2006 • S6 Principles Principles and of Guidelines a Curriculum for Para-ophthalmic Vision Education Specialist Force Task by International Presented on Para-ophthalmic Vision Specialist Education Council On of Behalf The International of Ophthalmology (ICO) Force: of Chairman Task (Malaysia) Sivaguru FRCS, FACS Selvarajah, and Editor Director:Education Mark O. MD (China) (USA) M. Tso, Supplement § Volume 223Volume www.thieme-connect.de • Page Page S1–S41 •

November 2006 November

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S3 I. Preamble Mark O.M. Tso, MD; Sivaguru Selvarajah, FRCS, FACS S4 II. Core Curriculum for Community Based Para-ophthalmic Personnel Sivaguru Selvarajah, FRCS, FACS S8 III. Advanced Curriculum for Community Based Para-ophthalmic Personnel Sivaguru Selvarajah, FRCS, FACS S12 IV. Curriculum for Hospital Based Para-ophthalmic Personnel Usha Kim, MD S19 V. Curriculum for Orthoptists Thomas D. France, MD S31 VI. Curriculum for Ophthalmic Technicians Melvin I. Freeman, MD

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November 2006 ´ Page S1 ± S41 ´ Volume 223 ´ Supplement 6 11 ´ 2006

Preface education in which goals, expectation, knowledge base, compe- tencies and technical training are carefully defined. The four in- In 1999 and 2000, the International Council of Ophthalmology ternational curricula are prepared with this general direction in and the Academia Ophthalmologica Internationalis developed mind. an International Ophthalmology Strategic Plan to preserve and The panels, which drafted these curricula, understand the impor- restore vision ± Vision for the Future. tance of accessibility of the educational materials and availability This strategic plan involved a multi pronged approach to reduce of mentorship. The International Task Forces encourage the do- and blindness worldwide, and the following nation of good teaching material to be included in these curricula actions have been completed or are underway to make this plan and to be available for teachers and students worldwide. The ICO a reality: also proposes the twinning of training programs of industrialized " IFOS/ICO fellowships have been established under the leader- and developing countries to encourage the exchange of mentors. ship of Professor Balder Gloor to provide overseas educational It is recognized that competency in the practice of medicine de- opportunities for junior ophthalmic faculty in ophthalmology pends on factors other than medical knowledge as outlined in departments in developing countries. these curricula. Inter-personal communication skills, profession- " The International Assessment for Ophthalmologists in both alism, system-based factors, surgical skills, a solid ethical foun- clinical and basic sciences has been successfully implemented dation, and others contribute substantially to the expertise and by Professor Peter Watson. competence of eye care specialists. These curricula only provide " Eye care guidelines to develop evidence-based eye care deliv- a framework to initiate the training process. ery, are being developed under the leadership of Professor Ri- Efficiency of eye care in the modern practice of ophthalmology chard Abbott. depends on teamwork, consisting of ophthalmic physician spe- " Advocacy for preservation and restoration of vision to in- cialists, ophthalmic nurses, orthoptists, optometrists, clinic man- crease public awareness of blindness prevention is being agers, and others. The balance and composition of an eye care headed by Professor Hugh Taylor. team is critical for maximum productivity of the care provided. " Research in ophthalmology and vision, for development of So in these curricula, training of the eye care team is being cov- new and improved therapies for blinding diseases, is being ered. led by Professor Alfred Sommer. The rapid development of medical technology in the 21st Century The ICO Strategic Planning Group also decided that ophthalmic has resulted in greater discrepancies in the levels of medical care education is the cornerstone to improve eye care globally. As in various geographic locations of the world. However, the world part of this Strategic Plan, four International Task Forces were es- does not work unless the world works together. These interna- tablished to develop curricula for training of the ophthalmic spe- tional curricula of ophthalmic education are attempts to encou- cialist, para-ophthalmic personnel, medical students, and for rage different players in the international ophthalmic education- continuing medical education. al arena to work together to develop a forward movement for im- After years of hard work by multiple international panels, the proved eye care worldwide. four curricula are being presented for publication in this issue of The International Council of Ophthalmology and the Internation- Klinischen Monatsblätter für Augenheilkunde as supplements. al Task Forces on Ophthalmic Education would like to thank the The curricula are presented, not as mandatory standards of train- editors, Professors Gerhard K. Lang and Gabriele E. Lang, Project ing or practice, but as an educational tool and consensus example Manager, Katrin Stauffer of Klinischen Monatsblätter für Augen- to stimulate multi-levels of training including basic, standard, heilkunde, for their gracious assistance in publishing these curri- and advanced programs. The International Council of Ophthal- cula. mology realizes the wide variability of educational standards, Mark O.M. Tso, MD, D. Sc. patterns and prevalence of diseases, and social structures for pro- Editor of International Curricula on Ophthalmic Education vision of eye care in geographic regions, and therefore encoura- Education Director ges continuous modification of these curricula according to the International Council of Ophthalmology needs of different global communities. G.O.H. Naumann, MD Traditionally, ophthalmology residency training runs on an ªAp- Former President (1998±2006) prenticeship Systemº where the teaching contents and format for International Council of Ophthalmology trainees frequently depend on the whims of the trainers. In re- Bruce E. Spivey, MD cent decades, there is a general movement to shift the appren- President ticeship system of education to a curriculum-based system of International Council of Ophthalmology Supplement S3

Principles and Guidelines of a Curriculum for Para-ophthalmic Vision Specialist Education Presented by International Task Force on Para-ophthalmic Vision Specialist Education ± On Behalf of The International Council of Ophthalmology (ICO)

Chairman of Task Force Sivaguru Selvarajah, FRCS, FACS (Malaysia)

Editor and Education Director, ICO Mark O.M. Tso, MD (USA) (China)

Bibliography Major Contributors: Executive Committee of ICO [1998±2006]: DOI 10.1055/s-2006-951845 Sivaguru Selvarajah, FRCS, FACS (Malaysia) Gottfried O.H. Naumann, MD, President Klin Monatsbl Augenheilkd Thomas D. France, MD (USA) (Germany) 2006; 223, Suppl 6: S3±S41 Melvin I. Freeman, MD (USA) Mark O.M. Tso, MD, Vice-President (USA) (China)  Georg Thieme Verlag KG Usha Kim, MD (India) Bruce E. Spivey, MD, Secretary General (USA) Stuttgart ´ New York ´ ISSN 1431-634X And Other Members of International Task Force* Balder Gloor, MD, Treasurer (Switzerland)

Corresponding Author Mark O.M. Tso, MD I. Preamble History of Task Force on Para-ophthalmic Wilmer Eye Institute, Johns ! Vision Specialists Hopkins University, 457 Woods Building, 600 North Wolfe At a planning session for Vision for the Future or- The task force was initiated under the leadership Street, Baltimore, MD 21287- ganized February 24±27,1999 in Egypt, the Inter- of Professors Rubens Belfort and Kazuichi Konya- 9142, USA; and Peking Univer- national Council of Ophthalmology and the Aca- ma. In January 2002, Professor Cristian Luco sity Eye Center, The Third demia Ophthalmologica Internationalis consid- briefly took over as Chair but due to the increased Teaching Hospital, Peking Uni- ered ophthalmic education to be an essential workload after his appointment as Executive Di- versity, 49 North Garden Road, part of the plan to eliminate avoidable vision rector of the Pan-American Association of Oph- Haidian District, Beijing loss and improve eye care worldwide. They rea- thalmology, Professor Luco asked to be relieved 100083, People's Republic of China, Fax: 410-614-1114 lized the great need for the service of para-oph- of this duty. In 2004, Professor Sivaguru Selvara- (USA); Fax: 8610-8208-9951 thalmic personnel to increase the productivity of jah who had extensive experience in training of (China) the ophthalmic specialists, and a task force on para-ophthalmic personnel in Malaysia, Thailand education of para-ophthalmic vision specialists and Southeast Asia, graciously took over the re- was established. Whereas training of ophthalmic sponsibility as Chairman of this International specialists requires many years, para-ophthalmic Task Force. personnel may be trained more expeditiously to meet urgent eye care needs in different conti- nents. Para-ophthalmic vision specialists include Special Features of the Para-ophthalmic optometrists, ophthalmic technologists, orthop- Vision Specialist Education tists, ophthalmic assistants, ophthalmic nurses, 1. It is recognized that the para-ophthalmic per- public health ophthalmic nurses, and others. sonnel may be divided into two groups. The Para-ophthalmic vision specialists can become a first group of para-ophthalmic vision specia- formidable bridge between the specialist service lists consists of community-based personnel, and the community in blindness prevention and who the World Health Organization (WHO) eye care. have termed as ªmid-levelº eye care personnel

Acknowledgement: ** Past and present members of the In- torial efforts of Jenni Anderson and Lenalee Fulton in coor- ternational Task Force on Para-ophthalmic Vision Specialist dinating and assembling these curricula. Education: Sivaguru Selvarajah, FRCS, FACS, Chair (Malay- sia); Rubens Belfort, MD (Brazil); Elaine Connell, MD (Aus- tralia); Daniel Etya'ale, MD (Switzerland); Thomas D. Publication of this curriculum was partially supported by France, MD (USA); Melvin I. Freeman, MD (USA); Usha a contribution from the International Council of Ophthal- Kim, MD (India); Kazuichi Konyama, MD (Japan); Chris- mology Foundation tian Luco, MD (Chile); Thulasi Raj, MBA (India); Juan Ver- daguer, MD (Chile). ICO gratefully acknowledges the edi- Manuscript Editor: Tina-Marie Gauthier

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for prevention of blindness. This group of specialists plays a II. Core Curriculum For Community Based critical role in eye care education, such as counseling, moti- Para-ophthalmic Eye Care Personnel vation, and follow-up care in the community. Under certain ! circumstances, they also provide the first line of eye care This curriculum is modified from the curriculum developed by treatment and interaction with the healthcare system in the the Western Pacific Region of the World Health Organization community, and referral to the primary and secondary eye for community based para-ophthalmic eye care workers. It con- care providers. sists of five modules of core curriculum, which are for the basic 2. The second group of para-ophthalmic vision specialists are or standard level. The training period is one year. The entry re- hospital-based eye care personnel with varying sophistica- quirement should be a graduate of a basic nursing course with tion in refraction, ophthalmic procedures, assistance in the some experience of work in an ophthalmic department. It is sug- operating room and eye clinic, and postoperative clinical care. gested that 48 weeks be devoted to theoretical work and for su- This group of specialists includes optometrists, ophthalmic pervised practical training, both to run concurrently. One week technologists, orthoptists, ophthalmic assistants, ophthalmic will be for assessment and examinations. The remaining three nurses, and others. weeks are for vacation breaks during the year. The five modules 3. The Training of the para-ophthalmic specialists is to be car- of the core curriculum are: Basic Community Eye Care, Basic ried out in accordance with regional practices of ophthal- Clinical Eye Care Functions, Basic Eye Health Care Management, mology and the local laws of medical practice. Medical prac- Basic Training Functions, and Basic Technical Functions. titioners in a regional medical center normally supervise the community-based para-ophthalmic personnel. The curricu- lum must be clearly defined, especially when concerned with Module 1.1: Overview of Blindness 1 week assigned duties compatible with the local legal system. I. Instructional Objectives 4. It is recognized that all allied para-ophthalmic personnel A. To acquire a concept of blindness and visual impairment. must be trained and organized under one system so that B. To develop an understanding of the social and economic there may be a unified effort of delivery of eye care. Within a implications of blindness and quality of life of the blind. unified training system, the proficiency of different levels of C. To have a knowledge of the magnitude, pattern, and dis- eye care services and number of service personnel may be tribution of blindness in the country where the curriculum carefully planned so that maximum efficiency for the team will be utilized. may be achieved. II. Subject/Topics 5. There are several sub-specialties within the para-ophthalmic A. Overview of blindness. vision specialists, such as orthoptists and optometrists. Or- 1. Definition (WHO classification of low vision and blind- thoptists deal with in children and adults and de- ness). pending on their country of practice, have a very specific job 2. Magnitude and prevalence of blindness. description. As a result, a specific curriculum for orthoptists is a. At global, national, and regional levels . laid out as a part of this curriculum. i. Major global causes of blindness. 6. The International Task Force decided that a curriculum for ii. Major national causes of blindness. optometry would be delayed until a future date. iii. Regional implications of blindness (individual, 7. The Task Force collected available curricula from different social/economical, etc.). parts of the world, including North and South America, West b. National Demographics. Africa, India, Pakistan, and the Western Pacific Region of i. National health indicators. WHO. The Task Force identified four categories of para-oph- ii. Eye health indicators. thalmic personnel for whom curricula were to be identified. iii. Special high-risk groups. Each member of the Task Force was given one category as III. Teaching/Methodology follows: A. Lecture/Discussions. Sivaguru Selvarajah: Community Based Para-Ophthalmic 1. Role-playing. Personnel 2. Audiovisuals. Usha Kim: Hospital Based Para-Ophthalmic 3. Student presentations. Personnel B. Student Assessment. Thomas D. France: Orthoptists a. Written and oral tests. Melvin I. Freeman: Ophthalmic Technicians b. Objective structured practical examination (OSPE). Each member has produced a curriculum modified from ex- isting curricula, and these are presented here. In using these curricula, the laws and regulations of the country in which Module 1.2: Overview of National Health Program they are used must be respected. The overlapping among for Prevention of Blindness 1 week curricula shows the different approaches to para-ophthalmic I. Instructional Objective education. The need to identify the tasks that can be delega- To develop knowledge of the national programs for prevention of ted, the suitable personnel to be trained, and the training blindness (PBL). needs of each particular group for any particular situation is II. Subject/Topics most important. A. Orientation to Vision 2020: The Right to Sight ± Global Initiative to Eliminate Avoidable Blindness. B. Overview of PBL and national health care programs. C. Structure of PBL and national health care delivery systems. D. Overview of PBL.

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1. History of PBL (vertical and horizontal programs). Module 1.5: Eye Health of Special Population 2. Team approach to PBL. Groups 1 week 3. Structure of the national eye health care delivery I. Instructional Objective system. To have an understanding of programs directed at specific 4. Major action plan of the national PBL population groups. III. Teaching/Methodology II. Subject/Topics A. Lecture/Discussion. Eye health of special population groups. B. Student assessment. 1. Pre-school children. Written and oral tests. 2. School children. 3. Industrial workers. 4. Elderly. Module 1.3: The Concept of Avoidable and Unavoidable 5. Low vision individuals. Blindness 1 week 6. Others (myopics, diabetics, age-related macular degen- I. Instructional Objective eration). To have an understanding of the concept of avoidable and una- III. Teaching/Methodology voidable blindness. Lecture/Discussion. II. Subject/Topics A. Basic concepts of comprehensive eye care. Reference B. Avoidable blindness. 1. World Health Organization. Strategies for the prevention of 1. List of conditions of avoidable blindness. blindness in national programs: a primary health care ap- a. Preventable. proach. Geneva: World Health Organization; WHO Publica- b. Curable. tions Centre USA distributor; 1984:88 2. Concept of prevention of avoidable blindness. C. Unavoidable blindness. 1. Types of blindness: corneal, lenticular, posterior Module 2.1: The Normal Eye, Common Eye Disorders segment, and undetermined. and Management 10 weeks 2. List of conditions of unavoidable blindness. I. Instructional Objectives III. Teaching/Methodology A. To develop adequate knowledge of the anatomy and phys- Lecture/Discussion. iology of the eye. 1. Student presentations. B. To develop knowledge and skills to recognize and take 2. Audiovisuals. appropriate action on common eye diseases and ocular emergencies. II. Subject/Topics Module 1.4: Primary Health Care/Primary Eye Care/Pre- A. Applied anatomy and physiology function of the eye vention of Blindness 1 week (the normal eye). I. Instructional Objective B. Common eye diseases and their management. To have an understanding of the concept of primary health C. Primary preventive and promoting measures for common and primary eye care and its application in community-based eye diseases and ocular emergencies. programs. III. Teaching/Methodology II. Subject/Topics A. Lecture/Discussion. A. Fundamentals of Primary Health Care (PHC). B. Demonstration. 1. Essential elements of PHC. C. Practical session. B. Basic strategies of PHC. D. Student assessment. 1. Health education, promotion, and counseling. a. Written and oral tests. C. Fundamentals of primary eye care. b. OSPE. 1. Elements of primary eye care (promotive, preventive, curative, and rehabilitative). 2. Integration of primary eye care into PHCand the estab- Module 2.2: Ophthalmic Clinical Skills & lishment of an eye care network/referral system. Nursing Care 5 weeks 3. Recording and reporting in primary eye care. I. Instructional Objectives III. Teaching/Methodology A. To develop the necessary practical skills and knowledge A. Lecture/Discussion. necessary to take the history of an eye patient, and provide B. Student Assessment. visual acuity testing, and a basic eye examination. a. Written and oral tests. B. To develop the required cognitive skills, practical skills, b. OSPE. and empathic skills necessary to perform all defined func- c. Post-test. tions. II. Subject/Topics A. History taking. B. Visual acuity testing. C. Basic eye examination. 1. Gross examination.

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2. Tonometry. C. Group discussions. 3. Optional: funduscopy. D. Exercises. III. Teaching/Methodology E. Student assessment. A. Lecture/Discussion. a. Written and oral tests. B. Demonstration. b. Continuous assessment. C. Practical session. c. OSPE.

Module 2.3: Development of Communication Module 3.2: Basic Eye Program Management 3 weeks Skills 3 weeks I. Instructional Objectives I. Instructional Objectives A. To acquire basic knowledge and competencies for program A. To develop knowledge and skills to communicate effec- planning, implementation, monitoring, and evaluation, tively with individuals and the community. including quality assurance. B. To promote awareness on eye health through health B. To demonstrate competency for eye health care manage- education. ment. II. Subject/Topics II. Subject/Topics A. Development of communication skills. A. Eye Health Care management. 1. Verbal and nonverbal communication. 1. Community health diagnosis (community demand). 2. Group dynamics. 2. Eye health planning. 3. Public relation strategies. 3. Data collection and analysis. B. Team approach. 4. Monitoring and evaluation. C. Awareness of cultural norms. a. Input. D. Strategies on health education. b. Process. III. Teaching/Methodology c. Outcome. A. Role-playing. 5. Standard operating procedure for quality assurance. B. Poster making/pictures. 6. Information systems in eye health management, C. Focused group discussion. recording, reporting, and monitoring systems in eye D. Simulations. health management. E. Body language exercises. III. Teaching/Methodology F. Mass media messages on health education. A. Student assessment. a. Written and oral tests. References b. Continuous assessment. 1. Standard ophthalmology text book. c. OSPE. 2. Friedlander MH. 20/20 A total guide to improving your vision and preventing . New York: Wing; 1991 Module 3.3: Community Resources for Health 2 weeks I. Instructional Objective Module 3.1: Basic Epidemiology 2 weeks A. To be able to work with community health resources and I. Instructional Objective assist the community. To develop basic knowledge of the principles of epidemiology II. Subject/Topics in relation to eye care and its application for program man- A. Community resources for health. agement. 1. Utilization of community resources. II. Subject/Topics 2. Community participation. A. Basic Epidemiology. 3. Non-governmental organizations in prevention of 1. Principles of basic epidemiology. blindness programs. a. Definition. 4. Community financing. b. Epidemiology fundamental assumption. 5. Volunteer system and training inter-sectoral collabora- c. Descriptive epidemiology. tion. d. Analytical epidemiology. B. Screening. e. Experimental epidemiology. 1. Principles of screening. 2. Epidemiology of ocular diseases. 2. Basic screening methodology (screening procedures). a. Distribution of eye health problem/diseases. III. Teaching/Methodology b. Determinants of eye health problem/diseases. A. Student assessment. c. Risk factors of eye health problem/diseases. a. Written and oral tests. d. Natural history of diseases. b. Continuous assessment. B. Applications of epidemiology to eye health care manage- c. OSPE. ment. C. Concept of health system research. III. Teaching/Methodology Module 3.4: Basic Screening Methodology 3 weeks A. Lectures. I. Instructional Objective B. Audiovisuals. To be able to assist and participate during screening activity for ocular morbidity and blindness.

