both eyes. a. What is the diagnosis of this case? b. Mention about the types of hypermetropia based on the accomodation c. What kind of glasses should be prescripse for hypermetropia patient d. What are the complications of hypermetropia and how it can happened? e. What is the differences between hypermetropia and presbyopia 2. A 25 years old woman complained of blurred vision and headache especially in frontal region. From the examination there are C-1.50 A 180° found in the right eyes and S-2.00 C-0.50 A0° in the left eye. a. What is the diagnosis of the both eye? b. Mention about the types of regular astigmatism c. Mention about the symptoms of astigmatism 3. A 30 years old man come to the ophthalmologist and has checked his visual acuity. From the right eye there is S-6.00 and his BCVA is 6/10 and from his left eye there is 6/6 with S-0.50 a. What is the diagnosis of this patient? b. What is the complication of myopia? c. What happen if the patient is given maximum correction of glasses? d. So what is the best treatment in this case to make better visual acuity and avoid the complication?

SELF ASSESSMENTS 1. Mentions and explain about types of myopia 2. Methods of objective refraction: a. Trial and errors techniques b. Streak retinoscopy c. Astigmatic clock dial d. Fogging technique e. Jackson cross cylinder

LEARNING RESOURSES: 1. Vaughan: General Ophthalmology 2. Ilyas S: Ilmu Penyakit Mata. FK UI 3. Deborah PL: Manual Diagnostic &Ocular Treatmentt. 4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 2006

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DAY 6 MODULE 6 Title of lecture INFECTION & IMMUNOLOGIC EYE DISEASES By NK.Niti Susila, MD/IGAM Juliari, MD

AIMS: Describe the Signs, Symptom, Patophysiology and management OF INFECTION AND IMMUNOLOGIC EYE DISEASES

LEARNING OUTCOMES: Can describe the Signs, Symptoms, Patophysiology and Management of: 1. Blepharitis 2. Hordeolum & Chalazia 3. Conjunctivitis 4. Scleritis & Episcleritis 5. Keratitis 6. Anterior Uveitis (Iritis & Iridosiklitis) 7. Dry Eye Syndrome & sicca

SELF DIRECTING LEARNING ( in depth learning of above lecture) 1. Blepharitis a. Pathogenesis of blepharitis b. Definition of chronic anterior blepharitis c. Definition of chronic posterior blepharitis d. Definition of Angular blepharitis e. Aetiology of blepharitis f. of chronic anterior and posterior blepharitis and angular blepharitis g. Diagnosis of chronic anterior and posterior blepharitis and angular blepharitis h. Management of blepharitis i. Associations of chronic blepharitis 2. Hordeolum a. Pathogenesis of hordeolum b. Definition of external and internal hordeolum c. Aetiology of external and internal hordeolum d. Signs and symptoms of external and internal hordeolum e. Diagnosis of external and internal hordeolum f. Management of external and internal hordeolum g. Complication of external and internal hordeolum 3. Chalazion a. Pathogenesis of chalazion b. Definition of chalazion c. Aetiology of chalazion d. Signs and symptoms of chalazion e. Diagnosis of chalazion f. Management of chalazion g. Complication of chalazion 4. Conjunctivitis a. Pathogenesis of conjunctivitis (Allergy, viral, bacterial) b. Definition of conjunctivitis c. Aetiology of conjunctivitis d. Signs and symptoms of conjunctivts

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e. Diagnosis of conjunctivitis f. Management of conjunctivitis g. Prognosis of conjunctivitis h. Differential diagnosis conjunctivitis due to aetiology i. Complication of conjunctivitis 5. Scleritis a. Pathogenesis of infection scleritis non infection scleritis b. Definition of infection or non infection scleritis c. Aetiology of infection or non infection scleritis d. Signs and symptoms of infection or non infection scleritis e. Diagnosis of infection or non infection scleritis f. Prognosis of infection or non infection scleritis g. Management of infection or non infection scleritis h. Different diagnosis of infection or non infection scleritis i. Complication of scleritis 6. Episcleritis a. Pathogenesis of episcleritis b. Definition of episcleritis c. Aetiology of episcleritis d. Signs and symptoms of episcleritis e. Diagnosis of episcleritis f. Prognosis of episcleritis g. Management of episcleritis h. Different diagnosis of episcleritis 7. Keratitis a. Pathogenesis of keratitis b. Definition of keratitis c. Aetiology of keratitis d. Signs and symptoms of keratitis e. Diagnosis of keratitis f. Prognosis of keratitis g. Management of keratitis h. Different diagnosis of keratitis i. Prognosis of kearatitis j. Complication of keratitis 8. Uveitis anterior a. Pathogenesis of uveitis anterior b. Definition of iritis and iridocyclitis c. Aetiology of iritis and iridocyclitis d. Signs and symptoms of iritis and iridocyclitis e. Diagnosis of iritis and iridocyclitis f. Prognosis of iritis and iridocyclitis g. Management of iritis and iridocyclitis h. Different diagnosis of iritis and iridocyclitis i. Prognosis of iritis and iridocyclitis j. Complication of iritis and iridocyclitis 9. Dry eye disorders a. Physiology of tear film b. Pathogenesis of dry eye syndrome c. Definition of dry eye d. Aetiology of dry eye e. Signs and symptoms of dry eye

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f. Diagnosis of dry eye g. Prognosis of dry eye h. Management of dry eye i. Different diagnosis of dry eye j. Prognosis of dry eye k. Complication of dry eye 10.Keratoconjunctivitis sicca a. Physiology of tear film b. Pathogenesis of Keratoconjunctivitis sicca c. Definition of Keratoconjunctivitis sicca d. Aetiology of Keratoconjunctivitis sicca e. Classification of Keratoconjunctivitis sicca f. Signs and symptoms of Keratoconjunctivitis sicca g. Diagnosis of Keratoconjunctivitis sicca h. Prognosis of Keratoconjunctivitis sicca i. Management of Keratoconjunctivitis sicca j. Different diagnosis of Keratoconjunctivitis sicca k. Prognosis of Keratoconjunctivitis sicca l. Complication of Keratoconjunctivitis sicca

ABSTRACT/SUMMARY The external eye is the most crucial part of the body exposed to outside word. The normal structure and function of the healthy eye rely on homeostasis of the entire body for protection against an adverse environment. Genetic and nutrition determine the embryogenesis and growth of the eye. Intact vascular and nervous systems stable metabolism, and immune system maintains surveillance. The cushioning effect of the periocular tissues and local barriers such as the orbital rim are needed to safeguard the globe. The eyebrows and catch small particles, and cilia also work as sensors to stimulate reflex eyelid closure. Blinking augments the lacrimal pump to rinse tears over the eye and flush off foreign material. The tear film also dilute toxins and allergens and contains proteins that control the normal flora. Mucin stabilizes that tear film and demarcates the living cells of the ocular surface from surrounding environment. The epidermis and epithelium of healthy eyelids, conjunctiva, and cornea adhere tightly to their basement membranes. Regulation of cellular growth and metabolism are critical to maintenance of an intact ocular surface and transparent cornea. The underlying extracellular matrix of the eye's mucous membrane is rich in blood vessels and conjunctiva- associated lymphoid tissue (CALT). The anterior segment of the eye provides a clear, protected entrance for light that is to be processed by the visual pathways through the central nervous system. Understanding the eye's innate defenses requires study of ocular histology and biochemistry and observation of many people, both healthy and ill. The practice of corneal and external eye disease builds on this understanding and extends from clinical examination to clinic-pathologic problem solving, molecular medicine, and microsurgery. The student should become familiar with ocular embryology, anatomy, physiology and biochemistry, ocular immunology, and ophthalmic pathology. Although the protections of the eye are very strong but the eye still can also be infected by bacteria, virus, fungi, and parasites. A detailed history and physical examination are essential to proper diagnosis of external eye infections or inflammatory etiology. The patient's chief complaint and a complete systemic and ocular history, including the presence of risk factors for infections of the external eye, should be noted. A complete eye examination should included special attention to skin of the face and eyelids, the preauricular lymph node, the globe-orbit relationship, ocular discharge, and conjunctiva and corneal morphology. Diagnostic tests

Udayana University Faculty of Medicine, DME 29

Study Guide The Visual System and Disorders are chose to differentiate between likely diagnostic entities and to assist in therapy. (eg. Antimicrobial sensitivity testing in microbial keratitis.)

1. Blepharitis Blepharitis is inflammation of the eyelid The chronic anterior blepharitis is very common cause of ocular discomfort and irritation. Involvement is usually bilateral and symmetrical. Blepharitis may be subdivided into anterior and posterior although there is overlap and both are often present. The poor correlation between symptoms and signs, the uncertain etiology and mechanism of the disease process all conspire to make management difficult.

2. Hordeolum and Chalazia Hordeolum is infection of the glands of the eyelid. It could involve meibomian gland (internal hordeolum) or Zeis's or Moll's glands (external hordeolum or ). Pain, redness, and swelling are the principal symptoms. Most hordeola are caused by staphylococcal infections, usually Staphylococcal aureus. Treatment consists of warm compresses three or four times a day for 10-15 minutes, antibiotic ointment applied to the conjunctival sac every 3 hours. If the process does not begin to resolve within 48 hours, incision and drainage is indicated. A chalazion is an idiopathic sterile chronic granulomatous inflammation of a meibomian gland, usually characterized by painless localized swelling. Surgical excision is performed via a vertical incision into the tarsal gland from the conjunctival surface followed by curettement. Intralesional steroid injection maybe usefull for small lesions.

3. Conjunctivitis Conjunctivitis is inflammation of the conjunctiva. It is the most common eye disease worldwide. There were several causes of conjunctivitis, such as bacterial, chlamydial, viral, rickettsial, fungal, parasitic, immunologic (allergic), chemical (irritative), systemic disease, secondary to or canaliculitis, or unknown etiology. The important symptoms of conjunctivitis are foreign body sensation, a scratching or burning sensation, a sensation of fullness around the eye, itching, and photofobia. The signs of conjunctivitis are hyperemia conjunctiva, tearing, exudation, pseudoptosis, papillary hypertrophy, chemosis, follicles, pseudomembranes and membranes. Specific therapy for conjunctivitis depends on the causes.

