Study Guide Visual Semester IV Tayang 21 Juni 2016

TABLE OF CONTENTS

Page

CONTENT

1

LEARNING OUTCOMES

2

BLOK TEAM

4

FASILITATORS

5

CORE CURICULUM

6

TIME TABLE

9

TIME TABLE CLINICAL SKILL

11

MEETING OF STUDENT REPRESENTATIVES

13

FORMAT OF ARTICLE REVIEW

13

TOPICS OF ARTICLE REVIEW

14

LEARNING PROGRAM

16

PRACTICUM AND BASIC CLINICAL SKILL GUIDES

45

LEARNING OUTCOMES

THE AIMS

Comprehend the underlying normal structure and function of the visual system and its practical or clinical implications.

Understanding the pharmacology and pharmacokinetic of the ocular medicines.

Able to manage common eye and visual disorders and refer of high risks patient with visual disorders for further investigation and management.

Awareness and responsiveness to the community aspects of health care, needs, education and promotion.

LEARNING OUTCOMES

Able to know and understand anatomy of the eye structures Able to know and understand Histology of the eye structures

Able to know and understand Physiology of the eye, and Physiology of vision

Able to know and understand the pharmacology and pharmacokinetic of the ocular medicines

Able to establish diagnosis and management patient with Refraction disorders such as Mild Hipermetropia, mild myopia, mild astigmatism and presbyopia.

Able to initially diagnose, manage and later refer patient with Refraction disorders such as anisometropia and contact lens problems.

Able to establish diagnosis and management patient with external eye diseases such us conjunctivitis, Dry eye Syndrome, Blepharitis, Hordeolum, and Episcleritis

Able to initially diagnose, manage and later refer patient with external eye diseases such as chalazion, scleritis, keratitis, corneal ulcer, and uveitis

Able to initially diagnose and later refer patient with external eye diseases such as keratokonjungtivitis sicca and endophthalmitis.

Able to initially diagnose, manage and later refer patient with glaucoma disorders.

Able to establish diagnosis and management patient with ocular injuries such as foreign bodies in the conjunctiva and subconjunctival bleeding

Able to manage and initially diagnose and later refer patient with ocular injuries such as hyphema and eyelids lacerations.

Able to initially diagnose and later refer patient with ocular injuries such as corneal erosion, foreign bodies on the cornea, thermal corneal burn and lacrimal duct lacerations. Able to establish diagnosis and management patient with eyelids and lacrimal system disorders such us trichiasis.

systems disorders such as dacrioadenitis and dacriocystitis

Able to initially diagnose and later refer patient with eyelids and lacrimal sytems disorders such as entropion, lagophthalmus, epichantus, ptosis, eyelids retraction and xanthelasma

Able to initially diagnose and later refer patient with cataract, lens dislocation and corneal disorders such as pterygium and keratoconus.

Able to initially diagnose and later refer patient with retinal disorders.

Able to initially diagnose and later refer patient with neuro ophthalmology & strabismus disorders including amblyopia and binocular diplopia.

Able to establish diagnosis and management patient with community ophthalmology disorders such as night blindness

Able to initially diagnose, manage and later refer patient with community ophthalmology disorders such as Xerophthalmia

Able to initially diagnose and later refer patient with community ophthalmology disorders

such as blindness due to 5 most common eye disorders (Cataract, Glaucoma, refractive errors, infection and immunology eye diseases and retina disorders)

CURRICULUM CONTENT

Anatomy, histology and physiology of the eye. Pharmacology of the eye medicines.

Refractive Errors.

Infection & Immunologic Eye Diseases. Glaucoma disorders

Eyelids and Lacrimal systems disorders Ocular Injuries

Cataract, corneal and lens disorders. Vitreous and Retinal disorders

BLOCK VISUAL SYSTEM AND DISORDERS

COORDINATOR : dr. Putu Budhiastra, SpM(K)

SECRETARY : dr. I Wyn Eka Sutyawan Sp.M

TIME : 21 June 2016 – 20 July 2016

Block Team

No Name

1 dr. Putu Budhiastra, Sp.M (K) 2 Prof.dr.NK Niti Susila, SpM (K)

3 dr. Ni Made Ayu Surasmiati, M. Biomed, Sp.M 4 dr. AAA Sukartini Djelantik, Sp.M (K)

5 dr. Made Agus Kusumadjaja, Sp.M (K) 6 dr. W.G Jayanegara, Sp.M (K)

7 Dr. dr. AAA Mas Putrawati T, Sp.M(K) 8 dr. Ariesanti Tri Handayani, Sp.M(K) 9 dr. Yuliana,MBiomed

10 Prof.dr.I Dewa Putu Sutjana,PFK,M.Erg 11 dr. I.G.A.Dewi Ratnayanti

12 Dr. dr. Made Jawi

13 dr. Ni Made Ari Suryathi, M. Biomed, Sp.M 14 dr. Ni Made Laksmi Utari, M.Biomed, Sp.M 15 dr. IGAM Juliari,SpM

16 dr. Wayan Eka Sutyawan,SpM 17 dr. Ari Andayani,SpM

18 dr. Krisna Dinata

Lectures

No Name Dept No Telp

1 dr. Putu Budhiastra, Sp.M (K) Ophtalmology 085238238999 2 Prof.dr.NK Niti Susila,SpM (K) Ophtalmology 08123643816 3 dr. Ni Made Ayu Surasmiati, M. Biomed, Sp.M Ophtalmology 081338341860 4 dr. AAA Sukartini Djelantik, Sp.M (K) Ophtalmology 081337314911 5 dr. Made Agus Kusumadjaja, Sp.M (K) Ophtalmology 08123981349

6 dr. W.G Jayanegara, Sp.M (K) Ophtalmology 0818909147

7 Dr. dr. AAA Mas Putrawati T, Sp.M(K) Ophtalmology 08123846995 8 dr. Ariesanti Tri Handayani, Sp.M(K) Ophtalmology 0818375611

9 dr. Yuliana,M.Biomed Anatomy 085792652363

10 Prof.dr.I Dewa Putu Sutjana,PFK,M.Erg Physiology 08123924477 11 dr. I.G.A.Dewi Ratnayanti, m.Biomed Histology 03618550344

12 Dr. dr. Made Jawi, M.Kes Pharmacology 08179787972

13 dr. Ni Made Ari Suryathi, M. Biomed, Sp.M Ophthalmology 085253651928 14 dr. Ni Made Laksmi Utari, M.Biomed, Sp.M Ophthalmology 082340393727

15 dr. IGAM Juliari,Sp.M Ophthalmology 08123615625

16 dr. Wayan Eka Sutyawan,Sp.M Ophthalmology 081338538499

17 dr. Ari Andayani,Sp.M Ophthalmology 08113803666

FACILITATORS Regular Class (Class A)

No Name Group Department Phone Room

1 dr. Pande Made Wisnu

Tirtayasa, Sp.U A1 Urology 082111133211

3rd floor: R.3.09 2 dr. Made Bramantya Karna,

Sp.OT A2 Orthopaedi

0817300133 3rd floor: R.3.10 3 dr. I Made Suka Adnyana,

Sp.BP-RE A3 Surgery

081236288975 3rd floor: R.3.11 4 dr. I G N Mahaalit Arimbawa,

Sp.An KIC A4 Anasthesi

0811396811 3rd floor: R.3.12

5 dr. Muliani, M.Biomed _{A5 Anatomy} 085103043575 3rd floor:

R.3.13 6 dr. I Wayan Sugiritama, M.Kes _{A6 Histology} 08164732743 3rd floor:

R.3.14 7 dr. I Made Agus Kresna

Sucandra, Sp.An A7 Anasthesi

081805470888 3rd floor: R.3.15 8 dr. I Gede Budhi Setiawan,

Sp.B (K) Onk A8 Surgery

08123923956 3rd floor: R.3.16 9 dr. I Putu Bayu Mayura, S.Ked A9 Microbiology 082236165801 3rd floor:_R.3.17

10 Putu Gede Sudira, Sp.S A10 DME 081805633997 3rd floor:

R.3.19

English Class (Class B)

No Name Group Department Phone Room

1 dr. I Made Mahayasa,

Sp.B-KBD B1 Surgery

08123990624 3rd floor: R.3.09 2 dr.Tjokorda Gde Dharmayuda,

Sp.PD-KHOM B2 Interna

0811394108 3rd floor: R.3.10 3 Dr.dr. I Made Muliarta, M.Kes B3 Fisiology 081338505350 3rd floor:

