OPHTH ALMOLOGY

OSPE

RAFID AZIZ CHOWDHURY || TATHAGATO DAS

JRRMC 22ND
 OSPE (OBJECTIVE STRUCTURED PRACTICAL EXAMINATION)
IN OPHTHALMOLOGY

Photograph + X-ray/CT scan

Instrument
Lenses
Drops
Examination/Procedure
Specimen
Scenario questions
Counselling
History taking

Out of all these, any 5 stations will be set in the exam

 SCENARIOS
1.
Question:- A 45 years old lady, presented with sudden painful loss of vision, ciliary congestion in right eye
associated with vomiting. She has shallow anterior chamber.

What is the most probable diagnosis?

- Acute congestive narrow angle glaucoma

What is the medical treatment?

- Antiglaucoma drug (Acetazolamide, Pilocarpine, Timolol maleate)
- To alleviate inflammation & congestion- Steroid
- To relieve pain & vomiting- Analgesic & Antiemetic

What is the surgical treatment?

- If the peripheral anterior synechia is >180o :- Trabeculectomy
- If the peripheral anterior synechia is < 180o :-
Laser Peripheral Iridotomy (Laser PI):- Noninvasive & better
Iridectomy (invasive)

What is the treatment of fellow eye? (Normal eye )

- Pilocarpine 2% eye drop for long time (to constrict the pupil)
- Prophylactic Laser peripheral iridotomy.

2.
Question:- A patient who is about to undergo cataract surgery has the following results during her pre-
operative assessment:-
Axial length = 23.00 mm
K1 = 42.00 DS
K2 = 44.00 DS
A = constant of the lens to be used = 118.0

Calculate the lens power needed to achieve emmetropia.

Answer:- Using the SRK formula

P = A – 2.5 x L (Axial length) – 0.9 x (average K reading)

= 118 – 2.5 (23) – 0.9 (43)

= 22D

Lens power = 22D

 3.
Scenario question:-
A 25 years old patient comes to eye OPD with complaints of watering from right eye.

How to evaluate the patient?

History:- Any H/O any foreign body, pain, redness, photophobia, discharge, nasal obstruction,
duration, previous episode?
Inspection:- Eyelid (ectropion, entropion, punctum malposition)
Lacrimal sac area, functions of orbicularis muscle
Palpation:- Regurgitation test
Slit lamp examination:- foreign body, punctum malposition, stenosis
Nasal examination:- Is there any obstruction in nasolacrimal duct opening?

Write down relevant eye test?

- Sac patency test
- Fluorescein dye test (Jones dye test )

Examination procedure
Examine the patient in Snellen chart

Procedure:-
Place the patient in 6 meters or 20 feet distance
Patient’s one eye must be covered
Each eye should be tested separately
Doctor mark the line in the Snellen chart and make the patient read that line.

Comment:- Patient’s visual acuity is 6/36 in right eye

 HISTORY
Headache
Patient of uveitis
Patient of gradual loss of vision

Points of taking history.

Duration
Side (Left or right)
Vision status
Associated with pain, redness, nausea, vomiting
Associated with joint pain, cough, evening fever
History of trauma
History of systemic disease
History of referred pain

Counselling station

POAG
Pathological myopia
Chronic dacryocystitis
Mature cataract

Points of counselling the patient.

Identification of disease to patient in patient’s language
Information of treatment options of disease to patient
Complications of treatment
If not treat, what’s happen in future?
-
 Photographs
1.

- This is a picture showing pterygium.

What is your diagnosis ?

- Pterygium.

What is pterygium ?
- It maybe defined as triangular wing like fold of conjunctiva that encroaches over the cornea in
horizontal direction, either from temporal side or from nasal side.

Parts of pterygium
- Head ( apical part of cornea) , Neck ( limbus) , Body ( conjunctiva)

What is the differential diagnosis ?

- Pinguecula

Differentiate between Pterygium & Pseudopterygium ?

-
Trait Pterygium Pseudopterygium
Definition As above Pterygium anywhere other
than in horizontal direction
Age Elderly ( >50 years) At any age
Etiology Degenerative Inflammatory
Site Direction
-

Probe test
Always horizontally
Can’t pass under it
At any site direction
-

Can be passed
otherhtohpiaznontal
Recurrence high Not so

Precaution during surgery

- Three things to prevent recurrence during surgery ;
Mitomycin C
Conjunctival grafting
Amniotic membrane grafting
2.

This is a picture showing foreign body on cornea/ superficial corneal foreign body.

What is your diagnosis ?

- Foreign body on cornea/ superficial corneal foreign body .

Name the instruments that help to diagnose this case

- Slit lamp biomicroscope & torch light.