4. Scleritis & Episcleritis Episcleritis is a relatively common localized inflammation of the vascularized connective tissue overlying the sclera. It tends to affect young people, third or fourth decade, affects woman three times as frequently as men. Symptoms of episcleritis include redness and mild irritation or discomfort. The condition is benign, and the course is generally self-limited in 1-2 weeks. Others therapy was needed in special causes. Scleritis is an uncommon disorder characterized by cellular infiltration, destruction of collagen, and vascular remodeling. These changes may be immunologically mediated or less commonly, the result of infection. Laboratory studies are often helpful in identifying associated systemic disease. There were 2 types of scleritis, anterior and posterior. Initial treatment of scleritis is with systemic nonsteroidal anti-inflammatory agents. If there is no response in 1-2 weeks, or if vascular closure becomes apparent, oral prednisone, 0.5-1.5 mg/kg/d, should be started.

5. Keratitis Keratitis is an inflammation of cornea. The specific symptoms are pain and . Examination is often fascilitated by instillation of a local anesthetic. Fluorescein staining can outline a superficial epithelial lesion that might otherwise be impossible to see. A patient's history is important in corneal disease. A history of trauma, corneal disease, and local should be investigated.

Udayana University Faculty of Medicine, DME 30

Study Guide The Visual System and Disorders

6. Anterior Uveitis (Iritis & Iridocyclitis) Anterior uveitis is most common and is usually unilateral and acute in onset. Typical symptoms include pain, photophobia, and blurred vision. Examination usually revealed circumcorneal redness with minimal palpebral conjunctival injection or discharge. The pupil may be or irregular due to the formation of posterior synechiae. Inflammation limited to the anterior chamber is called "iritis"; inflammation involving both anterior chamber and the anterior vitreous is called "iridocyclitis".

7. Dry Eye Syndrome & Keratoconjunctivitis sicca Dryness of the eye may result from any disease associated with deficiency of the tear film components (aqueous, mucin, or lipid), lid surface abnormalities, or epithelial abnormalities. Patients with dry eyes complain most frequently of a scratchy or sandy (foreign body) sensation. Other common symptoms are itching, excessive mucus secretion, inability to produce tears, a burning sensation, photosensitivity, redness, pain, and difficulty in moving the eyelid. The most characteristic feature on slitlamp examination is the interrupted or absent tear meniscus at the lower lid margin. Tenacious yellowish mucus strands are sometimes seen in the lower conjunctival fornix. The bulbar conjunctival loses its normal luster and may be thickened, edematous, and hyperemic. Diagnosis and grading of the dry eye conditions can be achieved with good accuracy using the following diagnostic methods, such as schirmer test, tear film break-up time, ocular ferning test, impression cytology, fluorescein staining, rose Bengal staining, tear lysozyme assay, tear osmolality, and lactoferrin. The treatment is according to the gradation of the dry eye.

SCENARIO 1. A 79-year-old woman complains of red eyes that constantly tear and burn. She also feels foreign-body sensation and reports that her vision is not clear as before. The vision varies with tear blink. She has noticed this condition over past several years. On exam find a poor tear film filled with debris. a. What is the diagnosis? b. What is the definition of dry eye? c. What are the components of the tear film? d. What are the most common signs of dry eye? e. What are the treatments for dry eye patients? 2. A 25-year-old man states that his eyes have been dripping with discharge over the past 8 hours. You notice significant purulent discharge, a preauricular node, and marked chemosis. a. What is the diagnosis? b. What is the next step? c. What are you looking for on the Gram stain? d. How should the patient be treated? e. What is the complication? 3. A 35-year-old complained of pain in his left eye for several days, watery discharge, and blurred vision. He thinks he has the same symptoms before. He admits to stress on the job as well as a recent cold sore. a. What is the diagnosis? b. What are you looking for on fluorescein staining? c. What are the signs of the ? d. What is the complication of herpes simplex keratitis? e. How should the patient be treated? 4. A 30-year-old man presents with severe phtophobia, pain, tearing, and decreased vision in his right eye for two days. This condition has occurred several times before. He says that it was better by using drops. On exam, his vision 20/50 in the right eye and 20/20 in the left eye. His pupil is poorly reactive on the right and

Udayana University Faculty of Medicine, DME 31

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miotic. The right eye is diffuse injected, especially the limbus. The anterior chamber is deep, but cell and flare are present with few fine keratic-precipitates. a. What is the diagnosis? b. What is the etiology of anterior uveitis? c. What are differences between nongranulomatous anterior uveitis and granulomatous anterior uveitis? d. What is the complication of anterior uveitis? e. How should the patient be treated? 5. A 27-year-old man present with foreign-body sensation and photophobia in both eyes after sleeping with soft contact lenses during his call night. a. What is the diagnosis? b. What is the etiology? c. What is the complication that could be happened? d. How should the patient be treated?

SELF ASSESMENTS 1. Mention about pathophysiology of blepharitis 2. Mention and explain about types of conjunctivitis 3. Mention and explain about types of keratitis 4. Mention about symptom and sign of anterior uveitis 5. Mention about tear film components and dry eye examination

LEARNING RESOURCES: 1. Vaughan: General Ophthalmology 2. Ilyas S: Ilmu Penyakit Mata. FK UI 3. Deborah PL: Manual Diagnostic &Ocular Treatment. 4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 2006

DAY 7 MODULE 7 Title of lecture GLAUCOMA By Md Agus Kusumadjaja,MD, Ari Suryathi,MD

AIMS: Describe the signs, symptoms, patophysiology and inital management of glaucoma disorders

LEARNING OUTCOMES: Can describe the signs, symptoms, pathophysiology and inital management of: 1. Acute angle closure 2. Primary Acute angle closure glaucoma 3. Secondary glaucoma 4. Primary open angle glaucoma 5. Congenital glaucoma

CURRICULUM CONTENT: 1. Acute angle closure 2. Primary Acute angle closure glaucoma 3. Secondary glaucoma due to lens opacity and trauma (hyphema) 4. Primary open angle glaucoma 5. Congenital glaucoma

Udayana University Faculty of Medicine, DME 32

Study Guide The Visual System and Disorders

ABSTRACT/ SUMMARY Glaucoma is a group of eye disorders characterized by progressive optic nerve damage causing typical visual field defects, and increase of intraocular pressure (IOP) as one of risk factors. Glaucoma can be classified into primary, secondary, congenital and absolute glaucoma. Glaucoma also can de differentiated into acute and chronic glaucoma based on their onset. Visual acuity examination, IOP measurement, Gonioscopy, Ophthalmoscopy and Visual field examination are required to establish glaucoma diagnosis. Primary acute angle closure glaucoma (PACG) occurs when sufficient iris bombe develops to cause occlusion of the anterior chamber angle by the peripheral iris. This blocks aqueous outflow and the intraocular pressure rises rapidly, causing severe pain, redness, and blurring of vision. Angle closure is likely to develop only in eyes with preexisting anatomic narrowing of the anterior chamber angle usually when it is exacerbated by enlargement of the crystalline lens associated with aging. The acute attack is often precipitated by papillary dilatation. This occurs spontaneously in the evenings when the level of illumination is reduced. Primary open angle glaucoma (POAG) / chronic glaucoma is the most common form in blacks and whites. The chief pathologic feature of POAG is a degenerative process in the trabecular meshwork, including deposition of extra cellular material within the meshwork and beneath the endothelial lining of Schlemm’s canal. The consequence is a reduction in adequate drainage leading to a rise in intraocular pressure. The major problem in detection of (POAG) is the absent of symptoms until relatively late in the disease.

SELF DIRECTING LEARNING (In depth learning of above lecture) 1. Basic knowledge of aquous humor production and outflow 2. Mechanism of primary and secondary acute angle closure 3. Signs, symptoms and diagnosis of acute angle closure and acute angle closure glaucoma 4. Initial management of acute angle closure angle and acute angle closure glaucoma 5. Mechanism of primary and secondary open angle glaucoma 6. Signs, symptoms and diagnosis of open angle glaucoma 7. Initial management of open angle glaucoma 8. Mechanism of congenital glaucoma 9. Signs, symptoms and diagnosis of congenital glaucoma

SCENARIO Case 1. A woman, 45 yo complained her eye suddenly painful, nausea and when she worked in her office. On the examination doctors found there is visual acuity decreasing and hyperemia of conjunctiva and pericorneal, corneal edema, and high intra ocular pressure. 1. Mention things you should elaborate from the patient during anamnesis 2. Mention physical examination you should do to this patient 3. Explain about the result from the examination 4. Mention differential diagnosis of the case 5. Which diagnosis is the most appropriate? 6. Explain about the initial management of this case

Case 2. A man, 65 yo complained about blur vision and narrowing visual field since three months ago. There was no redness and pain on his eye, but the blur vision getting worse every time. 1. Mention thing you should elaborate from the patient during anamnesis 2. Mention physical examination you should do to this patient 3. Explain about the result from the examination 4. Mention differential diagnosis of the case

Udayana University Faculty of Medicine, DME 33

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5. Which diagnosis is the most appropriate? 6. Explain about the management of this case.

Case 3. A man 65 years old complained about blur vision since six months ago and the blur vision getting worse every time. Ophthalmology examination found increasing intra ocular pressure on right eye, decreasing visual acuity both eye caused by lens opacity. There was no redness and pain on his eye. 1. Mention thing you should elaborate from the patient during anamnesis 2. Mention physical examination you should do to this patient 3. Explain about the result from the examination 4. Mention differential diagnosis of the case 5. Which diagnosis is the most appropriate? 6. Explain about the management of this case. 7. What is the suggestion for the patient?