R.3.11 4 dr. Ida Ayu Dewi Wiryanthini, M

Biomed B4 Biochemistry

081239990399 3rd floor: R.3.12 5 dr. Ni Made Ari Suryathi,

M.Biomed, Sp.M B5

Ophthalmology 085253651928 3rd floor: R.3.13 6 Prof. dr. I Gusti Made Aman,

Sp.FK B6 Pharmacology 081338770650

3rd floor: R.3.14 7 dr. Ketut Suardamana,

Sp.PD-KAI B7 Interna

08123985811 3rd floor: R.3.15 8 dr. Wayan Eka Sutyawan,Sp.M B8 Ophthalmology 081338538499 3rd floor:_R.3.16 9 Dr.dr. Dyah Kanya Wati, Sp.A _(K) B9 Pediatric 085737046003 3rd floor:_R.3.17 10 dr. I Gede Ketut Sajinadiyasa, _Sp.PD B10 Interna 085237068670 3rd floor:_R.3.19

CORE CURRICULUM

BLOCK : VISUAL SYSTEM AND DISORDER

SEMESTER : IV

SKS : 2

NO DAY LEARNING OUTCOME EDUCATIONAL

STRATEGIES

LEARNING SITUATION

METHOD OF ASSESMENT

1 1 Able to know and understand the Anatomy of the eye

Independent learning Integrated learning Problem based learning

Introductory lecture Student Project SGD

Practicum

MCQ

2 2 Able to know and understand the Histology of the eye

Independent learning Integrated learning Problem based learning

Introductory lecture Student Project SGD

Practicum

MCQ

3 3 Able to know and understand the Physiology of the eye

Integrated learning Integrated learning Problem based learning

Introductory lecture Student Project SGD

Practicum

MCQ

4 4 Able to know and understand the Pharmacology and Pharmacokinetic of the eye medicines

Problem based learning Integrated learning Problem based learning

Introductory lecture Student Project SGD

Practicum

MCQ

5 5 Able to establish diagnosis and manage patient with

INFECTION &

IMMUNOLOGIC EYE DISEASES such as :

- Conjunctivitis,

blepharitis, hordeoulum, chalazion and dry eye syndrome

- Scleritis, episcleritis - Keratitis,uveitis - Kerato-conjunctivi. sicca

- Iridocyclitis, Iritis - Endoftalmitis

Independent learning Integrated learning Problem based learning

Introductory lecture Student Project SGD BCS MCQ OSCE

6 6 Able to establish diagnosis and manage patient with OCULAR INJURY such as:

- Conjunctiva & cornea

foreign body,corneal erosion, thermal /burn injury - Sub conjunctiva

Haemorrhage, hyphema

- eyelid laceration, lacrimal duct

Integrated learning Integrated learning Problem based learning

Introductory lecture Student Project SGD BCS MCQ OSCE

laceration 7 7 Able to establish

diagnosis and manage patient with

GLAUCOMA

DISORDERSsuch as : - Acute glaucoma

- Chronic glaucoma - Secondary glaucoma

- Congenital glaucoma

Problem based learning Integrated learning Problem based learning

Introductory lecture Student Project SGD BCS MCQ OSCE

8 8 Able to establish diagnosis and manage patient with CORNEA & LENS DISORDERS such as :

- Cataract

- Lens dislocation - Keratokonus

Independent learning Integrated learning Problem based learning

Introductory lecture SGD

BCS

MCQ

9 8 Able to establish diagnosis and manage patient with VITREO RETINAL DISORDERS such as :

- Retinal detachment - Retinal vessel occlusion

- Degeneration macula - Diabetic retinopathy - Hypertensive retinopathy

Integrated learning Integrated learning Problem based learning

Introductory lecture Student Project SGD BCS MCQ OSCE

10 9 Able to establish diagnosis and manage patient with NEURO OPHTHALMOLOGY - Papilloedema - Optic Neuritis - Optic neuropathy - Optic atrophy & STRABISMUS EXAMINATION AND DISORDERSsuch as :

- diplopia - amblyopia - Esotropia - Exotropia

Problem based learning Integrated learning Problem based learning

Introductory lecture SGD Introductory lecture Student Project SGD MCQ MCQ

11 10 Able to establish diagnosis and manage patient with

REFRACTIVE

DISORDERS such as : - Myopia

- Hypermetropia - Astigmatism

Independent learning Integrated learning Problem based learning

Introductory lecture SGD

BCS

MCQ OSCE

- Presbiopia - Anisometropia 12 10 Able to know about:

COMMUNITY OPHTHALMOLOGY PROBLEMsuch as:

- Blindness, Loss of vision

- Community ophthalmology

Integrated learning Integrated learning Problem based learning

Introductory lecture

TIME TABLE Study load : 2 SKS = 10 days

DAY PROGRAMME LEARNING ACTIVITIES CLASS B CLASS A PIC

I 21/6/16 LEARNING OUTCOME 1 INTRODUCTION LECTURE :

- Anatomy of the Eye Independent Learning SGD Break Student Project Plenary session

08.00 - 08.15 08.15 - 09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00

09.00 - 09.15 09.15 - 10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Budi Yuliana Yuliana II 22/6/16 LEARNING OUTCOME 2,3 LECTURE:

- Histology of the eye Independent Learning SGD Break Student Project Plenary session 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Ratna/Mayun Ratna/Mayun III 23/6/16 LEARNING OUTCOME 3 LECTURE :

- Physiology of the eye Independent Learning SGD Break Student Project Plenary session 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Sutjana/ Krisna Sutjana/ Krisna IV 27/6/16 LEARNING OUTCOME 3,4 LECTURE :

- Physiology of the eye

- Pharmacology of

the ocular medicine Independent Learning SGD Break Student Project Plenary session

08.00 - 08.30 08.30-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00

09.00 - 09.30 09.30-10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Krisna Jawi Krisna, Jawi V 28/6/16 LEARNING OUTCOME 5,6,22 LECTURE:

- Visus and

Refraction - Refraction disorders Independent Learning SGD Break Student Project Plenary session 08.00-08.30 08.30-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-09.30 09.30-10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Ariesanti Eka Ariesanti, Eka

VI 30/6/16 LEARNING OUTCOME 7,8,9,21,22 LECTURE:

- Infection eye disorders

- Imunologic eye disorders Independent Learning SGD Break Student Project Plenary session 08.00-08.30 08.30-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-09.30 09.30-10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Niti Juliari Niti, Juliari VII 01/7/16 LEARNING OUTCOME 10,22 LECTURE:

- Congenital and Chronic

Glaucoma

- Acute and

Secondary Glaucoma Independent Learning SGD Break Student Project Plenary session 08.00-08.30 08.30 -09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-09.30 09.30 -10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Agus Ari Surya Agus, Ari Surya VIII 11/7/16 LEARNING OUTCOME 11,12,13,14,15 ,16 LECTURE:

- Ocular Injuries

- Eyelids and Lacrimal Disorders Independent Learning SGD Break Student Project Plenary session 08.00-08.30 08.30-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-09.30 09.30-10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Sukartini Laksmi U Sukartini, Laksmi U IX 12/7/16 LEARNING OUTCOME 17,18,22 LECTURE :

- Cornea and Lens

disorder - Retina Independent Learning SGD Break Student Project Plenary session 08.00-08.30 08.30-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-09.30 09.30-10.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Jaya Ari Jaya, Ari X 13/7/16 LEARNING OUTCOME 19,20 LECTURE : - Neuro Ophthalmology - Strabismus Independent Learning SGD Break Student Project Plenary session 08.00-08.30 08.30-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 09.00-09.30 08.30-09.00 12.00-13.30 13.30-15.00 11.30-12.00 10.00-11.30 15.00-16.00 Mas Surasmiati Juliari Mas, Surasmiati

XI 13-19/7/16

ARTICLE REVIEW PRESENTATION TEAM

XII 14-20/7/16

PRAKTIKUM / BASIC CLINICAL SKILL

(Histology, Physiology, Ophthalmology)

TEAM

XIII 21/7/16

PRE-EVALUATION BREAK TEAM

XIII 22/7/16

FINAL ASSESSMENT TEAM

Note.

