Clinical

Ophthalmology
Made Easy

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Clinical
Ophthalmology
Made Easy

A Samuel Gnanadoss
BD MS DO FIAMS

Dean and Professor of Ophthalmology

Aarupadaiveedu Medical College
Puducherry, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

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Clinical Ophthalmology Made Easy
2009, Jaypee Brothers Medical Publishers
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First Edition: 2009

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To
My wife Leela Samuel
Who stands by my side in everything in
my life
As she did so while I was writing
this book...

Preface
The basic clinical examination of eye and its adnexa
along with the diagnosis of some common ailments
are of importance to an ophthalmologist as well as to
general practitioners who, especially as family doctors,
have great responsibility to recognize the sightthreatening problems and treat/refer them immediately. Such basic eye examination, especially ocular
movements and pupil, is also a must for a neurologist
and physicianthey are also aided by fundus study.
Such an examination commences with that of lids,
meanders through that of lacrymal apparatus and
eyeball, and ends with ocular movements. Sometimes,
the examination of a patient as a whole is called in
more so if it is a case that requires neurology study.
Eye being window to the body cannot be ignored by
any physician/surgeon of any standing. Vision forming
90% of sensory input from external world underscores
the need for prompt diagnosis of any eye disease and
equally urgent therapy of such an ailment.
Needless to say, the first step is history elicitation,
which not only aids in the diagnosis but also helps in
eliminating unnecessary investigations (which have
nowadays become the fashion). Hence, this deserves

viii

CLINICAL OPHTHALMOLOGY MADE EASY

our first attention before we go into clinical examination to basic details of common eye diseases and to
common instruments that are used in ophthalmology
which are asked in clinical examination.
This book is aimed at undergraduate students of
ophthalmology with an eye on their university examination. At the end are given certain common questions that are asked in the oral examination and
questions that have appeared frequently in university
theory examinations. But the need for basic ophthalmology knowledge for general practitioners and for,
to some extent, postgraduates is not lost sight of while
writing this book.
A Samuel Gnanadoss

Acknowledgements
I am grateful to Dr Kalavathy, Deputy Director of
Dr Josephs Eye Hospital, Trichy and Dr N Rajendran,
Professor of Ophthalmology, Tuticorin Medical
College for the excellent photographs they provided
for this book.
Dr Vidhyavathy, Associate Professor of Medicine,
helped me in writing the chapter on neuro-ophthalmology. My sincere thanks to her.
I must thank my Computer Operators, Sundaranathan and Arun, and technician Sundararaman for
their assistance.
Most of the line diagrams have been drawn by me.
They may lack the artistic touch. But it is my desire
that they should be scientifically accurate.
My gratitude to my wife Leela is great for putting
up with all the inconveniences I caused to her while
preparing this manuscript.
Last, but never the least, I am duty bound to thank
M/s Jaypee Brothers Medical Publishers (P) Ltd, New
Delhi especially Shri Jitendar P Vij (Chairman and
Managing Director), Mr Tarun Duneja (Director-Publishing) and Mr Jayanandan (Chennai Branch) for their
useful suggestions and encouraging me to write this
book.

Contents
Introduction ............................................................ xiii
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

History Elicitation and Examination ................... 1

Lids ......................................................................... 15
Lacrymal Passage ................................................. 27
Conjunctiva ............................................................ 37
Cornea .................................................................... 65
Sclera ....................................................................... 95
Uveal Tract .......................................................... 103
Lens ....................................................................... 123
Glaucoma ............................................................. 149
Vitreous ................................................................ 175
Retina .................................................................... 183
Optic Nerve ......................................................... 209
Orbit ...................................................................... 223
Neuro-ophthalmology ....................................... 233
Squint .................................................................... 263
Ophthalmic Operations ...................................... 273
Instruments .......................................................... 299
Refraction ............................................................. 325
Dark Room Examinations ................................. 343
Ocular Therapeutics ........................................... 355
Community Ophthalmology ............................. 367
Frequently Asked Questions (FAQ)
in Oral Examinations.......................................... 391
23. Frequently Asked Questions (FAQ)
in Theory Examinations .................................... 401
Index ...................................................................... 407

