Study Guide Blok Visual

BLOCK
VISUAL SYSTEM AND DISORDERS
2 SKS
SEMESTER : IV GENAP 2019
31 Mei 2019 – 28 Juni 2019
Pengelola : dr. I Wayan Eka Sutyawan, SpM
1
TABLE OF CONTENTS
Page
CONTENT 2
LEARNING OUTCOMES 3
BLOK TEAM 5
FASILITATORS 7
CORE CURICULUM 8
TIME TABLE 10
TIME TABLE CLINICAL SKILL 12
MEETING OF STUDENT REPRESENTATIVES 22
FORMAT OF ARTICLE REVIEW 23
TOPICS OF ARTICLE REVIEW 25
LEARNING PROGRAM 26
PRACTICUM AND BASIC CLINICAL SKILL GUIDES 65
CURRICULUM MAP 83
2
LEARNING OUTCOMES
THE AIMS
1. Comprehend the underlying normal structure and function of the visual system and its
practical or clinical implications.
2. Understanding the pharmacology and pharmacokinetic of the ocular medicines.
3. Able to manage common eye and visual disorders and refer of high risks patient with
visual disorders for further investigation and management.
4. Awareness and responsiveness to the community aspects of health care, needs,
education and promotion.
LEARNING OUTCOMES
1. Able to know and understand anatomy of the eye structures

2. Able to know and understand Histology of the eye structures
3. Able to know and understand Physiology of the eye, and Physiology of vision
4. Able to know and understand the pharmacology and pharmacokinetic of the ocular
medicines
5. Able to establish diagnosis and management patient with Refraction disorders such as
Mild Hipermetropia, mild myopia, mild astigmatism and presbyopia.
6. Able to initially diagnose, manage and later refer patient with Refraction disorders such
as anisometropia and contact lens problems.
7. Able to establish diagnosis and management patient with external eye diseases such us
conjunctivitis, Dry eye Syndrome, Hordeolum, and Episcleritis
8. Able to initially diagnose, manage and later refer patient with external eye diseases such
as chalazion, scleritis, keratitis, and uveitis
9. Able to initially diagnose and later refer patient with external eye diseases such as
keratokonjungtivitis sicca and endophthalmitis.
10. Able to initially diagnose, manage and later refer patient with glaucoma disorders.
11. Able to establish diagnosis and management patient with ocular injuries such as
foreign bodies in the conjunctiva and subconjunctival bleeding
12. Able to manage and initially diagnose and later refer patient with ocular injuries such as
hyphema and eyelids lacerations.
3
13. 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.
14. Able to establish diagnosis and management patient with eyelids and lacrimal system
disorders such us trichiasis.
15. Able to initially diagnose, manage and later refer patient with eyelids and lacrimal
systems disorders such as dacrioadenitis and dacriocystitis
16. Able to initially diagnose and later refer patient with eyelids and lacrimal sytems
disorders such as entropion, lagophthalmus, epichantus, ptosis, eyelids retraction and
xanthelasma
17. Able to initially diagnose and later refer patient with cataract, lens dislocation and
corneal disorders such as pterygium and keratoconus.
18. Able to initially diagnose and later refer patient with retinal disorders.
19. Able to initially diagnose and later refer patient with neuro ophthalmology & strabismus
disorders including amblyopia and binocular diplopia.
20. Able to establish diagnosis and management patient with community ophthalmology
disorders such as night blindness
21. Able to initially diagnose, manage and later refer patient with community
ophthalmology disorders such as Xerophthalmia
22. 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
1. Anatomy, histology and physiology of the eye.

2. Pharmacology of the eye medicines.
3. Refractive Errors.
4. Infection & Immunologic Eye Diseases.
5. Glaucoma disorders
6. Eyelids and Lacrimal systems disorders
7. Ocular Injuries
8. Cataract, corneal and lens disorders.
9. Vitreous and Retinal disorders
10. Neuro Ophthalmology & strabismus disorders.
4
BLOCK VISUAL SYSTEM AND DISORDERS
COORDINATOR : dr. I Wyn Eka Sutyawan Sp.M