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II. Subject/Topics Module 4.3: Assessment of Needs 1 week Networking and referrals. I. Instructional Objective III. Teaching/Methodology To develop knowledge, attitude, and skill in the ways of A. Student assessment. assessing needs of a training course. a. Written and oral tests. II. Subject/Topics b. Continuous assessment. Assessment of needs. c. OSPE. 1. Interviews. 2. Questionnaire. References 3. Group discussions. 1. Documentation of the World Health Organization's Program 4. Written tests/Practical tests. for the Prevention of Blindness (WHO Headquarters Publica- III. Teaching/Methodology tions; WHO/PBL/91.23; Available from: URL: www.who.int/ Lecture/Discussion. ncd/vision2020_actionplan/documents/WHOPBDscanned- 1. Role-play. documents.PDF 2. Audiovisuals. 2. Training and educational materials for the prevention of 3. Student presentations. blindness. World Health Organization (WHO Headquarters 4. Case studies. Publications), WHO/PBL/94.44; Available from URL: www.who.int/ncd/vision2020_actionplan/documents/ WHOPBDscanneddocuments.PDF. Module 4.4: Setting Objectives of the Course 1 week 3. World Health Organization. Publications and documents. I. Instructional Objective Health Research Methodology: A Guide for Training in Re- To develop knowledge, attitude, and skill in designing a search Methods. Second Edition. Available from; URL: training course. www.wpro.who.int/publications/pub_929061157X.htm II. Subject/Topics A. What should the student be able to do after the course? B. What objectives are derived from required tasks of the Module 4.1: Training in Integrated Eye Care 1 week job? I. Instructional Objective C. What objectives specify the knowledge, empathy, and To develop the knowledge, attitude, and skills for training skills that the student must learn? primary level health personnel and the community in D. Designing the course. primary eye care. III. Teaching/Methodology II. Subject/Topics Lecture/Discussion. A. Primary Eye Care Training Course. 1. Role-play. B. Strategies in training. 2. Audiovisuals. C. Teaching methodology. 3. Student presentations. III. Teaching/Methodology 4. Case studies. Lecture/Discussion. 1. Role-play. 2. Audiovisuals. Module 4.5: Designing the Course 1 week 3. Student presentations. I. Instructional Objective 4. Case studies. To develop knowledge, attitude, and skill in designing a training course. II. Subject/Topics Module 4.2: Training Process 2 weeks How to achieve objectives. I. Instructional Objective 1. When, where, to whom, and what will be done to achieve To develop knowledge, attitude, and skill in the training pro- objectives. cess. 2. Lectures, demonstrations, discussions. II. Subject/Topics 3. Exercises, role-playing, projects. Training Process. 4. Field trips and observations. 1. Who are the students? 5. Self-instructional materials. 2. What are they able to do before the training? III. Teaching/Methodology 3. What should they be able to do after the training? Lecture/Discussion. 4. What behavioral changes should the course bring about? 1. Role-play. 5. What will be done to bring these changes? 2. Audiovisuals. 6. How can these changes be observed and assessed? 3. Student presentations. III. Teaching/Methodology 4. Case studies. Student assessment. a. Written and oral tests. b. Continuous assessment. Module 4.6: Evaluation of the Course 1 week c. OSPE. I. Instructional Objective To develop knowledge, ability, and skill to evaluate the course.

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II. Subject/Topics III. Teaching/Methodology A. Assessment of knowledge: written and oral tests. A. Lecture/Discussion. B. Assessment of ability: observations, role-playing, B. Demonstration. logbooks, and diaries. C. Practical session. C. Assessment of skills: checklists, rating scales, observation of actual performance, and practical tests. References III. Teaching/Methodology 1. Stein HA, Stein RM, Freeman MI. The ophthalmic assistant: a Lecture/Discussion. text for allied and associated ophthalmic personnel. 8th ed. 1. Role-play. Philadelphia: Elsevier Mosby; 2006: xviii, 871 2. Audiovisuals. 2. (No authors listed). The care and handling of surgical instru- 3. Student presentations. ments. St. Louis: Storz Co.; 1991 4. Case studies.

References III. Advanced Curriculum for Community Based 1. Teaching for Better Learning. A Guide for Teachers of Primary Para-ophthalmic Eye Care Personnel Health Care Staff. World Health Organization, 2nd edition. ! Available from; URL: www.who.int/bookorders/anglais/de- An advanced curriculum was developed for further training of tart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=377 chosen candidates who successfully completed the core curricu- 2. Ewan, C. Teaching skills development manual. Geneva: World lum, and then spent a variable period of time at their home base. Health Organization; 1982 This advanced training course is one year. Candidates who suc- 3. Gagne RM. Essentials of learning for instruction. Chicago: The cessfully complete the advanced training course can become Dryden Press; 1974 course instructors. The advanced curriculum consists of an orientation module and advanced courses in eye health care management, visual func- Module 5.1: Basic Eye Equipment and tion skills, and ophthalmic technology. Maintenance 4 weeks I. Instructional Objective To develop the knowledge, attitude, and skills necessary for Module 1.1: Refraction 4 weeks care, maintenance, and minor repair of ophthalmic equip- I. Instructional Objectives ment and instruments. A. To know the basic concepts about vision. II. Subject/Topics B. To learn the different types of and their A. General aspects of basic eye equipment and their use. proper correction. B. Ophthalmic surgical instruments. C. To perform simple refraction and be able to prescribe C. Standard cleaning procedures for ophthalmic equipment corrective lenses. and instruments. II. Subject/Topics D. Preventive maintenance and minor repair of eye equip- A. Basic concepts. ment and instruments. 1. as an optical system. III. Teaching/Methodology 2. Visual acuity with pinhole. A. Lecture/Discussion. 3. Meaning of 20/20. B. Demonstration. 4. . C. Practical session. B. Types of refractive error. D. Audiovisuals. 1. Ametropia: , hyperopia, and . E. Student assessment. 2. . 1. Return demonstration checklist. 3. How to correct refractive errors. 2. Written and practical examinations. a. Spherical and cylindrical lenses. C. Measuring the refractive errors. 1. Subjective vs. objective method. Module 5.2: Asepsis and Sterilization 4 weeks 2. Subjective refraction: fogging, astigmatic dial. I. Instructional Objective 3. Objective refraction. To develop knowledge, attitude, and skill in aseptic tech- a. Principle of cyclopedia refraction. niques. b. Manifest refraction: retinoscopy. II. Subject/Topics c. Technique of retinoscopy. A. Asepsis and sterilization. D. How to prescribe glasses. 1. Basic microbiology. 1. Subjective vs. objective. 2. Role of microbes in the transmission of diseases. 2. Adds for presbyopia. 3. Definition of disinfection and sterilization. 3. Measuring pupillary distance. B. Common sterilization techniques. 4. Writing prescriptions. 1. Advantages and disadvantages. E. Indications for referral. 2. Effective hand washing and scrubbing techniques. Any condition needing further attention. 3. Sterilization of instruments. III. Teaching/Methodology Written and oral tests.

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Module 1.2: Ocular Motility, Strabismus, 5. Distribution of hospitals and clinics in the community. 4 weeks 6. Building consensus. I. Instructional Objectives 7. Referral standards case management. A. To understand orthoptics purpose and significance. 8. Follow-up procedures. B. To assist in the assessment of binocular function and 9. Environmental assessment and protection. extraocular muscle dysfunction. III. Teaching/Methodology II. Subject/Topics A. Lectures. A. Development of visual function and critical periods in B. Tutorials. childhood. C. Discussion. B. Principles of binocular function. D. Demonstrations. C. Principles in the assessment of binocular function. E. Student assessment. D. Orthoptics. Written and oral tests. 1. Orthoptics and pleoptics. 2. Strabismus/amblyopia. 3. Definition. Module C1.2: Health Systems Research 3 weeks 4. Basic screening techniques for strabismus/amblyopia. I. Instructional Objective 5. Principles of management of strabismus and amblyo- To participate in health systems research. pia, and indications for referral. II. Subject/Topics III. Teaching/Methodology Research methodologies. Written and oral tests. 1. Non-intervention study. 2. Intervention study. 3. Bias in sampling: selection bias, information bias, and Module 1.3: Low Vision 4 weeks confounding principles of health system research. I. Instructional Objectives a. Literature review. A. To be able to screen for possible low vision patients. b. Questionnaire design. B. To assist in the assessment and provision of low vision c. Basic statistics. care for patients. III. Teaching/Methodology C. To be able to teach primary level low vision rehabilitation A. Lectures. techniques. B. Tutorials. II. Subject/Topics C. Discussion. A. Definition of low vision. D. Demonstrations. B. Psychological implications of low vision. E. Student assessment. C. Principles of functional assessment in low vision. Written and oral tests. D. Concepts of community-based rehabilitation. E. Problem-solving skills. 1. Environmental modifications. Module C1.3: Training Function 3 weeks 2. Adaptive daily living skills. I. Instructional Objective 3. Non-optical devices. To conduct training programs for instructors. 4. Sighted guide. II. Subject/Topics F. Overview of low vision devices. A. Assessment of training needs for instructors. G. Indications for referral. 1. Design of instructional plan. III. Teaching/Methodology 2. Implementation of instructional plan. Written and oral tests. 3. Instructional aids. 4. Evaluation of training course. B. Concept of learning and principles of teaching instruc- Module C1.1: Epidemiology 3 weeks tional methodologies. I. Instructional Objectives C. Characteristics of adult learning. A. To assist in the management of a screening and referral D. Competency of effective teachers. system for blindness. III. Teaching/Methodology B. Case management development ability. A. Lectures. II. Subject/Topics B. Tutorials. Screening Methodology. C. Discussion. 1. Principles of screening. D. Demonstrations. 2. Screening method: sampling. E. Student assessment. a. Random. Written and oral tests. b. Stratified. c. Systemic. d. Cluster. Module C1.4: Primary Health Care and 3. Validity: sensitivity and specificity. Primary Eye Care 3 weeks 4. Cost benefit effect: networking and referrals. I. Instructional Objective To acquire additional knowledge of primary health care and primary eye care concepts.

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II. Subject/Topics C. To learn the special considerations involved in correction A. Strategies on the integration of primary eye care into and prescription. primary health care. II. Subject/Topics B. Dynamics of eye care. A. Advanced techniques in refraction. C. Eye information system support for prevention of blind- 1. Review of retinoscopy. ness. 2. Cycloplegic refraction. D. Program monitoring and evaluation. 3. Cross cylinder technique. III. Teaching/Methodology 4. Duo chrome test. A. Lectures. 5. Auto-refractors. B. Tutorials. 6. Determination of cylinder axis and power. C. Discussion. 7. Cutting the cylinder and the spherical equivalent. D. Demonstrations. 8. Transposition while prescribing (plus toric vs. minus toric). B. Options for correcting refractive errors. Module C2.1: Caring for the Blind 1 week 1. Glasses (spectacles). I. Instructional Objectives a. Far point correction. A. To understand the multiple factors (physical, psychologi- b. Effect of accommodation. cal, social, and spiritual) that affect blind people. c. Partial vs. full correction. B. To understand the role of the family and community in the 2. Contact lenses (hard contact , soft contact lens, rehabilitation of the blind. rigid gas permeable lens). II. Subject/Topics a. Types: toric, disposable, extended wear. A. Preparing the blind and family for rehabilitation. b. Lens fitting. B. Environmental barriers in rehabilitation of the blind. c. Patient selection. C. Training home-helpers for the blind. d. Complications. III. Teaching/Methodology 3. Surgery ± RK, PRK, LASIK. A. Lectures. a. Preoperative evaluation: keratometry, pachymetry, B. Tutorials. topography. C. Discussion. b. Procedure. D. Demonstrations. c. Complication. E. Student assessment. III. Teaching/Methodology 1. Written and oral tests. A. Written and oral tests. 2. Continuous assessment. B. Practical. 3. OSPE. C. Tests. D. OSPE. E. Discussions. Module C2.2: Rehabilitation of the Blind 2 weeks F. Lectures. I. Instructional Objectives G. Tutorials. A. To assist in the referral and/or training of the blind to H. Visit school for the blind. enable self-reliance. I. Demonstration. B. To become familiar with the overall process of rehabilita- J. Practical sessions. tion of the blind. II. Subject/Topics A. Principles in the rehabilitation of the blind. Module C2.4: Low Vision 3 weeks B. Stages in rehabilitation of the blind. I. Instructional Objective 1. Activities for daily living. To assist in the assessment and rehabilitation of low vision 2. Socialization training (Braille, sports, etc.). patients in the institution. 3. Resources for the blind. II. Subject/Topics 4. Vocational training. A. Special considerations for correction. III. Teaching/Methodology 1. Strabismus. A. Performance checklist. 2. Refraction after surgery ± pseudophakia, B. Discussions. . C. Lectures. 3. . D. Tutorials. B. Psychological support for low vision patients. E. Visit school for the blind. C. Planning of goals for low vision services. D. Overview of adjunctive lenses and other optical low vision devices. Module C2.3: Refraction 7 weeks 1. Elementary skills for fitting optical low vision devices. I. Instructional Objectives 2. Elementary skills for fitting optical low vision aids. A. To perform advanced refraction and be able to prescribe E. Planning for public awareness. corrective lenses. F. Community resources for low vision. B. To know the different options for correct refractive errors. G. Follow-up of low vision patients. H. Special population with low vision.

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III. Teaching/Methodology C. Discussion. A. Discussions. D. Demonstration B. Lectures. E. Student assessment. C. Tutorials. Written and oral tests. D. Visit school for the blind. E. Demonstration. F. Practical sessions. Module C3.2: Minor Surgery 3 weeks I. Instructional Objective To perform or assist in various minor ophthalmic surgical Module C2.5: Orthoptics 3 weeks procedures. I. Instructional Objective II. Subject/Topics To assist in the assessment and management or rehabilitation A. Minor surgery. of binocular dysfunction and extraocular muscle problems in 1. Incision & curettage (). the institution. 2. Epilation (for ). II. Subject/Topics 3. lid procedures. A. Amblyopia and its management. 4. Removal of superficial corneal and conjunctival foreign 1. Causes of amblyopia. bodies. 2. Types of amblyopia. B. Administration of topical and infiltration (local) anesthe- a. Strabismic amblyopia. sia. b. Amblyopia with straight eyes. III. Teaching/Methodology c. Anisometropic amblyopia. A. Written and oral tests. 3. Treatment modalities. B. Test performance. a. Glasses, occlusion, training. C. Lectures. 4. Prevention of recurrence. D. Tutorials. B. Strabismus and its management. E. Discussion. C. Follow-up of patients with strabismus/amblyopia. F. Demonstration. D. Special populations with strabismus. G. Practical demonstration. III. Teaching/Methodology A. Lectures. B. Tutorials. Module C3.3: Diagnostic Procedures 3 weeks C. Practical sessions. I. Instructional Objective To perform or assist in specialized diagnostic procedures and some specialized therapeutic procedures. Module C3.1: Pharmacology 4 weeks II. Subject/Topics I. Instructional Objectives A. Specialized diagnostic procedures. A. To properly dispense specific topical eye drops. 1. Keratometry. B. To prepare specific topical eye drops from commercially 2. Tonometry. available preparations or raw materials. 3. Perimetry. C. To instruct patient on proper eye medication application. 4. Strabismus evaluation. II. Subject/Topics 5. Biometry/A-scan. A. Pharmacology of topical eye preparations. 6. B-scan ultrasound. 1. Steroids/NSAIDs. 7. Fundus photography. 2. Anesthetics. 8. Electrophysiologic tests. 3. Antimicrobial. 9. (VEP, ERG, EOG). 4. Mydriatics, cycloplegics. 10. Use of synoptophore. 5. Miotics/beta-blockers. 11. Assist in 6. Fluorescein dye/rose bengal stain. a. Fluorescein angiography. B. Classification of diagnostic and therapeutic agents. b. Laser therapy. C. Side effects of eye drops and eye ointment. III. Teaching/Methodology 1. Local and systemic. A. Written and oral tests. D. Principles of preparation of local topical eye drops. B. Test performance. 1. Good manufacturing procedures. C. Test. 2. Laws and regulations for safe sterilization of eye D. Performance. medication. E. Check list. E. Record keeping for eye medications. F. Lectures. F. Eye medications. G. Tutorials. 1. Application of topical eye drops and eye ointment. H. Discussion. 2. Subconjunctival injection. I. Demonstration. 3. Periorbital injection. J. Visit to eye bank. III. Teaching/Methodology A. Lectures. B. Tutorials.

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Module C3.4: Eye Banking 2 weeks 2. Stein HA, Stein RM, Freeman MI. The ophthalmic assistant: I. Instructional Objectives a text for allied and associated ophthalmic personnel. 8th ed. A. To be knowledgeable in the fundamentals of an eye bank Philadelphia: Elsevier Mosby; 2006:xviii, 871 and eye banking. B. To be able to assist in the procurement, quality control, Eye Diseases ± Diagnosis/Eye Diseases ± Therapy serological tests, and distribution of corneal tissue. 1. Trobe JD, American Academy of Family Physicians. The phy- II. Subject/Topics sician's guide to eye care. 2nd ed. San Francisco: Foundation A. Eye bank management. of the American Academy of Ophthalmology; 2001:xi, 228 1. Setting up an eye bank. 2. The ªAtlas of Ophthalmologyº (http://www.atlasophthalmo- 2. Eye bank operation. logy.com) is an online multimedica database edited by Georg III. Teaching/Methodology Michelson, MD, from the University Augenklinik in Erlangen, A. Demonstration. Germany and Robert Machemer, MD, from Duke University in B. Checklist. Durham, North Carolina, USA. It is endorsed by the ICO.

Module C3.5: Microbiology 2 weeks IV. Curriculum For Hospital Based Para-ophthalmic I. Instructional Objectives Personnel A. To be able to assist in eye bank management. ! B. To develop skills in getting specimens from ocular tissues Mid level ophthalmic personnel (MLOP) are proving to be a criti- for simple microbiological examination. cal human resource in eye care delivery in the areas of outpati- C. To be able to perform some simple microbiological proce- ent and inpatient care, as well as in the operating room. The set dures. of activities performed by MLOPs are a mix of patient care, use II. Subject/Topics and maintenance of advanced equipment, documentation, A. Specimen taking methodology and processing microbiol- maintenance of medical records, patient education, and counsel- ogy. ing. 1. Principles of diagnostic ocular microbiology. Mid level ophthalmic personnel should be trained with knowl- 2. Gram/Giemsa staining. edge and skills to assist the ophthalmologist in various eye care 3. Ocular cytology. activities. They should be able to perform duties assigned by the III. Teaching/Methodology ophthalmologist. However, MLOPs are not to be certified as in- A. Lecture/Discussion. dependent practitioners. B. Demonstration. A structured training for MLOPs with a standard curriculum and C. Practical sessions. evaluation, considerably enhance the quality of eye care services and significantly increase the number of patients served. The first step in the curriculum design is to conceptualize the roles Module C3.6: Spectacles and Low Vision and functions of this cadre of personnel, given the understand- Devices 2 weeks ing that they will be working in a hospital setting under an oph- I. Instructional Objective thalmologist. The following are identified as the job description: To learn how low cost spectacles, low vision devices, and IOLs can be produced. Overall Responsibilities II. Subject/Topics 1. To assist the ophthalmologist in various eye care activities. A. Low cost vision devices. 2. To perform duties assigned by the ophthalmologist. 1. Simples corrective lenses. 3. To generate important information to be used for diagnosis or 2. Aphakic lens. treatment (but not to generate medical or surgical diagnosis 3. Intraocular lens implants. or prescriptions). 4. Spectacles for low vision. B. Use of donated glasses. Specific Responsibilities III. Teaching/Methodology 1. History taking. A. Lecture/Discussion. 2. Vision checking. B. Demonstration. 3. Refraction. C. Practical sessions. 4. Color vision testing. 5. Vital parameters. References 6. Asepsis and sterilization. Ophthalmic Assistants ± Programmed Instruction 7. Assisting in ophthalmic surgeries. 1. Newmark E. Ophthalmic medical assisting: an independent 8. First aid and assistance in ocular emergencies. study course. 4th ed. San Francisco: American Academy of 9. Maintenance of ophthalmic instruments and equipment. Ophthalmology; 2006:xviii, 350 10. Preoperative and postoperative patient care. 11. Record keeping. Eye Diseases/ Diseases/Vision Disorders 12. Counseling. 1. Gwin NT. Overview of ocular disorders. Thorofare: Slack; 13. Community out-reach work. 1999:87

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The Course Measurement and recording of: The curriculum is covered over a period of two years and is de- a. Blood pressure. signed to equip the candidates with the required cognitive skills, b. Pulse. practical skills, and empathic skills necessary to perform the c. Temperature. above-defined functions. The course is full-time and on-the-job d. Respiratory rate. with 70% of time spent on skills development. The medium of in- 3. Student assessment. struction is in the local language. Written and oral tests. III. Ocular Anatomy and Physiology Selection of Trainees A. Instructional Objective. Selection of trainees should be based on the following criteria: 1. To acquire a knowledge of ocular anatomy and physiol- 1. Age: 17±25. ogy. 2. Education: Passed higher secondary exams or equivalent, B. Subject/Topics. preferably with a science background. Anatomy and Physiology of: 3. Transparency in selection based on merit/entrance test, 1. Lids and glands. interview. 2. . 3. . 4. and . Detailed Syllabus 5. Lens. ! 6. and vitreous. Curriculum for Hospital-based Para-ophthalmic 7. . Personnel SEMESTER 1 8. . I. Orientation to Medical Ethics, Professional Behavior, Medical 9. Circulation of the eye. and Ophthalmic Terminologies 10. Visual pathways. A. Instructional Objectives. 11. Cranial nerves III, IV, V, VI, and VII. 1. To acquire a concept of medical ethics and professional 12. Aqueous humor. behavior. 13. Light reflex, convergence, and accommodation. 2. To understand the importance of ophthalmic assis- C. Teaching/Methodology. tants. 1. Lecture/Discussions. 3. To develop required qualities. 2. Audiovisuals. 4. To become familiar with medical terminologies. 3. Student assessment. B. Subject/Topics. Written and oral tests. 1. Importance of ophthalmic assistants and required IV. Introduction to Ophthalmic Instruments & Equipment qualities. A. Instructional Objectives. 2. Medical ethics. 1. To acquire a knowledge of ophthalmic instruments and 3. Professional behavior and qualities required. equipment. 4. Medical terminology. 2. To develop skills for usage of ophthalmic instruments 5. Ophthalmic terminology. and equipment. C. Teaching/Methodology. B. Subject/Topics. 1. Lecture/Discussions. Ophthalmic instruments and equipment: 2. Audiovisuals. 1. Trial sets and frames. II. Human Anatomy and Physiology ± Introduction 2. Tonometer. A. Instructional Objectives. 3. Slit lamp. 1. To acquire a knowledge of the anatomy and physiology 4. Perimeter. of various systems of the human body. 5. Keratometer. 2. To develop skills for measurement and recording of 6. Lensometer. blood pressure, pulse, temperature and respiratory 7. A-scan. rate. 8. Surgical microscope. B. Subject/Topics. 9. Autoclave machines. 1. Digestive System. C. Teaching/Methodology. 2. Excretory System. 1. Lecture/Discussion. 3. Respiratory System. 2. Practical session. 4. Cardiovascular System. 3. Demonstration of use of ophthalmic instruments and 5. Musculoskeletal System. equipment. 6. Sensory System. V. Orientation to Ward, Outpatient Department and Operation 7. Endocrine System. Room 8. Reproductive System. A. Instructional Objective. 9. Nervous System. 1. To acquire an orientation to the inpatient ward, C. Teaching/Methodology. outpatient department (OPD), and operating room. 1. Lecture/Discussions. B. Subject/Topics. Audiovisuals. Introduction to: 2. Practical session. 1. Inpatient ward.