Name the instruments to remove the foreign body

- Instruments :
Universal eye speculum ( helps to expose the eye)
Foreign body spud or Hypodermic needle

Complications of this case

Corneal ulcer
Corneal opacity
Corneal neovascularization
Uveitis

Procedure remove the foreign body

Taking consent from patient
Applying surface anaesthesia/ local anaesthesia
Placing universal eye speculum to expose the cornea properly & localize the foreign body
First trying to remove the foreign body by injecting jet of fluid
If not removed, then trying with foreign body spud or hypodermic needle
Then applying antibiotic ointment & pad bandage for 24 hours
3.

This is a picture showing blood in anterior chamber of the eye

What is your diagnosis ?

- Hyphaema

What are the causes ?

Trauma
Intraocular surgery
Herpetic uveitis
Bleeding disorder
Blood dyscrasia

Complications of this case

Visual disturbance
Corneal endothelial staining
Secondary rise of intraocular pressure
Re-bleeding

Treatment of this case

Bilateral pad bandage ( for rest of the eye & preventing bleeding)
Antiglaucoma drugs ( to prevent ris of IOP), mydriatics ( atropine), steroid drops ( to
prevent inflammation)
Surgery – Paracentesis if hyphaema persists for 2-3 days .

What are the substances maybe present in anterior chamber ?

- Normally aqueous humor is present in anterior chamber.
Abnormally present substances :

Pus ( hypopyon)
Blood ( hyphaema)
Tumor cells ( pseudohypopyon)
Worm ( Loa loa)
Inflammatory cells
Foreign bodies ( cortical matter of lens, piece of wood, aluminium )
Silicon oil ( used in retinal detachment surgery may float in anterior chamber )
4.

This is a picture showing pus in anterior chamber of the eye

What is your diagnosis ?

- hypopyon.

What are the causes of this ?

- Corneal ulcer
- Uveitis

What is the difference of hypopyon in bacterial ulcer & fungal ulcer ?

Bacterial Corneal Ulcer Fungal Corneal Ulcer

Hypopyon is sterile, thin & mobile Hypopyon is unsterile, thick & immobile

What is the surgical treatment of corneal ulcer ?

Surgical debridement
Tarsorrhaphy
Chemotarsorrhaphy
Conjunctival hooding
Amniotic membrane grafting
Tissue adhesive glue ( TAG ) can be applied if the ulcer is very small
If the whole cornea is involved then Therapeutic keratoplasty is done

What are the drugs used in treating bacterial corneal ulcer ?

Local atropine sulphate 1%
Local antibiotic drops ( fortified ) – combined therapy ( Cefuroxime+Gentamycin) or
monotherapy (Ciprofloxacin)

What are the pupillary features of acute anterior uveitis ?

- Small, irregular, sluggish in reaction to light.
5.

This is a picture showing slit lamp view of an eye

What are the positive findings in this case ?

Conjunctival conjestion
Corneal oedema ( cloudy/ hazy cornea)
Pupil is vertically mid dilated dilated

What is your most probable diagnosis ?

- Acute congestive narrow angle glaucoma

What are the treatment options ?

- Medical treatment :
Antiglaucoma drugs ( Tab. acetazolamide / Inj. mannitol for decreasing IOP)
Steroid – To reduce inflammation
Analgesic – To relieve pain
Antiemetics – To relieve nausea & vomiting
- Surgical treatment (definitive) :
If the peripheral anterior synechia is <180 degree
i) Laser peripheral iridotomy( Laser PI )- noninvasive & better
ii) Iridectomy – invasive
If the peripheral anterior synechia is >180 degree – Trabeculectomy

What is the treatment for fellow eye ?

- Pilocarpine 2% eye drop 4 times a day ( to constrict the pupil)
- Prophylactic laser peripheral Iridotomy ( Laser PI )
6.

This is a picture showing drooping of upper eyelid of left eye

What is your diagnosis ?

- Ptosis of left eye

Definition of ptosis
- Drooping of upper eyelid below normal anatomical position is called ptosis.

Mention 4 acquired causes of it

- Neurogenic ptosis – 3rd nerve palsy & Horner’s syndrome
- Myogenic ptosis – Myesthenia gravis, Myotonic dystrophy
- Aponeurotic ptosis – Involutional ptosis
- Mechanical ptosis – Tumor, large chalazion

Write down 2 complications of it

- Amblyopia
- Abnormal head posture
7.

What is your diagnosis ?

- Chalazion on upper eyelid

What are the fates of this ?

- Spontaneous resolution
- Remain as it is
- Increase in size
- Infection- Internal hordeolum
- Burst
- Calcification
- Malignancy (rarely)

What are the important findings/ clinical features ?

- Painless swelling away from lid margin
- Swelling is nodular , firm, non-tender
- Skin over the swelling is normal & free from it

Write down the treatment plan of it

If small
Hot compression
Intralesional steroid injection
If large
Chalazion surgery ( incision & curettage )

What is chalazion & stye ?

Chalazion – It is a chronic granulomatous (lipogranulomatous) inflammation of the Meibomian gland.
Stye – It is an acute suppurative inflammation of follicles of eyelash including the gland of Zeis & Moll.
8.