TIME : 31 Mei – 28 Juni 2019
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. A.A 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 Prof. 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,Sp.M(K)
16 dr. Wayan Eka Sutyawan,SpM
17 dr. Ari Andayani,Sp.M(K)
18 Dr. 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. A.A 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 Prof. Dr. dr. Made Jawi, M.Kes Pharmacology 08179787972
5
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(K) Ophthalmology 08123615625
16 dr. Wayan Eka Sutyawan,Sp.M Ophthalmology 081338538499
17 dr. Ari Andayani,Sp.M(K) Ophthalmology 08113803666
18 Dr. dr. I Made Krisna Dinata, M.Erg Physiology 08174742566
6
FASILITATOR VISUAL
Regular Class (Class A)
Venue
No Name Group Departement Phone
(2nd floor)
dr. I Gusti Ayu Dewi Ratnayanti, 2nd floor
1 A1 Histology 085104550344
S.Ked., M.Biomed 2.01
Dr. rer. nat. dr. Ni Nyoman Ayu 2nd floor
2 A2 Biochemistry 081337141506
Dewi, M.Kes 2.02
Dr. dr. AA Mas Putrawati Triningrat, 2nd floor
3 A3 Ophtalmology 08123846995
Sp.M(K) 2.03
dr. Ni Putu Ekawati, M.Repro, Anatomy 2nd floor
4 A4 08113803933
Sp.PA Pathology 2.04
Dr. dr. Luh Made Mas Rusyati, Dermatovener 2nd floor
5 A5 081337338738 2.05
Sp.KK(K), FINSDV eology
Dr. dr. I Gusti Ayu Widianti, 2nd floor
6 A6 Anatomy 08123921765
M.Biomed 2.06
2nd floor
7 dr. Ida Ayu Sri Indrayani, Sp.S A7 Neurology 082139303191 2.07
Prof. Dr. dr. Putu Gede Adiatmika, 2nd floor
8 A8 Physiology 08123811019
M.Kes 2.08
dr. Ni Made Ayu Surasmiati, 2nd floor
9 A9 Ophtalmology 081338341860
M.Biomed, Sp.M 2.21
2nd floor
10 dr. IGN Sri Wiryawan, M.Repro A10 Histology 082341768888
2.22
English Class (Class B)
Venue
No Name Group Departement Phone (2nd floor)
dr. Ni Wayan Sucindra Dewi, 2nd floor
1 B1 Pharmacology 08113935700
M.Biomed 2.01
dr. Ida Bagus Putu Alit, Sp.F., DFM 2nd floor
2 B2 Forensic 081916613459
2.02
dr. Cokorda Agung Wahyu 2nd floor
3 B3 MHEDU 081337189997
Purnamasidhi, M.Biomed, Sp.PD 2.03
dr. Ni Made Ari Suryathi, 2nd floor
4 B4 Ophtalmology 085253651928
M.Biomed, Sp.M 2.04
2nd floor
5 dr. I Putu Kurniyanta, Sp.An B5 Anesthesiology 081805755222
2.05
Dr. dr. Desak Made Wihandani, 2nd floor
6 B6 Biochemistry 081338776244
M.Kes 2.06
dr. I Wayan Eka Sutyawan, Sp.M 2nd floor
2.07
2nd floor
8 dr. I Wayan Sugiritama, M.Kes B8 Histology 08164732743 2.08
2nd floor
9 dr. Ni Putu Witari, Sp.S B9 Neurology 081338724040
2.21
dr. Ni Made Laksmi Utari, 2nd floor
M.Biomed, Sp.M 2.22
7
CORE CURRICULUM
BLOCK : VISUAL SYSTEM AND DISORDER

SEMESTER : IV
SKS :2
NO DAY LEARNING OUTCOME EDUCATIONAL LEARNING METHOD OF

STRATEGIES SITUATION ASSESMENT
1 1 Able to know and Independent Introductory MCQ
understand the Anatomy of learning lecture
the eye Integrated Student
learning Project
Problem SGD
based learning Practicum
understand the Histology learning lecture
of the eye Integrated Student
learning Project
Problem SGD
understand the Physiology learning lecture
of the eye Integrated Student
learning Project
Problem SGD
understand the learning lecture
Pharmacology and Integrated Student
Pharmacokinetic of the eye learning Project
medicines Problem SGD
5 5 Able to establish diagnosis Independent Introductory MCQ
and manage patient with learning lecture OSCE
REFRACTION Integrated Student
DISORDERS learning Project
such as : Problem/case SGD
Myopia, Hyperopia, based learning BCS
Astigmatism, Presbyopia,
Anisometropia, Buta Senja
INFECTION & Integrated Student
IMMUNOLOGIC EYE learning Project
DISEASES such as: Problem/case SGD
Conjunctivitis based learning BCS
- Hordeoulum, Chalazion
and dry eye syndrome
- Scleritis, episcleritis
- Keratitis, Xeropthalmia,
Anterior Uveitis (Iritis &
Iridosiklitis), Hipopion.
8
GLAUCOMA DISORDERS Integrated Student
such as : learning Project
- Acute glaucoma Problem/case SGD
- Chronic glaucoma based learning BCS
- Secondary glaucoma
- Congenital glaucoma
and manage patient with learning lecture
RECONSTRUCTION, Integrated SGD
OCULOPLASTY & learning BCS
ONCOLOGY such as : Problem/case
Eyelid and lacrimal based learning
laceration, Entropion,
Trichiasis, Epicanthus,
Ptosis, Dacryoadenitis,
Dacryocystitis
CORNEA & LENS Integrated Student
DISORDERS such as : learning Project
- Pterygium, Keratoconus Problem/case SGD
- Senile Cataract, Lens based learning BCS
Dislocasion
VITREO RETINAL Integrated SGD
DISORDERS such as : learning
- Retinal detachment Problem/case
- Retinal vessel occlusion based learning
- Degeneration macula
- Diabetic retinopathy
- Hypertensive retinopathy
NEURO Integrated SGD
OPHTHALMOLOGY such learning BCS
as : Problem/case
Diplopia Binocular based learning
Hemianopia: bitemporal
dan Homonymous
Visual Filed Disturbance
Edema Papil
Neuropathy Optic (Atrophy
+ Neuritis)
STRABISMUS Integrated SGD
DISORDERS such as : learning
- Eye movement Problem/case
- Esotropia based learning
- Eksotropia
9
TIME TABLE OF CLASSES
DAY/DATE Class A ACTIVITY VENUE PIC
08.00- dr. I Md Agus