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2. Outpatient department. 2. Audiovisuals. 3. Operating room. 3. Practical session. C. Teaching/Methodology. a. Examination of the eye using a penlight. 1. Lecture/Discussion. b. Measurement and recording of: 2. Practical session. i. Intraocular pressure using tonometry. VI. Optics and Refraction ii. Lacrimal duct patency ± syringing. A. Instructional Objectives. 4. Student assessment. 1. To develop knowledge of optics and refraction. Written and oral tests. 2. To develop skills for vision testing and recording lens IX. Pharmacology power. A. Instructional Objectives. B. Subject/Topics. 1. To acquire necessary knowledge of ocular medica- 1. Introduction to light. tions. 2 Reflection and refraction. 2. To develop necessary skills in usage of ocular 3. Refractive errors. medications. 4. Optics of refractive errors. 3. To have a knowledge of prescription writing. 5. Eye as an optical instrument. B. Subject/Topics. 6. Lenses and their combinations. Commonly used ocular drugs: 7. Optical aberrations of the eye. 1. Mydriatics. C. Teaching/Methodology. 2. Miotics. 1. Lecture/Discussion. 3. Antibiotics. 2. Practical session. 4. Antifungals. Measurement and recording: 5. Antivirals. a. Visual acuity. 6. Anti-. b. Lens powers. 7. Diagnostic agents. VII. Inter-personal Relationships 8. Anesthetics. A. Instructional Objective. 9. Steroids. 1. To develop an understanding of inter-personal 10. Anti-allergy. relationships and its importance. 11. Non steroidal anti-inflammatory drugs. B. Subject/Topics. 12. Routes of administration. Fundamentals of Inter-personal relationships: 13. Prescriptions. 1. Empathy and values. C. Teaching/Methodology. 2. Personality and temperaments. 1. Lecture/Discussions. 3. Motivation. Audiovisuals. 4. Work tolerance. 2. Practical session. 5. Team work and being a team player. a. Instill eye drops. 6. Leadership qualities. b. Irrigation of the eye. 7. Delegation of responsibilities. 3. Student assessment. 8. Risk-taking. Written and oral tests. 9. Communication skills. X. Microbiology 10. Functional English. A. Instructional Objectives. C. Teaching/Methodology. 1. To acquire necessary knowledge of various micro- 1. Lecture/Discussion. organisms. 2. Role-playing. 2. To develop knowledge and skills in maintenance of 3. Focused group discussion. asepsis and sterilization. VIII. Orientation to Common Eye Diseases B. Subject/Topics. A. Instructional Objectives. 1. Bacteria, virus, fungus. 1. To acquire a knowledge of common eye diseases. 2. Asepsis and sterilization. 2. To develop skills for recording intraocular pressure C. Teaching/Methodology. and lacrimal system patency. 1. Lecture/Discussions. B. Subject/Topics. 2. Audiovisuals. Common eye diseases: 3. Practical session. 1. Common lid abnormalities: , chalazion, , 4. Student assessment. , , , trichiasis. Written and oral tests. 2. Conjunctiva: , , , XI. Biochemistry , foreign body. A. Instructional Objective. 3. Cornea: foreign body, epithelial defects, ulcer, scars. To acquire knowledge about various biochemical 4. Lens: cataract. investigations relevant to ophthalmology. 5. Glaucoma. B. Subject/Topics. 6. . Biochemical investigations relevant to ophthalmology. 7. Vitamin A deficiency. C. Teaching/Methodology. C. Teaching/Methodology. 1. Lecture/Discussions. 1. Lecture/Discussions. 2. Audiovisuals.

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XII. Common Medical and Ophthalmic Emergencies 9. Binocular single vision. A. Instructional Objective. 10. Anisometropia & . To acquire knowledge about common medical and 11. Accommodation and convergence. ophthalmic emergencies. 12. Phorias. B. Subject/Topics. 13. Tropias. 1. Vasovagal attack. 14. Amblyopia. 2. Hypoglycemia. 15. . 3. Foreign body. C. Teaching/Methodology. 4. Chemical injury. 1. Lecture/Discussions. 5. Ocular trauma. 2. Audiovisuals. 6. . 3. Practical session. C. Teaching/Methodology. Perform retinoscopy: 1. Lecture/Discussions. a. Myopia. 2. Audiovisuals. b. Hypermetropia. 3. Focused group discussion. c. Astigmatism. XIII. Community Ophthalmology d. Aphakia. A. Instructional Objectives. II. Common Eye Disorders 1. To acquire knowledge about the various components A. Instructional Objective. of Community Ophthalmology. To acquire knowledge of common eye disorders and 2. To have an understanding of the National Eye Care their identification. Programs and Vision 2020. B. Subject/Topics. 3. To acquire knowledge of diseases of the eye related to Common eye disorders. industrial hazards and nutrition. 1. Lids. B. Subject/Topics. 2. Lacrimal apparatus. 1. School screening. 3. . 2. Community-based rehabilitation. 4. Conjunctiva, limbus. 3. Community eye care. 5. Cornea, sclera. 4. Magnitude of blindness. 6. Uvea. 5. National Eye Care Programs & Vision 2020. 7. Glaucoma. 6. Industrial hazards. 8. Lens. 7. Nutrition and eye diseases. 9. Retina. C. Teaching/Methodology. 10. Trauma. 1. Lecture/Discussions. C. Teaching/Methodology. 2. Audiovisuals. 1. Lecture/Discussions. 3. Focused group discussion. 2. Audiovisuals. 4. Student assessment. 3. Practical session. Written and oral tests. a. Examination of the eye using a penlight. XIV. Semester I: Exit Competencies b. Identification of common eye diseases. 1. Will be able to receive patients. III. Outpatient Department (OPD) Instruments 2. Measure visual acuity. A. Instructional Objectives. 3. Check vital parameters. 1. To acquire knowledge of OPD instruments. 4. Check for lacrimal patency. 2. To develop skills for usage of OPD instruments. 5. Perform tonometry. B. Subject/Topics. 6. Instill drops in the eye. 1. Synaptophore. 2. RAF ruler. 3. Maddox rod. Curriculum for Hospital-based Para-ophthalmic 4. Maddox wing. Personnel SEMESTER 2 C. Teaching/Methodology. I. Refraction 1. Lecture/Discussions. A. Instructional Objectives. 2. Audiovisuals. 1. To acquire knowledge of refraction and refractive 3. Practical session. errors. a. Use of instruments: 2. To acquire skills in performing retinoscopy. i. RAF ruler. B. Subject/Topics. ii. Maddox rod and wing. 1. Retinoscopy. iii. Synaptophore. 2. Subjective refraction. b. Cover/uncover test. 3. Myopia. IV. Data Entry and Maintenance of Medical Records 4. Hypermetropia. A. Instructional Objective. 5. Astigmatism. To acquire knowledge of data entry and maintenance of 6. Aphakia. medical records. 7. Pseudophakia. B. Subject/Topics. 8. Muscle balance. 1. Data entry.

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2. Maintenance of medical records. B. Subject/Topics. C. Teaching/Methodology. 1. Techniques of local and regional anesthesia. 1. Lecture/Discussions. 2. Cataract complications. a. Data entry. 2 Intraoperative complications. b. Medical record maintenance. 3. Postoperative complications. V. Principles of Sterilization and Asepsis 4. Preoperative counseling. A. Instructional Objective. 5. Postoperative counseling. To acquire knowledge of sterilization and asepsis. C. Teaching/Methodology. B. Subject/Topics. 1. Lecture/Discussions. 1. Waste disposal. a. Local and regional blocks. 2. Handling of sterile supplies. b. Preoperative and postoperative counseling. C. Teaching/Methodology. 2. Practical session. 1. Lecture/Discussions. 3. Focused group discussions. a. Waste disposal. X. History Taking and Examination of the Eye b. Handling sterile supplies. A. Instructional Objectives. c. Handling sutures, intraocular lenses. 1. To acquire knowledge in History Taking and 2. Practical session. Examination of the Eye. VI. Surgical instruments B. Subject/Topics. A. Instructional Objective. 1. History taking and recording. To acquire knowledge of instruments required in 2. Examination of the eye. various ocular surgeries. C. Teaching/Methodology. B. Subject/Topics. 1. Lecture/Discussions. Instruments required in the following surgeries.: 2. Practical session. 1. Cataract. 3. Focused group discussions. 2. Minor procedures. XI. Eye Camp Set Up 3. Glaucoma. A. Instructional Objective. 4. Dacryocystectomy, dacryocystorhinostomy. 1. To develop knowledge for set up of an eye camp. 5. Others. B. Subject/Topics. C. Teaching/Methodology. 1. Orientation for set up of an eye camp. 1. Lecture/Discussions. C. Teaching/Methodology. 2. Practical session. 1. Lecture/Discussions. VII. Surgical Equipment 2. Practical session. A. Instructional Objective. a. Participating in various areas of the eye camp To acquire knowledge of equipment required in oph- 3. Focused group discussions. thalmic surgeries. XII. Semester 2: Exit Competencies B. Subject/Topics. 1. Will be able to examine the eye. 1. Operating light. 2. Enter data. 2. Microscope. 3. Perform retinoscopy in simple cases. 3. Cautery. 4. Sterilize instruments, equipment, and operating 4. Others. room. C. Teaching/Methodology. 5. Handle sterile instruments. 1. Lecture/Discussions. 2. Practical session. VIII. Concepts of Scrubbing, Gowning, and Gloving Curriculum for Hospital-based Para-ophthalmic A. Instructional Objective. Personnel SEMESTER 3 To acquire knowledge of the concepts of scrubbing, I. Patient Examination gowning, and gloving. A. Instructional Objective. B. Subject/Topics. 1. To acquire necessary knowledge in patient Techniques of: examination. 1. Surgical prepping and draping. B. Subject/Topics. 2. Gowning and gloving. 1. Color vision. C. Teaching/Methodology. 2. Visual fields. 1. Lecture/Discussions. 3. Ocular motility. 2. Practical session. C. Teaching/Methodology. a. Scrubbing, gloving, prepping, and draping. 1. Lecture/Discussions. b. Circulating in the operating room. 2. Practical session. IX. Preoperative Assessment and Counseling II. Lenses and Refractive Surgery A. Instructional Objectives. A. Instructional Objective. 1. To acquire necessary knowledge in preoperative 1. To acquire necessary knowledge of different types of assessment, anesthesia, and surgery-related lenses and refractive surgeries. complications. B. Subject/Topics. 2. To acquire counseling knowledge and skills. 1. Different types of lenses.

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a. Oblique cylinder. i. Different surgical types. b. Transposition. ii. Instruments and equipment required for c. Contact lenses. various techniques. 2. Refractive surgery. b. Glaucoma management. C. Teaching/Methodology. c. Other sub-specialty cases. 1. Lecture/Discussions. C. Teaching/Methodology. 2. Practical session. 1. Lecture/Discussions. III. Introduction to Computers 2. Practical session. A. Instructional Objective. a. Color vision testing. To acquire necessary knowledge of computers. b. Visual field examination. B. Subject/Topics. c. Ocular motility testing. Introduction to computers. d. Use of contact lenses. C. Teaching/Methodology. e. Use of computers. 1. Lecture/Discussions. f. Assisting in staining, scraping corneal ulcers. 2. Practical session. g. Assisting in surgeries. IV. Ocular and Systemic Emergencies i. Cataract. A. Instructional Objectives. ii. Glaucoma. 1. To acquire knowledge of ocular and systemic iii. Other sub-specialty cases. emergencies. VIII. Semester 3: Exit Competencies 2. To identify and act on emergencies. 1. Will be able to refract and prescribe. B. Subject/Topics. 2. Elicit patient information. 1. Ocular and systemic emergencies. 3. Assisting in cataract surgery. 2. Preventable emergencies. 4. Identify common diseases. 3. What requires immediate review by an ophthalmol- 5. Identify and act on emergencies. ogist. 6. Organize and perform in an eye camp set up. C. Teaching/Methodology. 1 Lecture/Discussions. 2. Practical session. Curriculum for Hospital-based Para-ophthalmic V. Overview of Blindness Personnel SEMESTER 4 A. Instructional Objectives. I. Seminars 1. To acquire a concept of blindness and visual impair- Perform all skills independently with periodic supervision. ment. II. Workshops 2. To develop knowledge of the national programs for Perform all skills independently with periodic supervision. the prevention of blindness. III. Semester 4: Exit Competencies B. Subject/Topics. 1. Will be able to refract and prescribe. 1. Causes of visual impairment and blindness. 2. Elicit patient information. 2. National programs for blindness control. 3. Assist in cataract surgery. C. Teaching/Methodology. 4. Identify common diseases. 1. Lecture/Discussions. 5. Identify and act on emergencies. 2. Practical session. 6. Organize and perform in an camp set up. VI. Eye Camp A. Instructional Objective. Teaching Aids 1. To acquire knowledge of functioning of an eye camp A. Model eye, specimens, posters. and guidelines for conducting eye camps. B. Printed materials, self-study materials. B. Subject/Topics. C. Slides. 1. Functioning of an eye camp. D. Videos/DVDs, CD-ROM, Internet. 2. Guidelines for conducting eye camps. C. Teaching/Methodology. Evaluation of Trainees 1. Lecture/Discussions. A. Mandatory Attendance: 80% attendance in Theory; 2. Practical session. 80% attendance in Practical. VII. Patient Examination and Surgical Assistance B. Maintenance of Logbook. A. Instructional Objectives. C. Internal assessment (60%): 1. To acquire knowledge in patient examination. a. Continuous assessment (20%). 2. To develop knowledge in assisting ocular surgeries. b. Periodic assessment (40%). B. Subject/Topics. D. Final Assessment (40%): 1. Evaluation of color vision, visual field, and ocular a. Theory and Practical/Clinical at end of two years. motility. E. Assessment in local language. 2. Contact lens and corneal ulcers, staining and F. Minimum Pass Marks - 50% or higher on Theory scraping. and Practical/Clinical examinations. 3. Use of computers. G. For candidates who fail, re-examination after six months. 4. Assisting in ocular surgeries for: Time Allocation a. Cataract management. A. Semesters: 4.

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B. Lectures/Demonstrations: 100 hours/Semester. 18. Rosenfield S. Basic and clinical science course section 11. C. Seminars: Total 20 hours at 2 hours each over the entire 2005±2006, lens and cataract. San Francisco: American course. Academy of Ophthalmology, 2005 D. Case Discussions: 20 over the entire course. 19. Kline LB. Basic and clinical science course section 5. 2005± Theory Hours 2006, neuro-ophthalmology. San Francisco: American Acad- A. Basic Sciences: 20%. emy of Ophthalmology, 2005: 400 B. Eye Diseases: 20%. 20. Simon JW. Basic and clinical science course section 6. 2005± C. Operating Room: 15%. 2006, pediatric ophthalmology and strabismus. San Francis- D. Refraction: 25%. co: American Academy of Ophthalmology, 2005: 482 E. Community Ophthalmology: 20%. 21. Stein HA, Stein RM, Freeman MI. The ophthalmic assistant: a Practical Hours text for allied and associated ophthalmic personnel. 8th ed. A. Outpatient Department and Refraction: 40%. Philadelphia: Elsevier Mosby, 2006; xviii: 871 B. Inpatient Department: 20%. 22. Trobe JD. Home study course for ophthalmic medical assis- C. Operating Room: 30%. tants. San Francisco: American Academy of Ophthalmology, D. Field Work: 10%. 1983: 296 23. Rhode SJ, Ginsberg SP. Ophthalmic technology: a guide for References the eye care assistant. New York: Raven Press, 1987; xvi: 492 1. Bedford MA. Color atlas of ophthalmological diagnosis. 2nd 24. (No authors listed). Basic skills for ophthalmic assistants. 4th ed. Chicago: Year Book Medical Publishers, 1986: 182 ed. San Francisco: American Academy of Ophthalmology, 2. Forrester JV. The eye : basic sciences in practice. 2nd ed. 1993 Edinburgh; New York: W.B. Saunders, 2002: 447 25. Newmark E. Ophthalmic medical assisting: an independent 3. Kanski JJ. Clinical ophthalmology: a systematic approach. study course. 4th ed. San Francisco: American Academy of 4th ed. Oxford; Boston: Butterworth-Heinemann, 1999; xii: Ophthalmology, 2006; xviii: 350 673 26. DuBois L. Basic procedures. Thorofare: SLACK Inc.; 1998:116 4. Stein HA, Slatt BJ, Stein RM. Ophthalmic terminology: speller 27. Jackson-Williams B. Ophthalmic surgical assisting. 2nd ed. and vocabulary builder. 3rd ed. St. Louis: Mosby, 1992; p.xiv: Thorofare, N.J.: Slack Inc., 1993: 172 378 28. Kersten R. Basic and clinical science course section 7, 2005± 5. Sutphin JE. Basic and clinical science course section 8, 2005± 2006, orbit, , and lacrimal system. San Francisco: 2006, external disease and cornea. San Francisco: American American Academy of Ophthalmology, 2005: 324 Academy of Ophthalmology, 2004; xiv: 324 29. Darling VH, Thorpe MR. Ophthalmic nursing. London: Bail- 6. Ruben M, Ruben S. Diagnostic picture tests in ophthalmolo- liere Tindall, 1975; ix: 205 gy. Chicago: Year Book Medical Publishers, 1987; 128 30. Rooke FCE, Rothwell PJ, Woodhouse DF. Ophthalmic nursing: 7. Wilson FM, Gurland JE. Practical ophthalmology: a manual its practice and management. Edinburgh, New York: for beginning residents. 4th ed. San Francisco, Calif.: Ameri- Churchill Livingstone, 1980; x: 242 can Academy of Ophthalmology, 1996; xvi: 415 31. Smith WAM, Percy E. Ophthalmology: ophthalmic tech- 8. Rhee DJ, Pyfer MF, Wills Eye Hospital (Philadelphia Pa.). The niques, 1973: 243 Wills eye manual : office and emergency room diagnosis and 32. Percy E, Smith WAM. Ophthalmology: ophthalmic nursing. treatment of eye disease. 3rd ed. Philadelphia: Lippincott London: William Heinemann Medical Books Ltd., 1973: 96 Williams & Wilkins, 1999; xxiii: 563 33. Grossniklaus HE. Basic and clinical science course section 4. 9. Sihota R, Tandon R. Parsons' diseases of the eye. 19th ed: 2005±2006, ophthalmic pathology and intraocular tumors. Butterworth-Heinemann, 2003; p.viii: 615 San Francisco: American Academy of Ophthalmology, 2005: 10. Schwab L. Eye care in developing nations. 3rd ed. San Fran- 332 cisco: American Academy of Ophthalmology, 1999; xiv: 270 34. Miller KM. Basic and clinical science course section 3. 2005± 11. (No authors listed). Basic and clinical science course volume 2006, optics, refraction, and contact lenses. San Francisco: 1, update on general medicine, 2004±2005. San Francisco: American Academy of Ophthalmology, 2005: 347 American Academy of Ophthalmology, 2004; xv: 366 35. Bhootra AK. Opticians guide: a manual for opticians. Kolkata: 12. Cibis GW. Basic and clinical science course Section 2. 2005± Optometric Association of India, 2002: 96 2006, fundamentals and principles of ophthalmology. San 36. Abrams D, Duke-Elder S. Duke-Elder's practice of refraction. Francisco: American Academy of Ophthalmology; 2005; 528 10th ed. Edinburgh ; New York: Churchill Livingstone, 1993; 13. Vaughan D, Asbury T. General ophthalmology. 10th ed. Los viii: 301 Altos, Calif.: Lange Medical Publications, 1983: 407 37. Elkington AR, Frank HJ, Greaney MJ. Clinical optics. 3rd ed. 14. (No authors listed). American academy of ophthalmology Oxford England ; Malden, MA: Blackwell Science, 1999: 264 basic and clinical science course, 15 volumes: 2004 ±2005. 38. Regillo C. Basic and clinical science course section 12. 2005± San Francisco: American Academy of Ophthalmology, 2004; 2006, retina and vitreous. San Francisco: American Academy p.xiii: 347 of Ophthalmology, 2005: 382 15. Jogi R. Basic ophthalmology: Jaypee Brothers, 2005: 409 39. Opremcak EM. Basic and clinical science course section 9. 16. Goldberg S. Ophthalmology made ridiculously simple. 2nd 2005±2006, intraocular inflammation and uveitis. San ed. Miami: MedMaster, 2001; vi: 89 Francisco: American Academy of Ophthalmology, 2005: 300 17. Simmons S. Basic and clinical science course section 10. 40. Rubin ML. Optics for clinicians. 2d ed. Gainesville, Fla.,: Triad 2005±2006, glaucoma. San Francisco: American Academy Scientific Publishers, 1974; xvi: 367 of Ophthalmology, 2005: 242 41. Hartstein J. Review of refraction. St. Louis: C.V. Mosby Co., 1971; xv: 246