This is a picture showing chalazion surgery.

Which instrument is used in this operation ?

- Chalazion clamp

In which condition the instrument is used ?

- Chalazion

Why vertical incision is made ? vertically

- To avoid cutting of ducts of meibomian glands which lie horizontally , as injury to these will hamper
precorneal tear film formation & result in dry eye

What re the complications of this surgery?

- Haemorrhage
- Skin injury
- Hematoma of the skin
9.

What is the diagnosis?

- Stye in upper eyelid.

Tell the findings ?

- Painful swelling on the lid margin
- Tender
- Skin over the swelling is fixed

How will you treat such a case?

Conservative treatment:-
- Hot compression
- Systemic antibiotic (Flucloxacillin)
- Systemic analgesic
- Local antibiotic
Surgical treatment:-
- Epilation of involved cilia
- Surgical incision if large abscess is formed.

What are the complications of such a case?

- Abscess formation
- Orbital cellulitis
10.

artificial
^
This is the picture showing Intraocular lens

What are the parts of IOL with their function?

Optic:- for vision
Haptic:- for support

What are the types of IOL?

- According to composition-
- Nonfoldable (Hard)- PMMA (Polymethyl methacrylate)
- Foldable (soft)- Acrylate, silicon
- Optically-
- Unifocal (Having 1 focal point)
- Multifocal (Having multiple focal point)
- According to location-
- Posterior chamber & Anterior chamber IOL
- According to design-
- Single piece:- (If optic & haptic consist of same material)
- Multi piece:- (If optic & haptic consist of different materials)

What are the complications of Anterior chamber lens?

UGH syndrome
- Uveitis, Glaucoma & Hyphaema

Enumerate the SRK formula

P = A - 2.5L – 0.9K
P = Power of IOL
A = Constant of the manufacturer
L = Axial length of eyeball

pacification
K = Keratometer reading.

Define PCO with treatment. •

Posterior capsular opacity is defined as thickening & - ossification of posterior capsule caused by
proliferation & migration of residual epithelial cells at the equatorial region.
Treatment:- Nd- Yag laser capsulotomy

Name some sutureless cataract surgery.

- SICS, Phacoemulsification, Phaconit & Microphaconit
11.

This is the picture showing Lacrimal apparatus

Mention the parts according to the picture.

Secretory portion:-
1. Lacrimal gland
2. Accessory lacrimal gland

Draianage portion:-
1. Lacrimal puncta
2. Lacrimal canaliculi
3. Lacrimal sac
4. Nasolacrimal duct

Mention the valves that may be present in it.

Valve of Rusenmuller:- at the junction of common canaliculus & lacrimal sac.
Valve of Hasner:- at the lower end of Nasolacrimal duct.

Write down 3 causes of epiphora.

1. Malposition of lacrimal puncta (Secondary to ectropion)
2. Obstruction anywhere along the lacrimal drainage system from the punctum to NLD
3. Lacrimal pump failure (7th nerve palsy)
12.

This is the picture showing Leucocoria in left eye

(White pupillary reflex or Cat’s eye reflex)

What are the Different diagnosis?

1. Congenital cataract
2. Persistent hyperplastic primary vitreous
3. Retinopathy of prematurity
4. Retinoblastoma
5. Coat’s disease
6. Toxocariasis

What is the most possible diagnosis?

- Retinoblastoma

What are the treatment options of most possible diagnosis?

Focal:- (for small sized tumor)
o Cryotherapy
o Photocoagulation
o Brachytherapy
Local:- (for medium/large sized tumor)
o External beam radiotherapy
o Enucleation
Systemic:- Chemotherapy
13.

What is the imaging & positive findings?

- This is a CT scan showing calcification in left eye.

What is the most likely diagnosis?

- Retinoblastoma

Write down common presentations of this case.

4. Leucocoria (White pupillary reflex or cat’s eye reflex)
5. Squint
6. Secondary glaucoma and uveitis with pseudohypopyon
7. Orbital inflammation
8. Proptosis
9. Metastatic spread

Write down treatment options.

- Discussed earlier.
14.

What is the diagnosis?

- Mature Cataract

What are the findings?

- Vision is reduced to counting fingers or hand movement
- Lens colour is pearly white
- Iris shadow is absent
- Fundal glow is absent

What are the complications if untreated?

- Phacolytic glaucoma
- Lens induced uveitis
- Subluxation/Dislocation of lens

How will you treat such a case?

- Cataract surgery.

Immature cataract

Findings:-
- Vision is reduced to 6/36 or 6/60 or counting fingers
- Lens colour is grayish white
- Iris shadow is present
- Fundal glow is present
**Phacomorphic glaucoma occurs in case of Immature cataract**
15.

This is the picture showing Myopic eye

What is myopia?
- It is a type of refractive error where parallel rays of light coming from the infinity after refraction
form a point focus in front of the retina when accommodation is at rest.

