Principles and Guidelines of a Curriculum for Ophthalmic ...3. Primary eye care (including...

SEMI-FINAL DRAFT 3/17/2006

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Principles and Guidelines of a Curriculum forOphthalmic Education of Medical Students

Presented by:International Task Force on Ophthalmic Education

of Medical Students

On Behalf of:The International Council of Ophthalmology (ICO)

Chairman of Task Force: Richard Parrish II, MD (USA)

Major Contributors:Richard K. Parrish II, MD (USA)Casey Mickler, MD (USA)Susan Lightman, MD (London, UK)Geoffrey Broocker, MD (USA)Adenike Aboise, MD (Nigeria)Miguel N. Burnier, MD (Canada)Akef El-Maghraby, MD (Saudi Arabia)Daniel Eyta’ale, MD (Switzerland)Zi-Liang Li, MD (China)Marilyn T. Miller, MD (USA)Kathleen A. McClellan, MD (Australia)Robert B. Nussenblatt, MD (USA)And Other Members of International Task Force*

Coordinator of Educational Programs of ICO and Editor:Mark O.M. Tso, MD (China, USA)

Executive Committee of ICO:Gottfried O.H. Naumann, MD, President (Germany)Mark O.M. Tso, MD, Vice-President (China, USA)Bruce E. Spivey, MD, Secretary General (USA)Balder Gloor, MD, Treasurer (Switzerland)

Publication of this curriculum was supported bya contribution from the

International Council of Ophthalmology Foundation

Copyright © 2006 International Council of Ophthalmology. All rights reserved.945 Green Street, San Francisco, California, USA 94133

Fax: (+1) 415 409-8403 E-mail: [email protected] Web: www.icoph.org


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TABLE OF CONTENTS PAGE

I. Preamble Mark O.M. Tso, MD 3& Richard K. Parrish II, MD

II. Curriculum for Ophthalmic Educationof Medical Students. Richard K. Parrish II, MD 7

I. Fundamentals and Principles of Ophthalmology 7II. Cornea and External Disease 9III. Lens and Cataract 11IV. Neuro-Ophthalmology 13V. Retina Vitreous 15VI. Glaucoma 16VII. Pediatric Ophthalmology and Strabismus 19VIII. Eyelid, Lacrimal and Orbit 20IX. Ocular Manifestations of Systemic Disease 23X. Intraocular Tumors 27XI. Refraction and Contact Lens 28XII. Refractive Surgery 29

III. References 31

IV. Additional Sources of Teaching Material 33

Acknowledgement: *Past and present members of the International Task Force onMedical Student Education: Richard K. Parrish II, (USA); Casey Mickler, (USA); SusanLightman, (London, UK); Geoffrey Broocker (USA); Adenike Aboise (Nigeria); Miguel N.Burnier, (Canada); Akef El-Maghraby (Saudi Arabia); Daniel Eyta’ale (Switzerland); Zi-LiangLi (China); Marilyn T. Miller (USA); Kathleen A. McClellan (Australia); Robert B.Nussenblatt (USA); Gerhard K. Lang, (Germany); Yasuo Tano, (Japan). ICO gratefullyacknowledges the editorial efforts of Jenni Anderson and Lenalee Fulton in coordinatingand assembling these curricula.


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I. Preamble

In the International Strategic Plan to Preserve and Restore Vision (1999), an International TaskForce on Medical Students Education was established. The leadership of ICO agrees thatophthalmic education of medical students should include the basic knowledge and skills toprovide appropriate levels of primary eye care, and medical students should learn the indicationsand need for referral to ophthalmologists for management of specialty cases. Evidence-basedophthalmic curriculum for medical students should be incorporated as core curriculum for allmedical schools. It is recognized that in different geographic regions of the world medicalgraduates may be required to provide primary eye care, while others may have easy access toreferral of ophthalmic specialists. Ophthalmic manifestations of systemic diseases are common,and an understanding of these eye manifestations is a necessary part of the comprehensiveeducation for modern physicians.

The International Council of Ophthalmology passed a resolution to call on all Medical Schoolsworld wide to establish a curriculum for ophthalmic education of medical students as part oftheir core curriculum for medical education, and not as an elective in the course of medicaleducation. Dr. Yasuo Tano (Japan) and Dr. Gerhard K. Lang (Germany) were asked to Chair theTask Force.

The Task Force took initiatives to begin developing a curriculum, and noted that1. In the 21st Century, eye care has become increasingly important in the general practice of

medicine.2. Vision is one of the vital factors influencing quality of life.3. Primary eye care (including recognizing eye diseases) should be the responsibility of

family physicians, as ophthalmic manifestations of systemic diseases are commonlyassociated with medical, neurological, and metabolic diseases.

4. A solid education in ophthalmology should be part of the comprehensive education ofmodern physician. The Task Force recommended that the educational programs of allmedical students should include a basic understanding of eye diseases and eyemanifestations of systemic diseases. However, the family physician should recognizecertain eye diseases, which would require a referral to an eye care specialist.

5. There has been a spectrum of teaching methods of ophthalmology for medical studentsconsisting of: 1) traditional didactic lectures and clinical demonstrations. 2) Illustrativecase studies to highlight particular eye diseases. 3) Evidence-based medical teaching,pairing ophthalmic teaching with neuro-science, neurology, endocrinology, pediatrics,and other relevant subjects. The Task Force emphasizes the importance of clinicalexposure to patients. Patient contact and bedside teaching in ophthalmology are criticalin providing clinical experience.

6. Ophthalmology is mostly a surgical specialty, so medical students should be given anopportunity to observe procedures in the operating room. By allowing students to beexposed to the surgical procedures, they will acquire a more realistic understanding ofophthalmic practice.

7. The time allotment for teaching students in ophthalmology is important. It is recognizedthat different medical subspecialties compete vigorously for time in the medical


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education curriculum. However, an adequate period of time must also be allotted forlearning eye care.

In January 2002, Dr. Richard Parrish took over the Chairmanship of the International Task Forceand started working on a detailed outline for a medical student curriculum. The Task Forceconsidered the importance of local diseases in different countries, especially in areas where eyediseases such as onchocerciasis or cataract are endemic. It is strongly believed that medicalstudents in those regions should have a more in-depth understanding of these conditions. Thefinal report consists not only of subjects in the curricula, but also covers sources of illustrativematerials for use in teaching.

Under the leadership of Dr. Richard K. Parrish II, new directions have developed and guided thecommittee in preparation of this document.

1. The reduction in time allotted for ophthalmic education in medical school threatens todiminish the clinical skills of graduating physicians throughout the world. This willadversely affect the quality of eye care knowledge worldwide.

2. An ophthalmic cognitive and clinical skill set should be defined for internationalmedical educators.

3. Basic ophthalmic knowledge and clinical skills should be recognized internationallyand included as part of the medical student’s general curriculum.

4. Recommendations of the Task Force should reflect the consensus of a broad-basedinternational ophthalmic educational community.

5. The Task Force should define minimum standards for medical student educationwhich are not intended to replace existing curricula, such as Blueprint 2001: Trainingof Doctors in the Netherlands, or the Swiss Catalogue of Learning Goals inOphthalmology.

6. Teaching materials, including clinical photographs, selected readings from existingtextbooks, and publications should be made available through the ICO website forinternational medical students who do not have ready access to printed material.

The Task Force Chairman queried members of the International Federation of OphthalmologicalSocieties in January and April 2003 to determine the minimum knowledge and clinical skills thatgraduating medical student should demonstrate. It was determined that all medical studentsshould demonstrate competency in these areas:

1. Measurement of near visual acuity with and without correction.2. Determination of visual fields by confrontation technique.3. Assessment of extra ocular motility in the six cardinal positions of gaze and primary

position.4. Measurement and interpretation of pupillary size and reaction to light.5. Penlight examination of the anterior segment, including upper lid eversion.6. Examination of the optic nerve and posterior pole with direct ophthalmoscopy.7. Removal of superficial corneal or conjunctival foreign body.


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With these skills the graduating medical student should be able to make the following diagnosesand initiate an appropriate treatment or referral plan for the following conditions: 1.)Conjunctivitis; 2.) Cataract; 3.) Corneal ulcer; 4.) Corneal foreign body; 5.) Maculardegeneration; 6.) Diabetic retinopathy; 7.) Hypertensive retinopathy; 8.) Glaucoma; 9.)Uncorrected refractive error; 10.) Ocular trauma; 11.) Papilledema; 12.) Hemianopic and bi-temporal visual field defects; 13.) Acute onset of cranial nerve palsies III, IV, VI; 14.) Acuteonset strabismus; 15.) Leukocoria.

The medical student curriculum designed by the ICO Task Force is divided into 12 parts. Thefirst section, Fundamentals of Ophthalmology, outlines the essential skills and serves as a basisfor the understanding the other 11 areas that provide information in subspecialty areas. Just asother widely circulated consensus documents reflect educational priorities, such as Blueprint2001: Training of Doctors in The Netherlands, the curriculum of the Task Force is intended tocompliment, not replace, these existing standards. The Task Force members understand thatlarge regional variations in disease prevalence preclude the development of an inclusivecurriculum for all medical students. This document is intended to serve as a resource that willprovide access to a wide range of important educational topics.

Educational PrioritiesEssential ophthalmic knowledge and clinical eye care skills are marked with a single asterisk *.This is basic information for all international medical students’ education. Skills and knowledgethat reflect a higher level of understanding are marked with two asterisks**. Although not basic,many medical schools may already include this material in their curriculum. Areas of advancedcognitive and clinical skills that are more appropriate for students who seek further training inophthalmology are marked with three asterisks***. While important to ophthalmic care, the TaskForce does not regard the cognitive or skill set designated with ** or *** as falling within thebasic curriculum of most international medical students. This material may form the basis for anophthalmology elective in medical school.

Hours in CurriculumThe Task Force strongly recommends that all medical schools include ophthalmology as a part ofthe essential curriculum and not exclusively as an elective. The increasing age of the worldpopulation, high prevalence of common problems such as eye injury and red eye, and importanceof vision in the information age support the need for the expansion of ophthalmic education. Toachieve this goal, the exact allotment of curriculum hours will depend on existing specificmedical school infrastructure and general curriculum. The Task Force strongly recommends thatsufficient time in the classroom and clinical setting be dedicated to mastering the learningobjectives and clinical skills that are labeled with a single asterisk * .We also strongly recommend that ophthalmic education should not be limited to the formalclassroom setting, but take place in the clinic and operating room. Each student should be givenan opportunity to observe common ophthalmic procedures, such as treatment of chalazion,removal of corneal foreign body, or cataract operation and to examine the anterior segment withslit lamp biomicroscopy. The Task Force estimates that the total educational commitmentthroughout medical school will require approximately 40-60 hours (or 5 to 8 days) exposure.

Specific Teaching Methods


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Three teaching methods have traditionally been described to achieve ophthalmic educationalgoals: didactic lectures and clinical demonstration; illustrative case method study; andevidence–based medicine teaching (where ophthalmic education is paired with neuroscience,neurology, endocrinology and geriatric medicine). The Task Force recommends thatinternational medical schools employ all methods to achieve these broad educational goals. TheTask Force judges these teaching techniques to be complimentary and not competitive in nature.As the body of new information acquired through randomized clinical trials expands rapidly, theTask Force believes that the importance of evidence-based medicine will continue to grow.