 Lecture: at class room (4.01), 4rd _{floor start on time}

 Class will be locked while the lecture begin, please do not late for the class

 Student Presentation: at class room (4.01)

TIME TABLE BASIC CLINICAL SKILL

Study load : 1 SKS = 5 days

DATE : 14 July 2016 – 20 July 2016

DAY LEARNING ACTIVITY CLASS B CLASS A PIC

I 14/7/16

LECTURE: VISUAL ACUITY EXAMINATION

BCS Visual Acuity Exam + Anterior segmen Break

Student Project Presentation

08.00 – 09.00 09.30-11.30 11.30-12.00 12.00-14.00

09.00 – 10.00 13.00-15.00 12.30-13.00 10.30-12.30 Laksmi Utari TEAM Eka II 15/7/16 LECTURE : - TONOMETRY - VISUAL FIELD/KONFRONTASI

- AMSLER GRID

BCS Tonometry + Konfrontasi + Amsler Grid

Break

Student Project Presentation

08.00-09.00 09.30-11.30 11.30-12.00 12.00-14.00 09.00-10.00 13.00-15.00 12.30-13.00 10.30-12.30 Mas Putrawati TEAM Surasmiati III 18/7/16 LECTURE :

- POST SEGMENT

EXAMINATION

BCS Post Segment Exam Break

Student Project presentation

08.00-09.00 09.30-11.30 11.30-12.00 12.00-14.00 09.00-10.00 13.00-15.00 12.30-13.00 10.30-12.30 Surasmiati TEAM Budi/Ari IV 19/7/16 LECTURE :

- Anterior Segment Examination

- Therapeutic Instillation & Drug Prescription

BCS Ant Segment Exam+ Terupeutis Break 08.00-08.30 08.30-09.00 09.30-11.30 11.30-12.00 09.00-09.30 09.30-10.00 13.00-15.00 12.30-13.00 Ari Suryathi TEAM

Student Project 12.00-14.00 10.30-12.30 Laksmi Utari

V 20/7/16

LECTURE :

- Histology Examination

-

Physiology Practice Lecture : Ishihara Plucido Kampimetri

Practicum Histology Break

Practicum Physiology

08.00-08.30 08.30-09.00 09.30-11.30 11.30-12.00 12.00-14.00

09.00-09.30 09.30 -10.00

13.00-15.00 12.30-13.00 10.30-12.30

Ratna Krisna Histology team

PHYSIOLOGY TEAM

Note:

Lecture for BCS Ophthalmology, Histology and Physiology will be held at Class Room (R.4.01)

BCS Ophthalmology will be held at Skill Lab. Histology Practicum will be

demonstrated in classroom. Physiology Practicum will be held in Physiology Dept. Each BCS will be divided into 4 small groups:

ENGLISH CLASS (CLASS B): Group A

Group B Group C Group D

REGULAR CLASS (CLASS A): Group A

Group B Group C Group D

MID BLOCK MEETING

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

PLENARY SESSION

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

ASSESSMENT METHOD

Assessment will be held on Monday, 27 Juli 2016. The Final examination will be held with the format of Computer Based Test. There are 100 questions for the examination that consist out Multiple Choice Questions (MCQ). The time provision is 100 minutes. The number of MCQ is 100. The minimal passing score for the assessment is 70.

The proportions of examination score are:

Small Group Discussion : 5%

Article Review (Student Project) : 15% Final assessment (MCQ) : 80% The Prerequisites of Final Examination: Attend 75% of total student activities

Uniform for Examination: white shirt, black trouser/ skirt, shoes. NO SANDALS ALLOWED to be wear at the class

Bring Student ID card with photo

Be present 15 minute before the examination starting time

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

Article Review

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

Format of Article Review

Article Review writed at top left corner Udayana Symbol

Name

Student Registration Number

Udayana University, School of Medicine, 2015 2. Introduction

3. Content: From Definition to Treatment 4. Summary

5. Reference (minimal 10 references)  Vancouver Example:

Journal.

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

Tex book

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

Note:

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

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

TOPIC OF ARTICLE REVIEW

English Class

Date SGD Presentation

Time

Title Evaluator

13/7/16 14/7/16 15/7/16 18/7/16 19/7/16

B1 10.00-10.30 Corneal Ulcer Niti/Juliari

B2 10.30-11.00 Endophthalmitis Niti/Juiari

B3 10.00-10.30 Congenital Cataract Eka S

B4 10.30-11.00 ROP Eka S

B5 10.00-10.30 Congenital Esotropia Surasmiati

B6 10.30-11.00 Eksotropia Intermitten Surasmiati

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

B9 10.00-10.30 Basal Cell Carcinoma Laksmi Utari

B10 10.30 -11.00 Squamous Cell Carcinoma Laksmi Utari

Note. Student presentation: at class room (4.01)

Regular Class

Date SGD Presentation

Time

Title Evaluator

13/7/16 14/7/16 15/7/16

A10 12.30-13.00 Endofthalmitis Niti/Juliari

A9 13.00-13.30 Corneal Ulcer Niti/Juliari

A8 13.00-13.30 ROP Eka S

A7 13.00-13.30 Congenital Cataract Eka S

18/7/16 19/7/16

A5 13.00-13.30 Congentital Esotropia Surasmiati

A4 12.30-13.00 Central Retinal Artery Oclusion Budiastra/ Ari A A3 13.00-13.30 Central Serous Chorioretinopathy Budiastra/Ari A A2 12.30-13.00 Squamous Cell Carcinoma Laksmi Utari

A1 13.00-13.30 Basal Cell Carcinoma Laksmi Utari

Note. Student presentation: at class room (4.01)

Article Review Assessments Form Block of Visual system and disorders

Name :………..

Student Reg. Number :………..

Facilitator :………..

Title :………..

Time Table of Consultation

No Point of Discussion Date Supervisor Sign

1 Outline of Paper 2 Final Discussion

No Item Assessment Range Score (%) Score

1 Ability to find the literature 0-20

2 Communication/attitude/presentation 0-30

3 Quality of material (SOAP) 0-40

4 Student interest and motivation 0-10

TOTAL 100

Facilitator,

(………) NIP

No Item Assessment Range Score (%) Score

1 Quality of material 0-60

2 Capability of Information Searching 0-10

3 Critical Thinking 0-30

TOTAL 100

Evaluator/Supervisor,

(………) NIP

LEARNING PROGRAM

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

SUMMARY

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

LEARNING TASK:

1. Describe four walls of orbit and the bones that construct the walls. 2. Describe blood supply of the eye

3. Describe about lacrimal apparatus components 4. Describe about orbit muscles

5. Describe about layers of eyeball

6. Describe about nerve supply of the eyes

SELF ASSESSMENT:

1.

Describe about the position of bones that construct the walls

2.

Describe about the position of lacrimal apparatus

LEARNING RESOURSES:

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

Day 2 MODULE 2 Title of Lecture HISTOLOGY OF THE EYE

Abstract

Like any other senses, eye is our window to the external world. Eye captures image continuously and transmits it to the brain for next processing and understanding. The structure of the eye is perfectly designed to perform its course. The light reflected by object enters the eye through cornea and pupil. The amount of light permitted is regulated by iris by dilating or constricting the pupil. Then, the refractive structures, lens and vitreous body, directing the light to the retina where it translated to a signal the brain can understand and perceived as an image. The shape and structure of the other eye walls support the photoreceptor function of the eye. The rigid and opaque sclera protects the eye and maintains the spherical shape needed for precise image in the back of the eye. The uvea provides nutrition and its melanin blocks lights from other angles, thus, only light comes from cornea is received. The accessory structures of the eye also support and protect the eye. It is consist of lacrimal gland, which produce tears; conjunctiva, covered the anterior part of the eye; and eye lids, the “on and off button” of the eye.

Vignette

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

Learning Task:

What histologic structure mainly affected in the case? Describe that histologic structure involve in the case above!

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

Learning Task:

1. What is the main structure disturbed in the case above?

2. Describe about the structure, which layer is mainly affected in the case above? 3. Describe all of the accessory structures that contributing in the formation of the

structure mentioned!

Self Assessment:

1. Describe in detail about the accessory structure involve in the case above 2. Describe the accessory structures that contributing in the formation of tear film! 3. Describe about the circulation and function of aqueous humor and tears! 1. Describe about the refractive media of the eye:

1. Cornea

2. Aqueous humor 3. Lens

4. Vitreous humor

2. Describe in detail about the histologic structure of the eye’s wall: 1. Sclera

2. Choroid 3. Retina

3. Describe about the structure that holds the lens, including the choroid body! 4. What fluid drains from the eye to the canal of Schlemm?