SELF ASSESSMENT: 1. Describe definition of acute glaucoma & chronic glaucoma. 2. Explain about pathogenesis of acute glaucoma & chronic glaucoma. 3. Mention classification of glaucoma based on onset and pathogenesis. 4. Mention symptoms could be found in acute glaucoma & chronic glaucoma. 5. Mention the examination needed to make diagnosis of acute glaucoma & chronic glaucoma. 6. Explain how you can establish diagnosis of acute glaucoma & chronic glaucoma. 7. What should you do if you have a patient with acute glaucoma & chronic glaucoma? 8. Mention what you should tell to the patient who has history of acute glaucoma & chronic glaucoma. 9. Mention about the pathogenesis, signs and symptoms of congenital glaucoma

LEARNING RESOURCES: 1. Vaughan: General Ophthalmology 2. Ilyas S: Ilmu Penyakit Mata. FK UI 3. Deborah PL: Manual Diagnostic &Ocular Treatment. 4. PERDAMI: Panduan Keterampilan dan Klinis Penyakit Mata, Jakarta, 2006

DAY 8 MODULE 8 Title of Lecture RECONSTRUCTION, OCULOPLASTY & ONCOLOGY By Sukartini AAA D, Laksmi Utari, MD

AIMS: Describe the sign, symptoms, patophysiology and management of reconstruction, oculoplasty & oncology case

LEARNING OUTCOMES: Can Describe the signs, symptoms, pathophysiology and management of: 1. Eyelid & lacrimal apparatus (lacrimal punctum & duct) laceration 2. and hyphema 3. Conjunctival, corneal, and intraocular foreign body 4. Corneal erosion, burn & chemical injury 5. Entropion & 6. Trichiasis 7. & eyelid retraction

Udayana University Faculty of Medicine, DME 34

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8. Epichantus 9. Ptosis 10. Xanthelasma 11. 12. Dacryocystitis 13. Dacryostenosis 14. Palpebral tumor (basal cell carcinoma & squamous cell carcinoma) 15. Intraocular tumor (retinoblastoma, melanoma) 16. Lacrimal apparatus tumor (benign mixed tumor)

CURRICULUM CONTENTS: 1. Ocular injury a. Mechanical injury (Sub Conjunctiva Bleeding & Hypema) b. Sharp injury (Laceration of the eyelid & Lacrymal apparatus) 2. Eyelid disorders 3. Lacrymal apparatus disorders 4. Ocular tumor

ABSTRACT/ SUMMARY OF LECTURE: Laceration of the eyelid can be partial-thickness or full-thickness. The wound should be cleaned thoroughly and antibiotics administered. Laceration must be repaired carefully to prevent lid margin notching and trichiasis. Subconjuntival bleeding may occur spontaneously, usually in only one eye, in any age group. The hemorrhage is caused by rupture of a small conjunctival vessel, sometimes preceded by a bout of severe coughing or sneezing. Contusive forces will frequently tear the iris vessels and damage the anterior chamber angle. Blood in the aqueous may settle out in a visible layer as hyphema. A pattern of vertical scratch marks on cornea indicates foreign bodies embedded on tarsal conjunctiva surface of the upper eyelid. Corneal foreign bodies and abrasion cause pain and irritation. A complaint of discomfort or blurred vision in an eye with history of striking metal upon metal, explosion, or high-velocity projectile injury should arouse a strong suspicion of intraocular foreign body. Entropion is turning inward of the eyelid, and may be involutional (spastic, senile), cicatrical, or congenital. The most common entropion is involutional which occurs as a result of aging. Ectropion (sagging and eversion of the lower eyelid) is usually bilateral and is frequent findings in older persons. It may be caused by relaxation of orbicularis oculi muscle, either as part of the aging process or following seventh nerve palsy. The symptoms are tearing and irritation, and exposure keratitis may occur. Trichiasis is impingement of eyelashes on the cornea and may be due to entropion, epibhlepharon, or simply misdirected growth. It causes corneal irritation and encourages ulceration. Epichantus characterized by vertical folds of skin over the medial canthi. It is typical of Asian and is present to some degree in most children of all races. The skinfolds is often too large to cover the part of nasal sclera and cause “pseudoesotropia”. Normally, the upper eyelid rests approximately midway between the superior limbus and the papillary margin. Ptosis or bhlepharoptosis is the condition in which one or both upper eyelids assume an abnormally low position. Ptosis may be congenital or acquired and can be hereditary in either case. Xanthelasma is a common disorder that occurs on the anterior surface of the eyelid, usually bilaterally near the inner angle of the eye. Xanthelasma represents lipid deposits in histiocytes in the dermis of the eyelid.

Udayana University Faculty of Medicine, DME 35

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Dacryoadenitis is the inflammation of lacrimal gland, which can be acute or chronic inflammation. It is a rare condition, which is most often seen in children as a complication of mumps, measles, or influenza and in adults in association with gonorrhea. Dacryocystitis is the infection of the lacrimal sac. It is moft often unilateral and always secondary to obstruction of nasolacrimal duct. Usually occurs in infants or postmenopausal women. Excessive tearing () is occasionally due to canalicular stenosis or obstruction of the common canaliculus and lacrimal sac. Most cases of the stenosis are acquired, due to the result of viral infections. Basal cell & squamous cell carcinoma are the most common malignant ocular tumors, which occur most frequently in fair-complexioned individuals who have had chronic exposure to the sun. Both of these types usually grow slowly and painlessly as a nodule. Biopsy is usually required to establish the correct diagnosis. Retinoblastoma is a rare but life-endangering tumor of childhood. Two-thirds of cases appear before the end of the third year. Retinoblastoma may exhibit outward (exophytic) or inward (endophytic) growth-either or both. Melanoma of the eyelids is similar to that elsewhere in the skin and includes three varieties: superficial spreading melanoma, lentigo malignant melanoma, and nodular melanoma. Benign mixed tumor is the most common benign epithelial tumor of the lacrimal gland. It can occur in any age (mean 39 years old).

SELF DIRECTING LEARNING (In depth learning of above lecture) 1. Anatomy of eyelid and lachrymal apparatus (punctum, lachrymal sac and duct) 2. Fisiology of lachrymal apparatus 3. Patophysiology of mechanical injury 4. Patophysiology of sharp and blunt injury 5. Patophysiology of base and acid ocular injury 6. Sign & symptom of eyelid disorders 7. Sign & symptom of lachrymal apparatus disorders 8. Sign & symptom of ocular tumors

SCENARIO: 1. A boy 5 years old came to the eye clinic with chief complained pain on left eye and suddenly blur after hit by mango while he played since 3 hours ago. Blur vision become worse while he lying down and better when he stand up. Ophthalmology examination found right eye within normal limit, and left eye visual acuity 1/60, unclear fundus reflex. According case above: a. Could you explain how this happened? (Why the visual acuity decreased and there was unclear fundus reflex?) b. Describe things you should elaborate from the patient to make diagnosis? c. Explain about diagnosis of the patient! d. What is the first aid for this case? e. What is the complication?

2. A woman 30 years old came to the eye clinic with chief complained left eye bleeding after felt down in the bathroom since 5 hours ago. Ophthalmology examination on left eye found there are eyelid ruptures. The visual acuity both eyes were good. According case above: a. Describe things you should elaborate from the patient to make diagnosis? b. Explain about diagnosis of the patient! c. What is the first aid for this case? d. What we should do after the first aid?

Udayana University Faculty of Medicine, DME 36

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3. A child 2 years old came to the eye clinic with her parent and her mother complained about her child’s eyes seems like cat’s eyes since 6 month ago. 1. Describe things you should elaborate from the patient to make diagnosis! 2. Mention sign and symptom could be seen in the patient! 3. Explain about diagnosis of the patient! 4. What should you do after making the diagnosis?

4. A Women 65 years old, complained about black mass on her lower eyelid since one year ago. The mass became more big, itchy and growth hair since a few month ago. Since a month ago the mass produce purulent liquid and became more pain. 1. Describe things you should elaborate from the patient to make diagnosis! 2. Mention sign and symptom could be seen in the patient! 3. Explain about diagnosis of the patient! 4. Explained about the different diagnosis? 5. What should you do after making the diagnosis?

SELF ASSESMENT: 1. Explain about conjunctiva, corneal & intraocular foreign bodies 2. What is corneal erosion? 3. Explain about the types of corneal burn injury and how to manage it 4. Explain about sign & symptoms of basal cell carcinoma 5. Explain about sign & symptoms of squamous cell carcinoma

LEARNING RESOURCES: 1. Vaughan: General Ophthalmology 2. Ilyas S: Ilmu Penyakit Mata. FK UI 3. Deborah PL: Manual Diagnostic &Ocular Treatment. 4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 2006

DAY 9 MODULE 9 Title of lecture LENS AND CATARACT By IWG Jayanegara, MD

AIMS: Describe the signs, symptoms, patophysiology and management of lens disorders

LEARNING OUTCOMES: Can describe the signs, symptoms, patophysiology and management of: 1. Cataract (senile, juvenile, congenital cataract 2. (subluxated and luxated lens ) 3. Pterygium & 4. Keratokonus 5. Microcornea & macrocornea

CURRICULUM CONTENTS 1. Lens & lens disorders 2. Corneal disorders

ABSTRACT / SUMMARY OF LECTURE A cataract is a clouding of the lens inside the eye that leads to a decrease in vision. It is the most common cause of blindness and is conventionally treated with surgery. Visual loss occurs because opacification of the lens obstructs light from passing and being focused on to the retina at the back of the eye.

Udayana University Faculty of Medicine, DME 37

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It is most commonly due to biological aging but there are a wide variety of other causes. Over time, yellow-brown pigment is deposited within the lens and this, together with disruption of the normal architecture of the lens fibers, leads to reduced transmission of light, which in turn leads to visual problems. Those with cataract commonly experience difficulty appreciating colors and changes in contrast, driving, reading, recognizing faces, and experience problems coping with glare from bright lights. Ectopia lentis is a displacement or malposition of the eye's crystalline lens from its normal location. A partial dislocation of a lens is termed lens subluxation or subluxated lens; a complete dislocation of a lens is termed lens luxation or luxated lens. A pinguecula is a yellowish, slightly raised thickening of the conjunctiva on the white part of the eye (sclera), close to the edge of the cornea. Pingueculae typically occur on the part of the sclera that is between your eyelids and therefore exposed to the sun. A pterygium is an elevated, wedged-shaped growth of the scleral conjunctiva that invades the cornea. Pterygia are benign (non-cancerous) growths, but contain blood vessels and form scar tissue on the eye. Because a pterygium resembles tissue or film growing over the eye, a person who has one may become concerned about personal appearance. As with pingueculae, prolonged exposure to ultraviolet light from the sun may play a role in the formation of pterygia. Keratoconus is a degenerative disorder of the eye in which structural changes within the cornea cause it to thin and change to a more conical shape than its normal gradual curve. Keratoconus can cause substantial distortion of vision, with multiple images, streaking and sensitivity to light. Macrocornea is a non-progressive enlargement of the cornea (more than 13 mm in diameter) without significant change in corneal thickness and normal clarity and function. Microcornea is an abnormally small cornea with a horizontal diameter of less than 10 mm. The condition is usually inherited, either as an autosomal dominant or autosomal recessive trait.