ResourcesSpecific educational information available through several existing publications of the AmericanAcademy of Ophthalmology are referenced and identified to facilitate access.

Complete lectures on many important topics have been prepared by Professor Susan Lightman,Department of Clinical Ophthalmology at Moorfields Hospital, London, U.K., and have beenused as a part of the Curriculum for Undergraduate Medical Education. These self-containededucational units are presented in their entirety and may be accessed as identified.

The existing Blueprint 2001: Training of Doctors in the Netherlands is referenced. References(REF.) to images, figures, and charts from publications of the American Academy and others arelisted within the curriculum to facilitate access. This may particularly be of value for thosestudents who do not have ready access to printed reference texts. The Task Force recommendsthat this information be made available without charge to all students and teachers foreducational purposes. Additionally the Task Force recommends that the Basic and ClinicalScience Manual teaching materials provided by the American Academy of Ophthalmology andthe Undergraduate Medical Lecture Series provided by Professor Sue Lightman, Department ofClinical Ophthalmology, Moorfields Eye Hospital, London, UK, shall be made available toteachers and students all over the world though the ICO website: http://www.icoph.org/


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II. Curriculum for Ophthalmic Education of Medical Students

I. Fundamentals and Principles of Ophthalmology

Educational Goals: Medical students should recognize external and internal ocularstructures of the normal human eye and know how to perform a basic eye examination.

• Medical student should:

1. Describe normal ocular anatomy* (REF.1E Slide 58, 59;) (REF. 21 FIG. G02)2. Obtain an accurate and complete ocular history (REF.1B Slide 14)

3. Measure and record near visual acuity in an adult with near correction andunderstand principles of distance acuity measurement in adults and children*

4. Assess pupillary reflexes*5. Evaluate ocular motility* (REF.4 Table1.2 and Figure 6.10)

6. Use the direct ophthalmoscope for assessment of red reflex, the optic nerve andposterior fundus examination* (REF.21 FIG. I03)

7. Dilate the pupils*8. Perform and evaluate visual fields by confrontation

A. Ocular Anatomy*Students should be able to define each of these structures and describe theirfunction (REF.4 FIG.1.1 and 1.2)

1. Eyelids2. Sclera3. Limbus4. Iris (REF.1E Slide 58)5. Pupil6. Conjunctiva7. Cornea (REF.1E Slide 58,59)

8. Extraocular muscles9. Anterior chamber (REF.1E Slide 58)

10. Lens (REF.1E Slide 58)11. Ciliary body (REF.1E Slide 58)

12. Posterior chamber13. Vitreous cavity14. Retina (REF.4 FIG.1.15)15. Macula16. Choroids17. Optic nerve (REF.23 Slide 03)

B. Visual Acuity*1. Students should understand the purpose of measuring near visual acuity

with and without correction and testing each eye individually. (REF.1E Slide07) (REF.4 FIG.1.8)


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2. Students should understand the concept of distance visual acuity testingwith and without correction and with a pinhole, but are not expected toperform refraction. (REF.4 Table1.1)

C. External Inspection* (REF. 21 FIG. G36, G40, G44)Students should understand the external ocular anatomy and evaluate theposition of the lids and inspect the conjunctiva, sclera, cornea and iris witha penlight.

D. Pupillary Reaction Testing* (REF.23 Slide 11)

Students should measure the pupillary size and assess the direct andconsensual pupillary reaction.

E. Ocular Motility Testing*Students should understand the importance of assessing ocular motility in the sixcardinal positions of gaze and ocular alignment in primary position.

F. Direct Ophthalmoscopy*Students should understand the use of a direct ophthalmoscope and know theimportance of testing the patient’s right eye with the ophthalmoscope held in theexaminer’s right hand, and left eye with the direct ophthalmoscope held in theexaminer’s left hand. Students should understand the basic function of anophthalmoscope and should know how to adjust the focus.

G. Pupillary Dilatation*Students should understand how to pharmacologically dilate pupils for examination of the ocular fundus (REF. 21 FIG. J05). Students should understandthe difference between retinal arterioles and retinal venules, the normalappearance of the optic nerve head, retinal pigment epithelium, and foveal reflex.Student should also recognize the normal uniform red-orange background retinalcolor due to retinal pigment epithelium.

.H. Intraocular Pressure Measurement* (REF. 21 FIG. C29, C30)

Students should understand the concept of assessing intraocular pressure, but arenot expected to measure intraocular pressure with a tonometer.

I. Anterior Chamber Depth Assessment*Students should understand how to assess anterior chamber depth with a pen lightheld at an oblique angle to the optical axis (REF.4 FIG. 1.10).

J. Confrontation Field Testing*Students should understand the principle and the technique of determining theperipheral visual field by finger counting confrontation technique.

K. Upper Lid Eversion*


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Students should know how to revert the upper lid and examine for the presence offoreign bodies (REF.4 FIG. 1.9).

L. Fluorescein Staining of the Cornea* (REF.1E Slide 61, 62, 63)

Students should know how to apply topical fluorescein and interpret staining ofthe cornea for detection of a corneal epithelial defect (REF.4 FIG. 1.12 and 1.13).

M. Indications for Referral*Students should know when to refer patients to an ophthalmologist for evaluationof suddenly reduced visual acuity, abnormal fundus appearance, and otherabnormal findings associated with serious ocular or systemic disease.

Competencies:*• Student should:

o Understand basic ocular anatomy.o Measure near visual acuity.o Test for direct, consensual, and afferent pupillary reactions.o Understand the rationale and interpretation of testing the red reflex.o Understand the importance of the dilated fundus examination.o Understand and perform direct ophthalmoscopy.o Understand normal fundus appearance of the optic disc, macula and major

vessels.o Understand important causes of reduced vision, abnormal fundus

appearance, and abnormal findings that require referral of a patient to anophthalmologist for evaluation.

II. Cornea and External Disease

Educational goal: Students should understand anterior segment anatomy of the humaneye and know the signs and symptoms of common causes of red eye. Students shouldalso know which corneal and external related conditions require immediate referral to anophthalmologist.

A. Anatomy (REF.1E Slide 59)

1. Lids* (REF.1E Slide 10,12)a. Glands of Zeis and Mollb. Lashesc. Meibomian glandsd. Lacrimal gland

2. Conjunctiva* (REF.1E Slide 28)

a. Bulbarb. Palpaebral

3. Regional lymph nodes**a. Pre-auricularb. Sub-mandibular

4. Cornea*


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a. Tear filmb. Epitheliumc. Stromad. Endothelium

5. Lacrimal system* a. Punctum – upper and lower b. Lacrimal sac

B. Red Eye* (REF.1E Slides 01-06)1. Acute angle closure glaucoma* (REF.1E. Slide 83-87), (REF. 21 FIG. C01,C05,C09)

2. Iritis or iridocyclitis* (REF.1E. Slide 81,82)3. Herpes simplex keratitis* (REF.1E. Slide 74,75), (REF. 2 Case 13, Ocular Herpes Simplex. p. 26), (REF. 21 FIG. B06)4. Bacterial keratitis (REF.1E. Slide.76), (REF.1C Slide 56), (REF. 21 FIG. B08)5. Conjunctivitis* (REF.1E Slide 29, 30, 31, 45)

a. Bacterial (REF.1E Slide 32,33,34)b. Viral (REF.1E Slide 35,36,74), (REF.2 Case 2, Viral keratoconjunctivitis. p. 4) (REF. 21 FIG. B01)

c. Allergic (REF.1E Slide 37, 38), (REF.1C Slide 53), (REF.4 FIG 4.17), (REF. 21 FIG. B51)d. Neonatal (REF.1E Slide 39, 40, 41, 42, 44, 45, 46)

e. Neonatal Gonococcal (REF.1E Slide 43)6. Episcleritis** (REF.1F Slide47) (REF. 21 FIG. B50)

7. Scleritis** (REF.1F Slide 48, 49, 50)8. Adnexal disease*

a. Blepharitis* (REF.1E Slide 15, 16, 17, 18), (REF. 2 Case 18, Blepharitis, p.36) (REF. 21 FIG. B49)b. Thyroid eye disease* (REF.1F Slide 64-74) (REF. 21 FIG. E19, E20,E21)

c. Dacryocystitis* (REF.1E Slide 25)d. Hordeolum* (REF.1E Slide 11) (REF.4 FIG 4.18, 4.19) (REF.2 Case 26, Hordeolum, p.32)

e. Chalazion* (REF.1E Slide13) (REF. 21 FIG. B43, B44)9. Subconjunctival hemorrhage versus hyphema* (REF.1E Slide 47) (REF.4 FIG5.10) (REF. 21 FIG. B38, L11)10. Pterygium* (REF.1E Slide 55) (REF. 21 FIG. B29, B30)11. Keratoconjunctivitis sicca* (REF.1E Slide 48, 49, 50) (REF. 21 FIG. B05)

12. Corneal abrasions and foreign body* (REF.1E Slide 62, 63, REF.1C Slide 40, 41, 42) (REF.4 FIG5.7 and 5.8) (REF. 21 FIG. L06)13. Secondary to abnormal lid function**

a. Bell’s palsyb. Thyroid ophthalmopathy (REF.1F Slide 64-74) (REF. 21 FIG. E19, E20, E21)

14. Hyphema (REF.1E Slide 80) (REF. 2 Case 16, Traumatic Hyphema, p.32) (REF. 21 FIG. L19)15. Chemical injury (REF.1E Slide 69, 70,71) (REF.2 Case 24, Alkali Burn, p.48) (REF. 21

FIG. B14, B15)

C. Symptoms associated with red eye*1. Blurred or decreased central visual acuity2. Photophobia3. Colored halos (REF.1E Slide 84)


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4. Discharge5. Itching

D. Steps to differentiate red eye and how to interpret findings1. Measure central acuity at near* (understand importance of reduced visual acuity)2. Determine location of redness*

a. Subconjunctival hemorrhage (REF. 21 FIG. B38)

b. Conjunctival hyperemia (epibulbar, palpaebral or both)c. Ciliary flush associated with corneal inflammation, iritis, and acuteglaucoma # (REF.3)

3. Assess discharge and characterize*a. Profuse or scantb. Purulent, mucopurulent, or serous

4. Assess for corneal opacity associated with edema, inflammation, ulcer*# (REF.3)5. Examine for corneal epithelial defect with fluorescein*6. Estimate anterior chamber depth associated with acute angle closure glaucoma*# (REF.3)

7. Examine pupils and understand the importance of pupillary size with iritis (miotic) and acute angle closure glaucoma (mid dilated)*# (REF.3)

8. Measure intraocular pressure if elevation suspected***9. Assess and detect

a. Proptosis associated with orbital mass*# (REF.3)b. Lid malfunction*c. Limitation of eye movement*d. Pre-auricular lymph node enlargement*

Competencies:• Student should:

o Measure central acuity with near cardo Assess corneal clarity with penlighto Assess anterior chamber depth and narrowness of angle with a penlighto Assess pupil size, shape, regularity, and reactivityo Determine if redness is associated with subconjunctival hemorrhage, ciliary

flush, or conjunctival hyperemiao Assess conjunctival dischargeo Determine if proptosis is presento Assess ocular motilityo Understand findings that are associated with serious ocular conditions that

require immediate ophthalmic care

III. Lens and Cataract

Educational goals: Students should recognize the symptoms and ophthalmic signs ofcataract as a cause of decreased central visual acuity. They should understand the general


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principles of cataract surgery and correction of aphakia with intraocular lenses, contactlenses, or aphakic spectacles.