5. What structures absorb the light that enters the eye?

7. What is the sclera made of?

8. What cells in the conjunctiva which produce substance that constitute the tear film? References:

1. Gartner, L. P. & Hiatt, J. L. 2011. Color Textbook of Histology. 3rd _{Ed. Philadelphia:} Saunders Elsevier. Pp. 514-526.

2. Fawcett, D. W. & Jensh, R. P. 2002. Concise Histology. 2nd _{Ed. London: Arnold.} Pp.301-313.

DAY 3 Module 3 Title of Lecture PHYSIOLOGY OF THE EYE

By Prof.dr.I Dewa Putu Sutjana, PFK,M.Erg

INTRODUCTION

The human know the environment because they had special senses, such as visual system, auditory, smell, taste, tactile which are call five senses. The visual system was control around 90% of the daily activity. The visual system detects and interprets light stimulations. The light stimulations are in form of electromagnetic waves of lengths between 400 to 700 nm, which make up visible light. The human can be known the environment because they had:

The optic system, for reflected the light enters the eye and focuses it on the retina The retina as photoreceptors transducer light energy into an nerves impulses

The optical neural, Neural pathways from the retina to the visual cortex at occipital lob of brain.

The visual cortex of the brain process nerve impulses into visual images.

I.OPTIC SYSTEM OF THE EYE

The optics system of the eye is equivalent to the usually photographic camera. It has a lens system, aperture system (call pupil) and retina that correspond to the film. The lens system of the eye is composed of four refractive interfaces. If all the refractive surfaces of the eye are added together and considered to be one single lens known as reduced eye. In reduced eye total refractive power 59 diopters when the eye accommodated for distant vision.

FORMATION OF AN IMAGE ON THE RETINA

The light from the objects refracted and focused by the optics system of the eye on the retina. The image is inverted and reversed with respect to the object. However, the mind perceives objects in the upright position.

PUPILLARY DIAMETER

Like in the camera the eye had the pupil which is formed by the iris. The major function of the iris is to control the diameter of the pupil. The diameter of the pupil is control the amount of light enters the eye. The stimulation of the parasympathetic nerve increases the diameter of pupil. The change of pupil diameter followed the accommodation

ACCOMODATION

The eye can be adjusted automatically the vision changes from the near to par objects, by changes the refractive power of the eye which is known as accommodation. In human eye the accommodation is due to change the refractive power of the lens (from 20 diopters to about 34 diopters), especially in children or the young person. The ability of eye accommodation (lens refractive power) is reduced with increased of age, and than followed by presbyopia.

NORMAL VISION AND ERROR OF REFACTION

Normal vision known as an emmetropic eye, if parallel light rays from distant objects are in sharp focus on the retina, when ciliary muscle completely relaxed. If the parallel light rays are focus behind the retina is known as hyperopia, if parallel light rays focus in the front of retina known as myopia, but if the different of the curvature of the cornea is known as astigmatism. The correction of refractive error is use of lens, concave spherical lens for myopia, convex lens for hyperopia and cylindrical lens for astigmatism.

VISUAL ACUITY

Visual acuity is the ability of the person to distinguished two bright pin point spots of light 10 meters away can barely distinguished the spots as separate entities when they are 1.5 to 2 millimeters apart. Clinical method to tested the visual acuity use the Snellen’s chart,

consist of letter of different sizes placed 20 feet away from the person being tested, with the formula:

V = d/D

V= visual acuity, d = distant of the person can read the letter, and D=distant of normal vision can read that letter.

FLUID SYSTEM OF THE EYE

For normal vision, the eye filled with intraocular fluid, which maintains sufficient pressure in the eyeball to keep it distended. The fluid can be divided into two portions: aqueous humor, which lies in front of the lens and vitreous humor, which is between the posterior surface of the lens and the retina. The aqueous humor is a freely flowing fluid, whereas the vitreous humor sometimes called the vitreous body, is gelatinous mass. Both water and dissolved substances can diffuse slowly in the vitreous humor but there is little flow of fluid. Aqueous humor is continually being formed and reabsorbed. The balance between formation and reabsorption of aqueous humor regulates the total volume and pressure of intra ocular fluid.

RECEPTOR AND NEURAL FUNCTION OF THE RETINA

Retina is the light sensitive portion of the eye, contain 9 layers from outside to inside as follows (1) pigmented layer, (2) layer of rods and cones, (3) outer nuclear layer, (4) outer plexiform layer, (5) inner nuclear layer, (6) inner plexiform layer, (7) ganglionic layer, (8) layer of optic nerve fiber, (9) inner limiting membrane. After the light passes through the lens system of the eye and then through the vitreous humor, it enters the retina from the inside layer and then finally reaches the layer of rods and cones. Cones located at the central fovea, a minute area in the center of retina occupying a total area around 1 square millimeter. The central fovea only 0.3 millimeters in diameter is composed almost entirely of cones. Outer of the center fovea located by rods.

PHOTORECEPTOR RHODOPSIN-RETINAL VISUAL CYCLE AND EXCITATION OF THE RODS

When light energy is absorbed by rhodopsin the rhodopsin begins to decompose within a very small fraction, cause photoactivation of electron, and then re-formation of rhodopsin again, which is call rhodopsin-retinal cycle. In that cycle vitamin A more important for normal vision, but if vitamin A is not enough, the night blindness occurs.

PHOTOCHEMISTRY OF COLOR VISION BY CONES

Photo chemicals in the cones have almost same to the rhodopsin at the rods. The difference is the protein portions, call the opsins (photopsins). According to the Young-Helmholtz theory, there are three type of color pigment in the cones cells (blue, green, red): blue sensitive pigment, green sensitive pigment, and red sensitive pigment. So different cones (three type of cone) are sensitive to different colors of light.

Color blindness. When a single group of color-receptive cones is missing from the eye, the person is unable to distinguish some colors from others, call color blindness. If the person loss of red cones it is called a protanope, if lacks of green called deuteranope. Red green color blindness is a genetic disorders, that at the female X chromosome. So that the color blindness almost in males.

NEURAL FUNCTION OF THE RETINA

Neural organization at the retina is more complex. The function of the neural pathways is to transmit the neural impulse from the retina (rods and cone) through the optic nerve to the brain. It is different at the peripheral retina and in the center foveal retina. That is way the center foveal retina for detail and color vision

LEARNING TASK

Describe the equivalent and the different optic system of the human eye to the photographic camera.

Describe the optic system of the eye

Describe the different of emmetropia, hyperopia and myopia.

What is accommodation, and in the human eyes which part of the optic system most important.

Describe the circulation of the eye fluid

Describe the different of rods and cones in the vision perception Describe the rhodopsin-retinal cycle, during light exposure to the rod Describe the role of vitamin A in rhodopsin retinal cycle

Describe the Young-Helmholtz theory of the color vision Describe many kind of color blindness

SELF ASSESSMENT

Can you mention the part of optic system

What is mean by presbyopia and why it is occur in the human? Can you explain the role of cilliary muscle during accommodation? Can you explain why color blindness almost occur in males. Can you explain the neural function of the retina

Can you explain why the niktalopia person difficult to see in the afternoon but not problem at the morning?

RESOURCES:

Guyton, A. The Textbook of Medical Physiology

Silverthorn, D.U. 2010. Human physiology. An Integrated Approach.Fifth Ed. Pearson. San Fransisco.

DAY 4 Module 3 Title of Lecture

PHYSIOLOGY OF THE EYE – Visual Pathways dr. I Made Krisna Dinata, M.Erg

Abstract

The Visual Pathways

The visualnerve signals leave the retinas through the opticnerves. At the optic chiasm, the optic nerve fibersfrom the nasal halves of the retinas cross to theopposite sides, where they join the fibers from theopposite temporal retinas to form the optic tracts. The fibers of each optic tractthen synapse in the dorsal lateral geniculate nucleus of the thalamus, and fromthere, geniculocalcarine fibers pass by way of the optic radiation (also called thegeniculocalcarine tract) to the primary visual cortex in the calcarine fissure areaof the medial occipital lobe. Visual fibers also pass to several older areas of the brain:

From the optic tracts to the suprachiasmatic nucleus of the hypothalamus, presumably tocontrol circadian rhythms that synchronize various physiologic changes of the body with night and day

Into the pretectal nuclei in the midbrain, to elicit reflex movements of the eyes to focus on objects of importance and to activate the pupillary light reflex

Into the superior colliculus, to control rapid directional movements of the two eyes Into the ventral lateral geniculate nucleus of the thalamus and surrounding basal regions of the brain, presumably to help control some of the body’s behavioral functions.