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42. Appleton B. Clinical optics. Thorofare: SLACK, 1990: 84 tified Ophthalmic Technician (COT) or as a Certified Ophthalmic 43. Appleton B, Blair B, Garber N, Wolfe CJ. Opticianry, ocularis- Medical Technologist (COMT). These organizations provide cer- try and ophthalmic technology. Thorofare: Slack Inc., 1990: tification to their target groups, but they do not provide an ad- 137 vanced degree in the fields of orthoptics or allied health in oph- 44. Borish IM, Indiana University Bloomington. Division of Op- thalmology. Dalhousie University in Halifax, Nova Scotia, Canada tometry. Clinical refraction. 3d ed. Chicago, Ill.: Professional has recently developed an advanced course in orthoptic training, Press, 1975; 2 v. xxi: 1381 lasting three years that leads to a Masters Degree in Visual Sci- 45. Corboy JM. The retinoscopy book: a manual for beginners. ence. Rev. ed. Thorofare: Slack Inc., 1984; x: 123 Much of what is included in this curriculum is taken with per- 46. Gettes BC. Practical refraction. New York: Grune & Stratton, mission directly from the curricula already established by the 1957: 170 programs at Aravind Eye Hospital in Madurai, India, and from 47. Reinecke RD, Herm RJ. Refraction: a programmed text. 3rd the American Orthoptic Syllabus, recently modified by the Edu- ed. Norwalk, Conn.: Appleton-Century-Crofts, 1983; x: 373 cation Committee of the American Association of Certified Or- 48. Sloane AE. Manual of refraction. 2d ed. Boston: Little Brown, thoptists. Each of these programs has set their curricula to reflect 1970; xiii: 282 the needs of their own environment. It is expected that any sug- 49. Thorington J. Refraction of the human eye and methods of gested curriculum developed here will be taken and modified for estimating the refraction, including a section on the fitting of use by each local program. The essentials for orthoptic training spectacles and eye-glasses. 3d ed. Philadelphia,: P. Blakis- are similar to all and will be listed first. ton's Son & Co. inc., 1939; viii: 412 50. Scheiman M, Rouse MW. Optometric Management of Learn- Orthoptic Needs ing-Related Vision Problems. 2nd ed. St. Louis: Mosby-Else- Children are difficult to examine and an experienced examiner vier, 2006; xiv: 752 requires considerable time to perform almost any test. Whereas 51. Ruben M, Woodward EG. Refraction clinical optics. London: the visual acuity examination is an easy procedure in an adult Macmillan, 1982; vi: 197 and older child, it becomes difficult with a toddler and nearly 52. Michaels DD. Visual optics and refraction: a clinical ap- impossible in an infant or neonate. This is an important concern proach. 3rd ed. St. Louis: Mosby, 1985; ix: 654 when dealing with diseases where it is mandatory to monitor 53. Stein HA, Freeman MI, Stenson SM. CLAO Residents curricu- visual improvement or deterioration. Orthoptists are specifically lum manual on refraction, spectacles and dispensing. Me- trained to recognize, examine, and in some cases, treat the prob- tairie, Los Angeles: CLAO Publications, 2001; x: 250 lems of amblyopia and strabismus in children and adults. They 54. Benton CD, Welsh RC. Spectacles for aphakia. Springfield: provide the ªphysician extenderº role that allows the highest Thomas, 1966; xii: 164 quality of care to these patients and allows the ophthalmologist 55. Abel R. The eye care revolution: prevent and reverse com- to provide efficient and focused care. mon vision problems. New York: Kensington,1999; xxvi: 453 56. Thibodeau GA, Patton KT. Anthony's textbook of anatomy Curriculum Objectives and physiology. 18th ed. St. Louis, London: Elsevier Mosby, The specific needs of the individuals being trained will require 2006; xv: 1228, 1228 the inclusion of basic science topics, including anatomy, physiol- ogy, general medicine, etc. These will be included in the appen- dices. The basic curriculum for orthoptic training must include V. Curriculum for Orthoptists gaining knowledge and expertise in the following areas: ! 1. Vision estimation in neonates, infants, toddlers, and young Orthoptics is a field of allied health in ophthalmology that spe- children. cializes in the study, evaluation, and treatment of defects of bi- 2. Diagnosis of all forms of strabismus including abnormalities nocular vision, strabismus, and amblyopia in children and of binocular single vision. adults. The number of orthoptists vary from country to country, 3. Detection and management of amblyogenic factors and am- and their specific job description depends on the needs of the in- blyopia in all age groups in the pediatric population. Famil- dividual country in which they work. iarity with and ability to use the various instruments in the The training of orthoptists around the world also varies accord- eye department which are used for the above purposes. ing to these needs. India, for example, has developed a six- 4. Good communication skills with the child and the parents. month course that only accepts students with previous opto- metric or ªrefractionistº training. In India, students are available Secondary Curriculum Objectives who are well trained in the basic anatomy and physiology of the Based on the needs of the local community, secondary objectives eye and the , and they don't require the basic train- may be included in the curriculum that are not necessarily ing that is necessary for students without prior ophthalmology thought of as being part of basic orthoptic training. These may experience. include knowledge of and technical expertise in: In North America, the American and Canadian Orthoptic Coun- 1. Refraction and common refractive errors in the pediatric cils that oversee the training and certification of orthoptists, population. have a two-year curriculum for college graduates with no pre- 2. Visual field examination. vious ophthalmology experience. There is the opportunity for 3. Tonometry. advanced standing (usually one year) for students that hold ad- vanced certification as allied health personnel in ophthalmolo- Eligibility Criteria gy. The advanced certification by the Joint Commission on Allied In general, a background in science, experience in medicine as an Health Personnel in Ophthalmology (JCAHPO) is either as a Cer- assistant or in specific aspects of ophthalmology such as oph-

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thalmic nursing, ophthalmic assistant, optometry, ªrefraction- 2:00 p.m. ± 5:00 p.m.: Pediatric Ophthalmology/Strabismus ist,º etc., are useful, but it is certainly possible to train interested, Department enthusiastic individuals from any background. 5:00 p.m. ± 6:00 p.m.: Library

Training Faculty The Program Director should be a senior orthoptist with at least Phase I: Basics Science 6 weeks five years of experience in the field. The Medical Director should A. Development of the eye and its functions. be a trained pediatric ophthalmologist or an ophthalmologist B. Anatomy of the extraocular muscles. with experience in working with children. C. Physiology of extraocular movements. D. Physiology of acuity of vision, color vision, field of vision, Training Facility binocular single vision, convergence and accommodation. The training facility should be an ophthalmology department in a large, clinically busy, academic setting that provides the neces- sary space, access to patients with professional oversight, library Phase II: Basics in Strabismus Management facilities (see Appendix I), and freedom to study. and Orthoptic Practice 8 weeks A. Various methods of vision estimation in children for all age Goals of Training groups including checking the fixation pattern, central, stea- It is important to list the goals of training in any educational pro- dy and maintained fixation preference (CSM); induced tropia gram. In the case of orthoptic training, the following is a good ex- with prism; Teller Acuity Cards, Cardiff Acuity Cards, Cam- ample of the goals to be achieved. bridge Crowding Cards, Allen cards, and other matching At the Conclusion of training, the student should be able to de- cards. Methods of recording results will be introduced. monstrate understanding and have skills in all of the following: B. Measurement of convergence and accommodation, and history taking, family history, past medical history, review of detection of their anomalies. pertinent systems, presence of allergies to medications, and cur- C. Examination of all types of strabismus, including concomi- rent medications; children's distance and near visual acuity re- tant and incomitant squint. cording; cover tests (to include single cover test, cross cover, or D. Examination and diagnosis of special forms of strabismus alternate cover test); assessment of ductions and versions (ocu- including syndromes in strabismus and preoperative and lar movement tests), Hirschberg method, Krimsky method, postoperative . prism cover tests, including simultaneous prism and cover test- E. Diagnosis and management of various types of amblyopia. ing, with and without glasses, the Worth four-dot test, stereopsis F. Non-surgical management of strabismus and amblyopia in- testing; near point of convergence, convergence and divergence; cluding optical correction, orthoptic exercises, prism therapy, amplitudes, both horizontal and vertical, near point of accom- orthoptic counseling, penalization, occlusion therapy. modation, grades of ; diplopia charting, (e.g., G. Knowledge of the surgical management of strabismus, in- Hess charting); normal and abnormal retinal correspondence; cluding surgical procedures such as muscle resection and angle of deviation in all cardinal positions of gaze; three-step recession and postoperative orthoptic evaluation. test; and eccentric fixation detection.º H. Exposure to other common pediatric eye problems, including various amblyogenic factors. Short Course Plan The course plan will depend on the local needs and availability. The following description of a short course (six months) shows Phase III: Clinical Exposure in Orthoptic many of the characteristics of any program, regardless of length. Evaluation 10 weeks A. Principle, construction, and use of orthoptic equipment. 1. Occluder and fixation targets. Short Course 2. Children's vision acuity charts (e.g., LEA Symbols, HOTV, ! Allen cards). Based on the Orthoptic Training Course at Aravind Eye Hospital, 3. Prism bar, loose prisms. Madurai, India, for students with some prior background in oph- 4. Fusion testing, e.g., the Worth four-dot test. thalmology. Teaching modes include video on extraocular mus- 5. Stereopsis testing, e.g., TNO, Titmus, Lang, etc. cles, anatomy, and physiology; examination of a case of strabis- 6. Bagolini lenses. mus; and handouts on almost all the topics. 7. Double Maddox rod. Duration of the Course: 24 Weeks (six months); 8. Maddox rod/Maddox wing. Monday ± Saturday 9. Hess-Lees screen. Total Classes: a. Theory: 36 classes, 1-hour each 10. Synoptophore, if available. b. Discussion: as necessary, 1-hour 11. Diploscope. each 12. Various small devices for orthoptic exercises. Hours of Work: Monday ± Saturday: 7:30 a.m. ± 6:00 p.m. Pediatric Refraction Day Breakdown: When indicated, the program may require and provide training 8:00 a.m. ± 9:00 a.m.: Theory classes or Discussion in: atropine refraction, cyclopentolate refraction, refraction dur- 9:00 a.m. ± 1:00 p.m.: Pediatric Ophthalmology/Strabismus ing examination under anesthesia (EUA), retinoscopy in child- Department hood aphakia and pseudophakia, glasses prescription, pediatric 1:00 p.m. ± 2:00 p.m.: Lunch contact lenses, tonometry, and visual fields.

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Long Course B. Contents: Vision estimation in children, types of strabis- ! mus, amblyopia, non-surgical and surgical management of In North America, the training course for orthoptists is usually strabismus. two years, after having earned a university degree. As noted 3. Part III above, this may be shortened for individuals with prior experi- A. Paper Heading: Clinical Exposure in Orthoptic Evaluation ence or those who have obtained advanced certification in allied and Management. health in ophthalmology by JCAHPO. These longer programs are B. Contents: Orthoptic instrumentation and usage, pediatric also arranged so that Phase I, the didactic course in basic scien- refraction (as needed). ces, is usually presented during the first few months. More ad- vanced didactic training, (see Phases 2 and 3 above) is usually done weekly during the entire course of study with the rest of Appendix I the time spent in the clinic, observing and examining patients. ! A minimum number of complete patient exams is required by Suggested Readings/Library Holdings the American Orthoptic Council each year of the course. 1. Edelman PM, American Orthoptic Council. Syllabus Com- Throughout the course, students are tested to ensure that they mittee, American Academy of Ophthalmology. Allied Health are obtaining the necessary knowledge before progressing on to Education Committee. Orthoptics: a syllabus of ocular moti- the next level. Each program develops their own lesson plans for lity. 2nd ed. San Francisco, Calif.: American Academy of their didactic teaching. Ophthalmology, 1992; xv: 107 2. Von Noorden GK. Atlas of strabismus. 4th ed. St Louis: Mos- Class Lesson Plans by; 1983:xiv, 223 Appendix II, lists the specific areas to be covered during the di- 3. Von Noorden GK, Campos EC. Binocular vision and ocular dactic portions of the course. It is taken from the recent AACO motility: theory and management of strabismus. 6th ed. St. modification of the American Orthoptic Council's Orthoptic Syl- Louis, Mo.: Mosby, 2002; xvi: 653 labus and is the guide used for the two-year programs in the 4. Calhoun JH, Nelson LB, Harley RD. Atlas of pediatric oph- United States and Canada. It is very specific as to the topics to thalmic surgery. Philadelphia: Saunders, 1987; vi: 304 be covered, but it is to be used only as a guideline as to what ma- 5. Cashell GTW, Durran IM, MacLellan AV. Handbook of or- terial is expected to be taught. Appendix II is the basis for the thoptic principles. 4th ed. Edinburgh ; New York: Churchill material covered in the final written and oral examinations for Livingstone, 1980: 168 certification by the American Orthoptic Council. 6. Mein J, Trimble R. Diagnosis and management of ocular mo- tility disorders. 2nd ed. Oxford; Boston; St. Louis: Blackwell Documentation Scientific Publications; Distributors USA Mosby-Year Book, A logbook should be kept to document the number and types of 1991; viii: 413 patients the student has seen/personally examined. 7. Helveston EM, Helveston EM. Surgical management of stra- bismus: an atlas of strabismus surgery. 4th ed. St. Louis: Assessment Mosby-Year Book, 1993; xii: 579 At regular intervals, the student should be examined to deter- 8. Isenberg SJ. The Eye in infancy. 2nd ed. St. Louis: Mosby-Year mine adequate progress. Students should obtain passing marks Book, 1994; xiii: 586 in each phase assessment before beginning the next phase. A 9. Lyle TK, Wybar K. Lyle and Jackson's practical orthoptics in suggested plan would include: the treatment of squint: and other anomalies of binocular 1st Assessment: End of the 1st Phase (6th week) vision. 5 ed. New Delhi: Jaypee Brothers, 1994 2nd Assessment: End of the 2nd Phase (14th week) 10. Vˆeronneau-Troutman S. Prisms in the medical and surgical 3rd Assessment: End of the 3rd Phase (24th week) management of strabismus. St. Louis: Mosby, 1994; xiii: 195

Final Assessment Written: 3 parts Total Marks 3 x 100 = 300 Appendix II Practical/Case/Viva Voce =100 ! TOTAL: 400 Lesson plans for topics to be covered in didactic lectures. (From the AACO modification of the American Orthoptic Syllabus) Paper Distribution Anatomy A program may require written papers to be prepared by the stu- I. Orbit dent. A suggested list of papers and timing within the course is A. Bones and their relationships. shown below: B. Openings. I. Part I C. Contents. A. Paper Heading: Basic Sciences. D. Function. B. Contents: Anatomy of extraocular muscles, physiology of E. Blood supply. extraocular movements, physiology of binocular single F. Nerve supply. vision, convergence and accommodation. G. Common Disorders. 2. Part II 1. Trauma. A. Paper Heading: Basics in Strabismus Management and 2. Inflammation. Orthoptic Practice. 3. Dystopia. 4. Tumor. 5. Orbital apex syndrome.

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II. Eyelids C. Uveal Tract (middle vascular layer of the eye). A. Structure. 1. . 1. Five principle plains of tissue: skin, striated muscle, a. Structure. areolar tissue, fibrous tissue, mucous membrane. b. Function. 2. Lid margins: anterior to posterior, , Zeis c. Blood supplied by major circle of iris. glands, Moll glands, posterior lid margin, lacrimal d. Nerve supply. punctum. e. Common disorders or anomalies: coloboma, nevus, 3. Palpebral fissure. corectopia, iritis, Brushfield spots, Lisch 4. Lid retractors: levator palpebrae superioris, Mueller's nodules, , transillumination defects, syne- muscle, inferior rectus. chiae. B. Function. 2. . C. Blood supply. a. Structure. D. Nerve supply. b. Function. 1. Sensory fibers. c. Blood supply. 2. Motor fibers. d. Nerve supply. E. Common disorders: blepharoptosis, , e. Common disorders: iridocyclitis, abnormalities of ectropion, entropion, chalazion, hordeolum, blepharitis, aqueous outflow. fissure slant, , trichiasis, blepharospasm, 3. . myokymia, dehiscence, Marcus-Gunn jaw winking syn- a. Structure. drome, telecanthus, . b. Function. III. Lacrimal Apparatus c. Blood supply from long posterior ciliary arteries. A. Structure. d. Sensory nerve supply by ciliary nerves. 1. Components. e. Common Disorders: choroidal de- Lacrimal gland, accessory glands in conjunctiva, tachment, choroidal folds, choroidal hemorrhage, pumping action of lids, puncta, canaliculi, lacrimal sac, nevus, tumors, . nasolacrimal duct. D. Lens. 2. Tear structure. 1. Structure. a. Oily layer, outer layer, secreted by meibomian 2. Development and aging. glands, prevents rapid evaporation. 3. Function. b. Aqueous layer: middle layer, secreted by lacrimal 4. Common disorders: cataract, presbyopia/hypoaccom- gland, composes majority of tear film. modation, . c. Inner mucin (mucous) layer: inner layer, closest to E. Vitreous. cornea, secreted by goblet cells of conjunctiva, 1. Structure. smoothes corneal epithelial surface. 2. Vitreous development. B. Function. 3. Function. C. Blood Supply. 4. Common disorders and anomalies: persistent hypo- D. Nerve Supply: sensory fibers, motor fibers. plastic primary vitreous (PHPV), Mittendorf's dot, E. Common disorders: , nasolacrimal duct obstruc- Bergmeister's papilla, posterior vitreous detachment tion, , , congenital alacrima, (PVD), , vitreous hemorrhage, asteroid hyalosis. sicca. F. Retina. IV. Conjunctiva 1. Structure. A. Structure. 2. Function. B. Function. 3. Blood supply. C. Blood supply. 4. Common disorders: of prematurity, dys- D. Nerve supply. chromatopsia, tumor (retinoblastoma), pig- E. Common Disorders: conjunctivitis, cysts, telangiectasias, mentosa, , tear or hole, toxoplasmo- Stevens Johnson syndrome, chemosis. sis or toxocara, age-related , co- V. loboma, central retinal artery occlusion, central retinal A. Cornea. vein occlusion, retinal dystrophy. 1. Structure. G. Sclera 2. Function. 1. Structure. 3. Blood supply. 2. Function, protection, and support. 4. Nerve supply (sensory only). 3. Blood supply. 5. Common disorders: keratoconjunctivitis sicca, kerato- 4. Common disorders: , , nevus, der- conus, microcornea, corneal dystrophies, congenital moid. corneal defects, buphthalmos, Haab's striae, corneal VI. abrasion/scar, , neovascularization. A. Nerve fibers. B. Anterior Chamber and Angle. 1. Composed of one million ganglion cell axons. 1. Structure. 2. Four segments: 2. Function. a. Intraocular (). 3. Common disorders: glaucoma, , b. Intracanalicular. , , hypotony.