A. Anatomy of lens*1. Intraocular location of lens behind the iris plane2. Optical clarity of normal lens3. Suspension of normal lens in retroiridic position by zonules

B. Symptoms attributable to cataract*(REF.1B. Slide 10, 51) (REF. 21 FIG. A01, A02,A03, A04, A05, A06)1. Slowly progressive blurring of vision2. Painless progressive loss of vision

C. Examination of the lens by direct ophthalmoscopy* Evaluation of red reflex(REF.4 FIG. 3.9, 3.10, and 3.11)

D. Abnormal lens features by direct ophthalmoscopy1. General*

a. Loss of normal red reflex (REF.4 FIG. 3.9, 3.10, 3.11)b. Dark spots in red reflex (REF.1B Slide 50)

c. Abnormal color of red reflex2. Lens abnormalities found in important systemic diseases (REF.7 Table9-1)* Marfan syndrome – spontaneous dislocation of lens (REF.14 Fig. 4-15A, B) (REF. 21 FIG. H38)3. Lens abnormalities found in important ocular diseases**

a. Cataract (clouding or opacification of lens) (REF. 21 FIG. A07, A10)b. Implanted artificial intraocular lens (REF. 21 FIG. A24, A26, A27)

E. Treatment of cataract (REF.2 Case 6, Cataract, p.12)

1. Surgical removal of lens (cataract extraction)*** (REF.1B Slide 52) (REF. 21 FIG. A19 – A23)2. Implantation of artificial lens in eye*** (REF.1B Slide 54)

F. When to refer patient to an ophthalmologist **1. Examination reveals abnormal red reflex or lens clouding or opacity3. Patient reports progressive visual loss or blurring


o Understand lens anatomy**o Describe presbyopia – definition and symptoms**o Diagnose cataract*

definition and symptoms* red reflex* slit lamp findings***

o Understand importance of lens dislocation in association with systemicconditions, such as Marfan syndrome and homocystinuria***


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o Describe management of cataract *** surgery intraocular lens

IV. Neuro-Ophthalmology

Educational goal: Students should understand the relationship of the eye and visualsystem within the context of the central nervous system. Students should also know howto test pupillary reactions and how to assess peripheral visual fields, and shouldunderstand conditions which require immediate ophthalmic evaluation, such as suddenvision loss, papilledema, and anterior ischemic optic neuropathy with giant cell arteritisin the elderly patient, III nerve palsy with pupillary involvement, IV and VI nerve palsies.

A. Anatomy** 1. Bony Anatomy

2. Vascular Anatomy3. Afferent Visual Pathways (REF.4 FIG. 7.12)4. Ocular Motor Pathways5. Facial Motor and Sensory Anatomy*

a. Trigeminal Nerve*b. Facial Nerve*6. Ocular Autonomic Pathways

a. Sympathetic Pathways (REF.23 Slide 13,14,15) (REF.4 FIG. 7.4)b. Parasympathetic Pathways

7. Pupillary pathways (REF.4 FIG. 7.1)

B. Neuroimaging**1. Glossary2. History3. Basics of MR and CT imaging4. Fundamental concepts in localization

C. How to examine the patient*1. Visual acuity testing*2. Visual field testing – confrontation*3. Extraocular motility – appearance of eyes in primary position and normal motility in six cardinal positions of gaze*

a. Strabismus- ocular alignment in primary positionb. Limitation of eye movementc. Limitation of gaze (both eyes affected similarly)d. Nystagmus (spontaneous jerking eye movements)

4. Position of the eyelids*a. Normal lid positionb. Upper eyelid retraction (REF.4 FIG. 8.9)

c. Upper eyelid ptosis5. Pupillary reflexes (REF.4 FIG. 7.2)


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. 6. Direct ophthalmoscopy*

D. How to interpret findings1. Pupillary disorders (REF.23 Slide 09, 11) (REF.4 FIG. 7.2)

a. Dilated pupil* (REF.23 Slide 10)(1) Unilateral(2) Bilateral

b. Tonic pupil** (REF.23 Slide 16)

c. Relative afferent pupillary defect* (REF.4 FIG. 7.2)d. Unilateral small pupil** (REF.23 Slide 12, 15) (REF.4 FIG. 7.3) (REF.9 Fig. 26-3 Right Horner syndrome, the first sign of localized intrathoracic neuroblastoma in a 6 month-old boy)

2. Neuro-motility abnormalitiesa. Cranial nerve palsies* (REF.1B Slide 70) (REF.23 Slide 19)

(1) III nerve (REF.1B Slide 71) (REF.1F Slide 61) (REF.23 Slide 18) (REF.4 FIG7.5) Pupil not involved vasculopathic – not urgent(REF. 21 FIG. H19) Pupil involved – compressive lesion – urgentreferral

(REF.8, Fig. 14 a, b, c)(2) IV nerve (REF.4 FIG. 7.6) (REF. 21 FIG. E01, E02)(3) VI nerve (REF.1B Slide 72) (REF.4 FIG. 7.7)(REF. 21 FIG. H20 – 22,E03,05)

b. Other cranial nerve palsies**(1) V cranial nerve(2) VII cranial nerve

c. Myasthenia Gravis** (REF.1F Slide 75) (REF.23 Slide 21, 22)d. Intranuclear ophthalmoplegia** (REF.23 Slide 20) (REF.4 FIG 7.8 and 7.9)

e. Nystagmus**3. Optic nerve disease

a. Optic disc elevation (REF.23 Slide 04)(1) Congenital anomalous disc elevation**(2) Papilledema* (REF.1F Slide 10, 11,12) (REF.23 Slide 08) (REF.2 Case12, Papilledema, p.28) (REF. 21 FIG. E16)(3) Papillitis** (REF.23 Slide 05)

(4) Ischemic optic neuropathy** (REF.1B Slide 73) (REF.1F Slide58, 59) (REF.2 Case 11, Anterior Ischemic Optic Neuropathy, p.22) (REF. 21 FIG. E09)

b. Amaurosis fugax** (REF.1F Slide 16, 17, 18, 19, 20)

c. Optic atrophy** (REF.2 Case 3, Optic Atrophy, p.6)d. Visual field defect ** (REF.4 FIG. 7.12)

4. Visual field defects (REF.23 Slide 23, 24, 25) (REF. 21 FIG. E28)a. Scotoma***b. Hemianopia* (REF.4 FIG. 7.12) (REF. 21 FIG. E25)c. Homonomous hemianopia* (REF.4 FIG. 7.12)

d. Bitemporal hemianopia* (REF.4 FIG. 7.12) (REF. 21 FIG. E26, E27)

Competencies:


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• Student should:o Measure visual acuity with near cardo Perform confrontation visual field testing in four quadrants for each eyeo Test pupillary function and recognize a relative afferent pupillary defecto Perform test of ductions and versions and recognize acute onset cranial nerve

palsies III, IV, VI which require immediate referralo Recognize and diagnose nystagmuso Exam the optic disc with the direct ophthalmoscope and recognize optic nerve

pallor and papilledema

V. Retina Vitreous

Educational goals: Students should understand the normal appearance and function ofthe retina. They should recognize abnormal anatomy and the signs and symptoms ofconditions that are associated with important causes of visual loss, such as maculardegeneration, diabetic retinopathy, central retinal artery and central retinal veinocclusion.

A. Anatomy of vitreous and retina** (REF. 21 FIG. G07, K54, K55)

1. Vitreous2. Normal retinal blood vessel walls

a. Arteriolesb. Venules

3. Location of rods and cones in retina relative to vitreous and choroids4. Retinal pigment epithelium5. Macula6. Choroids

B. Symptoms suggestive of vitreoretinal disorders**1. Flashes (REF.1B Slide 67)

2. Floaters (REF.4 FIG. 1.5)3. Blurring, distortion, and or minimalization of central visual acuity4. Abrupt or progressive dimming of vision in one eye5. Abrupt or progressive loss of peripheral visual field in one eye

C. Examination of the normal eye with direct ophthalmoscopy* (REF.1G Slide25, 26) (REF. 21 FIG. I03)

1. Red reflex (REF.1G Slide 23)2. Optic disc3. Retinal arterioles and venules (REF.4 FIG. 1.18)4. Posterior retina and choroids

D. Abnormal fundus features with direct ophthalmoscopy*1. General*

a. Loss of normal red reflex (REF.1G Slide 07) (REF. 21 FIG. K72)

b. Dark spots in red reflexc. Abnormal color of red reflex


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2. Fundus features of important systemic diseases*a. Diabetes mellitus

(1) Background diabetic retinopathy (REF.1B Slide 57) (REF.1A Slides 19,20, 21,22, 24) (REF. 21 FIG. K14, K15, K40)(2) Proliferative diabetic retinopathy (REF.1A Slide 26,27,28,30) (REF. 21 FIG. K41)

b. Systemic hypertension*(1) Vasospastic (accelerated) retinopathy(2) Sclerotic (chronic) retinopathy

Atherosclerotic carotid occlusive disease*(3) Central retinal artery occlusion

(REF.2 Case 19, Central Retinal Artery Occlusion, p.3) (REF.1B Slide 61)(REF. 21 FIG. K34-36)

(4) Branch retinal artery occlusion (REF.1B Slide 62) (REF. 21 FIG.K20)

(5) Central retinal vein occlusion (REF.1B Slide 63) (REF.2 Case 21, Central Retinal Vein Occlusion, p. 42) (REF. 21 FIG. K37)

(6) Branch retinal vein occlusion (REF.1B Slide 64) (REF. 21 FIG. K20)

c. Embolic cardiovascular diseased. AIDS** (REF.1F Slide 83, 84) (REF. 21 FIG. K29)e. Disseminated metastatic cancer*** (REF.1F Slide. 36)

3. Fundus features of important ocular diseasesa. Retinoblastoma* (REF.1G Slide 07) (REF. 21 FIG. H27-29)

b. Retinal detachment** (REF.1B Slide 68, 69) (REF. 21 FIG. K70-72)c. Age-related macular degeneration* (REF.1B Slide 24, 25, 26, 27) (REF.2 Case 17, Age-Related Macular Degeneration , p. 34) (REF. 21 FIG. K03-05)

E. When to refer patient to an ophthalmologist1. Abnormal red reflex or fundus**2. Visual loss or symptoms consistent with a vitreoretinal disorder**


o Understand anatomy and function of retina*o Understand definition and function of the macula*o Understand importance of dilated fundus exam*o Recognize a change in red reflex*o Recognize normal retinal vasculature*o Detect diabetic retinopathy*

Background Proliferative

o Understand definition and importance of retinal detachment***o Understand importance of retinoblastoma and recognize leukocoria*

VI. Glaucoma

Educational goals: Students should understand the anterior segment anatomy andunderstand the circulation of aqueous humor in the normal human eye and in primary


17

open angle glaucoma and primary angle closure glaucoma. Students should recognizethe risk factors, signs, and symptoms of primary open angle glaucoma and angle closureglaucoma.