The visual pathways can be divided roughly into an old systemto the midbrain and base of the forebrain and a new system for direct transmissionof visual signals into the visual cortex located in the occipital lobes. Inhuman beings, the new system is responsible for perception of virtually allaspects of visual form, colors, and other conscious vision.

Function of the Dorsal Lateral Geniculate Nucleusof the Thalamus

The optic nerve fibers of the new visual system terminate in the dorsal lateralgeniculate nucleus, located at the dorsal end of the thalamus and also calledsimply the lateral geniculate body, as shown in Figure 51–1. The dorsal lateralgeniculate nucleus

serves two principal functions: First, it relays visual informationfrom the optic tract to the visual cortex by way of the optic radiation(also called the geniculocalcarine tract). This relay function is so accurate thatthere is exact point-to-point transmission with a high degree of spatial fidelityall the way from the retina to the visual cortex.

Visual Field

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

Fusion of the Visual Images From the Two Eye

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

Case

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

Learning Task

Which area in visual pathways had been damage in that patient? Describe the transmit of visual impulse from retina to the brain What is called the monocular and binocular visual field

Differentiate the nasal and temporal visual field, and what tool for evaluation of the visual field

Describe how the visual image can be fusion

Self Assessment

Explain the different of visual field from left and right visual field What is called the monocular and binocular visual field

Discribe the neural pathways to control pupillary light reflex

Describe the neural pathways to the optic nerve to form the consensual reflex

Refferences

Medical Physiology eleventh edition, Guyton & Hall. Physiology fifth edition, Linda S. Costanzo.

Silvertharn, D.U. 2010. Human Physiology. An Integrated Approach. Fifth Ed. Pearson. San Fransisco

DAY 4 MODULE 4 Title of lecture

OCULAR PHARMACOLOGY By Dr. dr. I Made Jawi, M.Kes Abstract

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

SELF-DIRECTED LEARNING

1. Basic principles of drug that affect outonomic nervus system

2. Pharmacokinetic and pharmacodynamic of some drugs that use in visual system 3. Important side effects of drugs that use in visual system

SCENARIO Vignette

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

Learning Tasks

1. Which anti-glaucoma will you give to the patient according to the patient condition? Explain your answer.

2. What is the mechanism of action on the muscle of the iris and cilia? 3. What receptor mediates the action?

4. List parts of the eyes that are innervated by the autonomic nervous system and explain the effects of sympathetic and parasympathetic drugs to those parts.

5. List the drugs that can be used to treat glaucoma and explain their mechanism of action to reduce the intraocular pressure

6. Please explain, why topical application sometimes has systemic effect? 7. List the important side effects of anti-glaucoma agents.

8. Which drug can produce cycloplegia? Explain the mechanism of action of this drug. 9. Please compare the advantages and disadvantages between eye drops and eye

ointments.

Self Assessments

1. Please explain the factors that determine the rate and the extent of absorption of the drug after topical application to the eye.

2. Please explain the possible absorption pathways of an ophthalmic drug following topical application to the eye. Which routes are desired to localize ocular drug effects?

3. Please explain, why topical eye medication can cause systemic side effects? 4. Please explain how to apply eye drop to the eye to get optimal effect.

5. Please explain the characteristics of cholinoceptors in the peripheral nervous system.

6. Please explain the characteristic of adrenoceptors in the ANS.

7. Please explain the effects of sympathetic and parasympathetic drugs on the eye. 8. Please list some drugs used in glaucoma and explain their mechanisms of action. 9. Please list important side effects of drugs used in glaucoma.

10. Please list some drugs used in ophthalmology diagnostic.

RESOURCES Standard textbook

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

Additional Readings

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

DAY 5TH

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

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

LEARNING OUTCOMES:

Can describe the Signs, Symptoms, Patophysiology and Management of: 1. Myopia

2. Hyperopia 3. Astigmatism 4. Presbyopia 5. Anisometropia

CURRICULUM CONTENTS

1. Optics and Refraction 2. Refraction examination

3. Emetropia and Ametropia / Refractive Errors 4. Contact lens

ABSTRACT / SUMMARY OF LECTURE

The eye change refractive power to focus on near object by a process call it accommodation. Emetropia is absence of refractive errors and ammetropia is the present of refractive errors.

Light rays are focused on the retina to create sharp image. The light has to pass trough refractive media of the eye such as cornea, lens and vitreous body to reach retina. Some equipment are needed to examine refraction as follows Snellen chart, Trial lenses, trial frame, pupil distance ruler, lensometer, astigmatism chart, streak retinoscopy and autorefractor. The technique used in subjective refraction is trial and errors technique, while Astigmatic Clock Dial technique and Jackson Cross Cylinder technique were used to find astigmatism of the patient. Emmetropia is term used for eye with parallel light from distant object focused on retisna without accommodation of the eye. Ametropia is condition where parallel light is not focused on retina without eye accommodation. Classification of ammetropia is myopia, hypermetropia and astigmatism.

Miopia is a refractive error in which focus for light rays from a distant object is anterior to the retina. Hypermetropia is a refractive error in which the focus of light rays from a distant object is behind the retina. Astigmatism is a refractive error that prevents the light rays from coming to a point focus on the retina because of different degrees of refraction in the various meridians of the cornea or crystalline lens. Presbyopia (“old sight”) is a physiologically blurred near vision, commonly evident soon after age 40, due to reduction in the power of accommodation.

The management of refractive errors could be glasses, contact lens and refractive surgery. Contact lens could be used to treat refractive errors, theraphy for some ocular pathologies as well as cosmetic or prosthetic use. Some complication could be developed regarding the inappropriate handle and use of contact lens, such as allergic, Keratitis and corneal ulcer.

SELF DIRECTING LEARNING (in depth learning of above lecture)

1. Physiology of Optics and refraction 2. Definition of Emetropia and Ametropia 3. Refraction examination

5. Refractive Error: Hyperopia 6. Refractive Error: Astigmatism 7. Refractive Error: Presbyopia 8. Anisometropia

9. Managements of refractive errors

10. Benefits and complications of Contact lens use

SCENARIO

1. A 8 years old boy complain about intermittent blurred vision and headache at the frontal region. Everyday, the patient spent his time in front of his gadget all day. From physical examination found that he able to read all the letters from the Snellen chart. After given mydriatic drops and done the refraction, he can read all the letters with correction of S+2.00 D in both eyes.

a. What is the diagnosis of this case?

b. Mention about the types of hypermetropia based on the accomodation c. What kind of glasses should be prescripse for hypermetropia patient d. What are the complications of hypermetropia and how it can happened? e. What is the differences between hypermetropia and presbyopia

2. A 25 years old woman complained of blurred vision and headache especially in frontal region. From the examination there are C-1.50 A 180° found in the right eyes and S-2.00 C-0.50 A0° in the left eye.

a. What is the diagnosis of the both eye?

b. Mention about the types of regular astigmatism c. Mention about the symptoms of astigmatism

3. A 30 years old man come to the ophthalmologist and has checked his visual acuity. From the right eye there is S-6.00 and his BCVA is 6/10 and from his left eye there is 6/6 with S-0.50

a. What is the diagnosis of this patient? b. What is the complication of myopia?

c. What happen if the patient is given maximum correction of glasses?

d. So what is the best treatment in this case to make better visual acuity and avoid the complication?

SELF ASSESSMENTS

1. Mentions and explain about types of myopia 2. Methods of objective refraction:

a. Trial and errors techniques b. Streak retinoscopy

c. Astigmatic clock dial d. Fogging technique e. Jackson cross cylinder

LEARNING RESOURSES:

1. Vaughan: General Ophthalmology 2. Ilyas S: Ilmu Penyakit Mata. FK UI

3. Deborah PL: Manual Diagnostic &Ocular Treatmentt.

DAY 6 MODULE 6 Title of lecture

INFECTION & IMMUNOLOGIC EYE DISEASES By NK.Niti Susila, MD/IGAM Juliari, MD AIMS:

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

LEARNING OUTCOMES:

Can describe the Signs, Symptoms, Patophysiology and Management of:

1.