What is the criteria of simple myopia?

Non-hereditary
Stationary
It is not progressive after adolescence
Refractive power less than -6D
No pathological changes in the fundus

What are the complications of Pathological Myopia?

Complicated cataract
Vitreous hemorrhage & Vitreous degeneration
Macular hole
Retinal detachment
Posterior staphyloma
Divergent squint

What are the changes in fundus of Pathological Myopia?

Tesselated or Tigroid fundus
Large optic disc with temporal myopic crescent
Chorioretinal atrophy
Foster fuchs spot
Lacquer cracks

What are the treatment options of myopia?

Optical:-
- Spectacle (concave spherical lens)

Surgical:-
- LASIK (Laser in situ keratomileusis) Cornea
- LASEK (Laser subepithelial keratomileusis)
- Phakic IOL
- Clear lens extraction L ens
16.

This is the picture showing Hypermetropic eye

What is hypermetropia?
- It is a type of refractive error where parallel rays of light coming from the infinity after refraction
form a point focus behind the retina when accommodation is at rest.

What are the treatment options of hypermetropia?

Optical:-
- Spectacle (convex spherical lens)

Surgical:-
- LASIK (Laser in situ keratomileusis) Cornea
- LASEK (Laser subepithelial keratomileusis)
- Phakic IOL → L ens

What are the complications of hypermetropia?

In children:-
- Convergent squint
- Ambylopia
In Adult:-
- Predisposition to develop PNAG.
17.

What is the diagnosis?

- Phacolytic glaucoma.

What are the findings?

- Cornea is oedematous
- Lens is mature
- Pupil is dilated

What is the cause of this condition?

- If mature cataract is kept untreated

What are the D/D?

- Acute congestive glaucoma.

How will you treat such a case?

- At first, reduction of IOP
- Then, Cataract surgery.
18.

This is the picture showing Fundoscopic findings of diabetic retinopathy

What are the findings?

- Flame shaped haemorrhage
- Cotton wool spot
- Microaneurysm
- Hard exudate
- Macular oedema

What is cause of this disease?

- Diabetes mellitus

What are the treatment options?

Diabetic control
Anti VEGF intravitreal injection
Pan retinal photocoagulation (Laser therapy)
19.

What is the diagnosis?

- Trichiasis.

What are the causes?

- Trachoma
- Chemical burn
- Steven Jhonson syndrome

What are the complications?

- Recurrent corneal abrasion
- Superficial corneal opacities
- Corneal vascularization
- Non-healing corneal ulcer
20.

This is the picture showing procedure of Sac patency test

Write down the procedure of it.

1. Consent from the patient.
2. Application of local anaesthetic (Oxybuprocaine)
3. Dilate the lower punctum by Nettleship’s punctum dilator.
4. lacrimal cannula fitted in a syringe filled with normal saline /distilled water is inserted into the
lower punctum.
5. The plunger is pushed to irrigate the lacrimal passage.

Write down the interpretation of this procedure.

If saline/distilled water pass through the throat indicates patent nasolacrimal duct.
If saline/distilled water regurgitate through both punctum indicates obstruction of
nasolacrimal duct.

What are the complications during this procedure?

1. Punctum injury
2. False passage
21.

Name the operation shown in the photograph.

-Small incision cataract surgery (SICS)
Which knife is used here?
-Crescent knife
Write the steps of the procedure shortly.
Peribulbar anaesthesia by combination of lignocaine 2%, Bupivaicaine 0.75% & Hyaluronidase
↓
Eyeball is exposed by wire speculum
↓
Incision is made at the peripheral part of cornea or sclera-corneal junction
↓
OVD is applied to make the anterior chamber as this will collapse due to escape of Aqueous humor
↓
Central part of the Anterior capsule is removed by 2 methods-
- Capsulotomy (Can-opener method)
- Capsulorrhexis
↓
This lead to central opening & nucleus is removed by Vectis (As the procedure shown is SICS)
↓
Then, Cortical matter is removed by irrigation-aspiration cannula
↓
Then, Artificial IOL is implanted in the posterior chamber.

What are the complications of this surgery?

Peroperative:-
1. Posterior capsule rupture (During irrigation & aspiration of cortical matter)
2. Vitreous loss
3. Dropping of nucleus into vitreous .
Post-operative:-
Early:-
1. Striate keratopathy (Cornea oedematous & hazy)
2. Uveitis
3. Shallow anterior chamber
4. Hyphaema
5. Retention of cortical matter in Anterior chamber
6. Endophthalmitis
Late:-
1. Chronic Endopthalmitis
2. Posterior capsular opacity (PCO)
3. Retinal detachment
4. Cystoid maculo oedema
22.

Identification : Eye bandage is given.

What are the indications of the eye bandage ?