SELF DIRECTING LEARNING (in depth learning of above lecture) 1. Physiology of cormea and lens 2. Definition of Cataract (senile, juvenile, congenital cataract), Ectopia lentis (subluxated and luxated lens), Pterygium & pinguecula, Keratokonus, Microcornea & macrocornea 3. Management of Lens & lens disorders and Corneal disorders

SCENARIO 1. A 70 years old man complains of difficulty driving because of reduced vision. His best corrected visual acuity is 20/80 OD and 20/40 OS. Progressive nearsightedness. Problems with glare during the day. a. What need to be asking to the patient to make the diagnosis? b. Make the physical examination of this patient with imagination in correlation with the story above. c. What is the diagnosis of this case? d. How to diagnose this kind of cases? e. How to treated this case?

2. A 35 years old man came to the ophthalmologist and has checked his eyes. He complained of on both eye usually be seen as a fleshy, pink growth on the white of the eye. They occur between the eyelids ,on the right eye, in the corner of the eye, close to the nose, extend onto the cornea. a. What need to be asking to the patient to make the diagnosis? b. Make the physical examination of this patient with imagination in correlation with the story above. c. What is the diagnosis of this case? d. How to diagnosed this case? e. What is the best treatment in this case?

Udayana University Faculty of Medicine, DME 38

Study Guide The Visual System and Disorders

3. A young woman with her baby come to the ophthalmologist to checked her baby’s eye. She found Gray or white cloudiness of the pupil on her babys eye are present at birth. a. What need to be asking to the patient to make the diagnosis? b. Make the physical examination of this patient with imagination in correlation with the story above. c. What is the diagnosis of this case? d. How to diagnosed this case? e. What is the best treatment in this case?

SELF ASSESSMENTS 1. Mention and explain about types of cataract 2. Mention and explain about types of ectopia lentis 3. Mention and explain about corneal disorders 4. Referal procedure

LEARNING RESOURSES: 1. Vaughan: General Ophthalmology 2 Ilyas S: Ilmu Penyakit Mata. FK UI 3 Deborah PL: Manual Diagnostic &Ocular Treatment. 4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 2006

Day 9 MODULE 10 Title of Lecture VITREORETINAL DISORDERS By : Budhiastra MD and Ari Andayani MD AIMS : Describe the Signs, Symptoms, Patophysiology and Management of Vitreo Retina disorders.

LEARNING OUTCOMES Can describe the Signs, Symptoms, Patophysiology and Management of: 1. 2. Hypertensiv Retinopathy 3. Retinal Occlusion Retinal Disease 4. Retinal Detachment 5. Age Related

CURRICULUM CONTENT 1. Fundus Examination by Funduscopy Direct, Slit lamp with lens , Fundus Camera and OCT 2. Laser Photocoagulation 3. Anti VEGF Injection Intra Vitreal 4. Sceral Buckling dan Vitrectomy

ABSTRACT / SUMMARY OF LECTURE Diabetic Retinopathy is progressive microangiopathy characteristized by small vessel damage and occlusion. The earliest pathologic changes are thickening of the capillary endothelial basement membrane and reduction of the number of pericytes. In term both prognosis and treatment, it is useful to divide DR into Nonproliferative (NPDR) and Proliferative Diabetic Retinopathy (PDR). Diabetic (DME) can occur in both conditions.

Udayana University Faculty of Medicine, DME 39

Study Guide The Visual System and Disorders

Hypertensive retinopathy is the retinal change in is secondary to focal ischemia. Hypertension causes increases arterioral light reflex called copper and silver wiring. Classification of hypertensive retinopathy according to Keith-Wagener-Baker (KW): 1.KW 1: sclerosis, mild stenosis of arterial vessel, 2.KW 2: a-v crossing, hard exudates, 3 KW 3:hemorrhagic,soft exudates,4.KW 4:KW 3+papillaedema ( edema). Retinal detachment is separation of the sensory retina (photoreceptor and inner tissue layers) from underlying retinal pigment epithelium (RPE) layer. RD can be divided into: 1. Rhegmatogenous retinal detachment (RRD) with retinal tear (due to myopia, , trauma, degeneration or can be spontaneous). 2. Exudative (serous) retinal detachment with serous fluid under retina without tear, found in hypertensive retinopathy, eclampsia. 3. Tractional retinal detachment, due to traction on vitreous body by fibrotic tissue, found vitreous bleeding at diabetic retinopathy or trauma. The main treatment of Rhegmatogenous detachment are Drainage, Air (gas) injection, Cryo and Explants (DACE), but Tractional RD commonly need vitrectomy surgery. Vascular disorders retinal occusion includes central retinal vein occlusion (CRVO), branch retinal vein occlusion (BRVO), and central retinal arterial occlussion (CRAO), branch (BRAO). Usually present with sudden loss of visual field and with painless visual loss. CRVO is a common and easily diagnose retinal vascular disorders with potentially blind complication. Retinal artery occlusion can be caused by embolism, arteriosclerosis, infection, and phlebitis. We distinguish between ischemic and non - ischemic vein occlusion. The causes of retinal vein occlusion include compression of the veins, arteriosclerosis, infection, phlebitis cardiovascular diseases, hypertension and mellitus. The main treatment CRVO is anti-VEGF intra vitreal and laser photocoagulation. Age-Related Macular degeneration is a atrophy and degeneration of outer retina, retinal pigment epithelium, Bruch’s membrane and choriocapillaris. The disease includes a broad spectrum of clinical and pathologic finding that can classify into two groups: non exudative (“dry”) and exudative (“wet”). The exat cause is unknown, but the incidence increased with each decade over age 50, race usually Caucasian, sex slight female predominan, family history and a history of cigarette smoking. The main treatment of wet is injection anti-VEGF intravitral.

SELF DIRECTING LEARNING (in depth learning of above lecture) 1. History of Vitreo Retinal Diseases 2. Vitreo Retina Examination 3. Sign and Symptoms Vitreo Retinal Diseases. 4. Complications of Vitreo Retinal Diseases 5. Medication of Retinal Deseases 6. Treatment Vitreo Retinal Diseases by Laser Photocoagulation 7. Surgery of Vitreo Retinal Diseases by Surgery such as Screla Buckling, Cryo and Vitrctomy. 8. Prognosis of Vitreo- Retinal Diseases.

SCENARIO 1. A 50 years old male patient complained blurry vision on both of his eyes since 2 months prior. He has a history of hypertension, and diabetes mellitus. Redness and history of accident was denied. From the examination, the visual acuity was 6/30, hard to be corrected, anterior segment was normal, intraocular pressure was normal. From funduscopy examination there were flame shaped hemorrhages on all quadrants, exudates, microaneurysma, NVD on posterior pole. a. What kind of anamnesis that would be needed on this patient? b. Laboratory examination that would be needed on this patient? c. Opthalmology examination that would be needed on this patient?

Udayana University Faculty of Medicine, DME 40

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d. Explain retinal hemorrhages patophisiology on this patient e. What would be the Predisposision factors that influence retinal hemorhages on this case f. What would be the differential diagnosis for this case? g. What would be the therapy for this case? h. How would be the follow up for this patient? 2. A 55 years old man complained blurry vision on his left eye since 3 days before. He was diagnosed with hypertension and diabetes mellitus 3 years ago. From examination, visual acuity was 3/60, IOP was normal, anterior segment was normal. From funduscopy examination there were flame shaped hemorrhages on all quadrants, exudates, cotton woll spots, the optic nerve head was not well demarcated, the vessel were bending, and hemorrhaging. a. What kind of anamnesis that would be needed on this patient? b. Laboratory examination that would be needed on this patient? c. Opthalmology examination that would be needed on this patient? d. Explain retinal hemorrhages patophisiology on this patient e. What would be the Predisposision factors that influence retinal hemorhages on this case f. What would be the differential diagnosis for this case? g. What would be the therapy for this case? h. How would be the follow up for this patient? 3. A 41 years old woman complained a sudden blurry vision on her left eye since 5 days before. She has been wearing glasses since high school. From the examination, the visual acuity was 1/60 and was hard to be corrected, IOP was 10 mmhg, The anterior segment was normal, from funduscopy examination vitreous was clear and the retina was elevated on the inferior. a. What kind of anamnesis that would be needed on this patient? b. Laboratory examination that would be needed on this patient? c. Opthalmology examination that would be needed on this patient? d. Explain the patophisiology of this case e. What would be the Predisposision factors on this case f. What would be the differential diagnosis for this case? g. What would be the therapy for this case? h. How would be the follow up for this patient?

SELF ASSESSMENTS 1. Describe definition of retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty. 2. Explain about pathogenesis of retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty. 3. Mention classification of retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty. 4. Mention symptoms could be found in retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty. 5. Mention the examination needed to make diagnosis of retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty. 6. Explain how you can establish diagnosis of retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty. 7. What should you do if you have a patient with retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty? 8. Mention what you should tell to the patient who has history of retinal detachment, central artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty.

Udayana University Faculty of Medicine, DME 41

Study Guide The Visual System and Disorders

LEARNING RESOURSES : 1. Vaughan, Asburhy : General Ophthalmology 2. Deborah P Langstone : Manual Diagnosis and Ocular Tretment. 3. Perdami : Panduan Ketrampilan dan Klinis Penyakit Mata, Jakarta, 2006. 4. American Academy of Ophthalmology : 2012

Day 10 MODULE 11 Title of lecture NEURO-OPHTHLMOLOGY DISORDERS By AA Mas Putrawati Triningrat, MD

Aims Describe: the sign, symptoms, patophysiology and management of neuro ophthalmology disorder

Lerning outcomes: Can describe the: 1. Optic disc cupping 2. Edema papil 3. Atrophy optic 4. Neuropathy optic 5. Neuritis optic

Curriculum contents. 1. Optic disc evaluation 2. Visual pathway 3. Optic disc cupping 4. Edema papil 5. Atrophy optic 6. Neuropathy optic 7. Neuritis optic

Abstract / summary of lecture It is important to recognize that any disturbance in afferent function may result in the same complaints of visual loss seen with pathology affecting the retina, optic nerve and visual pathways. The optic nerve begins anatomically at optic disc but physiology and functionally within the ganglion cell layer that covers the entire retina. Optic neuropathies typically are associated with visual field loss, most demonstrate an afferent pupilary defect, although in case with very mild optic nerve dysfunction or with bilateral symmetric dysfunction, the defect may not detectable. The optic disc may be abnormal or normal in apprearance; abnormal disc maybe edematous or may show other abnormalities, such aas excavation, or atrophy. Certain causes of optic neuropathy may present in more than one way; for example, orbital compressive or infiltrate lesions may initially demonstrate either normal, edematous or atrophic. Edema papil is an optic disk swelling due to raised intracranial pressure of which the most common causes are cerebral tumors, absesces, subdural haematom, arteriovenous malformations, subarachnoid hemorrhage acquired hydrocephalus, meningitis and encephalitis.