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c. Intraorbital. Sensory Physiology and Pathology d. Intracraneal. I. Physiology of Normal Binocular Vision 3. Glial cells. A. Objective and subjective visual space. a. Astrocytes. B. Lines of direction and visual directions. b. Oligodendrocytes. 1. Visual direction. B. Support Structures (Meninges). 2. Principle visual direction. 1. Pia mater. 3. Secondary visual direction. 2. Arachnoid mater. C. Corresponding retinal points. 3. Dura mater. D. Horopter. C. Blood Supply. E. Panum's fusion area. 1. Central retinal artery. F. Fusion. 2. Short posterior ciliary arteries. 1. Sensory fusion. 3. Ophthalmic artery. 2. Motor fusion. D. Common disorders: apasia/dysplasia, hypoplasia and de- G. Depth perception. Morsiers syndrome, coloboma, optic atrophy, papillede- H. Retinal rivalry. ma, pseudopapilledema, tilted disc, drusen, / II. Abnormalities of Binocular Vision papillitis, myelination of nerve fibers. A. Diplopia. VII. Extraocular Muscle B. Confusion. A. Characteristics of striated muscle. C. Suppression. B. Extraocular muscle differs from other striated skeletal D. Amblyopia. muscle. E. Anomalous retinal correspondence. 1. Anatomic differences. 2. Physiological differences. Motor Physiology C. Extraocular muscle types. I. Basic Principles 1. Rectus muscle. A. Functional geometry and geometric optics of the eye. 2. Oblique muscle. 1. Major axes and angles. D. Fascia. 2. Nodal points of the eye. 1. Tenon's capsule. 3. Radius of curvature. 2. Ligaments. 4. Midsagittal plane. 3. Intermuscular septum. B. Kinematics of Ocular Rotations. 1. Types of movements. Neuroanatomy 2. Center of rotation of the globe. I. 3. Fick's axes. A. Cerebrum. 4. Degrees of freedom of motion of the globe. B. Vascular system. C. Physiology of muscle contraction. C. Ventricles. 1. Fibers. D. Meninges. a. Number of fibers/muscle. E. Cerebellum. b. Fiber size. F. Brain stem. c. Fiber types. G. Medial longitudinal fasciculus (MLF). d. Histochemistry. II. Spinal Cord e. Location of fibers. A. Located in the vertebral canal of the spinal column. 2. Innervation types. B. Functions. 3. Muscle force. III. Pathway of the Cranial Nerves D. Extraocular muscle action. Optic nerve, oculomotor nerve, trochlear nerve, abducens II. Eye Movements nerve, trigeminal nerve, facial nerve, acoustic nerve. A. Simple Eye Movements. IV. Visual Pathway 1. Monocular (ductions). V. Autonomic Nervous System 2. Sherrington's Law. A. Sympathetic. 3. Terminology. B. Parasympathetic. a. Agonist. C. Path of light reflex. b. Antagonist. D. Dilator pathway. c. Synergist. E. Path of the accommodation reflex. B. Complex Eye Movements. F. Clinical conditions: Argyll-Robertson , Marcus- 1. Binocular (versions). Gunn , Horner's syndrome, Adie's pupil, aberrant 2. Hering's law. regeneration of III cranial nerve, complete III cranial 3. Terminology. nerve palsy, internal ophthalmoplegia. 4. Purpose of complex eye movements. 5. Types. a. Movements that stabilize gaze: vestibular, optoki- netic, fixation maintenance. b. Movements that shift gaze to put an image onto the fovea: saccades, pursuit, vergence.

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Functional Classification of Eye Movements VI. Important Pharmacologic Agents and their Characteristics Movement Main Function A. Parasympathetic agonists. Visual Fixation Holds the image of a stationary object on 1. Direct-acting. the fovea when the head is stationary 2. Indirect-acting. Vestibular Holds images steady on the retina during B. Parasympathetic antagonists (parasympatholytics). brief head rotations C. Sympathetic agonists. Optokinetic Holds images steady on the retina during D. Sympathetic antagonists (beta-blockers). sustained head rotation E. Carbonic anhydrase inhibitors. Smooth Pursuit Holds image of the moving target on the F. Prostaglandin analogs. fovea G. Osmotics. Saccades Brings images of objects of interest onto H. Corticosteroids. the fovea I. Anesthetics. Vergence Moves eyes in opposite directions so that J. Biological dyes: fluoroscein, rose bengal. images are placed simultaneously on VII. Pharmacologic Tests for Pupillary Syndromes: Adie's both foveas syndrome, Horner's syndrome III. Supranuclear Control Systems for Eye Movements VIII. Use of Pharmacologic Agents in the Treatment and A. The vestibular and optokinetic systems (non-optic eye Diagnosis of Strabismus movements). Cholinesterase inhibitors, botulinum toxin, Tensilon, neos- B. Smooth pursuit. tigmine, Mestinon. C. Saccadic eye movements. IX. Pharmacology Supplement D. Vergence eye movements. A. Anti-metabolytes used in glaucoma filtering proce- E. Fixation maintenance. dures: 5-fluorouracil, mitomycin-C. IV. Principles of Clinical Examination of Eye Movements B. Pharmacologic adjuncts to retinal surgery: intravitreal A. Basic features of all eye movements: latency, velocity, gasses, C3F8 & SF6, silicone oil. accuracy. C. Perfluorocarbon heavy liquid. B. Measurement and recording techniques. D. Pharmacologic treatment of ocular allergies: NSAIDs, 1. Measure position and velocity (in order of accuracy). decongestants, antihistamines, mast cell stabilizers. 2. Measuring neural sign. E. Treatment of ocular manifestations of AIDS. C. Clinical examination of VOR-OKN function. F. Treatment for CMV retinitis: Foscarnet, Gancyclovir, D. Clinical examination of pursuit: technique, initiation antibiotics, antifungals, antivirals. (latency), gain (accuracy), symmetry. E. Clinical examination of saccades: velocity, latency, Ophthalmic Optics accuracy, localization of defect. I. Physical Optics F. Clinical examination of vergence. A. Light. 1. Tools: prism bar, rotary prism, loose prisms, amblyo- B. Electromagnetic spectrum. scope. II. Reflection 2. Blur, break, and recovery point. III. Absorption vs. Transmission 3. Absolute vs. relative vergence. IV. Refraction of Light Rays G. Clinical examination of fixation. V. Lenses: Calculations VI. Mirrors Pharmacology VII. Telescopes I. Pharmacologic Nomenclature VIII. Vertex Distance II. Terminology IX. Determination of Ophthalmic Lens Power A. Functional terms. X. The Eye as an Optical System B. Pharmacologic characteristics. A. Refractive components of the eye. 1. Tonicity. B. Axial length. 2. Buffers. C. Nodal point of the eye. 3. pH. D. Refractive states. 4. Stability shelf life. XI. Accommodation 5. Solution, suspension, or ointment. A. Mechanism. III. History Taking B. Range and amplitude. IV. Routes of Administration C. Presbyopia. A. Topical. XII. Contact Lenses B. Systemic administration. A. Relevant corneal anatomy and physiology. V. Autonomic Nervous System B. Instruments used in contact lens evaluation and fitting. A. Pathways and ocular innervation. C. Lens characteristics. 1. Parasympathetic. 1. Rigid lenses. 2. Sympathetic. 2. Soft lenses. B. Neurotransmitters. 3. Contact lens parameters. 1. Acetylcholine. 2. Norepinephrine.

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Vision Testing D. Set referral criteria for target group. I. Terminology and Principles of Subjective Tests 1. Vision. A. Minimum separable. 2. Alignment. B. Minimum resolvable. E. Identify other causes for referral. C. Minimum visible. 1. Red, watery eyes. D. Numerator and denominator for visual acuity. 2. Ptosis. E. Crowding phenomenon. 3. . F. Type of occlusion. 4. Nystagmus. G. Pinhole effect. 5. Compensatory head posture. H. Presentation of chart. I. Principles of neutral density filter. Sensory and Motor Testing J. Tests in the presence of nystagmus. I. Sensory Testing II. Objective Tests A. Vision testing. A. Importance of history. B. Visual field testing. 1. Observation. C. Assessment of fusion. 2. Fixation tests. II. Motor Testing 3. Cross fixation. A. Identify and define. 4. Fixation switch at midline. 1. Orthophoria. B. Light reaction. 2. . C. Vision function testing. B. Basic deviation. 1. Handling beads. C. Explain and demonstrate: 2. Forced choice preferential looking (FPL). 1. Cover tests with and without prism. 3. Optokinetic nystagmus. 2. Corneal light reflex tests. 4. Visually evoked potential/response (VEP/ER). 3. Dissimilar (one target) tests. 5. Electroretinogram. 4. Dissimilar (two target) tests. III. Tests of Malingering D. Identify pseudostrabismus. A. Optical (lens tricks). E. Identify and measure angle kappa (positive and negative). B. Vectograph. F. Evaluation of ocular motility including: C. Synoptophore. 1. Positions of gaze. D. Duochrome. 2. Measurement of deviation in all positions of gaze. E. Stereoacuity. 3. A and V patterns. F. Optokinetic devices. 4. Near vs. distance deviation. G. Teller cards. a. Classification. IV. Vision Screening b. Calculation of AC/A ratio. Part 1: Screening Fundamentals. 5. Near point of convergence. Part 2: Designing and Implementing a Screening Program. 6. Three-step test. A. Identify a target group of patients. 7. Evaluation of ocular excursions. B. Describe benefits and drawbacks of program targeted to: 8. Clinical evaluation of eye movement systems: saccades, 1. School-age population. pursuit, vergence, optokinetic nystagmus (OKN), 2. 4±5 year old Well-Child Program. vestibulo-ocular reflex (VOR). 3. 2±4 year old Well-Child Program. G. Describe ancillary tests: 4. Infant program. 1. Forced duction testing. A. Identify facility for screening to take place. 2. Active forced generation testing. B. Develop forms. 3. Saccadic velocity testing. 1. Screening forms. 4. Electromyography. 2. Referral forms. 5 Tensilon/prostigmin testing. 3. Follow up forms for parents/guardians. 6. Differential intraocular pressure. A. Educate screeners. 1. Pediatricians. Esodeviations 2. Family practitioners. I. Congenital (Infantile, Essential) 3. Nurses. A. Classic type. 4. School districts. B. Early onset with accommodative component. 5. Service groups. C. Nystagmus blockage syndrome (or nystagmus compensa- B. Establish screening technique for visual acuity testing. tion syndrome). 1. Select appropriate screening method per age group. D. Ciancia syndrome. C. Establish screening technique for ocular alignment test- E. Duane's syndrome. ing. F. Abducens palsy. 1. Select appropriate screening method for age group. G. Möbius syndrome. a. Sensory. II. Acquired Esodeviations b. Motor. A. Accommodative . Types:

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a. Refractive (aka: refractive accommodative or fully 4. Y pattern. accommodative). 5. ­ pattern. b. High AC/A ET (aka: nonrefractive accommodative). II. Prevalence c. Mixed mechanism ET (aka: partially accommodative). ~ 25% of total horizontal strabismus, V-ET is most common, B. Non-accommodative esotropia. A-XT is least common. 1. Basic esotropia. III. Examination 2. Non-accommodative convergence exceso. A. Measure at distance. If must be done at near, control 3. Acute comitant esotropia. accommodation to avoid misdiagnosing V-pattern. 4. Cyclic esotropia. B. Chin down ~ 258 for up-gaze, and chin up ~ 258 for 5. Idiopathic. down-gaze. 6. Decompensated accommodative esotropia. C. Note presence of compensatory head posture. C. Sensory esotropia. IV. Etiology D. Divergence insufficiency. A. Horizontal rectus school of thought: E. Divergence paralysis. 1. Medial rectus is believed to cause increased conver- F. Spasm of the near reflex. gence in down-gaze. G. Medial rectus restriction. 2. Lateral rectus is believed to cause increased divergence H. Lateral rectus weakness. in up-gaze. I. Surgical esodeviation (consecutive). B. Oblique dysfunction: Tertiary action of the obliques is III. Pseudo-esotropia abduction. IV. C. Vertical rectus: The tertiary function of the vertical recti is V. Microtropia adduction. D. Sensory torsion: Poor fusion causes globe to move to a Exodeviations position of rest over time. I. Etiology E. Structural causes (craniofacial anomalies). A. Unknown. B. Innervational abnormalities. Vertical Deviations C. Hereditary. I. Superior Oblique Palsy D. Monocular vision loss. A. Characteristics: II. Classification 1. of affected eye. A. By distance-near relationship. 2. Abnormal head posture is common. 1. Basic exodeviation. 3. Excyclotropia. 2. Divergence excess. 4. May be bilateral. 3. Convergence insufficiency. 5. Positive Bielschowsky head tilt test. B. By fusional status. 6. V-pattern in bilateral cases. 1. Phoria. 7. Diplopia when acquired. 2. Intermittent tropia. II. Inferior Oblique Palsy 3. Tropia. A. Characteristics: C. By age of onset. 1. Onset may not be well documented. 1. Congenital (infantile). 2. A-pattern. 2. Acquired. 3. Ipsilateral superior oblique overaction. III. Clinical Types 4. Negative forced ductions. A. Pseudoexotropia. 5. May have compensatory head posture. B. . 6. May have incyclotropia. C. Intermittent . III. Inferior Rectus Paresis D. Exotropia. A. Etiology: E. Congenital exotropia. 1. Trauma to the III nerve of inferior rectus muscle. F. Sensory exotropia. 2. Myasthenia gravis may mimic. G. Consecutive exotropia (aka: secondary exotropia). B. Characteristics: H. Supranuclear exotropia. 1. Hypertropia of involved eye in primary position I. Convergence insufficiency syndrome. (unless associated with trauma and entrapment). J. Third nerve palsy. 2. Deviation increases with involved eye in abduction. K. Duane's syndrome Type II. IV. Inferior Oblique Overaction A. Characteristics: Vertically Incomitant Horizontal Strabismus 1. Elevation of the eye in adduction. I. Definition 2. V-pattern may be present. A. A-pattern. 3. May be bilateral, symmetric, or asymmetric. B. V-pattern. 4. May be primary, or secondary to superior oblique C. Others: (SO) palsy. 1. l (lambda). 5. Common finding associated with childhood-onset 2. à (diamond). horizontal strabismus. 3. X pattern.

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V. Superior Oblique Overaction 2. Acquired. B. Characteristics: a. Paralysis of volitional saccades and pursuit in all 1. Hypotropia of the involved eye, worse in adduction. directions. 2. A-pattern may be present. b. OKN is absent. 3. May be primary or secondary to inferior oblique (IO) c. Vestibular nystagmus is normal. palsy. d. Normal random and visually evoked saccades but 4. Relatively common finding in childhood-onset inability to move eyes on command. horizontal strabismus. C. Cerebellar disorders. 5. May be associated with skew deviation. 1. Cogwheel (saccadic) pursuit. 6. May be associated with neurological deficits in 2. Hypometric saccades with reduced velocity. young children. 3. Gaze palsy with eyes tonically deviated in the direction VI. Brown Syndrome opposite to the lesion. A. Limitation of elevation. 4. Skew deviation. B. Characteristics: 5. Inability to maintain upward gaze. 1. Grossly symmetrical limitation of elevation across D. Vertical gaze disorders. superior fields. 1. Dorsal syndrome. 2. May be associated with chin-up posture. a. aka: Parinaud's syndrome or Sylvian aqueduct 3. Ptosis or pseudo-ptosis may be present. syndrome. C. Types: b. Pupils show light-near dissociation. 1. Restriction of the IR. c. Collier's sign (lid retraction). 2. Monocular elevation deficiency (aka: double elevator d. Lid lag. palsy). e. Paralysis of vertical gaze. VIII. Orbital Floor Fracture f. Bell's phenomenon and vestibule-ocular responses IX. Thyroid Ophthalmopathy may become paralyzed. X. Dissociated Vertical Deviation g. Attempts at upward saccades evoke convergence- A. Characteristics: retraction nystagmus. 1. Updrift of eye under cover, or spontaneously during h. Pinealomas and midbrain infarction are most periods of visual inattentiveness. common etiologies. 2. Dissociated eye may also extort and abduct. 2. Down-gaze palsy. 3. May be latent, intermittent, or manifest. a. Rare. 4. No associated hypotropia of the fellow eye. b. Lesion dorsal and medial to the red nuclei. 5. Associated with latent nystagmus. c. Associated with progressive supranuclear palsy. 6. Associated with horizontal infantile strabismus. 3. Pontine lesions. 7. Usually bilateral, but may be monocular or asym- a. Up-gaze palsy. metric. b. Persistence of gaze-evoked nystagmus. 8. May be superimposed on a true vertical deviation. E. Vergence disorders. 9. May mimic IO overaction. 1. Spasm of the near reflex. 10. Diplopia very rare. a. Usually encountered in conversion hysteria patients. 11. Associated with poor binocular vision. b. Apparent unilateral or bilateral VI nerve paresis. XI. Vertical Skew Deviation c. Pupillary . d. May be associated with generalized seizures. Paretic Strabismus e. May result from head injury. I. Supranuclear Disorders f. Associated with Arnold-Chiari malformations. A. Gaze palsy. 2. Convergence paralysis. 1. Cerebrovascular accidents result in contralateral gaze a. Exotropia at near. palsy. b. Diplopia. 2. Roth-Bielschowsky syndrome. c. May be organic or functional. 3. Unilateral midbrain. 3. Divergence paralysis. a. Loss of saccades and pursuit in opposite direction. II. Internuclear Disorders b. Contralateral gaze palsy. A. Lesions of the paramedian pontine reticular formation. c. Ipsilateral internuclear ophthalmolplegia and/or III 1. Ipsilateral gaze palsy. nerve palsy. a. If defect is located in upper , then vestibulo- d. Skew deviation. ocular movements are intact. 4. Progressive supranuclear palsy. b. If defect is at the level of the abducens nuclei, then 5. Parkinson's disease. vestibulo-ocular movements are abnormal. B. Ocular motor apraxia. B. Lesions of the medial longitudinal fasciculus. 1. Congenital. 1. Results in internuclear ophthalmoplegia (INO). a. Absence of saccadic refixations and smooth pursuit. a. Lesion is found between the III and VI nerve nuclei. b. Preservation of vertical eye movements. b. Absent adduction on ipsilateral side. c. Absence of fast phase during OKN or caloric stimu- c. Nystagmus, with fast phase directed into abduction lation. on attempted abduction of the contralateral eye. d. Head thrusts to accomplish refixations.

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d. Convergence may be absent if lesion is close to III d. Metastatic tumor. nerve. e. Fascicular lesions. e. Subtle INO may be revealed with OKN testing, f. Benedikt's syndrome. saccadic velocity testing, or ocular . g. Weber's syndrome. 2. Etiology. h. Interpeduncular lesions. a. If unilateral, may be vascular. i. Aneurysm. b. If bilateral, may be . j. Trauma. C. Combination parapontine reticular formation with medial k. Meningitis. longitudinal fasciculus lesions. l. Cavernous sinus lesions. 1. One-and-a-half syndrome (Fisher's syndrome). m. Orbital lesions. a. Brain stem vascular disease. n. Diabetic ophthalmoplegia. b. Produces contralateral INO and ipsilateral horizon- o. Guillain-BarrØ/Fisher syndrome. tal gaze palsy. p. Ophthalmoplegic migraine. III. Intranuclear Disorders q. Cyclic III nerve palsy/spasm. A. Abducens (VI nerve) palsy. r. Aberrant oculomotor regeneration. 1. Etiology. 2. Characteristics. a. Increased intracranial pressure. a. Ptosis. b. Head trauma. b. Dilation of pupil. c. Vascular hypertension. c. Limitation of adduction, elevation, and depression. d. Diabetes. d. Exotropia and hypotropia in primary position. e. Post infection. e. Accommodation weakness. f. Pontine syndromes (infarction, demyelinating D. Myasthenia Gravis. disease, tumor). E. Dysthyroid myopathy. g. Cerebellopontine angle lesions (acoustic neuroma), F. Myotonic dystrophy. clivus lesions. (nasopharyngeal carcinoma, clivus chordoma). Special Forms of Strabismus h. Middle fossa disorders (tumor, inflammation). I. Brown Syndrome i. Cavernous sinus or superior orbital fissure disorders A. Etiology. (tumor, aneurysm, inflammation). 1. Congenital. j. Carotid-cavernous or dural arteriovenous fistula. 2. Traumatic. k. Lumbar puncture or spinal anesthesia. 3. Inflammatory. l. Syphilis. 4. Iatrogenic. B. Trochlear (IV nerve) palsy. B. Characteristics. 1. Etiology. 1. Limitation of elevation in adduction. a. Traumatic. 2 Limitation does not improve on ductions. b. Vascular. 3. Forced ductions are positive. c. Diabetes. 4. Normal or near normal elevation in abduction. d. Posterior fossa tumor. 5. Often Y-pattern XT. e. Cavernous sinus or superior orbital fissure syn- 6. Often no strabismus in primary position. dromes. 7. No superior oblique overaction. f. Neurosurgical procedure. 8. May have widening of lid fissure on adduction. g. Herpes zoster. 9. May have head posture. h. Idiopathic/congenital. C. Differential diagnosis. 2. Characteristics. 1. Orbital floor fracture. a. Hypertropia of involved eye. 2. Endocrine myopathy. b. Excyclotropia of involved eye. 3. Double elevator palsy. c. V-pattern. 4. IO paresis. d. Positive Bielschowsky head tilt test. 5. III nerve paresis with aberrant regeneration. e. Compensatory head posture. II. f. Knapp's classification. A. Etiology. g. Assume bilateral until proven otherwise. 1. Congenital. 3. Diagnostic Testing. 2. Miswiring of lateral rectus muscle with branches from a. Versions. the medial rectus subnucleus. b. Three-step test. 3. Autopsy cases confirmed absence of VI nerve nucleus. c. Double Maddox rod test. B. Classification. d. Diplopia fields. 1. Type I. e. Objective (fundus) torsion. 2. Type II. C. Oculomotor (III nerve) palsy. 3. Type III. 1. Etiology. III. Vertical Retraction Syndrome a. Nuclear lesions. A. Characteristics. b. Infarctions. 1. Limitation of depression and/or elevation. c. Demyelination. 2. Globe retraction on vertical movement.