- Following corneal abrasion
- To arrest haemorrhage
- To reduce swelling after eyelid injury
- Following eye surgery
- For a child , to ensure the pad is not disturbed.
- To rest the eye in amblyopia. ( in amblyopia the pad bandage is applied to the sound eye).
- Hyphaema, vitreous haemorrhage

What is the procedure of applying eye bandage?

- Wash your hands
- Instilling eye drops ( surface anaesthetic agets )
- Applying eye ointment ( antibiotic )
- Eyelid closed
- Applying an eye bandage gently .
 INSTRUMENTS

1.

Picture showing “ Universal eye speculum”

Parts : It has a spring & 2 limbs & a screw to the adjacent the limbs .
Why universal ? : It’s called universal because for either eye ( used for both eyes )

Purpose : used to separate both eyelids for good exposure of eyeball

Uses :
- Removal of foreign body from cornea & conjunctiva
- Pterygium operation
- Squint operation
- Evisceration & enucleation
Advantages :
- More field of exposure
- Can be used for both eyes
Disadvantages :
- Not used in intraocular operation as it causes raised IOP
- It’s heavier hence cause more pressure over globes

Indications of enucleation : ( Complete removal of eyeball by cutting optic nerve stump )

Absolute :
- Retinoblastoma
- Malignant melanoma
Relative :
- Painful blind eye due to trauma - To collect donor eye for keratoplasty
- Anterior staphyloma - Absolute glaucoma
- Pthisis bulbi

Indications of evisceration : ( Removal of contents of eyeball leaving behind posterior 1/5th of sclera
adherent to optic nerve stump )
- Endopthalmitis - Panopthalmitis
( Optic nerve stump = Optic nerve + Vessels+ Meningeal covering )
2.

Picture showing “Irrigation-Aspiration Two way Cannula “

Irrigation with :
- Balance salt solution ( better )
- Ringer’s solution
- Hartmann’s solution - Available in or college , composition same as Aquous humor
so not harmful)

Aspiration of :
- Cortical mater of lens
- Visco-elastic substance
- Blood clots ( if hyphaema persists for 5-7 days )

Aims :
- Irrigation of anterior chamber
- Aspiration of Cortical mater of lens , OVD , clotted blood from anterior chamber
- Washing the anterior chamber
- For forming the anterior chamber

Uses :
- Cataract surgery
- Glaucoma surgery
- Keratoplasty
- Repair of corneal injury

Complications :
Per-operative complications :
- Posterior capsule rupture
- Vitreous loss
- Expulsive hemorrhage
- Dropping of nucleus into vitreous
Post-operative complications
- Corneal endothelial damage
Post operative complications of cataract surgery
Early :
- Striate keratopathy
- Uveitis
- Shallow anterior chamber
- Hyphaema
- Retention of cortical matter in Anterior chamber
- Endopthalmitis
Late :
- Chronic endopthalmitis
- Posterior capsule opacity
- Retinal detachment
- Cystoid macular oedema
 3.

Picture showing “Citelli’s Punch forceps”

Punch forceps types :

- Citelli’s punch forceps ( used commonly) – faced upwards
- Sphenoidal punch forceps – faced downwards

Uses : To cut the bone & enlarge the ostium in Decryocystorhinostomy ( DCR) operation.

Sterilization :
- Lysol 25%
- Dettol

Complications :

- Damage to nasal mucosa & lacrimal sac

- Damage to surrounding tissues – bleeding

( Size of the ostium is 12-15 mm. During DCR operation , mainly cut the frontal process of maxilla & lacrimal
bone , sometimes the part of ethmoid also needs to be cut . )
Causes of failed DCR :
Faulty selection of patient :
- DNS with hypertrophic inferior turbinate
- Atrophic rhinitis
Faulty technique :
- Small ostium
- High up ostium
- Improper anastomosis
4.

Picture showing “Chalazion clamp”

In which condition , it is used ?

- Chalazion

What are the parts of this instrument ?

- Handle with screw
- Round tip with solid blade ( skin side )
Or
- Round tip with fenestrated blade ( conjunctival side )

Functions :
- Fixation of chalazion of eyelid
- Eversion of eyelid
- Haemostasis

Type of incision given :

Vertical incision to prevent damage or cut of other ducts of meibomian glands ( if damaged ,
then formation of precorneal tear film is hampered & develops dry eye )

Complications :
- Secondary infection ( secondary hordeolum)
- Suppuration & burst through skin or conjunctiva ( fistula formation )
- Granuloma
- Mechanical ptosis
- Abscess

Fate of chalazion :
- Spontaneous resolution
- Remains as it is
- Increases in size
- Become infected > internal hordeolum
- Burst
- Calcification
- Malignancy ( rarely )
Common ocular problem by chalazion ?
- Mechanical ptosis
- Chalazion
-

Astigmatism
What is chalazion ?
Chronic granulomatous inflammation of the meibomian gland .

What is stye ?
Acute suppurative inflammation of the follicles of eyelash including gland of Zeis or Moll.
( external hordeolum )
 5.