Introduction Classroom
08.15 Kusumadjaja,SpM(K)
Lecture 1 dr. Yuliana

08.15-08.50
Anatomy of the Eye Class room
Lecture 2 Class room dr. Ratna

09.00-09.50
Histology of the Eye
Discussionroo
10.00-10.50 Independent learning
m
1 Friday Discussionroo
May 31 11.00-11.50 Student Project m
2019
12.00-12.50 Break
Lecture 3 Class room Prof Sutjana

13.00-13.50
Physiology
Lecture 4 Class room dr. Krisna
14.00-14.50
Physiology
Introduction BCS 1
15.00-15.50 Class room Histology Team
Histology Examination
08.00-
Facilitator
08.50 Discussionroo
SGD
09.00- m
Facilitator
09.50
10.00- dr. Yuliana , dr. Ratna

10.50 Pleno 1-4 Class room Prof Sutjana,
2 dr. Krisna
11.00-11.50
Monday,
12.00-
June 10 Break
12.50
2019
13.00-
13.50
14.00- Basic Clinical Skill

Skill Lab Team Lecture
14.50 Histology
15.00-
15.50
3 08.00- Lecture 5 Classroom Prof. Jawi

08.50 Pharmakologi
10
09.00- Lecture 6
Classroom
09.50 Physiology Practice
10.00-
Independent learning
10.50
11.00-11.50 Student Project

Tuesday, 12.00-
Break
June 11 12.50
2019 Lecture 7 Classroom Prof. Niti
13.00-13.50
Infection
Lecture 8
14.00-14.50 Classroom dr. Juliari
Immunologi
Introduction BCS 2
15.00-15.50 Classroom
Physiologi Practice
08.00-
08.50
SGD Discroom
09.00-
09.50
10.00-
10.50 Prof. Niti, dr. Juliari
Pleno 5-8 Class room
4
11.00-11.50
Wednesday,
12.00-
June 12 Break
12.50
2019
13.00-
13.50

Team Lecture
14.50 Physiologi
15.00-
15.50
5 08.00- Lecture 9
Classroom
Thursday, 08.50 Visus & Refraction dr. Eka Sutywan
June 13 09.00- Lecture 10 dr. Eka Sutyawan
Classroom
2019 09.50 Refraction Disorders
Discussion
10.00-10.50 Independent learning room

12.00-12.50 Break
13.00-13.50 Lecture 11 Classroom dr. Agus Kusumadjaja
Acute Glaukoma
11
Lecture 12 dr. Ratna
Classroom
14.00-14.50 Suryaningrum
Chronic Glaukoma
Visual Acuity Class room

15.00-15.50 dr. Ari Suryathi
Examination
08.00-
08.50 SGD Discroom Facilitator
09.00-09.50
10.00-10.50 dr. Eka Sutyawan,

dr. Agus
Kusumadjaja,
6 Pleno 9-12 Class room
11.00-11.50 dr. Ratna
Friday, Suryaningrum,
June 14 dr. Ari Suryathi
2019
12.00-12.50 Break
13.00-13.50
Basic Clinical Skill
14.00-14.50 Visus/Acuity Skill lab Team Lecture
Examination
15.00-15.50
08.00- Lecture 13 dr. AAA Sukartini

Class room
08.50 Ocular Djelantik
Lecture 14 Classroom dr. Laksmi Utari
09.00-09.50
Eyelid/Lacrimalis
Discussion
room
7
Monday, 11.00-11.50 Student Project
June 17 12.00-12.50 Break
2019
Lecture 15 Classroom dr. Jaya
13.00-13.50
Cornea Lens
14.00-14.50
Cornea Lens Disorders
Introduction BCS 4
15.00-15.50 Class room dr. Siska
Anterior Segmen
8 08.00-
Tuesday, 08.50 SGD Discroom Facilitator
June 18 09.00-09.50
2019 10.00-10.50 Pleno 13-16 Class room dr. AAA Sukartini
11.00-11.50 Djelantik, dr. Laksmi
Utari, dr. Jaya, dr.
Siska
12
12.00-12.50 Break
13.00-13.50
14.00-14.50 Anterior Segmen +
Posterior Segmen
15.00-15.50
08.00- Lecture 17
08.50 Retina Class room dr. Ari Andayani
09.00- Lecture 18
Classroom dr. Ari Andayani
09.50 Retina Disorders
10.00- Discussion
10.50 room
9 11.00-11.50 Student Project
Wednesday,
12.00-
June 19 Break
12.50
2019
13.00- Lecture 19
Classroom Dr.dr. AA Mas P
13.50 Neuro Ophthalmology
14.00- Lecture 20
14.50 NO Disorders
Introduction BCS 5 dr. Ratna
15.00-15.50 Class room
Amsler Grid Suryaningrum
08.00-
08.50
SGD Discroom Facilitator
09.00-
09.50
10.00-10.50 dr. Ari Andayani,

10 Dr.dr. AA Mas P,
Class room
Thursday, Pleno 17-20 dr. Ratna
11.00-11.50 Suryaningrum
June 20
2019
12.00-12.50 Break
13.00-13.50 Basic Clinical Skill
14.00-14.50
Visual Field + Amster
Grid
15.00-15.50
08.00- Lecture 21
Classroom dr. Surasmiati
11 08.50 Ocular Motility
Friday,
June 21 Lecture 22 Classroom dr. Surasmiati
09.00-09.50
2019 Ocular Motility Disorders
13
12.00-12.50 Break
Lecture 23 Classroom dr. Ari Suryathi