A. Anatomy 1. Aqueous humor**

a. Production(1) Ciliary body

b. Circulation (REF.1D Slide 10) (REF.1B Slide 35,46)(1) Movement from posterior chamber through pupil into anterior chamber

c. Outflow pathway (REF.1D Slide 11,13)(1) Trabecular meshwork in anterior chamber angle (REF. 21 FIG. C12)

(2) Uveoscleral outflow tract***2. Optic Nerve*

a. “Glaucoma may be defined as an optic neuropathy usually with characteristic optic nerve head and visual field changes.” (REF.1B Slide 33) (REF.1D Slide 03)

(1) Injury to axons from retinal ganglion cells at lamina cribrosa(2) Signs of optic nerve injury

(a) Increased size of central cup (REF. 21 FIG. C06, C54, C55)(b) Asymmetric cupping

3. Organization of axons and associated visual field defects*** (REF.1D Slide 05) (REF. 21 FIG. C26)

B. Examination1. Central visual acuity measurement*2. Visual field testing*

a. Confrontation testing with finger counting in 4 quadrants of each eyeb. Central color testing – red top bottle

3. Pupillary reaction*Relative afferent pupillary defect as sign of unilateral optic nerve injury4. Penlight examination* (REF.4 FIG. 1.10)

Anterior chamber depth estimation(a)Normal(b)Narrow

5. Intraocular pressure***a. Applanation tonometry (REF. 21 FIG.29)b. Normal value range. Direct ophthalmoscopy of signs of glaucomatous optic neuropathy* (REF.1B Slide 33) (REF. 21 FIG. C53-56)

C. How to interpret history and risk factors1. Primary open angle glaucoma* (REF.1D Slide 09) (REF.2 Case 12, Primary Open Angle Glaucoma, p.24)

a. Risk factors (REF.1B Slide 32) (REF.4 FIG. 3.1)(1) Increased intraocular pressure(2) African and Caribbean African ancestry*(3) Age greater than 75 years*(4) Primary family member with glaucoma*


18

b. Genetic influence*** GlC1a (myocillin gene) juvenile open angle glaucomac. Symptoms* Lack of symptoms until late in disease

2. Normal tension glaucoma***a. Optic nerve injury and visual field loss similar to primary open angle glaucomab. Not associated with elevated intraocular pressure

3. Primary Angle Closure Glaucoma* (REF.1B Slide 46) (REF. 21 FIG. C01, C05, C09)a. Risk Factors

(1) Anatomically narrow anterior chamber angle(2) Hyperopia(3) Dilating drops in eyes with narrow angles(4) Anti-cholinergic medications(5) Older age(6) Some Asian populations, Chinese (REF.1B Slide 45)

b. Symptoms*(1) Ocular pain (may be severe)(2) Ocular redness*(3) Blurred vision, colored halos, nausea

c. Signs*(1) Dilated fixed pupil (REF.1B Slide 47)

(2) Narrow anterior chamber angle(3) Pupillary block(4) Corneal edema

D. Pharmacological treatment for open angle glaucoma** (REF.1B Slide 37, 38) (REF. 21 FIG. C02-04)

1. Topical medications that increase aqueous humor outflowa. Parasympathomimetics (REF.1B Slide 41)b. Prostaglandin analogues (REF.1B Slide 42)

2. Medications that decrease aqueous productiona. Topical Beta blockers (REF.1B Slide 39)

b. Oral Carbonic anhydrase inhibitors (REF.1B Slide 43)c. Alpha2-agonistsd. Adrenergic agonists (REF.1B Slide 40)

E. Surgical treatment***1. Primary acute angle closure glaucoma

a. Peripheral iridectomy (REF.1B Slide 48) (REF. 21 FIG. C46, C47)2. Primary open angle glaucoma*** (REF.1B Slide 44)

a. Laser trabeculoplasty (REF. 21 FIG. C38)b. Filtering surgery (REF. 21 FIG. C41, C42, C43, C49, C50, C51)


o Obtain history to determine risk factors for primary open angle glaucoma


19

o Measure visual acuity with near card*o Perform confrontation visual field testing in four quadrants for each eye*o Assess pupillary reactions for relative afferent defect*o Estimate anterior chamber depth with penlight*o Diagnose primary acute angle closure glaucoma by history and penlight

examination*o Recognize signs of optic nerve injury – increased cupping and asymmetric

cupping *

VII. Pediatric Ophthalmology and Strabismus

Educational Goals: Students should understand the normal anatomy of the extra ocularmuscles and normal ocular alignment. Students should understand the principles ofabnormal ocular alignment, such as exotropia, and esotropia, and the risk of amblyopia inchildren. They should understand that infants and children with loss of red reflex requireimmediate ophthalmologic evaluation.

A. Anatomy of the Extraocular Muscles and their Fascia (REF. 21 FIG. G13)

1. Origin, course, insertion, innervations, and action of the extraocular musclesa. Horizontal rectus muscles*b. Vertical rectus muscles*c. Oblique muscles*d. Levator palpebrae superioris muscle*e. Insertion relationships of the rectus muscles*

2. Blood supply of the Extraocular muscles***a. Arterialb. Venous

3. Fine structure of the extraocular muscles** Fiber types

B. Amblyopia* (REF.1G Slide 10, 11, 12, 13, 14, 15) (REF.2 Case 22, Esotropia and amblyopia, p. 44)1. Strabismic amblyopia (REF.1G Slide 14,17) – major cause of unilateral

decreased visual acuity in children2. Refractive amblyopia (REF.1G Slide 12, 13)

3. Form deprivation and occlusion amblyopia (REF.1G Slide 11)

C. Strabismus*1. Concomitant strabismus (REF.4 FIG. 6.3)

2. Incomitant strabismus (REF.4 FIG. 6.4)3. Heterotropia* (REF.4 Table6.1 and Figure 6.5)

a. Esophoria: inward deviation - not manifest***b. Esotropia: inward deviation - manifest* (REF.1G Slide 17, 37) (REF. 21 FIG. H07,

H08)c. Exophoria: outward deviation - not manifest***d. Exotropia : outward deviation*- manifest (REF.1G Slide 37) (REF. 21 FIG. H09-12)

e. Hyperphoria: upward deviation - not manifest***f. Hypertropia: upward deviation*- manifest* (REF.8 IV Nerve Palsy, Fig. 9-13)


20

g. Hypophoria: downward deviation - not manifest***h. Hypotropia: downward deviation* -manifest (REF.1C Slide 29)

D. Examination of the eyes1. Visual acuity and amblyopia*

a. Newbornsb. Infants to 2 years old** (REF.1G Slide 29, 30)c. 2 to 4 years old** (REF.1G Slide 32, 33) (REF.4 FIG6.6)

d. 4 to 5 and up** (REF.1G Slide 34)

E. Strabismus Testing 1. General Inspection*

2. Corneal light reflex – Hirschberg test (REF.1G Slide 36, 37, 38) (REF.4 FIG. 6.11) (REF. 21 FIG. H06)3. Cover test**(REF.4 FIG 6.12)

4. Other tests**a. Red reflex (REF.1G Slide 19, 23)

b. Ophthalmoscopy (REF.1G Slide 24, 25, 26, 27)c. Pupillary testing

. F. Leukocoria*1. Retinoblastoma* (REF.4 FIG. 6.14) (REF. 21 FIG. H27-29)2. Persistent Hyperplastic Primary Vitreous (PHPV)*** (REF. 21 FIG. H39, H40)

3. Retinopathy of Prematurity (ROP) (REF. 9 Stages of retinopathy of prematurity, Fig.XXIV-2, XXIV-3, XXIV-4, XXIV-5, XXIV-6 p. 304)** (REF. 21 FIG. H32-36)

4. Cataract** (REF.1G Slide 42)

G. Management or referral*1. Amblyopia (REF.1G Slide 39)2. Strabismus3. Leukocoria* - cause for urgent referral


o Perform visual acuity testing in each eye in preverbal children by fixation andrecognizing fixation preference, if present. ***

o Understand the importance of measuring visual acuity in children 2-5 years withAllen cards or HOTV or tumbling E card with each eye.***

o Recognize and characterize ocular misalignment (strabismus) by performingHirschberg testing*

o Recognize leukocoria and importance*o Understanding the importance for urgent referral for leukocoria, amblyopia, and

strabismus in a child *

VIII. Eyelid, Lacrimal System, and Orbit


21

Educational goals: Students should understand the normal anatomy of the adnexalstructures and the presenting signs and symptoms of serious conditions associated withocular and systemic morbidity, such as orbital cellulitis.

A. Eyelid*1. Examination and Technique

a. Assess the position of the upper eyelid by measuring the distancebetween the lid margin and the corneal light reflex (Margin reflexdistance)b. Visual inspection of eyelids and periocular area

2. Normal anatomy**a. Anterior and posterior lamellae***b. Lid margin** (REF.1E FIG.10, REF.1E FIG.12)c. Orbital septum relationship to eyelid/orbit**d. Eyebrow**e. Levator aponeurosis**f. Blood supply – internal and external carotid circulation***g. Sensory supply – V1 and V2*h. Motor supply – CN III, CN VII, and upper eye lid sympatheticinnervations

3. Eyelid Diseasesa. Malpositions .

(1) Blepharoptosis** (REF.1B Slide 20)(2) Dermatochalasis**(3) Entropion* (REF.1B Slide 18) (REF. 21 FIG. F17-20)(4) Ectropion* (REF.1B Slide 19) (REF. 21 FIG. F14-16)

(5) Retraction*(REF. 10 Fig. 12-18)(6) Lagophthalmos* (REF. 10 Fig. 12-13)

b. Inflammations(1) Chalazion* (REF.1E FIG.13, REF.1E FIG.14)

(2) Blepharitis* (REF.1E FIG.16, REF.1E FIG.18)(3) Meibomitis** (REF. 21 FIG. B49)

c. Infections*(1) Hordeolum* (REF.1E FIG.11) (REF. 21 FIG. B43)

(2) Preseptal cellulitis** (REF. 21 FIG. H43)(3) Orbital cellulitis* (REF.1E FIG.19,20,21,22)

(4) Herpes Zoster Ophthalmicus (REF.1B Slide 23)d. Tumors

(1) Benign(2) Cysts***(3) Nevi**(4) Papillomas**(5) Xanthelasma* (REF. 7 Fig 13-6)(6) Malignant**

(a) Basal cell carcinoma** (REF.1B Slide 21) (REF.2 Case20, Basal Cell Carcinoma, p. 40) (REF. 21 FIG. F02, F03)

(b) Squamous cell carcinoma**


22

(c) Eyelid trauma** (REF.1C Slide.32, 33) (REF. 21 FIG.F53, F54)