Blepharitis

2.

Hordeolum & Chalazia

3.

Conjunctivitis

4.

Scleritis & Episcleritis

5.

Keratitis

6.

Anterior Uveitis (Iritis & Iridosiklitis)

7.

Dry Eye Syndrome & Keratoconjunctivitis sicca

SELF DIRECTING LEARNING ( in depth learning of above lecture)

1.

Blepharitis

a.

Pathogenesis of blepharitis

b.

Definition of chronic anterior blepharitis

c.

Definition of chronic posterior blepharitis

d.

Definition of Angular blepharitis

e.

Aetiology of blepharitis

f.

Signs and symptoms of chronic anterior and posterior blepharitis and angular blepharitis

g.

Diagnosis of chronic anterior and posterior blepharitis and angular blepharitis

h.

Management of blepharitis

i.

Associations of chronic blepharitis

2.

Hordeolum

a.

Pathogenesis of hordeolum

b.

Definition of external and internal hordeolum

c.

Aetiology of external and internal hordeolum

d.

Signs and symptoms of external and internal hordeolum

e.

Diagnosis of external and internal hordeolum

f.

Management of external and internal hordeolum

g.

Complication of external and internal hordeolum

3.

Chalazion

a.

Pathogenesis of chalazion

b.

Definition of chalazion

c.

Aetiology of chalazion

d.

Signs and symptoms of chalazion

e.

Diagnosis of chalazion

f.

Management of chalazion

g.

Complication of chalazion

4.

Conjunctivitis

a.

Pathogenesis of conjunctivitis (Allergy, viral, bacterial)

c.

Aetiology of conjunctivitis

d.

Signs and symptoms of conjunctivts

e.

Diagnosis of conjunctivitis

f.

Management of conjunctivitis

g.

Prognosis of conjunctivitis

h.

Differential diagnosis conjunctivitis due to aetiology

i.

Complication of conjunctivitis

5.

Scleritis

a.

Pathogenesis of infection scleritis non infection scleritis

b.

Definition of infection or non infection scleritis

c.

Aetiology of infection or non infection scleritis

d.

Signs and symptoms of infection or non infection scleritis

e.

Diagnosis of infection or non infection scleritis

f.

Prognosis of infection or non infection scleritis

g.

Management of infection or non infection scleritis

h.

Different diagnosis of infection or non infection scleritis

i.

Complication of scleritis

6.

Episcleritis

a.

Pathogenesis of episcleritis

b.

Definition of episcleritis

c.

Aetiology of episcleritis

d.

Signs and symptoms of episcleritis

e.

Diagnosis of episcleritis

f.

Prognosis of episcleritis

g.

Management of episcleritis

h.

Different diagnosis of episcleritis

7.

Keratitis

a.

Pathogenesis of keratitis

b.

Definition of keratitis

c.

Aetiology of keratitis

d.

Signs and symptoms of keratitis

e.

Diagnosis of keratitis

f.

Prognosis of keratitis

g.

Management of keratitis

h.

Different diagnosis of keratitis

i.

Prognosis of kearatitis

j.

Complication of keratitis

8.

Uveitis anterior

Pathogenesis of uveitis anterior Definition of iritis and iridocyclitis Aetiology of iritis and iridocyclitis

Signs and symptoms of iritis and iridocyclitis Diagnosis of iritis and iridocyclitis

Prognosis of iritis and iridocyclitis Management of iritis and iridocyclitis Different diagnosis of iritis and iridocyclitis Prognosis of iritis and iridocyclitis

Complication of iritis and iridocyclitis

9.

Dry eye disorders Physiology of tear film

Definition of dry eye Aetiology of dry eye

Signs and symptoms of dry eye Diagnosis of dry eye

Prognosis of dry eye Management of dry eye Different diagnosis of dry eye Prognosis of dry eye

Complication of dry eye 10.Keratoconjunctivitis sicca

Physiology of tear film

Pathogenesis of Keratoconjunctivitis sicca Definition of Keratoconjunctivitis sicca Aetiology of Keratoconjunctivitis sicca Classification of Keratoconjunctivitis sicca

Signs and symptoms of Keratoconjunctivitis sicca Diagnosis of Keratoconjunctivitis sicca

Prognosis of Keratoconjunctivitis sicca Management of Keratoconjunctivitis sicca Different diagnosis of Keratoconjunctivitis sicca Prognosis of Keratoconjunctivitis sicca

Complication of Keratoconjunctivitis sicca

ABSTRACT/SUMMARY

The external eye is the most crucial part of the body exposed to outside word. The normal structure and function of the healthy eye rely on homeostasis of the entire body for protection against an adverse environment. Genetic and nutrition determine the embryogenesis and growth of the eye. Intact vascular and nervous systems stable metabolism, and immune system maintains surveillance.

The cushioning effect of the periocular tissues and local barriers such as the orbital rim are needed to safeguard the globe. The eyebrows and eyelashes catch small particles, and cilia also work as sensors to stimulate reflex eyelid closure. Blinking augments the lacrimal pump to rinse tears over the eye and flush off foreign material. The tear film also dilute toxins and allergens and contains proteins that control the normal flora. Mucin stabilizes that tear film and demarcates the living cells of the ocular surface from surrounding environment. The epidermis and epithelium of healthy eyelids, conjunctiva, and cornea adhere tightly to their basement membranes. Regulation of cellular growth and metabolism are critical to maintenance of an intact ocular surface and transparent cornea. The underlying extracellular matrix of the eye's mucous membrane is rich in blood vessels and conjunctiva-associated lymphoid tissue (CALT). The anterior segment of the eye provides a clear, protected entrance for light that is to be processed by the visual pathways through the central nervous system.

Understanding the eye's innate defenses requires study of ocular histology and biochemistry and observation of many people, both healthy and ill. The practice of corneal and external eye disease builds on this understanding and extends from clinical examination to clinic-pathologic problem solving, molecular medicine, and microsurgery. The student should become familiar with ocular embryology, anatomy, physiology and biochemistry, ocular immunology, and ophthalmic pathology.

Although the protections of the eye are very strong but the eye still can also be infected by bacteria, virus, fungi, and parasites.

A detailed history and physical examination are essential to proper diagnosis of external eye infections or inflammatory etiology. The patient's chief complaint and a complete systemic and ocular history, including the presence of risk factors for infections of the external eye, should be noted. A complete eye examination should included special attention to skin of the face and eyelids, the preauricular lymph node, the globe-orbit

relationship, ocular discharge, and conjunctiva and corneal morphology. Diagnostic tests are chose to differentiate between likely diagnostic entities and to assist in therapy. (eg. Antimicrobial sensitivity testing in microbial keratitis.)

Blepharitis

Blepharitis is inflammation of the eyelid

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

Hordeolum and Chalazia

Hordeolum is infection of the glands of the eyelid. It could involve meibomian gland (internal hordeolum) or Zeis's or Moll's glands (external hordeolum or stye). Pain, redness, and swelling are the principal symptoms. Most hordeola are caused by staphylococcal infections, usually Staphylococcal aureus. Treatment consists of warm compresses three or four times a day for 10-15 minutes, antibiotic ointment applied to the conjunctival sac every 3 hours. If the process does not begin to resolve within 48 hours, incision and drainage is indicated.

A chalazion is an idiopathic sterile chronic granulomatous inflammation of a meibomian gland, usually characterized by painless localized swelling. Surgical excision is performed via a vertical incision into the tarsal gland from the conjunctival surface followed by curettement. Intralesional steroid injection maybe usefull for small lesions.

Conjunctivitis

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

Scleritis & Episcleritis

Episcleritis is a relatively common localized inflammation of the vascularized connective tissue overlying the sclera. It tends to affect young people, third or fourth decade, affects woman three times as frequently as men. Symptoms of episcleritis include redness and mild irritation or discomfort. The condition is benign, and the course is generally self-limited in 1-2 weeks. Others therapy was needed in special causes.

Scleritis is an uncommon disorder characterized by cellular infiltration, destruction of collagen, and vascular remodeling. These changes may be immunologically mediated or less commonly, the result of infection. Laboratory studies are often helpful in identifying associated systemic disease. There were 2 types of scleritis, anterior and posterior. Initial treatment of scleritis is with systemic nonsteroidal anti-inflammatory agents. If there is no response in 1-2 weeks, or if vascular closure becomes apparent, oral prednisone, 0.5-1.5 mg/kg/d, should be started.