13.00-13.50
Ophthal Community
Lecture 24 Classroom dr. Ari Suryathi
14.00-14.50
Ophthal Community
Introduction BCS 6
15.00-15.50 Classroom dr. Surasmiati
Theraupetic Instilation
08.00-
09.00-09.50
10.00-10.50 dr. Surasmiati,

11.00-11.50 dr. Ari Suryathi
12
Monday, 12.00-12.50 Break
June 24
2019 13.00-13.50
14.00-14.50
Basic Clinical Skill Skill Lab Team Lecture
15.00-15.50
13 08.00- Presentasi SP Class room Team Lecture

Wednesday, 08.50
June 26 09.00-
2019 09.50
10.00-
10.50
11.00-11.50
12.00-
12.50
13.00-
13.50
14.00-
14.50
15.00-
15.50
09.00-
09.50
14
10.00-
10.50
11.00-11.50
12.00-
12.50
13.00-
13.50
14.00-
14.50
15.00-
15.50
14
Thursday,
Pre Evaluation Break
June 27
2019
15
Friday,
Examination
June 28
2019
16
Monday,
July 8
2019
Remidial Examination
15
DAY/DATE Class B ACTIVITY VENUE PIC
08.00- dr. I Md Agus

Introduction Classroom
08.15 Kusumadjaja,SpM(K)
Lecture 1
08.15-08.50
Anatomy Class room dr. Yuliana
Lecture 2 Class room dr. Ratna

09.00-09.50
Histology
Discussionroo
m
1
Monday, Discussionroo
11.00-11.50 Student Project m
June 10
2019
12.00-12.50 Break
Lecture 3 Class room Prof Sutjana

13.00-13.50
Physiologi
Lecture 4 Class room dr. Krisna
14.00-14.50
Physiologi
Introduction BCS 1
15.00-15.50 Class room
Histo Examination 1
08.00-
2 08.50
Facilitator
Discussionroo
Tuesday, SGD Lecture 1,2,3,4
m
09.00-
June 11 Facilitator
09.50
16
10.00- dr. Yuliana , dr. Ratna
10.50 Pleno 1-4 Class room Prof Sutjana,
11.00-11.50 dr. Krisna
12.00-
Break
12.50
13.00-
2019 13.50

14.50 Histology
15.00-
15.50
08.00- Lecture 5
Classroom Prof. Jawi
08.50 Pharmacology
09.00- Lecture 6
Classroom
09.50 Physiology Practice
10.00-
10.50
Wednesday,
12.00-
June 12 Break
12.50
2019
Lecture 7 Classroom Prof. Niti
13.00-13.50
Infection
Lecture 8
14.00-14.50 Classroom dr. Juliari
Imunologi
Introduction BCS 2
Physiologi Practice
4 08.00-
Thursday, 08.50
SGD Discroom Facilitator
June 13 09.00-
2019 09.50
10.00-
10.50 Prof. Jawi, Prof. Niti,
dr. Juliari
11.00-11.50
12.00-
Break
12.50
13.00- Basic Clinical Skill Team Lecture

13.50 Physiologi
14.00-
14.50
17
15.00-
15.50
08.00- Lecture 9
Classroom
08.50 Visus & Refraction dr. Eka
09.00- Lecture 10 dr. Eka

Classroom
09.50 Refraction Disorder
Discussion
10.00-10.50 Independent learning room
5
Friday,
June 14 12.00-12.50 Break
2019 Lecture 11
13.00-13.50 Acute Glaukoma & Classroom dr. Agus
Sekunder
Lecture 12 dr. Ratna

Suryaningrum
Chronic Glaukoma
Class room
15.00-15.50 Visual Acuity Exam
08.00-
09.00-09.50
10.00-10.50 dr. Eka Sutyawan,

dr. Agus
Kusumadjaja,
11.00-11.50 dr. Ratna
Monday, Suryaningrum,
June 17 dr. Ari Suryathi
2019
12.00-12.50 Break
13.00-13.50
14.00-14.50 Skill lab Team Lecture
Visual Acuity
15.00-15.50
08.00- Lecture 13 dr. AAA Sukartini

Class room
08.50 Ocular Infection Djelantik
7 Lecture 14 Classroom dr. Laksmi Utari

09.00-09.50
Tuesday, Eyelid Lacrimalds
June 18 Discussion
2019 room

12.00-12.50 Break
18
13.00-13.50
Cornea Lens
14.00-14.50
Cornea Lens
Introduction BCS 4
15.00-15.50 Class room dr. Siska
Anterior Segmen
08.00-
09.00-09.50
10.00-10.50 dr. AAA Sukartini

8 Pleno 12-16 Class room Djelantik, dr. Laksmi
Wednesday, 11.00-11.50 Utari, dr. Jaya, dr.
Siska
June 19
2019 12.00-12.50 Break
13.00-13.50 Basic Clinical Skill

14.00-14.50
Anterior and Segmen Skill Lab Team Lecture
Posterior
15.00-15.50
08.00- Lecture 17
08.50 Retina Class room dr. Ari Andayani
09.00- Lecture 18
Classroom dr. Ari Andayani
09.50 Retina Disorders
10.00- Discussion
10.50 room