Picture showing Keratome knife (deep blue) Picture showing Keratome knife (pink)
( size : 5.2 ) ( size : 3.1 )

( Keratome knife is available in two sizes in Eye outdoor : 3.1 (pink) and 5.2(deep blue) , but color maybe
variable )
Identification : Thin diamond shaped blade with a sharp apex & two cutting edges .

Functions :
- Keratomes are used for making valvular ( self-healing) incisions for gaining entry
into the anterior chamber .

Indications/ Uses :
- SICS
- Phacoemulsification
- Paracentesis

Write down 3 important complications during cataract surgery

- Corneal endothelial injury
- Posterior capsule tear
- Expulsive haemorrhage

Advantages of SICS : Small incisions , self sealing , sutureless , short learning curve , secure , short
recovery .

Advantage of Phaco over SICS : Incision related complications are less in Phaco .
6.

Picture showing “Wire speculum”

Why is it called ‘wired’ ? : Because it has thinner arm

It has no screw . it is very light hence causes no pressure on the eyeball . So it can be used in
intraocular operations as well as extraocular operations .

Uses : To expose the eyeball as in

- Removal of foreign body
- Intraocular operations such as
a) Cataract surgery
b) Peripheral iridectomy
c) Trabeculectomy
- Pterygium surgery

Advantages :
- Little pressure
- Good exposure
- Lighter , so gives minimum pressure on globe

Disadvantage : without anaesthesia operation is not possible .

Pterygium : Wing like fibrovascular tissue of conjunctiva which encroach upon cornea horizontally
.
7.

Picture showing “Crescent knife”

Identification : It is a blunt-tipped bevel up knife having cut-splitting action at the tip and both the
sides.

Functions : It is used to make tunnel shaped incision in sclera & cornea .

Uses :
- Phacoemulsification
- SICS
- Trabeculectomy – Glaucoma surgery

8.

Picture showing “Nettleship’s Punctum Dilator”

Identification : It is a cylindrical metal handle with a conical pointed tip.

Function : Dilate the lacrimal punctum ( ampulla )

Uses :
- Syringing
- Probing ( in congenital dacryocystitis )
What are the other instruments use in Sac Patency Test ?
- Metallic lacrimal cannula connected to a saline filled syringe
- Anaesthetic instrument ( anaesthesia by oxybuprocaine )
agents
9.

Picture showing “DCR Tube”

Identification : It is a DCR tube or silicon tube

Uses :
- In case of failed DCR during Re-DCR
- If tear the lacrimal sac & nasal mucosa in DCR
- If excessive haemorrhage in DCR
-
Sterilization : Gamma radiation

Indications of DCR :

- Chronic dacryocystitis
- Lacrimal mucocele
- Lacrimal fistula intubation
- Congenital & infantile dacryocystitis when probing & lacrimation failed

Complications of DCR operation :

Peroperative :
- Haemorrhage
- Tearing of mucosa of lacrimal sac
- Injury to nasal mucosa
- Failure of anastomosis between sac and nasal mucosa
Postoperative :

Early :
- Infection
- Secondary haemorrhage
- Wound gap
- Nasal bleeding

Late : Scarring , failed DCR

Contraindications :
Absolute :
- Malignancy of lacrimal sac
- Atrophic rhinitis
Relative :
- Gross DNS
- Nasal polyp
- Hypertrophied inferior turbinate
- Congenital dacryocysitis below 4 years
- Acute dacryocystitis
10.

Picture showing Schiotz Tonometer with measuring weights

Identification : Picture showing Schiotz Tonometer with measuring weights ( such as 5.5 gm , 7.5
gm, 10 gm if present )

Uses : To measure the Intra-ocular pressure .

What are the other instruments to measure intra-ocular pressure ?

- Goldmann Applanation tonometer
- Air puff tonometer
- Tonopen

Name two new anti-glaucoma drugs .

- Prostaglandin analogues ( Latanoprost )
- Carbonic anhydrase inhibitor ( Acetazolamide )

Glaucoma – Chronic progressive optic neuropathy characterized by structural & functional changes
with or without rise of IOP.

IOP – It is the lateral pressure exerted by intraocular contents on the coats of the eyeball .

Methods of measuring IOP :

Digital method : by using digits
Instrument methods
- Contact :
a) Schiotz tonometer
b) Goldmann Applanation tonometer

- Non-contact : Air puff meter

( Viva – This instrument is available in Ophthalmology OPD in JRRMCH )

11.

Picture showing “Retinoscope”

Identification : This is a picture showing “Retinoscope”

Uses : To diagnose & correct the refractive error .

Methods of diagnosing refractive error ?

A) Objective : Retinoscope and autorefractometer

B) Subjective :

- Fogging method
- Jackson cross cylinder
- Astigmatic fan test
- Duochrome test

What are the type of refractive error ?

- Myopia
- Hypermetropia
- Astigmatism
12.