Introduction
Ophthalmology is a subject which is easy to grasp and
the academic examination easy to get through. Proper
attention during theory classes and sincerity in clinical
postings can assure a pass in the examination. Devoting
just 30 minutes per day is enough to succeed in the
examinations without any last minute mugging up and
sweating.
THEORY
Stick to one standard book. Understandably books
vary in minor points. If needed supplement your
standard book by referring to other books. Going
through books on MCQ before examination will brush
up ones knowledge of major points. Pay due attention
to photographs and diagrams in the standard textbook.
Do not underline and spoil the book. You may need it
later in life, or a poor junior may require it.
In written examinations, write in a neat and good
handwriting. Do not try to fill up pages. Write at least
20 to 25 lines per page. It is a good idea to answer
the questions first you know well. At the same time, it
is better you stick to the questions in the order in which
they are given in the question paper. Write clearly the

xiv

CLINICAL OPHTHALMOLOGY MADE EASY

question numbers. Between two answers draw a line.

It is preferable to leave a small space after each answer
so that you can add later on any point you might have
missed. Draw diagrams wherever they are needed.
Highlight the important points but do not underline
too many points. Never use red pen/pencil anywhere
in your answer book (except in diagrams, if needed).
Remember many examiners are lazy. So help them
to give you more marks.
CLINICAL AND ORAL
For clinical and oral examination, dress yourself well
and wear a clean doctors coat with the examination
register number attached to it.
In clinical examination, remember that you are
face- to-face with another human being (patient) for
the first time in your life in an examination. Spend a
few seconds establishing a rapport with him/her.
Never hurry into examining the patient. Ask for his/
her name, etc. and the complaints. Some patients who
have come for a few examinations before may not give
any reply unless you take care of them. You may
have to shell out some money (Authors own experience about 40 years ago). Do not worryanticorruption squad will not be around. Once paid, some
patients give the findings, diagnosis and even
treatment! (Again authors experience).
It will be a good idea, during undergraduate ophthalmology examination, to shine the torch in the
patients eye in the beginning itself, to find out what
case you are given. Most of the time by such cursory

INTRODUCTION

xv

examination you will be able to diagnose (If you cannot,

do not panic). This will help you in eliciting relevant
history and to decide whether general examination is
needed or not (in most of the cases it is not required).
When writing down, leave a small space after every
title (such as present history) so that you can add later
on what you think you have left out. But do not leave
a large space. The same is applicable while writing
down clinical findings. Do not make too many
alterationsit will look awful and the examiner is
liable to think that you got hints. Draw diagrams, if
needed.
Usually one long case and two short cases are given.
When you go to the examiner to present your cases,
you should remember the names of your patients, the
findings and the correct diagnosis for each one. Some
examiners get your paper and then ask you to present
the cases. When you are asked to give positive findings,
do not mention unwanted, normal, routine findings.
While presenting, keep going if you are not interrupted. Stop only after you have given the provisional
diagnosis and treatment. Speak in a steady and uniform
speed. Do not keep looking at the examiners face after
mentioning every finding. This is a poor practice.
In orals you must be familiar and thorough with
ophthalmic instruments, the questions related to them
and certain other routine questions (all given at the
end of this manual). When instrument is given to you,
get it in your hand first and then answer. You must
have a good knowledge of refraction, especially if you
are wearing spects. You must have studied the answers

xvi

CLINICAL OPHTHALMOLOGY MADE EASY

for the questions that were asked in your theory

question papers.
Do not forget the basic manners. Wish the
examiners first and get yourself seated only when you
are asked to. When you leave, thank the examiners
even if they do not deserve it!
In clinical as well as oral if you do not know an
answer, it is better to use the statement, Sorry sir, I
do not know, rather than Sorry Sir, I have forgotten. Examiners know that you never knew the
answer, and not that you once knew it and forgotten
it. Also, if you do not know an answer say that instead
of keeping quiet and creating a deadly, uncomfortable
silence between you and the examiners.
If you are a student from another (linguistic) state,
it is better you learn the local language. In some busy
centers, you may get the interpreter late or may not.
After morning clinical exams, confirm the time
when orals are going to be. Do not leave the examination area immediately after orals. Very rarely you
may be called back.