Keratitis

Keratitis is an inflammation of cornea. The specific symptoms are pain and photophobia. Examination is often fascilitated by instillation of a local anesthetic. Fluorescein staining can outline a superficial epithelial lesion that might otherwise be impossible to see. A patient's

history is important in corneal disease. A history of trauma, corneal disease, and local medications should be investigated.

Anterior Uveitis (Iritis & Iridocyclitis)

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

Dry Eye Syndrome & Keratoconjunctivitis sicca

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

SCENARIO

A 79-year-old woman complains of red eyes that constantly tear and burn. She also feels foreign-body sensation and reports that her vision is not clear as before. The vision varies with tear blink. She has noticed this condition over past several years. On exam find a poor tear film filled with debris.

What is the diagnosis?

What is the definition of dry eye?

What are the components of the tear film? What are the most common signs of dry eye? What are the treatments for dry eye patients?

A 25-year-old man states that his eyes have been dripping with discharge over the past 8 hours. You notice significant purulent discharge, a preauricular node, and marked chemosis.

What is the diagnosis? What is the next step?

What are you looking for on the Gram stain? How should the patient be treated?

What is the complication?

A 35-year-old complained of pain in his left eye for several days, watery discharge, and blurred vision. He thinks he has the same symptoms before. He admits to stress on the job as well as a recent cold sore.

What is the diagnosis?

What are you looking for on fluorescein staining? What are the signs of the herpes simplex keratitis? What is the complication of herpes simplex keratitis? How should the patient be treated?

A 30-year-old man presents with severe phtophobia, pain, tearing, and decreased vision in his right eye for two days. This condition has occurred several times before. He says that it was better by using drops. On exam, his vision 20/50 in the

right eye and 20/20 in the left eye. His pupil is poorly reactive on the right and miotic. The right eye is diffuse injected, especially the limbus. The anterior chamber is deep, but cell and flare are present with few fine keratic-precipitates.

What is the diagnosis?

What is the etiology of anterior uveitis?

What are differences between nongranulomatous anterior uveitis and granulomatous anterior uveitis?

What is the complication of anterior uveitis? How should the patient be treated?

A 27-year-old man present with foreign-body sensation and photophobia in both eyes after sleeping with soft contact lenses during his call night.

What is the diagnosis? What is the etiology?

What is the complication that could be happened? How should the patient be treated?

SELF ASSESMENTS

Mention about pathophysiology of blepharitis Mention and explain about types of conjunctivitis Mention and explain about types of keratitis

Mention about symptom and sign of anterior uveitis

Mention about tear film components and dry eye examination

LEARNING RESOURCES:

1. Vaughan: General Ophthalmology 2. Ilyas S: Ilmu Penyakit Mata. FK UI

3. Deborah PL: Manual Diagnostic &Ocular Treatment.

4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 2006

DAY 7 MODULE 7 Title of lecture

GLAUCOMA

By Md Agus Kusumadjaja,MD, Ari Suryathi,MD AIMS:

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

LEARNING OUTCOMES:

Can describe the signs, symptoms, pathophysiology and inital management of: 1. Acute angle closure

2. Primary Acute angle closure glaucoma 3. Secondary glaucoma

4. Primary open angle glaucoma 5. Congenital glaucoma

CURRICULUM CONTENT:

1. Acute angle closure

2. Primary Acute angle closure glaucoma

3. Secondary glaucoma due to lens opacity and trauma (hyphema) 4. Primary open angle glaucoma

ABSTRACT/ SUMMARY

Glaucoma is a group of eye disorders characterized by progressive optic nerve damage causing typical visual field defects, and increase of intraocular pressure (IOP) as one of risk factors. Glaucoma can be classified into primary, secondary, congenital and absolute glaucoma. Glaucoma also can de differentiated into acute and chronic glaucoma based on their onset. Visual acuity examination, IOP measurement, Gonioscopy, Ophthalmoscopy and Visual field examination are required to establish glaucoma diagnosis. Primary acute angle closure glaucoma (PACG) occurs when sufficient iris bombe develops to cause occlusion of the anterior chamber angle by the peripheral iris. This blocks aqueous outflow and the intraocular pressure rises rapidly, causing severe pain, redness, and blurring of vision. Angle closure is likely to develop only in eyes with preexisting anatomic narrowing of the anterior chamber angle usually when it is exacerbated by enlargement of the crystalline lens associated with aging. The acute attack is often precipitated by papillary dilatation. This occurs spontaneously in the evenings when the level of illumination is reduced.

Primary open angle glaucoma (POAG) / chronic glaucoma is the most common form in blacks and whites. The chief pathologic feature of POAG is a degenerative process in the trabecular meshwork, including deposition of extra cellular material within the meshwork and beneath the endothelial lining of Schlemm’s canal. The consequence is a reduction in adequate drainage leading to a rise in intraocular pressure. The major problem in detection of (POAG) is the absent of symptoms until relatively late in the disease.

SELF DIRECTING LEARNING (In depth learning of above lecture)

1. Basic knowledge of aquous humor production and outflow 2. Mechanism of primary and secondary acute angle closure

3. Signs, symptoms and diagnosis of acute angle closure and acute angle closure glaucoma

4. Initial management of acute angle closure angle and acute angle closure glaucoma

5. Mechanism of primary and secondary open angle glaucoma 6. Signs, symptoms and diagnosis of open angle glaucoma 7. Initial management of open angle glaucoma

8. Mechanism of congenital glaucoma

9. Signs, symptoms and diagnosis of congenital glaucoma

SCENARIO

Case 1.

A woman, 45 yo complained her eye suddenly painful, nausea and vomiting when she worked in her office. On the examination doctors found there is visual acuity decreasing and hyperemia of conjunctiva and pericorneal, corneal edema, and high intra ocular pressure.

1. Mention things you should elaborate from the patient during anamnesis 2. Mention physical examination you should do to this patient

3. Explain about the result from the examination 4. Mention differential diagnosis of the case 5. Which diagnosis is the most appropriate?

6. Explain about the initial management of this case Case 2.

A man, 65 yo complained about blur vision and narrowing visual field since three months ago. There was no redness and pain on his eye, but the blur vision getting worse every time.

1. Mention thing you should elaborate from the patient during anamnesis 2. Mention physical examination you should do to this patient

3. Explain about the result from the examination 4. Mention differential diagnosis of the case

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

IV. THERAPEUTIC SKILL

1. EYELID EVERSION 2. EYE DROP INSTILATION 3. EYE OINTMENT INSTILLATION 4. APPLY EYE DRESSING

5. REMOVAL CONJUNCTIVAL FOREIGN BODY

6. REMOVAL CORNEAL FOREIGN BODY (WITH COTTON BUD)

1. EYELID EVERSION

INFERIOR CONJUNCTIVA AND FORNIKS EXAMINATION

1. Patient look down, pushed the skin in the inferior part of inferior eyelids with thumb or point finger then pulled toward the maxilar bone.

2. Patient asked to see upgaze so the inferior forniks can be exposed and inferior

SUPERIOR PALPEBRAL CONJUNCTIVA EXAMINATION (2 HANDS TECHNIQUE) 1. Using thumb or point finger, pull several eyelashes, and pull away the edge of

superior eyelids against the eyeball

2. Put cotton tip applicator (cotton bud) in the sulcus of superior eyelids, along theegde of tarsus and pushed the applicator to the temporal part of the eye. 3. Pull the edge of superior eyelids outward and upward to see the superior bulbar

conjunctiva, through the applicator. Pulled the applicator and hold the edge of the eyelids to the skin of superior orbital rim with thumb to see the superior palpebral conjunctiva.

SUPERIOR PALPEBRAL CONJUNCTIVA EXAMINATION (1 HAND TECHNIQUE)

1. Ask the patient to look up, Pasien diminta untuk melihat ke atas, use the hand that temporal to the checked eye, and placed the thumb in inferior eyelids, then pull up.

2. Placed the edge of point finger to press superior eyelids up. Patient then asked to look down, hold for a couple of second. Pinch the superior eyelids using thumb and point finger

3. Rotate with the finger and wrist so the superior eyelids could be seen. The point finger holds the resistance in the lid crease. Thumb holds the edge of superior eyelids to the superior orbits.