Picture showing “Ophthalmoscope”

Identification : This is Ophthalmoscope

Uses : To view the retina / fundus such as for

- Visualization of cupping of optic disc in glaucoma

- Detection of the fundoscopic changes in diabetic retinopathy

13.

Picture showing “Convex Spherical lens”

Identifying points :
- Magnification of the image of the object
- Image of the object moves in both meridians & in opposite direction
- No distortion of image of object
Uses :
- Hypermetropia
- Presbyopia
- Aphakia
14.

Picture showing “Convex Cylindrical lens”

( convex as ‘’ + ‘‘ sign before power number , cylindrical as white ‘‘–‘’ sign )

Identifying points :
- Magnification of the image of the object
- Image of the object moves in one meridian & in opposite direction
- Distortion of image of object

Uses :
- Hypermetropic astigmatism

Types of astigmatism :
Based on the principle meridian
a) Regular – principle meridians are perpendicular
b) Irregular – principle meridians are not perpendicular

Based on the focus of the principle meridian

1. Simple
a) Simple hyperopic
b) Simple myopic
2. Compound
a) Compound hyperopic
b) Compound myopic
3. Mixed
15.

Picture showing “Concave spherical lens”

( concave as “ – “ sign before power number )
Identifying points :
- Minification of image of an object
- Image of object moves in both meridians & same directions
- No distortion of the image of the object

Uses : Myopia

Treatment of myopia :

a) Optic : Spectacles , Contact lens

b) Surgical :

On cornea : LASIK ( Laser in situ keratomileusis )

LASEK ( Laser subepithelial keratomileusis )
On Lens : Phakic IOL
Clear lens extraction
Refractive lens exchange

Complications of pathological myopia :

a) Complicated cataract
b) Vitreous degeneration
c) Vitreous haemorrhage
d) Macular hole
e) Retinal detachment
f) Posterior staphyloma
g) Divergent squint
16.

Picture showing “Squint hook”

Identification : It is a squint hook .

Use :
- During a squint surgery
- During cataract surgery it acts as a lens expressor
- For differentiating pseudopterygium from pterygium

17.

Picture showing “Cats Paw “

Identification : It is “Cats Paw”

Function : to retract the skin

Use :
- Dacryocystorhinostomy
- Dacryocystectomy
-
18.

Picture showing “Corneal scissor”

Identification : It is Corneal scissor or Scerocorneal scissor

Uses :

- To enlarge corneal corneoscleral incision during ECCE

- To enlarge corneal incision during keratoplasty operation

19.

Picture showing “Lacrimal Cannula”

Identification : This is a lacrimal cannula

Use : Used in sac patency test ( metallic lacrimal cannula connected to a saline filled syringe
inserted into the lower punctum .
20.

Picture showing “Bowman’s Melliable Lacrimal Probe”

Identification : This is Bowman’s Melliable Lacrimal Probe

Parts : Thin long probe having round tip

Uses :
- For probing in congenital nasolacrimal duct obstruction
- To identify the position of sac in Dacryocystorhinostomy

Methods : ( Probing & Syringing )

- Under general anaesthesia
- Probing is usually done through the upper punctum
- Start with a smaller sized probe & gradually increasing the size
- Always follow the direction of nasolacrimal passage during probing
- Syringing is done after 2-3 minutes of probing

Complications :
- False passage
- Orbital cellulitis
- Nasal bleeding
 DROPS & OCULAR VISCO SURGICAL DEVICE

DROPS
1.

Picture showing “Vial containing Proparacaine hydrochloride eyedrops”

( there may be picture of Oxybuprocaine hydrochloride eyedrop , following answers will be same for both )

Preparation : 0.4%

Onset of action : 15 seconds to 30 seconds

Duration of action : 20 – 60 minutes

Dosage : 1 drops 3 times 5 minutes interval

Mechanism of action :

Local anesthetic

Binds with specific receptor in the cell membrane

Blocks influx of sodium through voltage gated sodium channels

Blocks the depolarization

Blocks temporarily initiation & propagation of action potential

Indication :
- Removal of superficial corneal and conjunctival foreign bodies
- Measurement of Intraocular pressure
- Prior to sac patency test
- For scrapping of corneal ulcer
- Prior to laser application to eye

Adverse effects :
- Stinging or burning sensation - Skin rash
- Blurred vision - Nausea and vomiting ( rarely )
- Inflammation of eye ( Red eye )
2.

Picture showing “Fluorescein Dye”

( color of the dye : dark orange / red )

Mechanism of action : Fluoroscein is the property of certain molecules to emit light energy of longer
wave length ( 520-530nm ) when stimulated by light of shorter wave length ( 465-490nmm)

Preparation :

a) Topical :
- 2% solution
- Fluorescein strip 1%
b) Intravenous :
Fluorescein sodium – 10% 5cc
20% 3cc

Uses :
a) Topical :
- Staining of corneal abrasion
( takes green color when seen with blue filter by Slit lamp )
- Goldman Applanation tonometry
- To detect wound leak ( Siedel’s test : To detect escape of aqueous humor )
- Jones dye test ( I & II ) for patency of lacrimal passage ( for diagnosis of Chronic
dacryocystitis )
- Tear film breakup time ( to detect dry eye )
b) Intravenous :
- Fundus fluorescein angiography
- In corneal ulcer / abrasion wound appears green after fluorescein dye administration
3.