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Study Guide The Visual System and Disorders

Optic atrophy is a nonspecific response to optic nerve damage from any causes since optic nerve consist of retinal ganglion cell axons, optic atrophy may be the consequences of primary retinal disorder, such as pigmentosa, CRAO. Optic neuritis is a disk swelling caused by inflammation at the nerve head (intraocular optic nerve). Loss of vision is the cardinal symptom of optic neuritis and is particulary useful in differentiating papilitis from papiledema which it may resemble on ophthalmoscopic examination. Optic neuritis may be due to a variety of causes, but the most common is demyelinating dss, including multiple sclerosis.

Self directing learning 1. Anatomy of optic nerve 2. Visual pathways 3. Pupillary reactivity 4. Relative afferent pupillary defect 5. Optic disc cupping 6. Edema papil 7. Atrophy optic 8. Neuropathy optic 9. Neuritis optic

Scenario Case 1 Women 30 years old, complained about sudden blur vision, and visual filed disturbance on her left eye since two days before. He also complained about pain when moving her eye. On ophthalmology examination, doctor found decreasing visual acuity (VOS 3/60). 1. Mention things you should elaborate from the patien during anamnesis 2. Mention physical examination you should do for this patient 3. Explain about the result from the examination 4. Mention differential diagnosis of the case 5. Which diagnosis is the most appropriate? 6. Explain about the management of this case

Case 2 Men 45 years old, complained about headache, nausea, vomit and disturbance visual field on both eyes since 3 days before. On the ophthalmology examination, doctor found no disturbance of vision, but there was edema optic nerve both eyes. 1. Mention things you should elaborate from the patien during anamnesis 2. Mention physical examination you should do for this patient 3. Explain about the result from the examination 4. Mention differential diagnosis of the case 5. Which diagnosis is the most appropriate? 6. Explain about the management of this case

Self assessment NO 1. Describe definition of edema papil, atrophy optic, neuropathy optic, neuritis optic 2. Explain about pathogenesis of edema papil, atrophy optic, neuropathy optic, neuritis optic 3. Mention symptom could be found in edema papil, atrophy optic, neuropathy optic, neuritis optic 4. Mention the examination needed to make diagnosis of edema papil, atrophy optic, neuropathy optic, neuritis optic 5. Explain how you can establish diagnosis of edema papil, atrophy optic, neuropathy optic, neuritis optic

LEARNING RESOURSES: 1. Vaughan: General Ophthalmology

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Study Guide The Visual System and Disorders

2. Ilyas S: Ilmu Penyakit Mata. FK UI 3. Deborah PL: Manual Diagnostic &Ocular Treatmentt. 4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 20

DAY 10 MODULE 12 Title of Lecture STRABISMUS By Surasmiati MD

AIMS: Describe the determination of angle strabismus (angle of deviation), diplopia, amblyopia

LEARNING OUTCOMES: Can describe determination strabismus, diplopia, amblyopia

CURRICULUM CONTENTS: 1. Determination of angle strabismus 2. Diplopia 3. Ambliopia

ABSTRACT / SUMMARY OF LECTURE: STRABISMUS EXAMINATION A. Prism and cover test Cover tes consist of four parts: (1) the cover test, (2) The uncover test, (3) alternate cover test and (4) the prism cover test. 1. Cover tests: a cover is placed in front of the other eye to block its view of target while the examiner observes one eye. If the observe eye move to take up fixation, it was not previously fixating the target, and a manifest deviation (strabismus) is present 2. Uncover tests: As the cover is removed from the eye following the cover test, the eye emerging from undercover is observed. If the position of the eye changes, interruption of has allowed it to deviate and is present. 3. Alternate cover test: the cover is placed alternately in front of one eye and then the other. This test reveals the total deviation (heterotropia + heterophoria if also present) 4. Prism plus cover tests: to quantitatively measure the deviation and increasing strength of the prism is placed in front of one or both eyes until there is neutralization of eye movement on alternate cover testing. B. Objective Test Hirschberg Method – the patient fixates a light at a distance about 33 cm. decentering of the light reflection is noted in the deviating eye.

DIPLOPIA Up to age 7 or 8 years the brain usually developed responses to abnormal binocular vision that may not occure if the onset of strabismus is later. These changes include diplopia, subpression, anomallous retinal correspondence. If strabismus is present each fovea receiver a different image. The object image on the two fovea are same in the same direction in space the object visual by one of the fovea is image on a peripheral retinal area in the other eye. The foveal image is localized straight a head, while the peripheral image of the object in the other eye is localized in similar other direction. Thus the same object is seen in two places (Diplopia). Diplopia must be determined weather double vision is monocular or binocular

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Study Guide The Visual System and Disorders

(which is disappears of one eye is covered). Monocular diplopia is often split shadow, causes uncorrected refractive errors, cataract, corneal irregularities (Scar, keratoconus) Binocular can be vertical, horizontal, torsional.

AMBLYOPIA Amblyopia is decreased vision in one or both eyes due to abnormal development of vision in infancy or childhood. Prolonged abnormal visual experience in child under the age of 7 years may lead to amblyopia (reduced visual acuity in the absence of detectable organic disease in one eye). There are several different types and causes of amblyopia: strabismic amblyopia, deprivation amblyopia (eg congenital cataract) and refractive amblyopia (anisometropia). The end result of all forms of amblyopia is reduced vision in the affected eye

SELF DIRECTING LEARNING (In depth learning of above lecture) 1. Definition of binocular single vision. 2. Definition of Orthophoria, Heterotropia, Heterophoria 3. Anatomy of Extra ocular muscle 4. 5. Management of Diplopia 6. Management of amblyopia

SCENARIO A 6 years old girl complain blurred vision and eye discomport. From the visual acuity examination of the right eye is 6/30 with correction ∫ -2.25 visual acuity improve 6/12 and the left eye the visual acuity 6/6. Hirschberg test result that the corneal light reflex on the right eye fall in the lateral side at limbus a. What is the diagnosis of this case? b. What is the choice of medical treatment of this case? c. How about Hirschberg test? d. What is the complication of uncorrected refractive error? e. What is the treatment of amblyopia?

SELF ASSESSMENT: 1. Mention and explain about type of strabismus 2. Management of strabismus, Diplopia, and Ambliopia

LEARNING RESOURSES: 1. Vaughan: General Ophthalmology 2. Ilyas S: Ilmu Penyakit Mata. FK UI 3. Deborah PL: Manual Diagnostic &Ocular Treatmentt. 4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 2006

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Study Guide The Visual System and Disorders

PRACTICUM DAN BASIC CLINICAL SKILL STUDY GUIDE

BASIC CLINICAL SKILL VISUAL PHYSIOLOGY STUDY GUIDE

A. GOAL The goals of the study are to enhance the student’s knowledge and skill for examination of: 1. Visual acuity (visus) 2. Visual field 3. Pupil reflex, consensual reflex and pupil reflex during accomodation. 4. Organic and functional color blindness 5. Cornea arch

B. EQUIPMENT USE: 1. Optotype Snellen 2. Perimeter 3. Flashlight 4. Ishihara chart and wall thread 5. Keratoskope placido

C. WORK METHODE: 1. VISUAL ACUITY, (Snellen chart) a. Hang the Snellen chart at the wall at eye height during sitting b. Ask the subject sit on the chair which 6 meter distance from the Snellen chart c. For examination of the right eye, close the left eye with the left hand. d. Ask the subject to read the letter on the chart, begin with the upper to the lower raw, without any mistake e. Repeat this test to the other eye, with same method. f. Visual acuity (visus) is calculatefrom the formula: V = d/D, where V= visual acuity, d= the distance of subject from Snellen chart, and D= the distance that normal person can be read correctly (this is write at the Snellen chart). g. Must be remember that the value from d/D, can’t be to simplified. Learning task: Comprehend the influence of aging process to the visual acuity, what is the cause that problem?

2. VISUAL FIELD (use perimeter) a. The equipment for visual field test is perimeter. Place the perimeter on the laboratory table b. Ask the subject sitting face to the perimeter, and close one eye which is note test. If the right eye would be tested, close the feft eye and visepersa. c. Palace the subject chic on the chic support and ajust the height so the lower margin of their eye and the eye level equal to the center of perimeter. d. Fit he perimeter fist so the perimeter arc on the plane surface e. Ask the subject to focus their sight to the centre of perimeter during the examination. f. Take the sign tool (white) and move it along the perimeter arc from side to the center , and stop when the subject begin sea it, and read the number at the perimeter arc, and than write on the form. g. Repeated again that method after move the perimeter arc 30 degree clock wise direction h. Do it to the other eye with the same method. Learning task: comprehend the difference of visual field of right and left eye. What is the mono and binocular vision?

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Study Guide The Visual System and Disorders

3. PUPIL REFLEX, CONSENSUIL REFLEX and PUPIL REFLEX DURING ACCOMMODATION (use flashlight) a. Ask the subject sitting on the chair and relax b. Beam of light to the right eye of the subject with flashlight, and look at the change of pupil diameter of the right eye (if the pupil diameter is smaller, it mean pupil reflex positive). c. Repeat it again but now look the change of pupil diameter of the left eye (consensual reflex, If the diameter of left eye is smaller, it mean consensual reflex positive) d. Ask the subject to watch the examiner’s fingers from distance around 50 cm and than moving it approach the subject (focusing the eyes or accommodation), and the examiner watching the changes of pupil diameter .During accommodation the pupil diameter should be smaller. Learning task: describe the mechanism of pupil reflex and consensual reflex. Why the pupil diameter change to smaller during accommodation?