2. EYE DROP INSTALLATION

1. Patient look up gaze

2. Hold the inferior eyelids under the eyelashes and pull the eyelids out from the eyeball.

3. Give 1 drop into cul –de –sac, do not touch the eyelashes or eyelids to avoid contamination.

4. Gently pull the inferior eyelids upward until touching the superior eyelid while the eye looking downgaze.

5. Close the eyelids for about 3 minutes and try not to blink, so the drug can be pump into the nose and increase systemic absorption.

6. The excessive drug in medial canthal should be wipe out before open the eyelids. Another drug that should be instilled may be given in 10 minutes after the first drug instilled.

3. EYE OINTMENT INSTALLATION

1. Ointment used if the eye need longer duration of drug. Diperlukan bila menginginkan kontak dengan mata yang lebih lama.

2. Similar with application of eyedrops, but the amount that given to the patient usually as much as needed.

3. Patient asked to extend his head or lay in bed in supine position

4. Give the ointment into the cul – de – sac and keep away the tube from the eyelashes or eyelids.

5. Gently pull the inferior eyelids upward until touching the superior eyelid while the eye looking downgaze

6. For about 2 minutes press with thumb and point finger with closed eyelids.

4. APPLICATION OF A PRESSURE PATCH

1. The patient closes both eyes; the examiner must ensure good closure of the eyelids. 2. The examiner applies an eye pad to the closed eyelids, either lengthwise or folded in

half

3. The examiner places a second patch lengthwise over the first patch.

4. Finally, the examiner secures the patches with tape placed from the center of the forehead to the angle of the jaw across the patched eye. Usually, an antibiotic ointment is applied before patching, and the patient’s progress should be monitored daily

A B

C D

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

5. REMOVAL CONJUNCTIVAL FOREIGN BODY

1. Patient could be seat or lay in supine position. Extend the head while the patient sit. 2. Separate the eyelids with thumb and point finger in 1 hand or use the eye spreader /

speculum.

3. Wet the cotton bud with topical anesthesia, or normal saline or artifisial tears. Do not use the dry cotton bud because the cotton could leave its part in the eye.

4. Swab and rotate the mucous so it can be bond to the cotton bud. Usually swaping is done to inner canthal or inferior forniks.

5. Swab cotton bud through the superior and inferior forniks to clean the debris.. 6. Conjunctival sac can be filled with sterile isotonic liquid.

6. REMOVAL CORNEAL FOREIGN BODY (WITH COTTON BUD)

1. Instill 1 drop of topical anesthesia

2. Open the eyelids with thumb and point finger, remove the foreign body with wet cotton bud.

3. Rmove the foreign body that embedded in the cornea using 1 cc spuit with slitlamp. 4. If there is rust still stay in cornea, do the kuretase with needle or ring rust removal.

Ring rust should not be remove all if unnecessary to avoid cicatriks of the cornea. 5. Do the eye patching. Evealuate within 24 hours. (as the corneal erosion protocol))

V. DIRECT FUNDUSCOPY Purpose:

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

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

Basic :

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

Instruments:

1. Ophtalmoscopy 2. Midriatic drug

1. tropicamide 0.5%-1% (mydriacyl)

2. fenilefrin hidroklorida 2.5% (kerja lebih cepat)

Notes:

To dilated the pupil, at first we should measure the intraocular pressure. Beware of these condition and avoid the dilatation of the pupil:

- Shallow anterior chamber - Head trauma

- Iris fixated IOL

- The patient drive the vehicles alone - Narrow angle glaucoma

Technique

 Funduscopy should be done on the same side for patient andthe examiner. This being said, while examining the right eye, hold the funduscope with your right hand, and examining with your right eye on the right side of the patient



Setting the illuminated lens disc at positive (Green) usually from 4-10, stand from approximately 1 arm’s length from the patient while illuminating the patient’s both eyes using the large aperture. This enable you to examine the red reflex of the patient

 Select “0” on the illuminated lens disc and start with the small aperture as you approach the patient while fixing the “red reflex” pupil as your target. Remember to ask the patient to look straight at the distance to maintain pupil dilation

beam into the pupil. The optic disc should be within view as you are about 1-2 inches from the patient’s eye. Remember that the optic disc is slightly towards the nasal aspect of the fundus.

 Do not panic if you do not see the optic disc initially. Look for anearby retinal blood vessels. You’ll most likely find the optic disc by tracing at either one “end” or the other of the vessel. This is due to the developmental fact that retinal vessels branch from optic disc to the peripheral retina

 The optic disc may not be focused as you see it, as hypermetropic patients require more “plus” (green numbers) lenses for clear focus of the fundus while myopia patients require more “minus” (red numbers).

 Examine the optic disc for (the 4C’s): Color (pink, pale, hyperemia, etc) Contour (margin, shape, elevation, etc) Cup-disc ratio (compare the vertical diameter) Caliber of vessels (normal AV ratio around 2:3)

 the AV ratio mentioned is measured from the width of the vessels before 3rd

bifurcation from the origin of optic disc

 Follow each vessel as far to the periphery as you can look for any abnormalities such as venous dilatation, AV nipping,etc

 To examine the periphery, ask the patient to:

o Look up for examination of the superior retina

o Look down for inferior retina

o Look temporally for temporal retina

o Look nasally for nasal retina

 Lastly, locate the macula which is approximately 2 disc diameters temporally from the optic disc, between the superotemporal and inferotemporal vessels. Or you can ask the patient to look at the light of the ophthalmoscope, which would put the macula in good view. Look for abnormalities. Red filter facilitates the view of the macula

 For the examination of the left eye, the same procedure can be repeated, but with left hand and left eye on the left side

LEARNING TASK BASIC CLINICAL SKILL OPHTHALMOLOGY

A. Please demonstrate the subjective visual acuity examination

B. Please demonstrate how to external inspection of anterior segment

C. Please demonstrate how to measure intraocular pressure using Palpation and Schiotz tonometry

D. Please demonstrate how to apply eye drops E. Please demonstrate how to apply eye ointment

G.

Please demonstrate how to examine the posterior segment using direct ophthalmoscope

~ CURRICULUM MAP ~

Smstr

Program or curriculum blocks

10 Senior Clerkship

9 Senior Clerkship

8 Senior clerkship

7

Medical Emergency (3 weeks) BCS (1 weeks)

Special Topic: -Travel medicine (2 weeks)

Elective Study III (6 weeks)

Clinic Orientation (Clerkship) (6 weeks) 6 The Respiratory System and Disorders (4 weeks) BCS (1 weeks)

The Cardiovascular System and Disorders (4 weeks) BCS (1 weeks)

The Urinary System and Disorders (3 weeks) BCS (1 weeks)

The Reproductive System and Disorders (3 weeks)

BCS (1 weeks)

5

Elective Study II (1 weeks) Alimentary & hepato-biliary systems & disorders (4 Weeks) BCS (1 weeks)

The Endocrine System, Metabolism and Disorders (4 weeks) BCS (1 weeks)

Clinical Nutrition and Disorders

(2 weeks) BCS (1 weeks)

Special Topic : - Palliative medicine -Compleme ntary & Alternative Medicine - Forensic (3 weeks) Elective Study II (1 weeks) 4 Musculoskeletal system & connective tissue disorders (4 weeks) BCS (1 weeks)

Neuroscience and

neurological disorders (4 weeks) BCS (1 weeks)

Behavior Change and disorders (4 weeks) BCS(1 weeks) The Visual system & disorders (2 weeks) BCS (1 weeks) 3 Hematologic system & disor-ders & clinical oncology (4 weeks) BCS (1 weeks)

Immune system & disorders (2 weeks) BCS(1 weeks) Infection & infectious diseases (5 weeks) BCS (1 weeks)

The skin & hearing system & disorders (3 weeks) BCS(1 weeks) 2 Medical Professionalism (2 weeks) BCS (1 weeks)

Evidence-based Medical Practice (2 weeks) Health System-based Practice (3 weeks) BCS (1 weeks)

Community-based practice (4 weeks) Special Topic - Ergonomi - Geriatri (2 weeks) Elective Study I (2 weeks) 1 Studium Generale and Humaniora (3 weeks) Medical communication (3 weeks) BCS (1 weeks)

The cell as bioche-mical machinery (3 weeks) BCS(1 weeks) Growth & development (4 weeks) BCS: (1 weeks) Pendidikan Pancasila & Kewarganegaraan (3 weeks)