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3. May be bilateral. VIII. Congenital Defects and Disorders 4. May be ET, XT, or orthotropic. A. Craniofacial dystoses. 5. A and V patterns are common. 1. Apert's syndrome. IV. Möbius Syndrome 2. Crouzon syndrome. A. Characteristics. B. Craniosynostoses (premature closure of the bony 1. VI, VII, and IX nerve pareses with sparing of the lower sutures of the skull). facial muscles. 1. Plagiocephaly (uni-coronal synostosis). 2. May also involve XII nerve. 2. Trigonocephaly. 3. Aplasia of the involved brain stem nuclei. C. Fetal alcohol syndrome. 4. Absence of horizontal gaze. 5. Associated congenital malformations. Nystagmus 6. Difficulty with speech and facial expression; history of I. Terminology sucking difficulty at birth. A. Definition: rhythmic, involuntary oscillation of the eyes. 7. Atrophy of terminal third of tongue. B. Alexander's Law: jerk nystagmus is accentuated in am- 8. Often orthotropic in primary gaze. plitude on gaze toward the direction of the fast phase. V. Congenital Fibrosis C. Wave form. A. Characteristics. 1. Jerk: anomalous slow phase away from fixation 1. Usually familial (autosomal dominant). followed by fast, refixation saccades. 2. May affect only one muscle, or several, with severe 2. Pendular: sinusoidal oscillations with no fast phase. limitation of ductions. 3. Amplitude: magnitude of slow phase drift. 3. Globes are often fixed into down-gaze. 4. Frequency: number of oscillations per unit measure 4. Marked ptosis OU. of time. 5. Chin elevation. 5. Intensity: amplitude x frequency. 6. Exotropia common. a. Course: larger amplitude, low or moderate 7. Anomalous convergence movements on attempted frequency. up-gaze or lateral-gaze. b. Fine: small amplitude, high frequency. 8. Amblyopia common. 6. Foveation: time spent with the target on the fovea. VI. Strabismus Fixus a. Foveation saccades: fast eye movements intended A. Characteristics. to break the oscillation cycle and increase fovea- 1. One or both eyes anchored in extreme adduction or tion time. abduction. D. Null zone: gaze where the nystagmus intensity is mini- 2. Positive forced ductions. mal. 3. Usually caused by fibrosis of the muscles. E. Symptoms. VII. Orbital Floor Fracture 1. : illusory movement of the environment. A. Etiology. 2. Vertigo: dizziness. 1. Blunt force trauma to the orbit. II. Nystagmus in Infancy and Childhood B. Characteristics. A. Congenital nystagmus. 1. (occasionally proptosis). B. Latent (LN)/manifest latent nystagmus (MLN). 2. Chemosis. C. Nystagmus blockage syndrome. 3. Periorbital hematoma. D. Acquired nystagmus (in children). 4. Persistent hypesthesia of the infraorbital area. 1. Sensory nystagmus. 5. Entrapment of the IR muscle, the IO muscle, and/or 2. Spasmus nutans. orbital contents. III. Pendular 6. Hypotropia in primary position, increasing in up- A. Acquired pendular (aka: ocular myoclonus). gaze. B. Miner's nystagmus. 7. May have IR damage and secondary IR paresis. C. Convergence-evoked nystagmus. 8. Medial wall fracture may result in entrapment of D. See-saw nystagmus. medial rectus. E. Dissociated pendular. VIII. Myasthenia Gravis IV. Jerk A. Vestibular. Systemic Disease with Ocular Motor Involvement B. Gaze-evoked. I. Endocrine Ophthalmopathy 1. Physiologic (end point). A. Types 2. Gaze paretic. 1. Thyrotoxic disease (aka: Graves' disease). 3. Muscle paretic. 2. Thyrotropic disease = (ocular signs). 4. Internuclear ophthalmolplegia. II. Myasthenia Gravis 5. Rebound. III. Multiple Sclerosis C. Physiologic. IV. Chronic Progressive External Ophthalmoplegia (CPEO) 1. Optokinetic. V. Diabetes 2. Caloric. VI. Sylvian-Aqueduct Syndrome (aka: Parinaud's syndrome) D. Toxic. VII. Ischemia

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E. Pathologic primary position nystagmus: II. Goals 1. Down-beat. A. Alignment within 8? of orthotropia in primary position. 2. Up-beat. B. Wide field of single binocular vision, including primary 3. Periodic alternating nystagmus (PAN). position and down-gaze. V. Nystagmus Masquerades C. Full range of ocular rotations. (Non-nystagmoid oscillations and saccadic intrusions that D. Comitant deviation. may reflect cerebellar disease) III. Techniques A. Bobbing. A. Weakening procedures. B. Convergence-retraction. 1. Recession. C. Dysmetria. 2. Tenotomy/myotomy. D. Flutter. 3. Tenectomy/myectomy. E. Myoclonus. 4. Muscle disinsertion. F. Opsoclonus. 5. Z tenotomy. G. Superior oblique myokymia. 6. Posterior fixation suture. H. Square wave jerks. 7. Botulinum toxin injection. VI. Examination 8. Silicone expander. A. Visual acuity. 9. Denervation/extirpation. B. Ocular alignment. B. Strengthening procedures. C. Anterior segment. 1. Resection. D. Pupils. 2. Advancement. E. Fundus. 3. Tuck. F. Refraction. 4. Foster suture. G. Electrophysiology. C. Transposition procedures. VII. Treatment 1. Jensen procedure. A. Neurologic work-up, if appropriate. 2. Hummelscheim procedure. B. Correction of significant refractive era. 3. Knapp procedure. C. Amblyopia. 4. Harada-Ito procedure. D. Head posture. 5. Vertical displacement of the horizontal recti for pattern E. Low vision aids. strabismus. F. Surgery. 6. Inferior Oblique anteriorization. D. Adjustable sutures. Non-Surgical Treatment E. Recession of conjunctiva or Tenon's capsule. I. Antisuppression F. Traction sutures. A. Diplopia awareness. IV. Complications B. Antisuppression. A. Intraoperative. 1. Patching. 1. Hemorrhage. 2. Amblyoscope (no longer used for this purpose). 2. Lost muscle. 3. Binocular trainer. 3. Scleral perforation. 4. Cheiroscope. 4. Pulled In Two Syndrome (PITS). 5. Physiologic diplopia exercises. B. Postoperative. a. Two-pencil test. 1. Infection. b. Framing. 2. Suture reaction. c. Diploscope. 3. Granuloma d. Bar reading v. stereograms. 4. Conjunctival cyst. II. Stabilization of Fusion 5. Corneal dellen. A. Near point of convergence. 6. Anterior segment ischemia. B. Convergence amplitudes. 7. Muscle slippage. C. Divergence amplitudes. 8. Restriction secondary to scarring. III. Prism therapy 9. Adhesion syndrome. A. Prism adaptation. 10. Over-or-under correction. B. Treatment with prisms. References Principles of Strabismus Surgery 1. Orthoptic curriculum, Aravind Eye Hospitals, Madurai, Tamal I. Indications Nadu, India A. Misalignment of the visual axes. 2. Edelman PM, American Orthoptic Council. Syllabus Commit- B. Diplopia. tee., American Academy of Ophthalmology. Allied Health C. Disfiguring head posture due to incomitance. Education Committee. Orthoptics: a syllabus of ocular moti- D. Poor cosmetic appearance. lity. 2nd ed. San Francisco, Calif.: American Academy of Oph- E. Limitation of the binocular peripheral visual field. thalmology; 1992:xv, 107 F. Discomfort on ocular rotations (due to contracture or adhesions).

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VI. Curriculum for Ophthalmic Technicians Module II: Pharmacology/Eye Disease II ! Credit Hours: 2 Ophthalmic Medical Personnel (OMP) play an important role in I. Course Description the professional ophthalmology eye care team. Ophthalmic Continuation of Pharmacology/Eye Disease I. (See Course medical personnel possess knowledge and skills attained by di- Description Pharmacology/Eye Disease I.). dactic and clinical ophthalmic educational training. Formal II. Course Content, Competencies and Skills training institutional programs are available in colleges, univer- A. Introduction to Medications. sities, and special educational institutions in many parts of the 1. Define and pronounce vocabulary terms. 2. List and world. In addition, training can be an informal, on-the-job ex- briefly describe the uses, sources, names, classifications, perience, with the support of the ophthalmologist employer of and types of drugs. 3. Interpret abbreviations and com- the OMP and the completion of an approved independent study monly used symbols. course. In North America, training programs for Ophthalmic B. Ophthalmic Drug Identification. Medical Technicians (OMT) usually last two years. However, 1. Describe proper technique for instillation of topical countries that choose to use the modules presented here are at ophthalmic drops and ointment. 2. List advantages and liberty to adjust the period of training to suit their local needs. disadvantages of methods of drug delivery including A well-trained OMT can be a tremendous help to any ophthal- drops, ointments, sustained release medications, injec- mologist and many of the tasks that ophthalmologists do in their tions, and systemic medications. 3. Explain the technique busy practice can be delegated to the OMT. and rationale of punctal occlusion. 4. Differentiate be- The curriculum for training ophthalmic technicians presented tween mydriatic and cycloplegic medications. 5. Describe here is adapted from the course content and outcome guide of four different types of glaucoma medications with an the Portland Community College in Portland, Oregon, USA. It is example of each type. 6. List types, strengths, actions, copyrighted by the college, and is supplied courtesy of Joanne contraindications, and complications of anesthetics, M. Harris, COT, Program Director, Ophthalmic Medical Technolo- mydriatics and cycloplegics, epinephrine, beta-blockers, gy, Portland Community College. miotics, steroids, antibiotics, carbonic anhydrase inhibi- The following is an overview of the 24 course modules that com- tors, vasoconstrictors, antihistamines, osmotic agents, and prise the curriculum of the Ophthalmic Medical Technicians pro- nonsteroidal anti-inflammatories. 7. Demonstrate how to gram at Portland Community College. The synopsis of the cour- read the doctor's written prescription. 8. Explain first aid ses offered in the program list the course title, credit hours, techniques for acute ophthalmic drug reactions. hours per week of lecture, and/or laboratory and course dura- tion. A brief course description and course content, competen- cies, and skills are outlined for each course. Module III: Ophthalmic Office Procedures Credit Hours: 3 I. Course Description Module I: Pharmacology/Eye Disease I Credit Hours: 2 Utilization of techniques to obtain medical and ophthalmic I. Course Description history, transcription of information into the medical chart, Designed to teach students the commonly administered and common terms and abbreviations used in history taking. ophthalmic drugs, appropriate uses, effects, dangers, and Covers front office techniques, including basic functions of a precautions as well as routes of administration and the legal computer in the medical office. Develops skills needed to records and ethical standards necessary for the physician. obtain accurate patient visual acuity. This is a study of major diseases of the eye and related II. Course Content, Competencies and Skills structures integrated with symptomatology and treatment. A. Ophthalmic Equipment/Instruments. II. Course Content, Competencies and Skills 1. Identify and explain the use of common ophthalmic Eye Disease. equipment. 2. Perform proper cleaning and routine main- 1. Describe four common refractive errors. 2. Define infection tenance of ophthalmic equipment. 3. Check calibration of and inflammation. 3. List two classifications of inflammation instruments such as keratometer and lensometer. 4. De- and the ocular manifestation. 4. List possible causes of a red scribe how to implement proper in-office maintenance eye. 5. List different types of conjunctivitis. 6. Describe the and repair. 5. Safely change bulbs and fuses on ophthalmic two common forms of uveitis. 7. Discuss the signs and symp- equipment. toms of Graves' disease. 8. Define thrombus, embolus, clot, B. Medical/Ophthalmic History. aneurysm, ischemia, infarct, arteriosclerosis, myocardial 1. Describe how to take a complete medical and ophthal- infarct, cerebrovascular accident, and neovascularization. mic history. 2. Describe how to provide accurate historical 9. List four ocular disorders caused by diabetes. 10. List com- documentation. 3. Describe how to succinctly and effi- mon disorders of the cornea.11. Discuss the causes, prognosis, ciently transcribe obtained information into the patient and treatment of corneal abrasions. 12. Define cataract and chart. 4. Identify the difference between new and estab- list the various types and causes. 13. Describe the difference lished patients as they relate to documentation. 5. Define between primary open angle glaucoma and closed angle ªChief Complaintº and its importance in the medical re- glaucoma. 14. Describe the process which causes retinal cord. 6. Detail the components of a personal, family, and detachment. 15. List the primary causes of blindness in your social history. country and worldwide. 16. State the primary function of the C. Appointment Scheduling/Telephone Technique. immune system and the effect of the AIDS virus on the eyes. 1. Incrementally scheduling patient appointments to enable physician's office schedule to run smoothly. 2. Appointment triaging to determine when a request for

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an appointment should be considered as an emergency. rior chamber depth using both penlight and slit lamp 3. State the reason for recording failed appointments on screening methods. 2. List the estimation grading scale. the patient's chart. 4. Discuss the handling of cancellations D. Keratometry. and delays brought about by office situations. 5. List and 1. Discuss the technique for measuring the corneal curva- explain the basic guidelines to follow in scheduling ap- ture. 2. Define corneal astigmatism. 3. Define ªwith-the- pointments. 6. Demonstrate the appropriate method of ruleº and ªagainst-the-ruleº astigmatism. 4. Demonstrate placing and receiving phone calls. 7. Identify the kinds of measurement of corneal curvature using the keratometer. calls that need to be referred to the physician for response. E. Advanced History Taking. D. Medical Records Management. 1. List visual tests anticipated for tentative diagnoses such 1. State three important reasons for keeping good medical as cataract, open angle glaucoma, esotropia, migraine, etc. records. 2. Illustrate the meaning of subjective and objec- F. Basic Tonometry. tive information in a medical history. 3. Explain the basic 1. Discuss the principles and differences between appla- differences between traditional and problem-oriented nation and indentation tonometry, and the advantages medical records. 4. List the items of personal data needed and disadvantages of each. 2. Discuss possible errors in in a patient medical record. 5. Discuss changing an entry tonometry testing. 3. Discuss proper methods of cleaning in the medical record and the importance of following and disinfecting tonometers. 4. Discuss technique for each correct procedure. method of tonometry. 5. Discuss the methods of assessing E. Visual Acuity. scleral rigidity. 6. Name factors altering intraocular pres- 1. Compare methods of measuring visual acuity in children sure. 7. Demonstrate non-contact tonometry and Schiotz and adults. 2. Explain methods of near vision testing. 3. tonometry. Describe the various methods of expressing vision testing G. Assisting the Patient. for distance and near acuities. 4. Discuss methods to test 1. Discuss methods for assisting physically and visually illiterate and preschool children. 5. Define accommoda- disabled patients. 2. Discuss methods of assisting the tion. Explain how it is measured and how it affects visual physician with children. acuity testing. 6. Give indications and procedure for uti- H. Retinoscopy/Refractometry Theory. lizing the Potential Acuity Meter. 1. Discuss the principles and techniques of retinoscopy. F. Vital Sign Measurement. 2. Describe the steps in refractometry, including use of 1. List the four components of measuring vital signs. fogging, astigmatic dials, cross cylinder, duochrome tests, 2. Demonstrate proper measurement of pulse rate, and tests of accommodation. respiration rate, body temperature, and blood pressure. I. Ocular Mobility. 3. List the normal rate of pulse, respiration, body tem- 1. Demonstrate motility screening tests including cover/ perature, and the normal values of blood pressure. uncover and alternate cover tests. 2. Demonstrate phoria and tropia. 3. Demonstrate Krimsky and Hirschberg esti- mation. 4. Demonstrate use of the Maddox rod, Worth Module IV: Introduction to Clinical four-dot test, red glass, duction, and version testing. 5. Skills Credit Hours: 3 Demonstrate near point of convergence/accommodation. I. Course Description 6. Demonstrate vergence amplitudes. 7. Demonstrate use Covers basic test principles and techniques, including the of the Risley rotary prism. ocular screening exam, visual acuity measurement, slit lamp examination, tear function, and color vision tests. Tonometry, refractometry, and retinoscopy will be reviewed in theory Module V: General Medical Terminology Credit Hours: 3 only. I. Course Description II. Course Content, Competencies and Skills Analyze the structure of medical words and apply to basic A. Lensometry. anatomy, physiology, and disease processes of the human 1. Demonstrate location of the optical center of the lens. body, stressing spelling and pronunciation. 2. Demonstrate measurement of single vision and II. Course Content, Competencies and Skills multifocal spectacles. 3. Demonstrate measurement of A. General Concepts of Medical Terminology. spectacles with prism. 4. Discuss the significance of vertex 1. The goal is to understand a given medical term, give its distance. definition by breaking it into component parts, and iden- B. Introduction to Visual Fields/Amsler Grid. tifying the body system to which it relates. 2. Students 1. Define the limits of the visual field. 2. Discuss the ªisland must also understand body structure. of visionº analogy. 3. Define visual field terminology in- B. Musculoskeletal System. cluding: isopters, threshold, apostilb, decibel. 4. Discuss 1. Understand the basic anatomical structures, terminolo- methods of measuring the visual field. 5. List visual field gy, and functions of the musculoskeletal system. 2. Know screening methods. 6. List manual techniques for testing basic diseases and pathological conditions commonly en- the visual field. 7. List automated methods for testing the countered in this system. visual field. 8. Distinguish the differences between static C. Circulatory System. and kinetic field-testing. 9. Demonstrate Amsler grid, 1. Understand the basic concept of the circulation of blood confrontation fields, and tangent screen visual fields. through the body and its function, and basic pathological CEstimation of Anterior ChamberDepth. disorders of blood and the circulatory system. 1. Demonstrate the technique for estimation of the ante- D. Respiratory System. 1. Understand basic anatomical structures, terminology,