Thursday, 12.00-
Break
June 20 12.50
2019 13.00- Lecture 19
13.50 NO (Lapang Pandang)
14.00- Lecture 20
14.50 NO Disorders
Introduction BCS 5
dr. Ratna
15.00-15.50 Visual Field + Amsler Class room
Suryaningrum
Grid
10 08.00- SGD Discroom Facilitator

Friday, 08.50
June 21 09.00-
09.50
19
10.00-10.50 dr. Putu Budhiastra,
dr. Ari Andayani,
Class room Dr.dr. AA Mas,
Pleno 17-20
11.00-11.50 dr. Ratna
Suryaningrum
12.00-12.50 Break
2019
13.00-13.50
14.00-14.50
Visual Field + Amsler Skill Lab Team Lecture
Grid
15.00-15.50
08.00- Lecture 21
08.50 Ocular Motility
Lecture 22
09.00-09.50 Ocular Motility
(Strabismus)

Monday,
June 24 12.00-12.50 Break
2019
Lecture 23
Classroom dr. Ari Suryathi
13.00-13.50 Ophthalmologi
Community
Lecture 24
Classroom dr. Ari Suryathi
14.00-14.50 Opthalmologi
Community
Introduction BCS 6
15.00-15.50 Classroom dr. Surasmiati
Theraupetic Install
08.00-
09.00-09.50
10.00-10.50 dr. Surasmiati,

Tuesday, 11.00-11.50 dr. Ari Suryathi
June 25
12.00-12.50 Break
2019
13.00-13.50
Basic Clinical Skill Skill Lab Team Lecture
14.00-14.50
Treraupetic
15.00-15.50
20
08.00-
08.50
09.00-
09.50
10.00-
10.50
11.00-11.50
12.00-
12.50
13.00-
13.50
14.00-
17 14.50
Wednesday, 15.00- Presentasi SP Class room Team Lecture
June 26 15.50
2019 09.00-
09.50
10.00-
10.50
11.00-11.50
12.00-
12.50
13.00-
13.50
14.00-
14.50
15.00-
15.50
19
Tuesday,
PreEvaluation Break
June 27
2019
20
Friday,
Examination
June 28
2019
21
Monday,
Remidial Examination
July 8
2019
21
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
Basic Clinical Skill Blok Visual

Koordinator : dr. Ni Putu Ekawati, M.Repro, Sp.PA
Team Instruktur :
Dr. dr. A.A. Mas Putrawati T, Sp.M(K)
dr. I Wayan Eka Sutyawan, Sp.M
dr. Ari Andayani , Sp.M(K)
dr. I G A M Juliari , Sp.M(K)
dr. Ni Made Laksmi Utari , M. Biomed, Sp.M
dr. Ni Made Ayu Surasmiati, M.Biomed, Sp.M
dr. Ni Made Ari Suryathi, M.Biomed, Sp.
MID BLOCK MEETING
The meeting between block planner team, facilitators and the student group representatives will
be held on 18 June 2019 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, 1 July 2019 The Final examination will be held with the
format of Computer Based Test. There are 100 questions for the examination that consist out
22
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
1. Cover: Title
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.
23
Supervisor (Facilitator) Score with 60% qualification, while Evaluator Score the Presentation with
40% qualification.
TOPIC OF ARTICLE REVIEW
English Class
Date SGD Presentation Title Evaluator
Time
B1 Corneal Ulcer Niti/Juliari
B2 Endophthalmitis Niti/Juiari
B3 Amblyopia Eka S
B4 Ainsometria in children Eka S
B5 Congenital Esotropia Surasmiati
26/6/19 08.00-15.50
B6 Eksotropia Intermitten Surasmiati
B7 Age Macular Degeneration Budiastra/Ari A
B8 Diabetic Retinopathy Budiastra/Ari A
B9 Dacriosistitis Laksmi Utari
B10 Ptosis Laksmi Utari
Note. Student presentation: at class room (4.01)
Regular Class
Date SGD Presentation Time Title Evaluator
A10 Endofthalmitis Niti/Juliari
A9 Corneal Ulcer Niti/Juliari
A8 Ainsometria in children Eka S
A7 Amblyopia Eka S
A6 Eksotropia Intermitten Surasmiati
26/6/19
A5 08.00-15.50 Congentital Esotropia Surasmiati
A4 Diabetic Retinopathy Budiastra/ Ari A
A3 Age Macular Budiastra/Ari A
Degeneration
A2 Ptosis Laksmi Utari
A1 Dacriosistitis Laksmi Utari
Note. Student presentation: at class room (4.01)
24
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
25
TOTAL 100
Facilitator,
(………………………………………)
NIP
Article Review Assessments Form