B. Lacrimal System1. Examination TechniqueVisual inspection of medial canthal area* (REF.1C Slide34)2. Anatomy REF.1 FIG.24)

a. Upper lacrimal system – puncta, canaliculi and lacrimal sac*b. Lower lacrimal system – bony and mucosal nasolacrimal duct***

3. Lacrimal Diseasesa. Congenital nasolacrimal duct obstruction**b. Acquired nasolacrimal duct obstruction**c. Dacryocystitis** (REF.1E Slide 25) (REF. 21 FIG. F13)

d. Lacrimal trauma**

C. Orbit1. Examination technique

a. Observe laterally and superiorly to compare both eyes to identify axial proptosis*b. Exophthalmometer***

2. Anatomya. Seven bones comprise 4 walls – floor, medial and lateral walls androof*** (REF.4 FIG. 5.1)

b. Orbital septum relationship to orbit**c. Contents of orbit – extraocular muscles, lacrimal system, ophthalmicartery, nerves (CN II, IV, V, VI, sympathetic, and parasympathetic)*Relationship of orbit to surrounding structures – sinuses, cranial cavity*

3. Orbital Diseasesa. Orbital cellulitis* - life threatening condition requiring urgent referral (REF.1E Slide 19, 20, 21, 22)b. Graves’ ophthalmopathy* (Thyroid Eye Disease) (REF.1F Slide 64,74)c. Orbital inflammatory disease**d. Orbital tumors –

(1) Muscle (REF. 9 Fig 26-1 Rhabdomyosarcoma in a 4-year old boy presenting withright upper eyelid ptosis of 3 weeks duration and a palpable subcutaneous mass)(2) Vascular (REF. 9 Fig.26-5 Capillary hemangioma in a 2-month old girl involvingthe right upper eyelid and orbit with displacement of the globe and induction of 8D ofastigmatic error)(3) Neural (REF. 8 Fig. 8a-f )

a. Clinical photograph of a child with a right optic nerve glioma displaying proptosis and esotropia

b. Fundoscopic view of the same patientc. fMR imaging studies

(4) Lacrimal (REF.10 Fig. 15)

a. Proptosis and downward displacement of the left eye in a manwith benign mixed tumor of the lacrimal gland.

b. Axial CT scan


23

c. Coronal CT study (REF. 21 FIG. F25-29)(5) Metastatic (REF.9 Fig. 26-2 Bilateral orbital metastases of neuroblastoma

presenting with bilateral ecchymosis in a 2-year old child)**a. Orbital trauma** (REF.1C Slide 36, 37, 38)

Blowout fracture (REF.1C Slide 29, 30) (REF. 21 FIG. F38-42)Competencies:• Student should:

o Understand structure and function of eyelids, commonly associatedmalpositions, and acquired disorders.*

o Understand tear production and drainage.**o Understand orbital structure and common abnormalities.**o Understand the importance of orbital cellulitis as a potentially life threatening

condition that requires emergent attention.

IX. Ocular Manifestations of Systemic Disease

Educational goal: Students should understand the signs and symptoms of ocularconditions that are associated with important systemic diseases and diagnoses, such ascongenital, traumatic, vascular, neoplastic, autoimmune, idiopathic, infectious, metabolicor endocrine, and pharmacologic or toxic conditions.

A. Congenital (REF.1F Slide 4,5,6)***

Neurofibromatosis (REF. 21 FIG. E08)

B. Trauma (REF.1F Slide 7)Shaken baby syndrome

C. Vascular causes1. Hypertension (REF.2 Case 5, Hypertensive Retinopathy, p. 10)

a. Posterior segment (REF.1F Slide 8,9,10)

(1) Arteriolar narrowing* (REF.1F Slide 9)(a) Copper wire(b) Silver wire

(2) Hemorrhages (flame-shaped)*(a) Exudates (cotton wool spots, macular star)*

(3) Papilledema (malignant hypertension)* (REF.1F Slide 10)

2. Intracranial hypertension (REF.1F Slide 11, 12)3. Embolic Hollenhorst plaque (REF.1F Slide13,14,15 (REF. 21 FIG. K47)

4. Amaurosis Fugax (REF.1F Slide16-20)a. Transitory Ischemia Attack (TIA)* (REF.1F Slide 13)

(1) Visual changes*(2) Fundus findings** (REF.1F Slide 18)

b. Cerebrovascular accident - stroke(1) History*(2) Visual field findings* (REF.4 FIG7.12)

(a) Homonymous hemianopia


24

(b) Homonymous quadrantanopia5. Central retinal vein occlusion (REF.1F Slide 21) (REF. 21 FIG. K37)

6. Migraine (REF.1F Slide 22-24)7. Blood dyscrasias (REF.1F Slide 25-32)

a. Sickle cell anemia(1)Anterior segment

(a) Importance of recognizing traumatic hyphema as a risk for acute vision loss*(b) Anterior segment ischemia***

(2) Posterior segment (REF.1F Slide 30,31,32)

(a) Salmon patch***(b) Black sunburst***(c) Sea fan***

D. Malignancy (REF.1F Slide33)1. Primary

a. Intraocular**(1)Retinoblastoma* (REF. 21 FIG. H27-H29)

(2) Uveal malignant melanoma**(REF.2 Case 7, Malignant ChoroidalMelanoma, p. 14) (REF. 21 FIG. K25, K26)

(3) Lymphoma*** (REF.1B Slide 65)

b. Eyelid(1) Basal cell carcinoma** (REF. 21 FIG. F02, F03)

(2) Sebaceous carcinoma**(3) Melanoma***

c. Orbit(1) Lymphoma***(2) Lacrimal gland tumors*** (REF. 21 FIG. F25-29)(3) Other

2 Secondarya. Extension from sinus carcinoma***b. Metastasis***

(1) Adults-carcinoma (REF.1F Slide 34,35,36)

(2) Children-leukemia –Roth Spots (REF.1F Slide 28)

E. Autoimmune disease (REF.1F Slide39-76)1. Thyroid (Graves) disease (REF.2 Case 4, Endocrine Ophthalmopathy, p.8)

a. Clinical (Werner classification) (REF.1F Slide 66, 67, 68, 69, 70, 71)b. Treatment for thyroid orbitopathy**

(1) Non-surgical**(a) Corticosteroids(b) Radiation

(2) Surgical***(a) Eyelid (REF. 21 FIG. F52)(b) Orbital decompression

2. Rheumatoid arthritis (REF.1F Slide46,47, 48, 49, 50, 51)a. Dry eyes (REF. 21 FIG. B05)


25

b. Episcleritis (REF.1F Slide47) (REF. 21 FIG. B50)c. Scleritis** (REF.1F Slide48, 49, 50)

d. Peripiheral corneal ulceration (REF.1F Slide 51) (REF. 21 FIG. B25)3. Myasthenia gravis

a. Ocular motility disturbance – noncommitantb. Lid eye malposition – ptosis (REF.1F Slide 75)

4. Wegener granulomatosisa. Orbital involvement (REF.10, Fig. 4-11a, b, c)

F. Sarcoidosis** and other inflammatory diseases (REF.2 Case 10, Sacroid uveitis, p 20.)

1. Sarcoidosisa. Clinical findings

(1) Eyelid nodules(2) Conjunctival nodules

b. Uveitis – granulomatous versus nongranulomatous(1) Non-granulomatous*** (associated systemic diseases-JuvenileRheumatoid Arthritis, Reiter, Behcet disease (REF.29)(2) Granulomatous*** (associated diseases-sarcoidosis, Tuberculosis, fungal) (REF.1F Slide 78)

c.. Choroiditis and retinal vasculitis (REF.1F Slide 79)

d. Diagnostic tests(1) Imaging, gallium scan*(2) ACE level**

2. Behcet syndromeClinical triad findings (REF. 12 Fig 7-15-17) (REF. 29)

a. Acute iritis with hypopyonb. Aphthous stomatitis (canker like mouth ulcers)c. Genital ulceration

G. Infectious1. AIDS

a. Adnexal(1). Bacterial infections of the lids and adnexa (REF.18, Fig. 4-10 Fatal orbital cellulitis due to Staphylococcus aureus, p.41)*(2). Kaposi sarcoma*(REF.18 Fig. 4-2 Extensive Kaposi sarcoma of face and eyelids, limiting vision, p.37(3) Non-Hodgkin lymphoma (REF.18 Fig. 4-11, Bilateral lid swelling due

to orbital lymphoma p. 41)b. Conjunctiva

(1) Kaposi sarcoma (REF.18 Fig.4-3 Kaposi sarcoma in the inferior cul-de- sac, mimicking subconjunctival hemorrhage, Fig. 4-4)

(A) Multiple Kaposi sarcoma lesions on bulbar conjunctiva(B) High power view of one such lesion reveals its vascular nature, p. 37).(2) Squamous cell carcinoma Ophthalmology (REF.18 Fig. 4- 6 Squamous cell carcinoma of conjunctiva of superior limbus p.39)


26

c. Posterior segment (REF.1F Slide 82)(1) CMV retinitis* (REF.1F Slide 83) (REF.2 Case 25, Cytomegalovirus Retinitis, p.50) (REF. 21 FIG. K29) (2) Cotton wool patches* (REF.1F Slide 84)

2. Syphilisa. Anterior segment

(1)Interstitial keratitis***(2) Anterior uveitis**

b. Posterior segment(1) Neuroretinitis**(2) Papillitis***(3) Posterior uveitis***

3. Other systemic infectionsa. Viral (herpes zoster ophthalmicus “shingles”)* (REF.4 FIG8.13)b. Fungal (e.g. Candida endophthalmitis)***c. Bacterial (e.g. Tb uveitis)***d. Toxoplasmosis (REF. 21 FIG. K82-85)

e. Onchocerciasis (REF. 16, Fig 21 1-2, and 21-3)

H. Diabetes*1. Anterior segment

a. Corneal wound healing***b. Cataract*

2. Posterior segment a. Diabetic retinopathy* (REF.1A Slide 18,19,34)

(1) Background retinopathy-hard exudates (REF. 21 FIG. K40) hemorrhages, microaneurysms* (REF.1A Slide 19, 20, 21, 22, 24) (REF.2 Case 1, Nonproliferative Diabetic Retinopathy, p. 2) (REF. 21 FIG. K14, K15, K40, K41)(2) Preproliferative retinopathy-soft exudates, intraretinal microrovascular abnormality*** ( REF.1A Slide 25)

(3) Proliferative retinopathy – neovascularization of the disc (REF. 21 FIG. K41), neovascularization elsewhere* (REF.1A Slide 26,27)

vitreous hemorrhage* (REF. 21 FIG. K86) (REF.1A Slide. 28) (REF.2 Case 9, Proliferative Diabetic Retinopathy, p. 18)

b. Ischemic optic neuropathy***


o Recognize retinal exudates and hemorrhages on dilated fundus exam*o Understand importance of traumatic hyphema in sick cell anemia***o Recognize retinal arteriolar narrowing (copper wire/silver wire) on dilated

fundus exam*o Detect disc edema on fundus exam with direct ophthalmoscopy*o Perform neurologic assessment of all cranial nerves*o Perform confrontational visual fields with recognition of hemianopias*o Recognize limited ocular motility*


27

o Recognize proptosis*o Recognize photophobia as symptom of uveitis*o Assess for malignant neoplasms of eyelids (carcinoma, melanoma)***

X. Intraocular Tumors

Educational goal: Students should understand that malignancy may affect the eye andadnexa and recognize the signs and symptoms of childhood retinoblastoma.