Picture showing “Vial containing Pilocarpine eyedrops”

Onset of action : within 20 minutes

Peak : At 2 hours

Duration : upto 4-6 hours

Preparation : 1% , 2% , 4% ( 2% important in diagnostic & therapeutic use)

Dosage : 1 drop 4 rimes daily

Mechanism of action : Pilocarpine is direct acting parasympathetic ( Muscarnic) direct acting

Cholinergic drug . It causes miosis

Pharmacological effect in Glaucoma :

a) It is used in chronic open angle glaucoma to increase the facility of aqueous outflow due to ciliary
muscle contraction & pull on the scleral spur & trabecular meshwork
b) It is used in acute narrow angle glaucoma to move the iris away from the angle

Uses :
a) Diagnostic :
- To detect peripheral anterior synechia
- Holmes Adie’s pupil ( 0.125% Pilocarpine )
b) Therapeutic :
- In primary open angle glaucoma
- In primary narrow angle glaucoma
Side effects :
a) Ocular :
- Contact allergy ( Follicle )
- Myopia
- Miosis
- Shallowing anterior chamber
b) Systemic :
- Sweating
- Salivation
- Headache
- Bradycardia
- Hypotension
4.

Picture showing “Vial containing Atropine eyedrops”

Pharmacologically : It is parasympatholytic or anti-cholinergic

Pharmacological action of atropine on eye :

- Mydriasis
- Loss of accommodation cycloplegia
- Blurring of vision

Therapeutic uses :
- Acute anterior uveitis
- Corneal ulcer
- Malignant glaucoma
- Neovascular glaucoma

Diagnostic uses : For cycloplegic action in

- Fundoscopy
-

- Retinoscopy
i children
cycloplegia refraction
in

What are the cycloplegic drugs ?

Drugs that cause paralysis of ciliary muscle thereby loss of accommodation
- Atropine
- Homatropine
- Cyclopentolate
- Tropicamide

Mechanism of action of the drug :

Blocks the muscarinic receptor of sphincter pupillae

Radial muscles of iris remain unopposed

Dilatation of pupil
 Role of use in acute anterior uveitis :
- Relief of pain by preventing spasm of ciliary muscle
- Prevent formation of posterior synechiae
- Causes detachment of posterior synechiae

Systemic toxic effects of Atropine :

- Dry mouth
- Body temperature is raised
- Difficulty in swelling skin is dry, red , hot
- Tachycardia

Contraindications of atropine :
- Angle closure glaucoma
is iii)
ii
- ) Very shallow anterior chamber anterior chamber IOL

Name some common mydriatics with duration of action

Name Duration of action

Atropine 2-3 days weeks
-

Homatropine 2-3 days

Tropicamide 4-6 hours

Some informations on Tropicamide :

Onset: within 5 minutes

Duration : 4-6 hours

Preparation : 0.5%, 1%

Uses :
- To dilate the pupil for fundus examination
- Preoperative dilatation of pupil ( Tropicamide 0.8% + Phenyephrine 5% )
- Prior to YAG laser capsulotomy , Photocoagulation

Contraindications of mydriatics :
- Angle closure glaucoma
- Very shallow anterior chamber
- Anterior chamber IOL
5.

Picture showing “Ampoule of Trypan blue ”

Identification : Ampoule of Trypan blue

Other dyes used in ophthalmology : Fluorescein dye , indocyanin dye , alcian blue

Use : It is used in cataract surgery for staining and contrasting the anterior capsule of lens

Name the retinal function tests :

- Perception of light
- Projection of rays
- Maddox rod test
- Two point discrimination
- Colour vision
- Pupillary reaction
OCULAR VISCO SURGICAL DEVICE

Picture showing “Ocular Visco Surgical Device”

Identification : This is the picture showing “Ocular Visco Surgical Device”

Substances used :
- Hydroxypropyl methyl cellulose
- Sodium hyaluronate
- Chondroitin sulphate
- Methyl cellulose

Aims/Role :
- It creates space( Spacer ) or maintain the depth of the anterior chamber during surgery
(Cataract surgery)
- It protects endothelium of cornea & other structures
- It lubricates the Intraocular lens for implantation of Intraocular lens

Indications :
- Cataract surgery
- Penetrating keratoplasty
- Glaucoma filtering surgery
- Vitreo-retinal surgery

Complication : Secondary rise of IOP ( Secondary glaucoma ) due to block of angle of anterior
chamber by ocular visco surgical device