Block of Visual system and disorders
Name :…………………………………………..
Student Reg. Number :…………………………………………..
Facilitator :…………………………………………..
Title :…………………………………………..
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.
26
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
DR. RATNAYANTI
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
27
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:
1. What histologic structure mainly affected in the case?
2. 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!
3. Describe about the refractive media of the eye:
1. Cornea
2. Aqueous humor
3. Lens
4. Vitreous humor
4. Describe in detail about the histologic structure of the eye’s wall:
1. Sclera
2. Choroid
3. Retina
5. Describe about the structure that holds the lens, including the choroid body!
6. What fluid drains from the eye to the canal of Schlemm?
7. What structures absorb the light that enters the eye?
8. The area in the retina that contains no photoreceptor cells is called….
9. What is the sclera made of?
10. 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. 2nd Ed. Philadelphia:
Saunders Elsevier. Pp. 514-526.
2. Fawcett, D. W. & Jensh, R. P. 2002. Concise Histology. 2 nd Ed. London: Arnold. Pp.301-
313.
28
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:
1. The optic system, for reflected the light enters the eye and focuses it on the retina
2. The retina as photoreceptors transducer light energy into an nerves impulses
3. The optical neural, Neural pathways from the retina to the visual cortex at occipital lob
of brain.
4. The visual cortex of the brain process nerve impulses into visual images.
I.OPTIC SYSTEM OF THE EYE
29
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.
30
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 CYCLEAND 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
1. Describe the equivalent and the different optic system of the human eye to the
photographic camera.
2. Describe the optic system of the eye
3. Describe the different of emmetropia, hyperopia and myopia.
4. What is accommodation, and in the human eyes which part of the optic system most
important.
5. Describe the circulation of the eye fluid
6. Describe the different of rods and cones in the vision perception
7. Describe the rhodopsin-retinal cycle, during light exposure to the rod
8. Describe the role of vitamin A in rhodopsin retinal cycle
9. Describe the Young-Helmholtz theory of the color vision
10. Describe many kind of color blindness
SELF ASSESSMENT
1. Can you mention the part of optic system
31
2. What is mean by presbyopia and why it is occur in the human?
3. Can you explain the role of cilliary muscle during accommodation?
4. Can you explain why color blindness almost occur in males.
5. Can you explain the neural function of the retina
6. Can you explain why the niktalopia person difficult to see in the afternoon but not problem
at the morning?
RESOURCES:
1. Guyton, A. The Textbook of Medical Physiology
2. 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:
1. 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
2. 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
3. Into the superior colliculus, to control rapid directional movements of the two eyes
4. 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.
32
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. Itwas 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 interferenceexcitation 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
1. Which area in visual pathways had been damage in that patient?
2. Describe the transmit of visual impulse from retina to the brain
3. What is called the monocular and binocular visual field
4. Differentiate the nasal and temporal visual field, and what tool for evaluation of the visual
field
5. Describe how the visual image can be fusion
Self Assessment
1. Explain the different of visual field from left and right visual field
2. What is called the monocular and binocular visual field
3. Discribe the neural pathways to control pupillary light reflex
4. Describe the neural pathways to the optic nerve to form the consensual reflex
Refferences
1. Medical Physiology eleventh edition, Guyton & Hall.
2. Physiology fifth edition, Linda S. Costanzo.
33
3. 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
34
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
4. Important drug for glaucoma treatment, cycloplegic and antibiotic.
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
35
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 Eka Sutyawan,MD
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
6. Buta Senja
CURRICULUM CONTENTS
1. Optics and Refraction
2. Refraction examination
36
3. Emetropia and Ametropia / Refractive Errors
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
4. Refractive error: Myopia
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
37
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.
4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit Mata, Jakarta, 2007
DAY 6
MODULE
6
Title of lecture
INFECTION AND IMMUNOLOGIC EYE DISEASE
By N.K. Niti S,MD/IGAM Juliari, MD
AIMS:
Describe the Signs, Symptom, Patophysiology and management of CONJUNCTIVITIS
INFECTION AND IMMUNOLOGIC IN CORNEA, CILLIARY BODY, AND ANTERIOR CHAMBER ,
HORDEOLUM AND CALAZION, SCLERITIS AND EPISCLERITIS, DRY EYE DISORDERS.
LEARNING OUTCOMES:
1. Keratitis
2. Xeropthalmia
3. Anterior Uveitis (Iritis & Iridosiklitis)
4. Hipopion
5. Conjunctivitis
38
6. Hordeolum and Chalazion
7. Scleritis and Episcleritis
8. Dry eye disorders
SELF DIRECTING LEARNING ( in depth learning of above lecture)
1. 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
2. Xeropthalmia
a. Pathogenesis of xeropthalmia
b. Definition of xeropthalmia
c. Aetiology of xeropthalmia
d. Signs and symptoms of xeropthalmia
e. Diagnosis of xeropthalmia
f. Prognosis of xeropthalmia
g. Management of xeropthalmia
h. Different diagnosis of xeropthalmia
3. Uveitis anterior
a. Pathogenesis of uveitis anterior
b. Definition of iritis and iridocyclitis
c. Aetiology of iritis and iridocyclitis
d. Signs and symptoms of iritis and iridocyclitis
e. Diagnosis of iritis and iridocyclitis
f. Prognosis of iritis and iridocyclitis
g. Management of iritis and iridocyclitis
h. Different diagnosis of iritis and iridocyclitis
i. Prognosis of iritis and iridocyclitis
j. Complication of iritis and iridocyclitis
4. Hypopion
a. Physiology of hypopion
b. Pathogenesis of hypopion
c. Definition of hypopion
d. Aetiology of hypopion
e. Signs and symptoms of hypopion
f. Diagnosis of hypopion
g. Prognosis of dry eye
h. Management of dry eye
i. Different diagnosis of dry eye
39
j. Prognosis of dry eye
k. Complication of dry eye
1. Conjunctivitis
a. Pathogenesis of conjunctivitis (Allergy, viral, bacterial)
b. Definition of conjunctivitis
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
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. 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
5. Episcleritis
Pathogenesis of episcleritis
Definition of episcleritis
Aetiology of episcleritis
Signs and symptoms of episcleritis
Diagnosis of episcleritis
Prognosis of episcleritis
40
Management of episcleritis
Different diagnosis of episcleritis
6. Dry eye disorders