A. Retinoblastoma* (REF.2 Case 27, Leukocoria/Retinoblastoma, p.54) (REF. 21 FIG. H27-29)

1. Knudson’s two-hit hypothesis2. Genetics

a. 13q14 deletionb. Heritable vs. sporadic

3. Clinical presentationa. Leukocoriab. Strabismus

4. Treatment***a. Chemotherapy and radiation therapyb. Surgical (enucleation)

5. Differential diagnosis***a. Retinopathy of Prematurity (ROP) (REF. 9, Stages of retinopathy ofprematurity, Fig XXIV-2, XXIV-3, XXIV-4, XXIV-5, XXIV-6 p. 304.) (REF. 21 FIG.H32-36)b. Coats’ disease (REF. 21 FIG. K31, K32)c. Persistent Hyperplastic Primary Vitreous (REF. 21 FIG. H39, H40)

B. Uveal Melanoma** (REF.2 Case 7, Malignant Choroidal Melanoma, p. 14)

1. Most common primary intraocular malignancy2. Variants***

a. Irisb. Ciliary bodyc. Choroidal (REF. 21 FIG. K25, K26)

3. Clinical presentation*a. Asymptomatic vs. symptomatic*b. Pigmented vs. amelanotic***

4. Prognosis***a. Sizeb. Cell type

5. Treatment*** a. Non-surgical

b. Surgical (enucleation)6. Differential diagnosis***

a. Choroidal nevusb. Metastastis to eyec. Retinal detachment


28

C. Other intraocular tumors***1. Lymphoma-primary large cell lymphoma vs. systemic lymphoma2. Metastasis-carcinomas in adults (REF.1F Slide 35, 36)3. Leukemia infiltration of optic nerve (REF.1F Slide 29)


o Assess red reflex with flashlight/penlight and direct ophthalmoscope*o Assess ocular alignment with Hirschberg test.*o Obtain history for risk factors for retinoblastoma*o Recognize retinal detachment/intraocular tumor on fundus exam of adult***

XI. Refraction and Contact Lens**

Educational goal: The student should understand that the human eye is an opticalsystem and principles of common refractive errors, such as myopia, hyperopia,astigmatism, and presbyopia. The student is expected to know how to measure visualacuity with a near card and near correction.

A. Refraction States (as it affects direct ophthalmoscopy)*1. Emmetropia (REF. 6 Fig.3-8 and Fig. 4-18)2. Myopia (REF. 6 Fig. 3-9, p.118, and Fig. IV-18) (REF. 21 FIG. G30, G31, G34)

3. Hyperopia (REF. 6 Fig. 3-10, p.119) (REF. 21 FIG. G25, G26, G29)Astigmatism (REF. 14 Fig.3) (REF. 11 Fig 15,16) (REF. 21 FIG. G21, G22)

4. Presbyopia and accommodation (REF. 6 Table IV-2, Average Accommodative Amplitudesfor different ages, p. 151)

B. Spectacle Correction***1. Spherical lenses2. Bifocals, trifocals, multi-focal lenses (progressive lenses)

C. Special Lens Material***1. Plastic2. Impact resistant high index plastic3. Polycarbonate lens

D. Contact Lenses***Clinically important features of contact lens –

1. Optics2. Field of vision3. Image size4. Hard contact lens5. Flexible contact lens6. Therapeutic contact lens

E. Intraocular Lens**Concept of correcting the refractive error caused lens removal


29

F. Refractive Surgery***Concept of correcting myopia and hyperopia

G. Patients with Low Vision*** (REF.1B Slide 78, 79) (REF. 16 Table 3-3a, 3-3b) (REF. 21 FIG. D02-09)

1. Understand that patients may benefit from low vision aids2. Need for special rehabilitation with low vision optical devices.


o Understand emmetropia, myopia, hyperopia, astigmatism, and presbyopia**o Measure near central acuity in adults with near card and understand measurement

of acuity in children with Allen cards or tumbling E*o Understand optical principles of contact lens, intraocular lens, and refractive

surgery**o Understand the need for low vision rehabilitation*

XII. Refractive Surgery*** (This section is optional)

Educational goal: Students should understand the eye as an optical system and shouldknow how refractive surgery corrects common refractive errors of emmetropia, myopia,hyperopia, and astigmatism.

A. Refractive errors* 1. Myopia – long eye or steep cornea or both

2. Hyperopia – short eye or flat cornea or both\3. Astigmatism – uneven curvature of cornea4. Presbyopia – inability to focus at near due to aging

B. Types of surgical techniques to correct refractive errors***1. Incision – weaken cornea structurally to change curvature (REF. 21 FIG. J01, J02, J16)2. Lamellar – change cornea shape with addition or removal of tissue3. Thermal – shrink corneal collagen to steepen or flatten the anterior corneal curvatures4. Intraocular lens implantation with or without removal of crystalline lens

C. Newer procedures –with excimer laser***1. Photorefractive keratectomy (PRK) (REF. 21 FIG. J17,18)

2. Laser in situ keratomileusis (LASIK) (REF. 21 FIG. J06-11, J13-15)

D. Effectiveness of refractive surgery***1. Continual improvement2. LASIK may be more predictable than Radial Keratotomy3. Uncorrected visual acuity of 20/40 or better in most patients4. Larger range of treatable refractive errors


30

E. Risks associated with refractive surgery include***1. Infection2. Loss of best-corrected visual acuity3. Overcorrection, under correction, regression to baseline refractive status4. Visual aberrations such as glare and halos

F. Success in refractive surgery (depends on)***1. Careful preoperative evaluation2. Exclusion of systemic diseases and eye disorders that may be contraindicated3. Options and risks and benefits of each procedure


o Understand refractive errors and their relations to eye length, cornealcurvature, and lens status*

o Describe refractive surgical theory and practice***o Understand risks and benefits of commonly discussed and performed

refractive procedures***


31

III. REFERENCES

1. The "Atlas of Ophthalmology" (www.atlasophthalmology.com) is an onlinemultimedia database edited by Georg Michelson, MD, from the UniversityAugenklinik in Erlangen, Germany and Robert Machemer, MD, from DukeUniversity in Durham, North Carolina, USA. It is endorsed by the ICO.

2. Coleman AL. Eye Care Skills on CD-ROM, A. Diabetes and Eye Disease; B. EyeCare for the Elderly; C. Eye Trauma and Emergencies; D. Glaucoma:Diagnosis and Management; E. Managing of the Red Eye; F. OcularManifestations of Systemic Disease; and G.Understanding and PreventingAmblyopia. Developed by the Interspecialty Education Committee of theAmerican Academy of Ophthalmology. 2001; Slides 1-85

3. Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students,Instructor Manual, Second Edition. San Francisco: Amer. Acad. Ophthal. 1993-2003; Cases 1- 24

4. Bradford CA. Basic Ophthalmology for Medical Students and Primary CareResidents, (7th Edition). San Francisco: Amer. Acad. Ophthal. 1999; Chapter 4,75-97

5. Bradford CA. Basic Ophthalmology, (8th Edition). San Francisco: Amer. Acad.Ophthal 2004; Fig. Table

6. Cibis G. Basic and Clinical Science Course Section 2. 2005-2006, Fundamentalsand Principles of Ophthalmology. San Francisco: Amer. Acad. Ophthal. 2005.

7. Miller KM. Basic and Clinical Science Course Section 3. 2005-2006, Optics,Refraction, and Contact Lenses. San Francisco: Amer. Acad. Ophthal. 2005.

8. Grossniklaus H. Basic and Clinical Science Course Section 4. 2005-2006,Ophthalmic Pathology and Intraocular Tumors. San Francisco: Amer. Acad.Ophthal. 2005.

9. Kline LB. Basic and Clinical Science Course Section 5. 2005-2006, Neuro-Ophthalmology. San Francisco: Amer. Acad. Ophthal. 2005.

10. Simon JW. Basic and Clinical Science Course Section 6. 2005-2006, PediatricOphthalmology and Strabismus. San Francisco: Amer. Acad. Ophthal. 2005.

11. Kersten RC. Basic and Clinical Science Course Section 7. 2005-2006, Orbit,Eyelids, and Lacrimal System. San Francisco: Amer. Acad. Ophthal. 2005.

12. Sutphin JE. Basic and Clinical Science Course Section 8. 2005-2006, ExternalDisease and Cornea. San Francisco: Amer. Acad. Ophthal. 2005.


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13. Opremcak EM. Basic and Clinical Science Course Section 9. 2005-2006,Intraocular Inflammation and Uveitis. San Francisco: Amer. Acad. Ophthal. 2005.

14. Simmons ST. Basic and Clinical Science Course Section 10. 2005-2006,Glaucoma. San Francisco: Amer. Acad. Ophthal. 2005.

15. Rosenfeld SI. Basic and Clinical Science Course Section 11. 2005-2006, Lens andCataract. San Francisco: Amer. Acad. Ophthal. 2005.

16. Regillo C. Basic and Clinical Science Course Section 12. 2005-2006, Retina andVitreous. San Francisco: Amer. Acad. Ophthal. 2005.

17. VanNewkirk M. Basic and Clinical Science Course Section 13. 2004-2005,International Ophthalmology. San Francisco: Amer. Acad. Ophthal. 2003.

18. Weiss JS. Basic and Clinical Science Course Section 14. 2004-2005, RefractiveSurgery. San Francisco: Amer. Acad. Ophthal. 2003.

19. Cunningham, E.T, Jr. Belfort R. HIV/AIDS and the Eye: A Global Perspective.Ophthalmology Monographs 15. San Francisco: Amer. Acad. Ophthal. 2002.

20. Jr. Flynn HT, Smiddy WE. Diabetes and Ocular Disease: Past, Present, andFuture Therapies. Ophthalmology Monographs 14. San Francisco: Amer. Acad.Ophthal. 2000.