4. ORGANIC AND FUNCTIONAL COLOR BLINDNESS (use Ishihara chart and wall thread). 4.1. Organic visual blindness : a. Ask the subject to select many color of wall thread and collect it with same color. The examiner write the incorrect color. b. Ask the subject to read the Ishihara chart, and write their mistake, use the guide of the Ishihara chart. 4.2. Functional color blindness. a. Ask the subject to watch the white sky through the green or red glass for view minute, and than ask them to watch the wall thread or read the Ishihara chart. b. The subject difficult to choose the wall thread or read the Ishihara chart. It is functional color blindness. Learning task: Describe the mechanism of organic or functional color blindness.

5. CORNEA ARCH (use keratoskope placido) a. Ask the subject to sit down back to the light, and place the keratoskope placido 20 cm front of the subject. b. Ask the subject always watch the keratoskope placido during examination, and the examiner watch the cornea of the subject through the hole at the center of keratoskope palcido. The image of the keratoskope placido can be watch at front surface of the cornea in form of black circle. c. If the image form is full and concentric circle, it mean the surface of cornea is normal d. If the image form is crooked on one side and difference to the other side, it mean the front surface of the cornea is abnormal. Learning task: what is call astigmatism? what is to correct it?

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Study Guide The Visual System and Disorders

STUDY GUIDE BASIC CLINICAL SKILL OPHTHALMOLOGY

CONTENTS: 1. Subjective visual examination 2. External inspection: • Eyelid • Conjunctiva • Sclera • Lachrymal apparatus • Pupil • Light reflex and convergence • Cornea • Camera Oculi Anterior • Iris • Lens 3. Intra Ocular Pressure • Palpation • Tonometry Schiotz 4. Therapeutic Skill • Eyelid eversion • Eye drops installation • Eye ointment installation • Applying eye dressing • Removal conjunctiva foreign body • Removal corneal foreign body (with cotton bud)

I. SUBJECTIVE VISUAL EXAMINATION Eye Examination: • Visual Acuity • Visual field examination with confrontation test, perimetry (kinetic and static) • Dark adaptation – measurement of least luminance required to produce a visual sensation • Contrast sensitivity – is measurement of the smallest distinguishable contrast, it is assessment of quality of vision • Colour vision –with lantern test (Edridge green lantern) and Isochromatic charts

Subjective examination of the function of eye Definition. It is defined as the measurement of the smallest retinal image which can be appreciated with reference to its shape and size. it is actually measure of form sense. • Central or direct vision • Distance vision with Snellen test type • Near vision with Snellen test type or Jaeger’s test type • The principal of assessment is measurement of spatial resolution of the eye i.e. an estimation of ability of eye to discriminate between two points.

DISTANCE VISION Two distant points can be visible as separate only when they subtend an angle of 1 minute at the nodal point of eye.

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Study Guide The Visual System and Disorders

Principle • Each individual letter subtends an angle of 5 minutes and each component of letter subtends an angle of 1 minute at the nodal point of eye from the distance in meters written as numerical. • Snellen chart is having different number of letters in different rows and the letter at top line should be read clearly at distance of 60 m. similarly the letters at subsequent lines as are read at 36, 24,18,12,9,6,5mts respectively • Numerical convention is used for recording visual acuity. In fraction, the numerator is the distance at which the patient is sitting from chart and the denominator is the distance at which person (with normal vision) should be able to read the last line that person is able to read.

Procedure of testing • Patient is seated at the distance of 6 meters from Snellen’s chart (distance of 6 mts is taken as at this distance it is assumed that the rays are almost parallel and patient exert minimum accommodation) • The chart should be properly illuminated at minimum of 20 feet candles. Patient is asked to wear trial frame. It is adjusted according to patient inter pupillary distance. • Ask the patient to read with one eye from the top letter while the contra lateral eye is closed gently with the patient palm or with occulder in the trial frame. • Now patient is asked to reads the Snellen’s chart from top letter to smaller letter, and depending upon the smallest line that the patient can read from distance of 6mt. His vision is recorded as 6/6, 6/9, 6/12,6/18, 6/24, 6/36, 6/60. • But if patient is not able to see the top line from 6mts he is asked to count the examiner finger at 5,4, 3, 2, 1 mts (or reverse, from 1 to 5 mts) and noted as 5/60,4/60,3/60,2/60,1/60 respectively (or CF=counting finger 1m, CF 2m, CF 3m,CF 4m, CF 5m)

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Study Guide The Visual System and Disorders

• If patient not able to count examiner finger close to face then examiner waves or moves his hand in about 25 cm from the patient eye and asks patient whether he is able to see hand movement or not. Visual acuity then recorded as HM+ or 1/300. • When patient cannot distinguish hand movements, the examiner use penlight in front of the patient eye (± 20 – 25cm) and notes whether the patient can perceive light or not. If he perceive light it is noted as LP (light perception) +ve otherwise as LP-ve. The examiner then reflect the penlight from four directions (nasal, superior, temporal, inferior) and asked the patient to mention the direction of the light. • Record accordingly if present patient perceive light from all directions it is marked as PR (Projection of rays) present or else mark as absent or defective. The test is repeated for the other eye in similar fashion

Pin hole test Method • Place the pin hole occluder in front of the eye with reduced vision • Ask the patient to move their eye and head until some letters can be read on the letter chart • Ask the patient to read the lowest line of letters he can see looking through the pinhol Interpretation • If patient vision is improved with pin hole it means the poor acuity is due to refractive errors. (eg. 6/12 PH 6/6 means visual acuity 6/12 can be improved with pinhole until 6/6) • If static acuity means may be due to structural or organic cause.(eg.6/12 NI PH = non improved PH means the visual acuity still 6/12 with non improvement with pin hole) • If reduced the poor visual acuity may be due to or lenticular opacity occupying papillary area or macular pathology.

Charts for testing near vision are : 1) Snellen near vision chart 2) Jaeger chart 3) Roman test type Method of recording near vision • Ask the patient to sit with his back to the light • If the patient is using glasses for distance the same number will be put on the trial frame. Occlude one eye with an occulder • Ask the patient to hold the near vision by his right hand at a distance of 25 to 33 cms. • Note the near vision as per the letter read • Repeat the test for the other eye.

II. EXTERNAL INSPECTION 1. Eyelids Eyelids conditions • Diffuse swollen or edema, usually found in nephritic syndrome, heart disease, anemia, dacryoadenitis and hyperthyroid.. • Eyelid swollen with sharp edge in chalazion, tumor. • Blepharospasm, happened on corneal erosin, anterior uveitis, acute glaucoma. Essential Blepharospasm did not result from organic disorders and usually happened billateraly. Blepharospasm could also be found at psychiatric patient with hysteria. • Echymosis, the color of the eyelid changes as a result of blood extravatation after trauma.

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• Ectropion, is turning outward of the eyelids, could be found in elderly, paralise of the muscles, cikatriks and other. • Entropion, turning inward of the eyelids.In Trachomas patient the entropion usually happen in upper eyelids. Entropion could also happen due to parese of the muscles, cikatriks and senile condition. • Lagoftalmos: inabillity to close the eyelids completely. • Redness, inflamation, squama, tumour Merah, radang, keropeng (skuama), tumor. • Pseudoptosis, difficulties to open the eyelids as if it is drooping. Happen on , phtisis bulbi, chalazion or the other eyelids tumour, eyelids edema and blepharochalazis. • Ptosis, drooping eyelids. Usually happen in elderly with history of intraocular surgery, Myasthenia gravis, Horner Syndrome, N III palsy, botulinum toxin injection • Cikatriks, scar on the eyelids • Trikiasis, silia atau bulu mata tumbuh salah arah sehingga dapat merusak kornea. Trikiasis dapat disebabkan blefaritis dan entropion. • Xantelasma, penimbunan deposit berwarna kekuning-kuningan pada kelopak, terutama nasal atas dan bawah. Xantelasma biasanya dihubungkan dengan hiperlipidemia dan dapat tanpa hiperlipidemia seperti pada histiosis dan retikulohistositoma. Abnormality of lower eyelids: • Similar with upper eyelids • Swollen of lacrimal sac, redness and sometimes pus came out when it be pushed. • . Inerpalpebral Fissure • Normal • Narrow or small, if there is eyelids edema, blepharitis, ptosis, pseudoptosis, blepharophymosis • Wide or bigger, happened in hyperthyroid or intraocular tumour. Eyelids margin • Complete cilia • Trichiasis • Meibomian gland punctum secretion • Redness, pain and ulceration 2. Conjunctiva Upper Tarsal Conjunctiva Can be checked by eversion the upper eyelids using finger or cotton tip applicator. Abnormality of the conjunctiva: • Cobble stone follicles, deposite of macrophages and lymphoid cells under the conjunctiva. Dome shaped appearance, about 1 mm. Most follicles can be seen in forniks area because in this area consist of a lot of lymphoid tissues. • Membrane, inflammatory cells beyond the conjunctiva that will be bleed iwhen excised. This membrane usually appears like mass surrounding tarsal or bulbar conjunctiva. It is consists of necrotic tissues, penetrated to the deeper layer and greyish, usually can be found in patient with bacteria conjunctivitis or rarely happened on viral conjunctivitis. • Pseudomembrane, membranes that not get bleed if excised. Happened in ocular pemphygoid and Steven Johnson Syndrome. • Papillae, tiny dome shaped nodule that consist of hyperemic central core blood vessels of the conjunctiva that protrude up and perpendicular to the tarsal plate surrounded by edema and inflammatory cells

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Study Guide The Visual System and Disorders