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and functions of the respiratory system. 2. Know the basic C. Visual Acuity. diseases and pathological conditions commonly encount- 1. Identify methods of measuring visual acuity in adults ered in this system. and children. 2. Demonstrate accurate recording of acuity E. Urogenital and Male Reproductive Systems. measurements in the medical record. 3. Demonstrate 1. Understand the basic anatomical structures, terminolo- ability to accurately measure near vision. 4. Define gy, and functions of the genitourinary system. 2. Know the common abbreviations used in recording visual acuity. basic diseases and pathological conditions commonly en- 5. Operate the lensometer accurately and efficiently. countered in this system. F. Female Reproductive System. 1. Understand the basic anatomical structures, terminolo- Module VII: Clinical Optics I Credit Hours: 2 gy, and functions of the female reproductive system. 2. I. Course Description Know the basic diseases and pathological conditions Introduces mathematics used in optical prescriptions, commonly encountered in this system. manufacturing, and dispensing. Basic principles governing G. Digestive System. transmission of light and its interaction with optical media. 1. Understand the basic anatomical structures, terminolo- Includes experimentation to visually inform the student of gy, and functions of the digestive system. 2. Know the ba- the laws of geometric optics. sic diseases and pathological processes commonly en- II. Course Content, Competencies and Skills countered in this system. A. History of Ophthalmics/Medicine. H. Endocrine System. 1. Explain how optical lenses, spectacles, and contact len- 1. Understand the basic anatomical structure, terminology, ses came to be developed and know some of the associated and functions of the endocrine system. 2. Know the basic historical names. 2. Identify the different tasks of opti- diseases and pathological processes commonly encount- cians, optometrists, ophthalmologists, and ophthalmic ered in this system. medical technicians. 3. Distinguish types of medical prac- I. Nervous System. tices such as individual private practice, partnerships, 1. Understand the basic anatomical structure, terminology, group practices, health maintenance organizations, and and functions of the nervous system. 2. Know the basic government programs, as well as ambulatory and out- diseases and pathological processes commonly encount- patient surgical facilities. ered in this system. B. The Specific Knowledge and Tasks of the OMT. J. Sensory System. 1. Define tasks of an ophthalmic medical technician func- 1. Understand the basic anatomical structure, terminology, tioning in an office-based practice or ambulatory surgery and functions of the sensory system. 2. Know the basic center. 2. State the diagnostic tests an ophthalmic medical diseases and pathological processes commonly encount- technician will be expected to perform. 3. List skills nec- ered in this system. essary to become a certified ophthalmic technician. K. Skin. C. Employment Opportunities. 1. Understand the basic anatomical structure, terminology, 1. State employment opportunities in an office based and functions of the integumentary system. 2. Know the practice, multi-specialty clinic, surgical setting, or other basic diseases and pathological processes commonly related occupations for an Ophthalmic Medical Techni- encountered in this system. cian. D. Organizations. 1. Explain what ªJCAHPOº, ªATPOº, and ªAAOº stand for, Module VI: Practicum I Credit Hours: 1 and how these organizations serve Ophthalmic Medical I. Course Description Technicians. Introductory clinical work designed for application of techni- E. Physical Description of Models Used to Describe Action of cal skills acquired in previous course work. Student will be Light. supervised on-site by an ophthalmic technician. Prerequisite: 1. Describe wave fronts, wavelengths, frequency, and Students must have completed the first two terms of the OMT speed of light. 2. Define parallel light radiation, conver- program before taking this course. gence, and divergence of light radiation, polarization, dif- II. Course Content, Competencies and Skills fraction, and dispersion. A. Front Office/Medical Records Management. F. Electromagnetic Radiation Spectrum. 1. Demonstrate proper method of greeting and interview- 1. Describe wave and particle theories of light. 2. Describe ing patients. 2. Demonstrate ability to handle patient tele- electromagnetic spectrum radiation, visible spectrum phone calls appropriately, including triage, and appoint- radiation, ultra-violet radiation, and infrared radiation. ment scheduling. 3. Perform routine front office duties 3. Describe electromagnetic radiation in terms of nanom- such as insurance billing, reception, maintenance, and eters. 4. Describe visible spectrum in units of color. cashier work. 4. Prepare and demonstrate ability to prop- 5. Describe and define visible, UV, and IR as wavelengths/ erly handle medical records (i.e., initiation, filing, charting, frequency of electromagnetic radiation. content, and purging). G. Concepts of Optical Imaging. B. Medical Ophthalmic History. 1. Define formation of a real image and impossibility of 1. Take appropriate and complete medical and ophthalmic formation of a virtual image. 2. Define and demonstrate history. 2. Demonstrate ability to perform adequate his- image sizes as compared to object sizes (enlarged, same torical documentation. 3. Transcribe obtained information size, minified). 3. Define and demonstrate image states as into the chart succinctly and efficiently. compared to object states (upright, inverted, and rever-

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ted). 4. Define aberration. 5. Define and list examples of ed into 360 degrees. 5. Explain that 0 degrees on convex opaque, translucent, and transparent substances. surface of a lens is on the right side, and that 180 degrees H. Basic Mathematics for Optics. on the convex surface is on the left and 90 refers to both 1. Compare measuring units (millimeter, centimeter, me- top and bottom of the lens. 6. Differentiate 0 degrees ter, and inches). 2. Demonstrate working with positive and placement on both concave and convex lens surfaces. negative numbers (addition, subtraction, multiplication, 7. Describe how most optical protractors used for marking and division of positive and negative numbers). 3. Review lenses are marked in red numbers for convex surfaces and addition, subtraction, multiplication, and division of frac- black numbers for concave surfaces. tions. 4. Demonstrate conversion of fractions to decimals O. Lens Forms and Base Curves. and decimals to fractions. 1. Explain how front surface curves (base curves) are I. Basic Lens Terms. related in image formation as perceived by the brain. 1. Define: meniscus surfaces, plano, spherical, cylinder, 2. Use a formula to select a base curve for any Rx. 3. Dis- and toric surfaces and powers. 2. Using the words: sphere, cuss magnification as related to base curves. 4. Discuss cylinder, and toric, describe how lenses may be classified ranges of base curves available from lens manufacturers. into the following combinations: spherical, sphero-cylin- 5. Define ANSI standards for base curve tolerance. der, plano-cylinder, and crossed-cylinder. 3. Define and/or P. Astigmatic Refractive Errors and Prescriptions. locate the following descriptive points on a lens: optical 1. Define astigmatic errors. 2. Define corneal, refractive, center, optical axis. 4. Describe a minus and a plus lens (in residual, and total astigmatism. 3. Explain corneal topo- terms of center and edge thickness, and in terms of motion graphy as related to with-the-rule, against-the-rule, and and magnification). 5. Define emmetropia, myopia, hyper- oblique astigmatism. 4. Define and write a hypothetical Rx opia, ametropia, and presbyopia. 6. Relate ametropia to in both plus and minus cylinder for the five classifications corrective lens type. 7. Define radius of curvature as relat- of toric prescriptions: simple myopic, compound myopic, ed to depth of a surface curve of a lens surface. 8. Compare simple hyperopic, compound hyperopic and mixed astig- flat surface curvature to radius number, and steeply matism. 5. Discuss the keratometer (ophthalmometer) for curved surfaces to radius number. 9. Describe synonyms measuring corneal curves. 6. Define unit of measurement for front and back lens surfaces. by the keratometer of corneal curves in diopters, and/or J. Reflection. radius of curvature in millimeters. 1. Define the basic unit of measurement of dioptric power Q. Nominal Power Formula to Find Surface Powers of Rx and of a lens. 2. Define specular (regular) reflection, diffuse Lens Graphs. (irregular) reflection, angle of incidence, angle of reflec- 1. Explain the nominal power formula's essential items for tion, normal, and plane. 3. Define/describe law of reflec- computations: Rx, front surface power, back surface pow- tion: angle I = angle R, object plane vs. image plane. er. 2. Use a formula to solve problems for spherical and K. Ray Tracing to Find Image Distances and Characteristics ± toric Rx's. Find: Rx, D1 and D2. 3. Describe and write lens Curved Surfaces. graphs for spherical and toric Rx's. 4. Describe use of signs 1. Find image distances and characteristics when object is for surface powers on the lens graph. 5. Explain on plus at defined distances from the vertex of a concave or convex lenses why the absolute power of D1 surface is always surface by ray tracing (object at infinity or object at any higher (larger number). other distance from vertex). 2. Give example of reciprocals, R. Lensometer. showing the focal length of lens in meters can be divided 1. Demonstrate correct eyepiece setting procedure. into one to equal diopters, and dioptric power can be 2. Measure spherical and toric lenses and multifocal addi- divided into one to equal focal length in meters. tions. 3. Read the power of toric lens in minus and plus L. Explaining the Prescription (Rx). cylinder form. 4. Write the neutralized power of toric len- 1. Define how spherical and cylinder power components of ses readings in plus and minus cylinder forms. 5. Position an Rx are combined to find the power produced at right the optical center of lenses according to: Rx with no prism angles. 2. Define and describe the optical cross as a device and mark, and Rx with prism and mark. 6. Replace light to show placement of power on a lens. bulbs in a lensometer. M. Transposition. 1. Explain transposition as technique used to change from one cylinder to another without changing the Rx. 2. Ex- Module VIII: Clinical Optics II Credit Hours: 2 plain the steps needed to transpose an Rx (algebraically I. Course Description combine sphere and cylinder power, change sign of cylin- Continues the study of advanced optical mathematics, geo- der number, or change axis number by adding or sub- metric optics including prisms, ray tracing, lens aberrations, tracting 90 degrees). 3. Demonstrate how optical cross is and formulas for finding image distances. Effective use of drawn and how powers are noted. lensometers, radius/diopter formulas, multifocal prescrip- N. Prescription Axis Notation and Optical Protractors. tions, and power calculations. 1. Explain why the axis of the toric Rx must be oriented II. Course Content, Competencies and Skills when placed before the eye for proper alignment of optical A. Refraction. powers. 2. Explain how meridians of power relate to Rx 1. Define basic terms used in the geometry of refraction toric components. 3. Explain how the axis of an Rx de- including: parallel, intersection, perpendicular, normal, scribes placement of powers and relate axis to the pro- diverging/converging, angle of incidence, and angle of tractor. 4. State difference between the protractor used by refraction. 2. Relate index of refraction to refractive power the optical industry, and a normal protractor that is divid- of ophthalmic lens materials. 3. Define and describe use-

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fulness of Snell's Law. 4. Solve refractive index problems 8. Write and define ANSI standards for MRP, segment dis- mathematically using Snell's law. 5. Graph and compare tances and heights. angles of incidence vs. angle of refraction using various I. Vertex Power Changes and Compensation for Positional index materials. Changes: B. Prisms and Refraction Through Prisms. 1. Define vertex distance. 2. State at what powers or con- 1. Describe prism shape. 2. Locate base and apex of a ditions positional compensation for Rx must be consid- prism. 3. Locate and describe images as seen through ered. 3. State ªusualº refraction distance. 4. Discuss ªruleº prisms. 4. Describe direction of refraction through a prism. about lenses losing plus power as vertex distance decrea- 5. Using Snell's law, mathematically predict angle of re- ses. 5. Use a chart to find effective power of new Rx. 6. Use fraction through prisms. a formula to find effective power of new Rx. C. Refraction Through Simple Plus and Minus Lenses. J. Ophthalmic Prism. 1. Define, describe and/or locate the following terms: focal 1. Review prism, apex/base designation, and direction of lengths, vertex point/optical center, axis line, object/image light and images seen through prisms. 2. Discuss prism distance, optical center, image characteristics, virtual/real, use in refractive examinations. 3. Define orthoptics and magnified/same size/minified. 2. Describe nature and use of prism lenses. 4. Define prism diopter. 5. Define Pre- characteristics of images formed by negative lenses when ntice's Rule (prism = decentration in cm x Rx, Decentration object is any distance from lens. 3. Describe nature and in cm = prism/Rx, Rx = prism/decentration in cm). 6. Figure characteristics of images formed by positive lenses when base direction for plus or minus lenses when the optical object is at: infinity, 1/2, 1, 2, 3 times the focal length of the centers of lenses are not directly in front of the patient's lens. pupils. 7. Figure amount of prism in any (necessary) meri- D. Lensmaker's Equation. dian of a lens. 8. Use the lensometer to check for unwanted 1. Describe usefulness of Lensmaker's equation. 2. De- or prescribed prism. 9. Define anisometropia. 10. Define scribe accuracy of using Lensmaker's equation for high bicentric or slab-off grinding. 11. Using the formula, figure plus lenses. 3. Describe/define component parts of Lens- the amount of wanted slab-off prism. 12. Know the lim- maker's formula: R1, R2, n, F. 4. Mathematically solve itations of bicentric grinding and pre-molded slab-off Lensmaker's equation problems. lenses. 13. Use a lens clock for checking accuracy of bicen- E. Defects of Imaging Through Lenses. tric grinding. 14. Define and discuss reasons for splitting a 1. Define spherical and chromatic aberration. 2. Define prism. 15. Define compound and resolving prisms. 16. Use astigmatism of oblique incidence. 3. Define distortion. a formula, charts and/or nomogram for compounding F. Radius of Curvature and Diopter Conversion-Marked prisms. 17. Use a chart or a formula to compute thickness Power and True Power. differences induced by a prism. 18. Describe some effects 1. Describe two properties that help decide what power a of unwanted prisms. lens surface will produce. 2. Define index of refraction. 3. K. Thick Lens Equations. Define surface curvature. 4. Define marked power or index 1. Define the following terms: front vertex power, back 1.530 (industrial standard index). 5. Name instruments/ vertex power, and index of refraction. 2. Define use of calculations that use industrial standard index. 6. Describe nominal lens power formula accuracy and thick lens pow- how lens material indexes other than 1.530 will create an er formula accuracy. 3. Using formulas, solve thick lens important difference in diopter curve or true power of the power problems. surface. 7. Use a formula to convert diopters to radius of L. Ophthalmic Dispensing. curvature in millimeters. 8. Use a formula to convert ra- 1. Describe the materials used to make ophthalmic frames dius of curvature to diopters. and list the advantages and disadvantages of each. 2. De- G. The Near Addition-Bifocals, Trifocals, and Presbyopia. scribe the process of frame selection, cosmetic considera- 1. Recognize presbyopia by inclusion of additional power tions, interpretation of a prescription, and measurements to an Rx, or listening to patients' visual complaints. 2. Al- that are necessary. 3. Identify various tools used for dis- gebraically, calculate a near or intermediate Rx from pa- pensing. 4. Explain the use of salt pans in dispensing, and tients Rx's. 3. Using the lensometer, neutralize near or in- techniques for adjusting frames to avoid damage. 5. Define termediate Rx. 4. Define fused and one-piece multifocals. lensometry, its application with single vision lenses, mul- 5. Give examples of fused and one-piece multifocals as tifocal lenses, and prisms. 6. Compare the techniques for related to lens material. 6. Define intermediate power as a measuring multifocal lenses and prismatic lenses. 7. State percentage of near power. 7. Write ANSI standards for ad- the uses and techniques of the lens clock and vertometer. dition power. 8. Discuss importance of gathering informa- 8. Explain the various tints and coatings common to oph- tion concerning patients near and intermediate visual thalmic lenses. needs. H. The Boxing System of Frame Measurements. 1. Discuss frame markings for sizing. 2. Define the follow- Module IX: Ocular Anatomy ing terms and give synonyms for: ªAº, ªBº, ªEDº, ªDBLº, and & Physiology Credit Hours: 2 ªFPD.º 3. Explain how the optician checks frame measure- I. Course Description ments. 4. Define Major Reference Point (MRP). 5. Explain Relates structure and function of the human visual system. MRP and optical center (OC) differences. 6. Define lateral Anatomy and physiology of the eyeball, orbit, and ocular ad- and vertical decentration of MRP in finishing of single vi- nexa are covered. Special emphasis placed on ocular termi- sion lenses and multifocals. 7. Define total decentration. nology.

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II. Course Content, Competencies and Skills action during accommodation. 9. Describe the action of A. Orbit and Adnexa. the dilator and sphincter muscles. 10. Describe the direct 1. Locate and describe the shape and function of the orbit. and consensual light reflex. 2. Identify the seven bones of the orbit. 3. Identify the E. Retina. three openings into the orbit from the cranial vault. 4. List 1. Locate the retina and describe its general function. the vessels that course through each of the three openings. 2. Locate and describe the optic nerve, macular lutea, fovea 5. List and locate the four sinuses that surround the orbit. centralis, central retinal artery, and ora serrata. 3. Describe 6. Describe the nerve fibers that flow through the ciliary the visual pathway from the retina to the occipital cortex. ganglion. 7. Locate the origination of ocular muscles in the 4. Locate and describe the function of the chiasm. 5. List orbit. 8. Locate and describe the function of the optic the ten layers of the retina. 6. Locate and describe the nerve. 9. Locate and describe the geographical landmarks general function of the pigment epithelium. 7. Locate and as related to the upper and lower eyelids, including canthi describe rod and cone function. 8. Describe photopic and and palpebral fissures. 10. Describe the general functions scotopic vision. of the eyelids. 11. List in order the pre-corneal tear film layers. 12. Locate the main lacrimal glands, Meibomian glands, and Goblet cells and describe the general purpose Module X: Diagnostic Procedures I Credit Hours: 4 of fluids secreted by each. 13. Locate and describe the col- I. Course Description lection system for tear film including puncta, canaliculi, Introduction to fundamentals of diagnostic testing and tech- and lacrimal sac. 14. Define and explain the role of the en- niques including: applanation and Schiotz tonometry and zyme lysozyme. 15. Name and locate the bulbar and pal- biomicroscopy. Presents principles and techniques of refrac- pebral conjunctiva and fornix. 16. Describe conjunctival tometry and retinoscopy, with emphasis on skill develop- tissues. 17. Locate and define Tenon's Capsule. 18. Name ment utilizing the schematic eye. the six muscles responsible for ocular movements. 19. Lo- II. Course Content, Competencies and Skills cate the insertion points of the ocular muscles on the A. Tonometry/Biomicroscopy. globe. 20 Locate and describe the trochlea. 21. Define ad- 1. Describe the contrast between different tonometers. duction and abduction, elevation and depression, and in- 2. Explain how to use each tonometer. 3. Outline an tortion and extortion. 22. Locate and describe the function approach for accurate tonometry. 4. Decide which instru- of the cilia and brows. ment to use to accomplish the measurement with greatest B. General Dimensions and Descriptions of the Human Eye. accuracy, efficiency, and least amount of discomfort to the 1. Describe the location of the equator of the globe. 2. Lo- patient. 5. Explain the principles of applanation tonometry cate the anterior and posterior poles of the globe. 3. De- and indentation tonometry. 6. Describe the selection of scribe the average diameter of the eye between the ante- proper disinfection techniques for tonometers. 7. Calibrate rior and posterior pole in inches and millimeters. 4. Define and disinfect each type of instrument. 8. Perform appla- and locate the visual axis of the globe. 5. Name three coats nation, non-contact, and indentation tonometry. 9. Out- of the eye. 6. Describe the average front surface power of line the advantages and disadvantages of each method of the cornea in diopters and millimeters of radius. 7. State tonometry. 10. Perform and record results of the flashlight the refractive index of the cornea. 8. List the chambers test. 11. Utilize biomicroscopy to perform an anterior seg- found within the eye. 9. List the structures found within ment and ocular adnexa examination. each chamber. B. Retinoscopy and Refractometry. C. Cornea and Sclera. 1. State and explain the principles of and indications for 1. Describe the vascular state of the normal cornea. 2. De- retinoscopy and refractometry. 2. Describe the mechanism scribe the thickness of the cornea centrally and peripher- and functioning of the streak retinoscope. 3. Describe the ally. 3. Name the sources of oxygen and oxygen require- various types of behavior of the retinoscopic streak. 4. Ex- ments of the cornea. 4. Describe normal corneal sensitiv- plain the recording of retinoscopic results and transpose ity. 5. Name each layer of the cornea and its regenerative those results into sphero-cylindrical form. 5. Perform reti- qualities. 6. Describe the types of cells in the epithelium. noscopy on the schematic eye. 6. Perform retinoscopy on 7. Describe the source of oxygen and nutrition of the en- the human eye. 7. Demonstrate appropriate maintenance dothelium. 8. Describe the normal pH of tear chemistry. of various phoropters and retinoscopes. 8. Differentiate 9. Locate the limbus and describe the limbal blood supply. between refraction and refractometry. 9. Describe subjec- 10. Locate and describe the average width of the corneal tive and objective methods of measuring refractive error. scleral limbus. 11. Locate and describe the function of the 10. Explain the refinement technique using a cross cylin- sclera and lamina cribrosa. der lens. D. Vascular Layer (Uvea). 1. Locate and describe the iris, ciliary body, and choroid. 2. Define melanin vs. iris color. 3. Describe the ciliary pro- Module XI: Diagnostic Procedures II Credit Hours: 4 cess and formation of aqueous humor. 4. Describe normal I. Course Description intraocular pressure and tonometry. 5. Locate and describe Presents principles and techniques of various methods of the aqueous drainage system including: ªangleº, trabecu- visual field examination. The visual pathway, common causes lar meshwork, and Schlemm's canal. 6. Locate and de- of visual field loss, and related anatomy will be covered with scribe the ciliary muscles, suspensory ligaments, and lay- emphasis on Goldmann perimetry. Also covers principles and ers of the crystalline lens and accommodation. 7. Define techniques of exophthalmometry, color vision, and tear func- amplitude of accommodation vs. age. 8. Describe pupillary tion tests. Emphasis is placed on skill development.