21. Kline L.B. Optic Nerve Disorders. Ophthalmology Monographs 10. SanFrancisco: Amer. Acad. Ophthal. 1996.

22. Ophthalmic Images Collection. CD-ROM. San Francisco: Amer. Acad. Ophthal.2002; V.3, Figure

23. Lightman S. Medical Lecture Diabetic Retinopathy. London, UK: 2003-2004;Slides 1-14

24. Lightman S. Undergraduate Medical Lecture Neuro-Ophthalmology. London,UK: 2003-2004; Slides 1-25

.25. Lightman S. Undergraduate Medical Lecture Systemic Disease and the Eye,

Diabetic Retinopathy 2-9, Central Retinal Vein Occlusion 10, Central RetinalArtery Occlusion 11, Thyroid Eye Disease 12-17, Sacroidosis 18-31,Phacomatoses 32-47, Rheumatoid Arthritis 48, Wegeners Granulomatosis andPolyarteritis Nodosa 49, Giant Cell Arteritis 50-56, Ocular Manifestations ofHIV Infection 57-89. London, UK: 2003-2004; Slides 1-97


33

26. Lightman S. Undergraduate Medical Lecture Visual Loss in the Elderly, Cataract3-7, Glaucoma 8-12, Anterior Ischemic Optic Neuropathy 13-14, Retinal VeinOcclusion 15, Central Retinal Vein Occlusion 16-17, Macular Disease 18-20.London, UK: 2003-2004; Slides 1-20

27. Lightman S. Undergraduate Medical Lecture Ocular Manifestations of HIVInfection and Glossary. London, UK: 2003-2004; Slides 1-35

28. Lightman S. Undergraduate Medical Lecture Red Eye. London, UK: 2003-2004;Slides 1-2

29. Lightman S. Undergraduate Medical Lecture Giant Cell Arteritis. London, UK:2003-2004; Slides 1-7

30. Lightman S. Undergraduate Medical Lecture Giant Cell Behcet’s Disease.London, UK: 2003-2004; Slides 1-9

IV. Additional Sources of Teaching Material

Metz JCM, Verbeek-Weel AMM, Huisjes HJ. Blueprint 2001: Training of Doctors inThe Netherlands. ( Appendix List of Skills, List of Clinical Pictures Ophthalmology).English translation by David TE & JE, Van de Wiel A, Gorsira MLB. 2001; pages 53-56.

CorneaLesions of corneal, superficial (actinic keratitis, erosion, contact lenses;Cornea, foreign body; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: L06Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseasesand Cornea. FIG XIX-10, A-D, Cornea, foreign body; FIG XIX-11, Corneal rust ring and multipleretained iron foreign bodies; San Francisco: Amer. Acad. Ophthal. 2002-2003; 380, 382.Burns: alkali; Ophthalmic Images Collection, V.3: B14, B15; San Francisco: Amer. Acad. Ophthal.Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XIX-1 Mild alkali burn; FIG XIX-2 Moderate alkali burn with edema & haze; San Francisco: Amer. Acad.Ophthal. 2002-2003; 365-368Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 24Diagnosis: Alkali Burn. San Francisco: Amer. Acad. Ophthal. 2003; 48Burns: acid; Burns:heat; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3:B23

KeratitisKeratitis with corneal ulcer; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3:B08Jr. Flynn HW, Smiddy WE. Diabetes and Ocular Disease: Past, Present and Future. Ophthalmology Monograph 14.(Fig.10-1); Neurotrophic ulcer in patient with decreased corneal sensitivity, Amer. Acad. Ophthal. 2000; 223Dendritic keratitis (Herpes simplex); Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal.2002; V.3: B06Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students. Instructor Manual. Second Edition.Case 13Diagnosis: Ocular Herpes Simplex. San Francisco: Amer. Acad. Ophthal. 2003; 26Kerato-conjunctivitis sicca; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3:B05


34

Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG V-6 Keratoconjunctivitis sicca with punctuate epithelial erosions, shown by rose bengal stain; FIG VI-10Conjunctival xerosis with focal keratinization (Bitot spot) as a result of vitamin A deficiency. San Francisco: Amer.Acad. Ophthal. 2002-2003; 77-86Corneal edema;Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XIX-2 Moderate alkali burn with corneal edema and haze. San Francisco: Amer. Acad. Ophthal. 2002-2003; 366Corneal dystrophy; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: B02-04,B16Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XV-12 Fuchs endothelial dystrophy showing microcystic epithelial edema. San Francisco: Amer. Acad. Ophthal.2002-2003; 308Keratoconus; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: B11-13Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XV-16 Keratoconus. San Francisco: Amer. Acad. Ophthal. 2002-2003; 312

ConjunctivaConjunctival, foreign body;Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XIX-9 Foreign bodies seen on the everted surface of the upper eyelid. San Francisco: Amer. Acad. Ophthal. 2002-2003; 379Pterygium; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: B29, B30Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Managing of the Red Eye. Amer. Acad. Ophthal. 2001; ECS. red eye 54, 55Subconjunctival hemorrhage; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002;V.3 B38Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Managing of the Red Eye. Amer. Acad. Ophthal. 2001; ECS. red eye 47Bradford CA. Basic Ophthalmology, (8th Edition). San Francisco: Amer. Acad. Ophthal. 2004; FIG 5.10Neoplasm of the conjunctiva; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad.Ophthal. 2002; V.3 B47, B48Jr Cunningham ET, Jr Belfort R. HIV/AIDS and the Eye, A Global Perspective, Ophthalmology Monographs 15. 4-1Adnexal Manifestations; FIG 4-6 Squamous cell carcinoma of conjunctiva at superior limbus. San Francisco: Amer.Acad. Ophthal. 2002; 39

ScleraNodular episcleritis; Diffuse anterior scleritis; Nodular scleritis;Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG IX-19 Nodular episcleritis; FIG IX-20 Diffuse anterior scleritis; FIG IX-21 Nodular scleritis. San Francisco:Amer. Acad. Ophthal. 2002-2003; 222-224

EyeballEyeball, contusion;Eyeball, perforation; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: L22Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XIX-13 Rupture of globe secondary to blunt trauma. San Francisco: Amer. Acad. Ophthal. 2002-2003; 387Eyeball, intraocular foreign body; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal.2002; V.3: L15Regillo C. Basic and Clinical Science Course Section 12. Retina and Vitreous. San Francisco. Amer. Acad.Ophthal. 2005-2006; Fig.13-6.Endophthalmitis;


35

Opremcak ME, Jr. Cunningham ET, Foster SC, Forster D, Moorthy RS, Lopatynsky M. Basic and Clinical SciencesCourse Section 9. Intraocular Inflammation and Uveitis. FIG 11-1 Exogenous postoperative endophthalmitis (bacterial;FIG 11-2 Endogenous endophthalmitis (meningococcal meningitis). San Francisco: Amer. Acad. Ophthal. 2004-2005;207-209Microphthalmos; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: H15Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XIII-2 Severe microcornea and microphthalmos OD; Both irides are colobomatous. San Francisco: Amer. Acad.Ophthal. 2002-2003; 272Buphthalmos; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: C08Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG XXI-1 A. Congenital glaucoma, right eye; B. Right cornea larger and hazy; C. Left corneal clear; D.Late congenital glaucoma, left eye. San Francisco: Amer. Acad. Ophthal. 2002; 255

Anterior ChamberHyphema Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: L11Sutphin JE, Chodosh, J, Dana MR, et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG XIX-5 Layered hyphema from blunt trauma; FIG XIX-6 Total, or “eight-ball,” Hyphema. San Francisco: Amer.Acad. Ophthal. 2002-2003; 374-375Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 16Diagnosis: Traumatic Hyphema. San Francisco: Amer. Acad. Ophthal. 2003; 32Hypopyon; Cunningham ET Jr, Belfort R Jr, HIV/AIDS and the Eye, A Global Perspective, Ophthalmology Monographs15, 5-4 Anterior Uveitis, FIG 5-7 Severe anterior uveitis with fibrin exudates and hypopyon and posterior synechiaeformation in patient taking ribabutin. San Francisco: Amer. Acad. Ophthal. 2002; 50

Iris & Ciliary BodyOphthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: L10, L12Iridocyclitis, iritis;Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 10Diagnosis: Sacroid Uveitis. San Francisco: Amer. Acad. Ophthal. 2003; 20Tumor of iris;Grossniklaus HE, Brown HH, Glasglow BJ, et al Basic and Clinical Sciences Course Section 4. Ophthalmic Pathologyand Intraocular Tumors. FIG XX-1 Metastasis to the iris associated with hyphema; FIG XX-2 Metastasis from breastcarcinoma to the iris. San Francisco: Amer. Acad. Ophthal. 2002-2003; 270

GlaucomaGlaucoma, congenital; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002;V.3: H03,H04Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG XXI-1 A. Congenital glaucoma, right eye; B. Right cornea larger and hazy; C. Left corneal clear; D.Late congenital glaucoma, left eye. San Francisco: Amer. Acad. Ophthal. 2002; 255Simple glaucoma; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: C06, C11,C26Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case12, Diagnosis: Primary Open Angle Glaucoma. San Francisco: Amer. Acad. Ophthal. 2003; 24Acute glaucoma; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: C01, C05,C09Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Managing of the Red Eye. Amer. Acad. Ophthal. 2001; ECS. red eye 83, 84, 85, 86Secondary glaucoma; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: C10,C13, C18, C23, C24, C25


36

LensCataract; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: A01-07, A10Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 6,Diagnosis: Cataract. San Francisco: Amer. Acad. Ophthal. 2003; 12Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG XXII-7 Bilateral congenital cataracts. San Francisco: Amer. Acad. Ophthal. 2002-2003; 271Aphakia;Pseudophakia; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: A19-26Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Eye Care for the Elderly. Amer. Acad. Ophthal. 2001; (REF.1B Slide54Lens dislocation; Marfan Syndrome; Homocyntinuria. Ophthalmic Images Collection, CD-ROM. SanFrancisco: Amer. Acad. Ophthal. 2002; V.3: H38Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. PediatricOphthalmology and Strabismus. FIG XXII-5 A and B Superotemporal displacement of lenses,bilateral; C, Inferonasal displacement, right eye; D, Lens dislocation into vitreous, left eye. SanFrancisco: Amer. Acad. Ophthal. 2002-2003; 269Rosenfeld SI, Blecher MH, Bobrow JC et al Basic and Clinical Sciences Course Section 11. Lens andCataract. FIG 4-15 Marfan Syndrome A, Arachnodactyly in a patient with Marfan syndrome B, Sub-luxated lens in Marfan syndrome. San Francisco: Amer. Acad. Ophthal. 2004-2005; 41

Refraction and accommodationHyperopia; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3:G25, G26, G29Miller KM, Atebara NH, Fellenz M, et al Basic and Clinical Sciences Course Section 3, Optics, Refraction, and ContactLenses. FIG 3-10 Hyperopia with accomodation relaxed A,B. San Francisco: Amer. Acad. Ophthal. 2004-2005: 117Myopia; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3:G30, G31, G34Miller KM, Atebara NH, Fellenz M, et al Basic and Clinical Sciences Course, Section 3, Optics,Refraction, and Contact Lenses. FIG 4-18 A diverging lens is used to correct myopia. San Francisco:Amer. Acad. Ophthal. 2004-2005: 144Astigmatism; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: G21, G22Weiss JS. Basic and Clinical Science Course Section 14, Refractive Surgery. Fig. 3-5 San Francisco: Amer. Acad.Ophthal. 2004-2005; 48

Cycloplegia; Presbyopia; Miller KM, Atebara NH, Fellenz M, et al Basic and Clinical Sciences CourseSection 3 Optics, Refraction, and Contact Lenses. Table 4-1 Commonly Used Cycloplegic Agents; Table4-2 Average Accommodation Amplitudes for Different Ages. San Francisco: Amer. Acad. Ophthal.2004-2005: 142,149

Vision and visual fieldsAmblyopia; Diplopia; Suppression; Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students,Instructor Manual, Second Edition, Case 22, Diagnosis: Esotropia. San Francisco: Amer. Acad. Ophthal. 2003; 44Hemianopia, bitemporal, and homonymous; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad.Ophthal. 2002; V.3: E26, E27Bradford CA. Basic Ophthalmology, (8th Edition). San Francisco: Amer. Acad. Ophthal. 2004; FIG 7.12