• Giant Papillae, polygonal shaped, flat and coukd be found in vernal conjunctivitis, superior limbic keratitis, and iatrogenic conjunctivitis. • Cicatriks, in usually the direction of the cicatriks is parallel with eyelids margin. • Simblepharon, stickyness of tarsal and bulbar conjunctiva and kornea. Can be found in chemical trauma or Steven Johnson Syndromes • Hordeolum or Stye • Chalazion. Inferior tarsal conjunctiva Konjungtiva tarsal inferior The abnormalities could be: • Cobble stone follicles. • Papil. • cicatriks • Hordeolum or Stye. • Chalazion. Bulbar conjunctiva The abnormalities could be: • Discharge • Conjunctival Injection, vasodilatation of superior conjunctival arteries • Cilliary Injection, vasodilatation of pericorneal arteries or anterior cilliaris arteries. • Episcleral injection, vasodilatation of episcleral vessels • Subconjunctival bleeding. • Flickten, inflammatory surrounded with neovascularization on conjunctiva • Simblepharon. • Degeneration plaque • Pinguecula, conjunctival degeneration plaque in palpebral fissure area, triangular shape in nasal and temporal cornea • Pterygium, proliferation of fibrous tissues process with neovascularization on conjunctiva, triangular shape with the apeks toward the cornea • . • Flickten, inflammatory cells and neovascularization on the cornea. 3. Sclera Abnormalities that coulb be found in sclera: • Local or diffuse episcleral injection. • Nodulle. 4. Lacrimal Apparatus The abnormalities includes: • Epifora. • Stenosis or obstruction of lacrimal punctum • Lacrmal sac inflammation Peradangan di sakus lakrimal. • Yellowish discharge or pus in lacrimal punctum 5. Pupil Pupil abnormalities: • Isokoria, similarities of shape and size of pupil in both eyes • Anisokoria, the size of both pupil is different, found in monocular granuloma uveitis and Afferent pupillary defect • Midriasis, happened as a results of parasympatolitik drugs (atropine, skopolamine) atau sympatomimetik (adrenaline and cocaine). • Miosis, happened in miotic spastics (meningitis, ensephalitis dan ventrikel haemorraghe), morfine and antikolinesterase intoxication. In miotic paralitic or simpatic parese as Horner syndrome, miosis, ptosis dan anhidrosis were the Trias.

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• Hippus , also known as pupillary athetosis , is spasmodic, rhythmic, but irregular dilating and contracting pupillary movements between the sphincter and dilator muscles • Pupil occlusion, pupil covered by inflammatory tissues in front of the lens • Seklusi pupil, the whole pupil is attached to anterior lens • Leukokoria, white pupil or whitish reflex of the pupil. Can be found in cataract, retrolental fibroplasia, endophthalmitis, vitreous hyperplasia, high myopia, retinal detachment andretinal tumour as retinoblastoma • No pupil reaction, can be found in intoxication of mydriatics and miotic drug, sphincter pupil rupture, posterior sinekia, blind Light reflex and convergence • Positive light reflex, miotic effect when pupil get exposed to the light • Negative light reflex, happened on sphincter pupillae rupture, no Light perception patient, parasympatic abnormalities, drug induced angd posterior synekia • Convergence reflex consist of accommodation, miosis and convergence if there is a changes focus from far point to near point. Kornea Abnormalities of the cornea: • Normal corneal diameter is 12 mm • Macrocornea: diameter of the corena is larger than normal • Microcornea: diameter of the cornea is smaller than normal • Arkus senilis, whitish or grey ring in outer segement of cornea • Corneal edema, the cornea is unclear and thickened, happened in congenital glaucoma as well as acute glaucoma, after intra ocular surgeries, endothelial decompensation, trauma and corneal infection • Erosion, corneal epithelial detachment, give rise to positive fluourescein test • Infiltrat, deposit of inflammatory cells on the cornea that makes cornea unclear and positive placido test • Pannus, inflammatory cells with neovascularization, usually at the superior limbal area of the cornea, happened in trachoma, contact lens warpage, flicten, superior limbic keratoconjunctivitis and corneal burn • Corneal Ulcer, loss half of corneal layer due to necrosis in infection or allergic condition • Corneal Xerosis, the dryness of the corneal surface and unclear cornea. • Keratomalasia, softened and protruded cornea • Cicatriks, scar on the cornea, consist of nebula, macula and lecoma • Leukoma adheren, cornea is attached to the iris • Corneal Staphyloma, protrusion of the cornea due to corneal ulcer or cornea become thin with exposed uvea in the back of the cornea • Keratik presipitat, inflammatory cell in the corneal endothel 6. Anterior Chamber Abnormalities: • Shallow anterior chamber in lens dislocation, iris tumour, anterior synekia, iris bombe due to pupillary block and acute glaucoma • Deep anterior chamber, in aphakia, myopia, congenital glaucoma and angle resession • Flare, deposit of inflammatory cells and fibrin in anterior chamber • Hipopion, the deposit of inflammatory cells in lower part of anterior chamber. 7. Iris Abnormalities: • Coloboma • • Iris atrophy

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• , neovascularization in the iris • Anterior Synekia, attachment of the iris with cornea • Posterior Synekia, attachment of the iris to the lens 8. Lens Abnormalities: • Cataract, clouding of the lens • Lens dislocation, changes in lens position from its normal position, can be subluxated or luxated to anterior or posterior II. TONOMETRI 1. PALPATION TONOMETRI Basic: intra ocular pressure measurement by examiner finger Instrument: examiner finger tekanan bola mata dengan jari pemeriksa. Technique • The patient close his eyes Penderita memejamkan mata with down gaze • One of the pointing finger pushed the eyeball while the other finger constantly hold the eyeball, and the other finger hold the forehead and patient chin.

Interpretation • The eyeball soft enough when it is pushed by finger (N = normal palpation) • N+1, N+2, N+3 atau N-1, N-2, N-3 is the notation that show the higher or lower intraocular pressure • If the intraocular pressure is higher than normal the glaucoma is suspicious. Notes This methods can be used if tonometry is not available or the tonometry could not be used in some eye condition such as cicatriks on the cornea, irregular cornea and corneal infection. This methods need more practical skill because of subjective interpretation. Beware of oculo cardiac reflex if the eyeball being pushed innapropiatelly.

2. SCHIOTZ TONOMETRI The Schiotz tonometer was once the most widely used tonometer. It is used much less often in today’s office setting, but still serves as an accurate, inexpensive, portable, autoclavable instrument for use in the operating room or in nonophthalmologic or nonoptometric settings. The instrument is a simple mechanical device that employs a weight to press a freely moving plunger against the cornea, indenting it. The amount of indentation produced by this weight is read from a scale with a needle indicator moved by the plunger. The plunger must move freely within the cylinder of the tonometer, so the instrument must be kept scrupulously clean. Any debris or oils from the hands can accumulate in the cylinder and affect the movement of the plunger.

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The Schiotz tonometer. (Courtesy of Sklar Instruments)

Cleaning the Tonometer The entire instrument must be carefully cleaned between each patient to avoid the possible spread of infection. The instrument is made entirely of metal, so it can withstand steam sterilization and noncorrosive chemical disinfection. However, it is more common to clean the tonometer with isopropyl alcohol.

Calibrating the Schiotz A metal test block is provided with every instrument. It is in the corner of the storage box and should be wiped clean before use. The calibration is checked by resting the tonometer perpendicularly on the test block. The needle should indicate zero on the left end of the scale. If it does not, a small screw at the base of the needle can be loosened to rezero the needle. The needle itself should be perfectly straight because bending it will give a false reading.

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Study Guide The Visual System and Disorders

The instrument is placed on the test block to test calibration. (Photo by Mark Arrigoni.) (Reprinted from Herrin MP. Ophthalmic Examination and Basic Skills . Thorofare, NJ: SLACK Incorporated; 1990.)

Performing Schiotz Tonometry The patient must be reclining so that the eyes are looking straight up at the ceiling. A drop of anesthetic is instilled in each eye. The patient is instructed to relax and keep both eyes open and positioned straight ahead; a target placed on the ceiling is helpful. The tonometer should already have been cleaned and tested. A right-handed assistant should hold the tonometer in the right hand using the 2 curved arms attached to the side of the cylinder. The scale mount rotates easily and should be turned so that the scale is facing the assistant. The left hand is used to gently hold the lids of the patient’s right eye apart, anchoring them against the orbital rim so that no pressure is applied to the globe. An alternative hand position is to hold the upper lid with the left hand and the lower Lids with the small finger of the right hand. In either case, the hand holding the tonometer can rest on the patient’s cheek or forehead for stability. The tonometer is gently lowered onto the eye so that the footplate rests on the central cornea and the instrument is perpendicular. The cylinder is then lowered slightly, so that the tonometer is resting on the eye and the assistant is providing only lateral support. The cylinder should neither lift up nor press down on the footplate at this point. Looking straight at the scale, the needle position is noted. If the scale is not directly facing the assistant, an erroneous reading will be made. The tonometer is quickly lifted straight up off. Because the plunger indents the cornea, any movement of the tonometer while it is on the eye may cause an abrasion. The scale readings do not indicate IOP in mm Hg but must be converted according to a table provided with the instrument. The scale readings are inversely proportional to the IOP; lower numbers indicate higher pressures. The standard weight on the plunger is 5.5 gm, and 2 additional weights (2.0 and 4.5 gm) may be added to this for a total of 7.5 and 10.0 gm, respectively. If the scale reading is less than 3 (ie, the IOP is more than 25), the next weight is added, and the measurement is taken again. If the 7.5 weight still gives a reading of less than 3, then the third weight is added, and the measurement is retaken. Along with the IOP, the assistant should also document the weight used.

Udayana University Faculty of Medicine, DME 56

Study Guide The Visual System and Disorders

Manual technique for Schiotz tonometry. (Courtesy of Sklar Instruments.)

IV. THERAPEUTIC SKILL 1. EYELID EVERSION 2. EYE DROP INSTILATION 3. EYE OINTMENT INSTILLATION 4. APPLY EYE DRESSING 5. REMOVAL CONJUNCTIVAL FOREIGN BODY 6. REMOVAL CORNEAL FOREIGN BODY (WITH COTTON BUD)

1. EYELID EVERSION INFERIOR CONJUNCTIVA AND FORNIKS EXAMINATION 1. Patient look down, pushed the skin in the inferior part of inferior eyelids with thumb or point finger then pulled toward the maxilar bone. 2. Patient asked to see upgaze so the inferior forniks can be exposed and inferior

SUPERIOR PALPEBRAL CONJUNCTIVA EXAMINATION (2 HANDS TECHNIQUE) 1. Using thumb or point finger, pull several eyelashes, and pull away the edge of superior eyelids against the eyeball 2. Put cotton tip applicator (cotton bud) in the sulcus of superior eyelids, along theegde of tarsus and pushed the applicator to the temporal part of the eye. 3. Pull the edge of superior eyelids outward and upward to see the superior bulbar conjunctiva, through the applicator. Pulled the applicator and hold the edge of the eyelids to the skin of superior orbital rim with thumb to see the superior palpebral conjunctiva.