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II. Course Content, Competencies and Skills B. Amblyopia. A. Visual Fields. 1. Define amblyopia. 2. Describe the types of amblyopia 1. Name and describe the anatomical structures of the and methods for detection. 3. Name the tests that may be visual pathway. 2. Demonstrate visual field screening necessary to diagnose amblyopia. 4. Distinguish possible techniques. 3. Demonstrate and properly record a con- treatment methods for amblyopia. frontation field-test. 4. Perform and properly record an Amsler Grid test. 5. Relate visual field loss to specific ocular dysfunction/pathology. 6. Perform a tangent screen Module XIII: Surgical Assisting visual field according to standard procedure and in a Procedures Credit Hours: 3 timely manner. 7. Perform a Goldmann visual field exami- I. Course Description nation with emphasis on correct procedure for selecting Addresses the ophthalmic technician's role in minor office stimulus and correcting lens power, plotting isopters, surgery and assisting in the operating room. Topics covered finding defects, and investigating visual field loss. 8. Cali- include: proper aseptic technique, scrubbing, gowning and brate the Goldmann perimeter. 9. Describe common visual gloving, sterilization of instruments, the importance of sur- field artifacts and their causes. 10. List common visual field gical conscience/legal responsibilities, proper disposition of defects from: retinal disease, optic nerve disease/glauco- supplies/medications, and security procedures of medica- ma, and neurological disease. tions as regulated by law. B. Exophthalmometry, Color Vision, Tear Function. II. Course Content, Competencies and Skills 1. Perform measurement of proptosis using a Hertel 1. List methods of disinfecting and sterilization. 2. Demon- exophthalmometer. 2. Demonstrate color vision testing strate how to prepare items for sterilization. 3. Explain using Ishihara test plates. 3. Demonstrate color vision guidelines for packing and loading the sterilizer. 4. Describe testing using the Farnsworth-Munsell D-15 test. 4. Name operation room sanitation procedures. 5. List sources of con- alternate methods of color testing. 5. Take a history rele- tamination and infection control measures. 6. Define princi- vant to identifying a possible ªdry eyeº patient. 6. List the ples of aseptic technique. 7. Demonstrate practical applica- steps to perform Schirmer tear test I and II. 7. Define and tions of sterile techniques. 8. Outline methods of opening and demonstrate a tear film ªbreakup timeº test. distributing sterile goods. 9. Define terminology associated with asepsis and sterile techniques. 10. Review historical concepts and background of infection control. 11. Describe Module XII: Ocular Motility Credit Hours: 2 types of operating room attire. 12. Describe the surgical scrub I. Course Description procedure. 13. Demonstrate gowning and gloving of self and Introduction to ocular motility and binocular vision. Empha- others. 14. Define and demonstrate the procedure for remov- sis is placed on understanding the presentation, characteris- ing gown and gloves aseptically. 15. Demonstrate positioning tics, and natural history of the strabismus patient. Amblyopia of patients for ophthalmic procedures. 16. List steps in anes- and binocular vision are addressed. thesia preparation and frequently used eye medications. II. Course Content, Competencies and Skills 17. Define intraoperative care. 18. Perform preparation of the A. Extraocular Muscles/Strabismus. eye and face for surgery. 19. Demonstrate the general princi- 1. Name the extraocular muscles and their function. ples of draping. 20. Describe equipment and supplies used in 2. Take a relevant history for a strabismus workup. ophthalmic procedures. 21. Define the types and sizes of eye 3. Describe how to perform the basic measurement pro- suture materials and needles. 22. Outline suggested basic and cedures in the screening examination of a strabismic pa- emergency eye instrument trays. 23. Describe medications tient. 4. Describe cover/uncover test, alternate cover test, used in eye procedures. 24. Describe the proper method to and Krimsky and Hirschberg tests. 5. Distinguish between inventory clinical supplies and medications. 25. Define safe- phoria and tropia. 6. Distinguish between ductions, ver- ty/security procedures regarding disposition of medications. sions, and vergences. 7. Describe the diagnostic positions 26. Classify medication as to shelf life/expiration dates. of gaze. 8. Explain the object of motility testing and why 27. Demonstrate techniques for cleaning instruments in the binocular function is important. 9. Explain fusion, diplo- operating room. 28. State the steps in preparing a set of in- pia, and suppression. 10. Describe use of the Maddox rod, struments. 29. State the steps in cleaning and sterilizing Worth four-dot, red glass, and Bagolini lenses in testing for instruments. 30. Describe how to process a micro eye tray. fusion. 11. Describe various methods of assessing visual 31. Define the proper care of gem blades. 32. State ways to acuity and their significance in strabismus. 12. Describe store surgical instruments. 33. Define a qualified mainte- how to perform vision screening in preschool children nance and troubleshooting program. 34. List the steps for using appropriate testing methods for the age.13. Describe admitting a surgical patient to the hospital. 35. List the steps the physiologic mechanisms (motor and sensory) implicit necessary to prepare a child and their parent for surgery. in strabismus management. 14. Describe the role of surgi- 36. Describe how to prepare an adult for major surgery. cal vs. medical (including orthoptic) management of stra- 37. Identify questions commonly asked by patients regarding bismus. 15. Describe the characteristics, presentation, and ocular surgery. 38. Discuss the various types of anesthesia for natural history of pseudostrabismus, congenital esotropia, ocular surgery. 39. State the technician's role in the care of a accommodative esotropia, and intermittent deviations. 16. postoperative patient. 40. List the four components of meas- Distinguish between comitant and incomitant deviations. uring vital signs. 41. Demonstrate proper measurement of 17. Discuss the significance of primary and secondary de- pulse rate, respiration rate, body temperature, and blood viations. 18. Define restrictive strabismus and describe the pressure. 42. List the normal rate of pulse, respiration, body various types. temperature, and the normal values of blood pressure.

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43. Describe how ophthalmic lasers work. 44. Define the Module XV: Content Lens I Credit Hours: 3 types of lasers. 45. List advantages of laser surgery. 46. State I. Course Description necessary safety precautions with laser use. 47. Define the Covers fundamentals of contact lens. Principles of lens struc- role of the ophthalmic medical technician when the laser is tures, materials used in manufacturing, categorization, and used. comparison of characteristics of soft and rigid lenses. In- cludes theory and utilization of instruments commonly used in fitting and assessing contact lenses. Includes use of kerat- Module XIV: Therapeutic Assisting ometer, biomicroscope, radiuscope, lensometer, gauges, Procedures Credit Hours: 4 loupes, magnifiers, and fluorescent tubes. I. Course Description II. Course Content, Competencies and Skills Focus on the technician's role in assisting in the management A. Describe the Basic Principles of Fitting the Major Types of of preoperative and postoperative patients. More advanced Contact Lenses. ophthalmic procedures include ultrasound, potential acuity B. Describe and Perform These Fitting Procedures Utilizing: meter, direct ophthalmoscopy, and contrast sensitivity. Spe- 1. Keratometry. 2. Corneal diameter. 3. Pupil diameter. cimen collection for the laboratory is addressed. 4. Tear secretion. 5. Eyelid tightness. 6. Fluorescein pat- II. Course Content, Competencies and Skills tern. 7. Spectacle blur. 8. Over-refraction. 9. Pediatric A. Echography. patients. 10. Contraindications. 1. List the classifications of ultrasound. 2. Explain termi- C. Describe Patient Instruction For: nology related to echography. 3. Describe clinical applica- 1. Insertion. 2. Removal. 3. Cleaning. 4. Storage. 5. Hygiene. tions of diagnostic ultrasound. 4. List the steps necessary 6. Solutions. 7. Wearing time. to measure the axial length of an eye. 5. List the methods of performing diagnostic B-scans. 6. List the methods to prepare a patient for a diagnostic B-scan. 7. Name the Module XVI: Content Lens II Credit Hours: 3 components of ophthalmic ultrasound instrumentation. I. Course Description 8. List the methods available to document ultrasound Continuation of Contact Lens I. Covers fitting theories and images. 9. Demonstrate proper maintenance of ultrasound principles for soft and rigid contact lenses, solutions for care equipment. 10. Define corneal thickness and list the steps and maintenance, dispensing, patient education, post fitting necessary to perform pachymetry. 11. Define standardized observations, and theories on fitting and bifocal echography. 12. Demonstrate proper labeling of echo- contact lenses. Lab activities will allow for observation of grams. 13. State the effects of corneal power, lens power, physical properties and fitting challenges of contact lenses. and overall length of the eye on IOL calculations. 14. Cal- II. Course Content, Competencies and Skills culate an accurate IOL lens power. 1. Perform contact lens modifications. 2. Perform vision as- B. Advanced Ophthalmic Procedures. sessment. 3. Perform verification of lens power, base curve, 1. Demonstrate proper examination techniques using a diameter, central thickness, and edge profile. 4. List the ANSI direct ophthalmoscope. 2. Perform a contrast sensitivity standards for contact lens tolerances. 5. Describe patient as- test. 3. Perform and score a 100-Hue test. sessment and follow up procedures including indications/ C. Microbiology. contraindications, medications, charting, follow up, re-order- 1. Identify terms and definitions of microbiology. 2. De- ing, and disposable lenses. scribe the types of bacteria commonly seen in ophthalmic practice. 3. Describe the ocular viruses. 4. State the meth- ods for collecting cultures and inoculation techniques. Module XVII: Practicum II Credit Hours: 4 5. List the steps required to obtain a conjunctival culture. I. Course Description 6. List the steps required to obtain a lash margin culture. Introductory clinical work designed to apply technical skills 7. List the steps required to obtain a corneal/conjunctival acquired in previous course work. Student will assist patients scraping. in all phases of care including performance of advanced oph- D. Photography. thalmic testing procedures. Student will be supervised on- 1. Identify terms and definitions of basic photography (in- site by an ophthalmic technician. Prerequisite: Practicum I. cluding film, exposure, focal length, depth of field, syn- II. Course Content, Competencies and Skills chronization, beam splitters, reticles, ocular, focus, video, A. Front Office/Medical Records Management. and astigmatic correction). 2. List the steps required to 1. Demonstrate proper method of greeting and interview- perform fundus photography. 3. Identify photographic de- ing patients. 2. Demonstrate ability to handle patient tele- fects/artifacts. 4. Describe the relationships among shutter phone calls appropriately, including triage and appoint- speed, aperture number, and film speed. 5. Define the ment scheduling. 3. Perform routine front office duties relationship between ISO/ASA film rating, and film sensi- such as insurance billing, reception, maintenance, and tivity. 6. Differentiate between digital, fluorescein, and in- cashier work. 4. Prepare and demonstrate ability to prop- docyanine green angiograms. 7. List major indications for erly handle medical records (i.e. initiation, filing, charting, fluorescein angiography. 8. List contraindications of an- content, and purging). giography. 9. List mild and major reactions to fluorescein B. Medical/Ophthalmic History. injection. 10. List treatments for adverse reactions. 1. Take an appropriate and complete medical and oph- thalmic history. 2. Demonstrate ability to perform ade- quate historical documentation. 3. Transcribe obtained information into the chart succinctly and efficiently.

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C. Visual Acuity. patient's eye if necessary. 4. Measure a patient's axial 1. Identify methods of measuring visual acuity in adults length. 5. Set up and assist in a diagnostic B-scan. 6. De- and children. 2. Demonstrate accurate recording of acuity monstrate methods to document ultrasound. 7. Maintain measurements in the medical record. 3. Demonstrate ultrasound equipment properly. 8. Explain pachymetry ability to accurately measure near vision. 4. Define com- and perform the measurement of corneal thickness. mon abbreviations used in recording visual acuity. 9. Label echograms in an accepted manner. 10. Calculate 5. Operate the lensometer accurately and efficiently. an IOL power accurately. D. Visual Fields/Tangent Screen/Amsler Grid. D. Advanced Ophthalmic Procedures. 1. Demonstrate static and kinetic perimetry. 2. Demon- 1. Perform a potential acuity meter test on a patient and strate performance of manual and automated perimetry. accurately document the findings. 2. Perform direct oph- 3. Define isopter, , depression, contraction, central thalmoscopy on a patient and record the findings. 3. Per- threshold target, and suprathreshold perimetry. 4. De- form a contrast sensitivity test on a patient and record monstrate methods for exploring defects with manual findings. perimetry. 5. Relate visual field loss to specific ocular dys- E. Microbiology. function/pathology. 6. Demonstrate the performance and 1. Select the proper medium for transport of ocular speci- properly record a confrontational field test. 7. Explain mens. 2. Demonstrate the proper method for collecting quantification of and depressions. 8. State four cultures. 3. Demonstrate the steps necessary to obtain a advantage of automated perimetry. 9. Identify which size conjunctival culture. 4. Demonstrate and explain the steps stimulus on a Goldmann perimeter is equivalent to the in obtaining a lash margin culture. 5. Demonstrate and usual test stimulus on a Humphrey Field Analyzer. 10. explain the steps in obtaining a conjunctival scraping. Perform a Goldmann visual field examination with em- 6. Demonstrate and explain the steps in obtaining a phasis on correct procedure for plotting isopters, finding corneal scraping. scotoma, and investigating visual field loss. 11. Perform a Tangent screen (if available). 12. Properly calibrate a Gold- mann perimeter. 13. Demonstrate, instruct, and perform Module XIX: Practicum IV Credit Hours: 4 an Amsler Grid. I. Course Description E. Tonometry/Biomicroscopy. See Course Description Practicum III. Prerequisite: Practicum 1. Perform non-contact tonometry. 2. Perform applanation III. tonometry with a Tonopen. 3. Clean and calibrate a Schiotz II. Course Content, Competencies and Skills tonometer (if available). 4. Estimate anterior chamber See Course Content, Competencies and Skills Practicum III. depth with the flashlight. 5. Evaluate pupillary reaction. 6. Perform biomicroscopy of the anterior segment and ocular adnexa. Module XX: OMT Seminar I Credit Hours: 1 F. Exophthalmometry, Color Vision, Tear Function. I. Course Description 1. Perform measurement of proptosis using a Hertel Review major professional subject areas. Discussion of clini- exophthalmometer. 2. Demonstrate color vision testing cal practicum experiences, including concerns, issues, case using Ishihara test plates. 3. Name alternate methods of studies, and procedures. Use videos and lecture to explore color vision testing. 4. Take a history relevant to identify- ethics, patient confidentiality, and CPT coding. Discuss the ing a possible dry eye patient. 5. Perform Schirmer tear history of your country's healthcare as well as current trends test I and II. 6. Define and demonstrate a tear breakup time in healthcare. test. II. Course Content, Competencies and Skills A. History of Health Care in Your Country. 1. Highlight a brief chronological history of medicine. Module XVIII: Practicum III Credit Hours: 4 2. Describe historical developments, which currently I. Course Description influence the health care field. 3. Distinguish types of See Course Description Practicum II. Prerequisite: Practicum medical practices such as individual private practices, II. partnerships, group practices, health maintenance II. Course Content, Competencies and Skills organizations, and government programs. A. See Course Content, Competencies and Skills Practicum II. B. Medical Ethics. B. Surgical Patient Care. 1. Define common terms in the science of ethics. 2. Define 1. Perform all steps necessary to admit a patient to the courtesy, ethical, and legal concepts. 3. Explain the princi- hospital. 2. Explain the surgical experience to a child and ples of ethics of the Medical/Ophthalmological Societies in parents. 3. Prepare an adult for ocular surgery. 4. Answer your country. 4. Define principles involved in ethical care questions commonly asked by patients regarding their of patients. 5. Describe law/policies for the control, use, ocular surgery. 5. Identify the various types of anesthesia and release of health information, including corrective used during ocular surgery. 6. Properly complete all pa- lens and contact lens prescription. 6. Specify procedures perwork necessary for outpatient or inpatient surgery. for insuring the confidentiality of health information. 7. Demonstrate the technician's role in the care of the 7. Describe procedures for insuring security of computer- postoperative patient. ized information. 8. Respond ethically to requests for C. Echography. patient information. 9. Define informed consent and 1. Explain the ultrasound procedure to a patient. 2. Prepare explain its importance. 10. Discuss patient confidentiality the equipment for the procedure. 3. Instill drops in the and define the professional's role in maintaining confi-

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dentiality. 11. Identify various torts in medical practice and image-retina system works to produce perception of move- explain the consensual nature of the physician-patient ment. 11. Explain how the eye-head system works to produce relationship. perception of movement. 12. Explain the principles involved C. Procedural/Diagnostic coding. in cinema and television being able to give the illusion of 1. Explain the use of ICD-9 and CPT in translating physician movement. 13. Explain a retinal after-image. 14. Explain what services to insurers (if applicable). 2. Describe the com- the ªphi phenomenonº is. 15. Explain the difference between mon CPT codes used in ophthalmology (if applicable). scotopic and photopic vision. 16. Explain what causes differ- 3. Define the technician's role in office and surgical coding. ent degrees of color deficiencies and in dif- ferent individuals. 17. Explain the color-opponent theory of color perception. 18. Demonstrate negative after-images. Module XXI: OMT Seminar II Credit Hours: 2 19. Explain how tinted lenses can affect our perception of I. Course Description color and detail. 20. Explain some of the problems caused by Discussion of clinical practicum experiences including con- putting corrective lenses in front of our eyes, including ani- cerns, issues, case studies, and procedures. Discuss challen- seikonia and diplopia. 21. Explain how increasingly better ges confronting practitioners and the presentation of new lens designs are able to alleviate many visual perception material in the field. Course will include field trips and guest problems. 22. Explain how iseikonic lenses are designed to speakers on topics of interest. alleviate aniseikonia. 23. Explain how bicentric lenses are II. Course Content, Competencies and Skills designed to alleviate diplopia. 24. Explain how prism lenses 1. Employment opportunities in the ophthalmic field. 2. are used to alleviate diplopia. 25. Explain what it means to be Emerging job markets in ophthalmology. 3. Associated areas legally blind. 26. Explain low vision. 27. Demonstrate some of of employment - research, eye bank, pharmaceutical, and the problems encountered by low vision patients trying to technical training. navigate in the world. 28. Describe diseases of the eye that can cause low vision. 29. Explain how magnification is related to dioptric power and in what way magnification increases Module XXII: OMT Seminar III Credit Hours: 2 relative size. 30. Describe different types of hand-held and I. Course Description stand magnifiers, and how they can be used to help some low See Course Description OMT Seminar II. vision patients. 31. Explain the importance that increased II. Course Content, Competencies and Skills lighting plays for those with low vision problems. 32. De- See Course Content, Competencies and Skills OMT Seminar II. scribe different types of spectacle aids for low vision. In addition: 4. ResumÕ preparation, interview techniques. 33. Describe some of the advantages and disadvantages of projection magnifiers for low vision patients.

Module XXIII: OMT Seminar IV Credit Hours: 2 I. Course Description RESOURCES: Books, Videotapes, CD-ROMs See Course Description OMT Seminar II. ! II. Course Content, Competencies and Skills 1. American Academy of Ophthalmology. Introducing ophthal- See Course Content, Competencies and Skills OMT Seminar II. mology: a primer for office staff. 2 ed. San Francisco: Ameri- can Academy of Ophthalmology, 2002 2. American Academy of Ophthalmology. Preferred practice Module XXIV: Perception & Low Vision Credit Hours: 2 pattern: [multiple subjects]. San Francisco: American Acad- I. Course Description emy of Ophthalmology, 2002 Introduction to basic and advanced visual aids, and their ap- 3. American Academy of Ophthalmology. The academy guide to plication to patients with various forms of low vision. Covers on-site medical staff training. San Francisco: American theories of visual perception, including depth perception, Academy of Ophthalmology, 1996 color vision, optical illusion, and how lenses affect percep- 4. Cassin B. Fundamentals for ophthalmic technical personnel. tion. Philadelphia: W.B. Saunders, 1995 II. Course Content, Competencies and Skills 5. Cassin B, Rubin ML. Dictionary of eye terminology. 4th ed. 1. Explain the difference between ªlearnedº vs. ªinnateº visual Gainesville, Fla.: Triad Pub. Co., 2001: 286 perception. 2. Explain how culture and environment can in- 6. Corboy JM. The retinoscopy book: an introductory manual fluence what an individual perceives. 3. Explain how the for eye care professionals. 5th ed. Thorofare: Slack, 2003; xii: brain organizes and adapts to stimulus. 4. Identify brain 141 functions that take place as stimuli are received. 5. Explain 7. Joint Commission on Allied Health Personnel in Ophthal- the organization principles that interpretation of visual mology. JCAHPO Learning Systems Modules 1±6 (Computer- stimulus are based upon, including: figure ground, closure, based skill areas simulation programs). St. Paul: Joint Com- proximity, similarity, perceptual sets, and constancy. mission on Allied Health Personnel in Ophthalmology, 2004 6. Explain how the brain can be ªfooledº by visual illusions. 8. (Multiple Authors). Clinical skills DVD/videotapes [multiple 7. Explain how binocular disparity, corresponding points, subjects]. San Francisco: American Academy of Ophthalmol- and fusion work together to help us see the world in three ogy; Reviewed for currency 2004 dimensions. 8. Explain what cues are available to the mono- 9. (Multiple Authors). The basic bookshelf for eyecare profes- cular (and binocular) individual for determining distance. sionals [multiple subjects]. New Jersey: Slack, 1998 9. Explain how focus and constancy scaling work to help humans determine the size of objects. 10. Explain how the

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10. Newmark E. Ophthalmic medical assisting: an independent Ophthalmic Allied Health Personnel Self-Study Course study course. 4th ed. San Francisco: American Academy of Programs Ophthalmology, 2006; xviii: 350 1. American Academy of Ophthalmology, PO Box 7424, San 11. Physicians' desk reference for ophthalmic medicines 2006. Francisco, California 94109, USA. 34th ed. Montvale: Thomson PDR, 2006: 291. Updated an- 2. Centennial College, PO Box 631, Station A, Scarborough, nually. Ontario, M1K 5E9, Canada. 12. Stein HA, Slatt BJ, Stein RM. Ophthalmic terminology: speller 3. Southern Alberta Institute of Technology, 1301 ± 16th Avenue and vocabulary builder. 3rd ed. St. Louis: Mosby, 1992; xiv: NW, Calgary, Alberta, T2M 0L4, Canada. 378 13. Stein HA, Stein RM, Freeman MI. The ophthalmic assistant: a text for allied and associated ophthalmic personnel. 8th ed. Philadelphia: Elsevier Mosby, 2006; xviii: 871

Klin Monatsbl Augenheilkd 2006; 223, Suppl 6: S3±S41  Georg Thieme Verlag KG Stuttgart ´ New York ´ ISSN 1431-634X