RetinaRetinal detachment; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: K70-72Rosenfeld SI, Basic and Clinical Science Course Section 11. Lens and Cataract. Fig. 11-15; Retinaldetachment with proliferative retinopathy. San Francisco: Amer. Acad. Ophthal. 2003-2004: 270


37

Retina, vessel occlusion or bleeding; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal.2002; V.3: K20Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case19, Diagnosis: Central Retinal Artery Occlusion; Case 21, Diagnosis: Central Retinal Vein Occlusion. San Francisco:Amer. Acad. Ophthal. 2003; 38, 42Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: K34-K36Degeneration of macula, age dependent; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad.Ophthal. 2002; V.3: K03-K05Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case17, Diagnosis: Age-Related Macular Degeneration. San Francisco: Amer. Acad. Ophthal. 2003; 34Retinoblastoma; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: H27-29Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case27, Diagnosis: Leukoria/Retinoblastoma. San Francisco: Amer. Acad. Ophthal. 2003; 54Retinopathy of prematurity; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3:H32-36Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. Table 24-1 International Classification of Acute Stages of Retinopathy of Prematurity; FIG XXIV-2 -XXIV-6 Stages of retinopathy of prematurity. San Francisco: Amer. Acad. Ophthal. 2002-2003; 302,304Retinopathy, diabetic; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: K14,K15, K40, K41Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 1,Diagnosis: Nonproliferative Diabetic Retinopathy; Case 9, Diagnosis: Proliferative Diabetic Retinopathy. SanFrancisco: Amer. Acad. Ophthal. 2003; 2,18Retinopathy, hypertensive;Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 5,Diagnosis: Hypertensive Retinopathy. San Francisco: Amer. Acad. Ophthal. 2003; 10Retinitis; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: K29Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case25, Diagnosis: Cytomegalovirus Retinitis. San Francisco: Amer. Acad. Ophthal. 2003; 50

ChoroidChorioretinitis;Cunningham ET Jr, Belfort R Jr, HIV/AIDS and the Eye, A Global Perspective, Ophthalmology Monographs 15, FIG 6-5Retinal Vein or Artery Occlusion, FIG 6-10 Pneumocystis carinii choroiditis. San Francisco: Amer. Acad. Ophthal.2002; 67Neoplasms of the choroids; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3:K25, K26Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 7,Diagnosis: Malignant Choroidal Melanoma. San Francisco: Amer. Acad. Ophthal. 2003; 14

VitreousVitreous hemorrhage; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: K86Regillo C, Basic and Clinical Science Course Section 12, Retina and Vitreous. FIG 5-9 Neovascularization ofthe disc with small vitreous hemorrhage in proliferative diabetic retinopathy. (Standard photograph 10A,courtesy of DRS). Even without vitreous hemorrhage, this amount of NVD is the lower limit of moderateNVD, and is considered high-risk Proliferative Diabetic Retinopathy. San Francisco: Amer. Acad. Ophthal.2003-2004; 110

Optic Disc and Optic NerveOptic disc cupping; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: C54-57


38

Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case12, Diagnosis: Primary Open Angle Glaucoma.San Francisco: Amer. Acad. Ophthal. 2003; 24Papilledema; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: E16, E17Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case14, Diagnosis: Papilledema. San Francisco: Amer. Acad. Ophthal. 2003; 28Optic atrophy; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: C58Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 3,Diagnosis: Optic Atrophy. San Francisco: Amer. Acad. Ophthal. 2003; 6Optic neuropathy; (e.g. Optic neuritis)Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case11, Diagnosis: Anterior Ischemic Optic Neuropathy. San Francisco: Amer. Acad. Ophthal. 2003; 22Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG XXV-7 Optic neuritis, left eye – normal right eye shown for comparison. San Francisco: Amer. Acad.Ophthal. 2002-2003; 337

EyelidsBlepharitis; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: B49Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case18, Diagnosis: Blepharitis. San Francisco: Amer. Acad. Ophthal. 2003; 36Hordeolum;Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case26, Diagnosis: Traumatic Hordeolum. San Francisco: Amer. Acad. Ophthal. 2003; 32Chalazion; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: H02, B43, B44Sutphin JE, Chodosh, J, Dana MR, Et al. Basic and Clinical Sciences Course Section 8. External Diseases and Cornea.FIG V-5 Chalazion. San Francisco: Amer. Acad. Ophthal. 2002-2003; 71Eyelid laceration; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: F34, F35Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Eye Trauma and Emergencies. Amer. Acad. Ophthal. 2001; ECS.etrauma.32,ECS.etrauma33Entropion; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: F17Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG XII-5 Involutional entropion; FIG XII-8 Cicatricial entropion. San Francisco: Amer. Acad. Ophthal.2002-2003; 184,186Ectropion; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: F14Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG XII-1 Types of ectropion. A, Involutional. B, Cicatricial. San Francisco: Amer. Acad. Ophthal. 2002-2003;177Trichiasis;Blepharoplasty; Lagophthalmos;Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. Fig. XII-13 – Bilateral symmetric congential ptosis; FIG XII-21 Lower eyelid retraction followingblepharoplasty. San Francisco: Amer. Acad. Ophthal. 2002-2003; 195, 214Epicanthus;Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG XI-3 Congenital eyelid deformities. C, Epicanthus. San Francisco: Amer. Acad. Ophthal. 2002-2003; 137Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG XVI-6 Epicanthus, bilateral. San Francisco: Amer. Acad. Ophthal. 2002-2003; 197Ptosis; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: F45, F47Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG XII-14 Ptosis with levator aponeurosis dehiscence A,B,C. San Francisco: Amer. Acad. Ophthal. 2002-2003; 197


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Lid Retraction; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: F52Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG XII-8 Thyroid Eyelid retraction. San Francisco: Amer. Acad. Ophthal. 2002-2003; 205Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 4,Diagnosis: Endocrine Ophthalmopathy; San Francisco: Amer. Acad. Ophthal. 2003; 8Xanthelasma;Grossniklaus HE, Brown HH, Glasglow BJ, et al Basic and Clinical Sciences Course Section 4. Ophthalmic Pathologyand Intraocular Tumors. FIG XIII-6 Xanthelasma. San Francisco: Amer. Acad. Ophthal. 2002-2003; 176Eyelid tumor; (e.g. basal cell carcinoma) Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal.2002; V.3: F02, F03Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG XI-18 Basal cell carcinoma; FIG XI-19 Morpheaform sclerosing basal cell carcinoma. San Francisco:Amer. Acad. Ophthal. 2002-2003; 158Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case20, Diagnosis: Basal Cell Carcinoma. San Francisco: Amer. Acad. Ophthal. 2003; 40

Lacrimal apparatusDacryoadenitis; Tumor of lacrimal gland; Ophthalmic Images Collection, CD-ROM. SanFrancisco: Amer. Acad. Ophthal. 2002; V.3: F25-29Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG V-18 A,B,C. San Francisco: Amer. Acad. Ophthal. 2002-2003; 82Dacryocystitis; Dacryostenosis; Lacrimal duct, laceration; Kerston RC, Bartley GB, Nerad JA, et al. Basic and ClinicalSciences Course Section 7. Orbit, Eyelids, and Lacrimal System. FIG XIV-11 Acute Dacryocystitis with cellulitis. SanFrancisco: Amer. Acad. Ophthal. 2002-2003; 249

OrbitInflammation of orbit, orbital cellulitis; Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences CourseSection 7. Orbit, Eyelids, and Lacrimal System. FIG IV-2 A, Right orbital cellulitis with exotropia. San Francisco:Amer. Acad. Ophthal. 2002-2003; 41Fracture of orbit; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: F38-42Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids, and LacrimalSystem. FIG VI-5 Blow out fracture with x-ray. San Francisco: Amer. Acad. Ophthal. 2005-2006; 103Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG XXI-5 Orbital roof fracture in infants who fell with frontal impact. A, Marked right upper eyelidswelling from hematoma originating in the superior orbit adjacent to a linear fracture. B, Coronal CT image of adifferent patient, showing a bone fragment displaced into left orbit. San Francisco: Amer. Acad. Ophthal. 2002; 409Tumor of orbit; Kerston RC, Bartley GB, Nerad JA, et al. Basic and Clinical Sciences Course Section 7. Orbit, Eyelids,and Lacrimal System FIG V-21, Metastatic Prostate Cancer. FIG V-22a, Woman with enophthalmos and motilityrestriction secondary to metastatic breast carcinoma to the orbit. San Francisco: Amer. Acad. Ophthal. 2004-2005; 95

Squint – Motility disturbancesConvergent strabismus; congenital esotropia; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad.Ophthal. 2002; V.3: H07, H08Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case22, Diagnosis: Esotropia; San Francisco: Amer. Acad. Ophthal. 2003; 44Divergent strabismus; (exotropia) Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002;V.3: H09-12Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG.VIII-2 A, This 10 month-old infant with congenital exotropia also shows moderate motordevelopmental delay. San Francisco: Amer. Acad. Ophthal. 2002-2003; 107


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Upward deviation strabismus; (hypertropia) Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad.Ophthal. 2002; V.3: E02Kline LB, Basic and Clinical Science Course Section 5. Neuro-Ophthalmology. IV Nerve palsy 9-13c. SanFrancisco: Amer. Acad. Ophthal. 2004-2005; 238Downward deviation strabismus; (hypotropia)Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Eye Trauma and Emergencies. Amer. Acad. Ophthal. 2001; ECS.etrauma29Latent strabismus; (heterophoria). Strabismus, intermittent;Simon JW, Buckley EG, Drack AV, et al Basic and Clinical Sciences Course Section 6. Pediatric Ophthalmology andStrabismus. FIG.VIII-1 A, A 3-year old boy with intermittent exotropia. San Francisco: Amer. Acad. Ophthal. 2002-2003; 102Strabismus, paralytic; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal. 2002; V.3: H19Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 8,Diagnosis: Third Nerve Palsy. San Francisco: Amer. Acad. Ophthal. 2003; 16

Issue of knowledge, other than clinical picturesEye disorders due to diabetes mellitus; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer. Acad. Ophthal.2002; V.3: K14, K15Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Diabetes and Eye Disease. Amer. Acad. Ophthal. 2001; ECS.diabetes18-24, 34Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 1,Diagnosis: Nonproliferative Diabetic Retinopathy. San Francisco: Amer. Acad. Ophthal. 2003; 2Eye disorders due to hyperthyroidism; Graves disease; Ophthalmic Images Collection, CD-ROM. San Francisco: Amer.Acad. Ophthal. 2002; V.3: E19-21Coleman AL. Eye Care Skills on CD-ROM developed by the Interspecialty Education Committee of the AmericanAcademy of Ophthalmology. Ocular Manifestations of Systemic Disease. Amer. Acad. Ophthal. 2001; ECS.ocularman64 -74Mannis MJ, Smith ME. Case Studies in Ophthalmology for Medical Students, Instructor Manual, Second Edition, Case 4,Diagnosis: Endocrine Ophthalmopathy. San Francisco: Amer. Acad. Ophthal. 2003; 8

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