SUPERIOR PALPEBRAL CONJUNCTIVA EXAMINATION (1 HAND TECHNIQUE) 1. Ask the patient to look up, Pasien diminta untuk melihat ke atas, use the hand that temporal to the checked eye, and placed the thumb in inferior eyelids, then pull up.

Udayana University Faculty of Medicine, DME 57

Study Guide The Visual System and Disorders

2. Placed the edge of point finger to press superior eyelids up. Patient then asked to look down, hold for a couple of second. Pinch the superior eyelids using thumb and point finger 3. Rotate with the finger and wrist so the superior eyelids could be seen. The point finger holds the resistance in the lid crease. Thumb holds the edge of superior eyelids to the superior orbits.

2. EYE DROP INSTALLATION 1. Patient look up gaze 2. Hold the inferior eyelids under the eyelashes and pull the eyelids out from the eyeball. 3. Give 1 drop into cul –de –sac, do not touch the eyelashes or eyelids to avoid contamination. 4. Gently pull the inferior eyelids upward until touching the superior eyelid while the eye looking downgaze. 5. Close the eyelids for about 3 minutes and try not to blink, so the drug can be pump into the nose and increase systemic absorption. 6. The excessive drug in medial canthal should be wipe out before open the eyelids. Another drug that should be instilled may be given in 10 minutes after the first drug instilled.

3. EYE OINTMENT INSTALLATION 1. Ointment used if the eye need longer duration of drug. Diperlukan bila menginginkan kontak dengan mata yang lebih lama. 2. Similar with application of eyedrops, but the amount that given to the patient usually as much as needed. 3. Patient asked to extend his head or lay in bed in supine position 4. Give the ointment into the cul – de – sac and keep away the tube from the eyelashes or eyelids. 5. Gently pull the inferior eyelids upward until touching the superior eyelid while the eye looking downgaze 6. For about 2 minutes press with thumb and point finger with closed eyelids.

4. APPLICATION OF A PRESSURE PATCH 1. The patient closes both eyes; the examiner must ensure good closure of the eyelids. 2. The examiner applies an eye pad to the closed eyelids, either lengthwise or folded in half 3. The examiner places a second patch lengthwise over the first patch. 4. Finally, the examiner secures the patches with tape placed from the center of the forehead to the angle of the jaw across the patched eye. Usually, an antibiotic ointment is applied before patching, and the patient’s progress should be monitored daily

Udayana University Faculty of Medicine, DME 58

Study Guide The Visual System and Disorders

A B

C D (Taken from Pallay DA, Krachmer JH, M.D. Primary Care Ophthalmology, Mosby,2005)

5. REMOVAL CONJUNCTIVAL FOREIGN BODY 1. Patient could be seat or lay in supine position. Extend the head while the patient sit. 2. Separate the eyelids with thumb and point finger in 1 hand or use the eye spreader / speculum. 3. Wet the cotton bud with topical anesthesia, or normal saline or artifisial tears. Do not use the dry cotton bud because the cotton could leave its part in the eye. 4. Swab and rotate the mucous so it can be bond to the cotton bud. Usually swaping is done to inner canthal or inferior forniks. 5. Swab cotton bud through the superior and inferior forniks to clean the debris.. 6. Conjunctival sac can be filled with sterile isotonic liquid.

6. REMOVAL CORNEAL FOREIGN BODY (WITH COTTON BUD) 1. Instill 1 drop of topical anesthesia 2. Open the eyelids with thumb and point finger, remove the foreign body with wet cotton bud. 3. Rmove the foreign body that embedded in the cornea using 1 cc spuit with slitlamp. 4. If there is rust still stay in cornea, do the kuretase with needle or ring rust removal. Ring rust should not be remove all if unnecessary to avoid cicatriks of the cornea. 5. Do the eye patching. Evealuate within 24 hours. (as the corneal erosion protocol))

V. DIRECT FUNDUSCOPY

Purpose : Test to know the posterior segment condition, including optic nerve, retina, blood vessel, vitreous and macula

Udayana University Faculty of Medicine, DME 59

Study Guide The Visual System and Disorders

The funduscopy or direct ophthalmoscopy (Funduscopy made easy, Wong Yee Ming, 2009)

Basic : The light that come into the posterior segment will give fundal reflex. Orange reflex is seen in clear media and called positive fundal reflex. Negative fundal reflex if there is no orange reflex or dark reflex (black)

Instruments : 1. Ophtalmoscopy 2. Midriatic drug 1. tropicamide 0.5%-1% (mydriacyl) 2. fenilefrin hidroklorida 2.5% (kerja lebih cepat)

Notes : To dilated the pupil, at first we should measure the intraocular pressure. Beware of these condition and avoid the dilatation of the pupil: - Shallow anterior chamber - Head trauma - Iris fixated IOL - The patient drive the vehicles alone - Narrow angle glaucoma

Technique • Funduscopy should be done on the same side for patient andthe examiner. This being said, while examining the right eye, hold the funduscope with your right hand, and examining with your right eye on the right side of the patient • Setting the illuminated lens disc at positive (Green) usually from 4-10, stand from approximately 1 arm’s length from the patient while illuminating the patient’s both eyes using the large aperture. This enable you to examine the red reflex of the patient • Select “0” on the illuminated lens disc and start with the small aperture as you approach the patient while fixing the “red reflex” pupil as your target. Remember to ask the patient to look straight at the distance to maintain pupil dilation • Tilting slightly at 15-25° lateral to the patient, move forward as you direct the light beam into the pupil. The optic disc should be within view as you are about 1-2 inches

Udayana University Faculty of Medicine, DME 60

Study Guide The Visual System and Disorders

from the patient’s eye. Remember that the optic disc is slightly towards the nasal aspect of the fundus. • Do not panic if you do not see the optic disc initially. Look for anearby retinal blood vessels. You’ll most likely find the optic disc by tracing at either one “end” or the other of the vessel. This is due to the developmental fact that retinal vessels branch from optic disc to the peripheral retina • The optic disc may not be focused as you see it, as hypermetropic patients require more “plus” (green numbers) lenses for clear focus of the fundus while myopia patients require more “minus” (red numbers). • Examine the optic disc for (the 4C’s): Color (pink, pale, hyperemia, etc) Contour (margin, shape, elevation, etc) Cup-disc ratio (compare the vertical diameter) Caliber of vessels (normal AV ratio around 2:3) • the AV ratio mentioned is measured from the width of the vessels before 3 rd bifurcation from the origin of optic disc • Follow each vessel as far to the periphery as you can look for any abnormalities such as venous dilatation, AV nipping,etc • To examine the periphery, ask the patient to: o Look up for examination of the superior retina o Look down for inferior retina o Look temporally for temporal retina o Look nasally for nasal retina • Lastly, locate the macula which is approximately 2 disc diameters temporally from the optic disc, between the superotemporal and inferotemporal vessels. Or you can ask the patient to look at the light of the ophthalmoscope, which would put the macula in good view. Look for abnormalities. Red filter facilitates the view of the macula • For the examination of the left eye, the same procedure can be repeated, but with left hand and left eye on the left side

LEARNING TASK BASIC CLINICAL SKILL OPHTHALMOLOGY A. Please demonstrate the subjective visual acuity examination B. Please demonstrate how to external inspection of anterior segment C. Please demonstrate how to measure intraocular pressure using Palpation and Schiotz tonometry D. Please demonstrate how to apply eye drops E. Please demonstrate how to apply eye ointment F. Please demonstrate how to remove foreign body from the conjunctiva and cornea G. Please demonstrate how to examine the posterior segment using direct ophthalmoscope

Udayana University Faculty of Medicine, DME 61

Study Guide The Visual System and Disorders

~ CURRICULUM MAP ~

Smstr Program or curriculum blocks

10 Senior Clerkship

9 Senior Clerkship

8 Senior clerkship

Medical Special Topic: Elective Study III Clinic Orientation Emergency -Travel medicine (6 weeks) (Clerkship) 7 (3 weeks) (2 weeks) (6 weeks)

BCS (1 weeks) The Respiratory The Cardiovascular The Urinary System The Reproductive System and System and and Disorders System and Disorders Disorders Disorders (3 weeks) (3 weeks) 6 (4 weeks) (4 weeks)

BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) Elective Study II Alimentary The Endocrine Clinical Nutrition and Special Topic : Elective (1 weeks) & hepato- System, Metabolism Disorders - Palliative Study II biliary systems and Disorders (2 weeks) medicine (1 weeks) & disorders (4 weeks) -Compleme

(4 Weeks) BCS (1 weeks) ntary & 5 BCS (1 weeks) Alternative BCS (1 weeks) Medicine - Forensic (3 weeks) Musculoskeletal Neur oscience Behavior Change The Visual system & and and disorders system & connective neurological (4 weeks) disorders

tissue disorders disorders (2 weeks) 4 (4 weeks) (4 weeks) BCS BCS (1 weeks) BCS (1 weeks) BCS(1 weeks) (1 weeks) Hematologic Immune Infection The skin & hearing system & disor- system & & infectious system ders & clinical disorders diseases & disorders 3 oncology (2 weeks) (5 weeks) (3 weeks) (4 weeks)

BCS (1 weeks) BCS(1 weeks) BCS (1 weeks) BCS(1 weeks) Medical Evidence-based Health System-based Community-based Special Topic Elective Professionalism Medical Practice Practice practice - Ergonomi Study I 2 (2 weeks) (2 weeks) (3 weeks) (4 weeks) - Geriatri (2 weeks) (2 weeks) BCS (1 weeks) BCS (1 weeks) Studium Medical The cell Growth Generale and communication as bioche- & Humaniora (3 weeks) mical machinery development (3 weeks) (3 weeks) (4 weeks) 1 BCS (1 weeks) BCS(1 weeks) BCS: (1 weeks)

Pendidikan Pancasila & Kewarganegaraan (3 weeks)

Udayana University Faculty of Medicine, DME 62