Physiology of tear film
Pathogenesis of dry eye syndrome
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
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.)
1. Keratitis
41
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.
2. Xeropthalmia
Xeropthalmia is a medical condition in which the aye fail to produce tears. It may caused by
vitamin A deficiency, which is sometime used to describe that condition, although there may be
other causes. Xeropthalmia caused by a severe vitamin A deficiency is described by pathologic
dryness of the conjunctiva and cornea. The conjunctiva becomes dry, thick and wrinkled. If
untreated, it can lead to corneal ulceration and ultimately to blindness as a result of corneal
damage.
3. 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".
4. Hypopion
Hypopion is a medical condition invoving inflammatory cells in the anterior chamber of the eye. It
is a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the
conjunctiva and the underlying episclera. It is a sign of inflammation of the anterior uvea and iris,
i.e. iritis, which is a form of anterior uveitis. The exudate settles at the dependent aspect of the
eye due to gravity. It can be sterile (in bacterial corneal ulcer) or not sterile (fungal corneal ulcer).
5. 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.
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.
6. 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-
42
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.
7. 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.
8. Dry Eye Syndrome

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
1. 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.
a. What is the diagnosis?
b. What are you looking for on fluorescein staining?
c. What are the signs of the herpes simplex keratitis?
d. What is the complication of herpes simplex keratitis?
e. How should the patient be treated?
2. 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.
43
b. What is the etiology of anterior uveitis?
c. What are differences between nongranulomatous anterior uveitis and
granulomatous anterior uveitis?
d. What is the complication of anterior uveitis?
e. How should the patient be treated?
3. 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.
b. What is the etiology?
c. What is the complication that could be happened?
d. How should the patient be treated?
4. A 67 -year-old man has red eye on both eye since 1 week. No pain, no blur vision. There is a
yellow secrets on both eyes, provious. His palpebral were swelling and difficult to open.
History of medication on the eye was positive, but he didn’t remember the brand. History of
traditional medicine was positive, he used urine for wash his eye
b. Mention about the type of conjunctivitis
c. What is the etiology of this case?
d. What are differences between bacterial and viral conjunctivitis?
e. How to manage the bacterial conjunctivitis?
5. 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?
SELF ASSESMENTS
1. Mention and explain about types of keratitis
2. Mention and explain about types of xeropthalmia
3. Mention about symptom and sign of anterior uveitis
4. Mention about hypopion
5. Mention and explain about types of conjunctivitis
6. Mention about tear film components and dry eye examination
LEARNING RESOURCES:
3. Deborah PL: Manual Diagnostic &Ocular Treatment.
44
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
45
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
5. Congenital 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.
46
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
6. Explain about the management of this case.
Case 3.
A man 65 years old complained about blur vision since six months ago and the blur vision getting
worse every time. Ophthalmology examination found increasing intra ocular pressure on right
eye, decreasing visual acuity both eye caused by lens opacity. There was no redness and pain
on his eye.
1. Mention thing you should elaborate from the patient during anamnesis
6. Explain about the management of this case.
7. What is the suggestion for the patient?
SELF ASSESSMENT:
1. Describe definition of acute glaucoma & chronic glaucoma.

2. Explain about pathogenesis of acute glaucoma & chronic glaucoma.
3. Mention classification of glaucoma based on onset and pathogenesis.
4. Mention symptoms could be found in acute glaucoma & chronic glaucoma.
5. Mention the examination needed to make diagnosis of acute glaucoma & chronic
glaucoma.
6. Explain how you can establish diagnosis of acute glaucoma & chronic glaucoma.
7. What should you do if you have a patient with acute glaucoma & chronic glaucoma?
8. Mention what you should tell to the patient who has history of acute glaucoma & chronic
glaucoma.
9. Mention about the pathogenesis, signs and symptoms of congenital glaucoma
LEARNING RESOURCES:

47
DAY 8
MODULE
8
Title of Lecture
RECONSTRUCTION, OCULOPLASTY & ONCOLOGY
By Sukartini AAA D, Laksmi Utari, MD
AIMS:
Describe the sign, symptoms, pathophysiology and management of reconstruction, oculoplasty &
oncology cases
LEARNING OUTCOMES:
Can Describe the signs, symptoms, pathophysiology and management of:
1. Eyelid and lacrimal laceration
2. Entropion
3. Trichiasis
4. Epicanthus
48
5. Ptosis
6. Dacryoadenitis
7. Dacryocystitis
CURRICULUM CONTENTS:
1. Ocular injury
a. Sharp injury (Laceration of the eyelid & Lacrimal system)
b. Blunt injury (Sub Conjunctiva Bleeding & Hypema)
2. Eyelid disorders
3. Lacrimal system disorders
ABSTRACT / SUMMARY OF LECTURE:

Ocular injury is most often found in cases of reconstruction and oculoplastic
division. There are two mechanisms that cause injury to the eye, which is due to sharp
and blunt object. Both of them can cause damage to all orbital tissue. Eyelid and lacrimal
apparatus most frequently injured. Laceration of the eyelid and lacrimal system need
special management. The wound should be cleaned thoroughly and given antibiotics.
Laceration must be repaired carefully to maintain its contour and prevent any complication such
as epiphora, trichiasis, entropion or ectropion, lagophthalmos and ptosis.
Entropion is turning inward of the eyelid, and may be involutional (spastic, senile),
cicatrical, or congenital. The most common entropion is involutional which occurs as a result of
aging.
Ectropion (sagging and eversion of the lower eyelid) is usually bilateral and is frequent
findings in older persons. It may be caused by relaxation of orbicularis oculi muscle, either as
part of the aging process or following seventh nerve palsy. The symptoms are tearing and
irritation, and exposure keratitis may occur.
Trichiasis is impingement of eyelashes on the cornea and may be due to entropion,
epibhlepharon, or simply misdirected growth. It causes corneal irritation and encourages
ulceration.
Epichantus characterized by vertical folds of skin over the medial canthi. It is typical of
Asian and is present to some degree in most children of all races. The skinfolds is often too large
to cover the part of nasal sclera and cause “pseudoesotropia”.
Normally, the upper eyelid rests approximately midway between the superior limbus and
the pupillary margin. Ptosis or bhlepharoptosis is the condition in which one or both upper eyelids
assume an abnormally low position. Ptosis may be congenital or acquired and can be hereditary
in either case.
Excessive tearing (epiphora) is occasionally due to canalicular stenosis or obstruction of
the common canaliculus and lacrimal sac. Most cases of the stenosis are acquired, due to the
result of viral infections.
Dacryoadenitis is the inflammation of lacrimal gland, which can be acute or chronic
inflammation. It is a rare condition, which is most often seen in children as a complication of
mumps, measles, or influenza and in adults in association with gonorrhea.
Dacryocystitis is the infection of the lacrimal sac. It is moft often unilateral and always
secondary to obstruction of nasolacrimal duct. Usually occurs in infants or postmenopausal
women.

1. Anatomy of eyelid and lacrimal system (punctum, canaliculi, lacrimal sac and duct)
2. Physiology of lacrimal system
3. Patophysiology of sharp and blunt injury
4. Sign & symptom of eyelid disorders
5. Sign & symptom of lachrymal apparatus disorders
49
SCENARIO:
1. A woman 30 years old came to the eye clinic with chief complained left eye bleeding after
felt down in the bathroom since 5 hours ago. Ophthalmology examination on left eye
found there are eyelid ruptures. The visual acuity both eyes were good.
According case above:

a. Describe things you should elaborate from the patient to make diagnosis?
b. Explain about diagnosis of the patient!
c. What is the first aid for this case?
d. What we should do after the first aid?
2. A woman 16 years old came to the eye clinic with chief complained redness and watery
on her right eye since 2 weeks ago. Ophthalmology examination on right eye found on
her inferior eyelid there are eyelashes touching her cornea, with conjunctival hyperemia
The visual acuity both eyes still good.
c. What we should do for this patient?
3. A man 45 years old came to the eye clinic with chief complained swollen and pain on his
left eye since 2 weeks ago. He also mention that his left eye always watery since 2
months ago after he had an accident and trauma on his face. Ophthalmology
examination on left eye found there are redness and swollen on his inferior left eyelid.
The visual acuity both eyes were good.
c. What is the management for this patient?
SELF ASSESMENT:
1. Explain about lacrimal system (tear outflow)
2. Explain about sign & symptoms of dacryoadenitis
3. Explain about sign & symptoms of dacryocystitis
LEARNING RESOURCES:
4. PERDAMI: Panduan Ketrampiilan dan Klinis Penyakit
DAY 9
MODULE
9
Title of lecture
CORNEA LENS PROBLEM
By IWG Jayanegara, MD
50
AIMS:
Describe the signs, symptoms, patophysiology and management of pterygium, keratoconus,
senile cataract, lens dislocation
LEARNING OUTCOMES:
Can describe the signs, symptoms, patophysiology and management of pterygium, keratoconus,
senile cataract, lens dislocation
CURRICULUM CONTENTS
1. Pterygium
2. Keratoconus
3. Senile Cataract
4. Lens Dislocasion
A pterygium is an elevated, wedged-shaped growth of the scleral conjunctiva that invades

the cornea. Pterygium are benign (non-cancerous) growths, but contain blood vessels and form
scar tissue on the eye. Because a pterygium resembles tissue or film growing over the eye, a
person who has one may become concerned about personal appearance. Prolonged exposure
to ultraviolet light from the sun may play a role in the formation of pterygium.
Keratoconus is a degenerative disorder of the eye in which structural changes within the
cornea cause it to thin and change to a more conical shape than its normal gradual curve.
Keratoconus can cause substantial distortion of vision, with multiple images, streaking and
sensitivity to light.
A cataract is a clouding of the lens inside the eye that leads to a decrease in vision. It is the
most common cause of blindness and is conventionally treated with surgery. Visual loss occurs
because opacification of the lens obstructs light from passing and being focused on to the retina
at the back of the eye. It is most commonly due to biological aging. Over time, yellow-brown
pigment is deposited within the lens and this, together with disruption of the normal architecture
of the lens fibers, leads to reduced transmission of light, which in turn leads to visual problems.
Those with cataract commonly experience difficulty appreciating colors and changes in contrast,
driving, reading, recognizing faces, and experience problems coping with glare from bright lights.
Lens dislocation is a displacement or malposition of the eye's crystalline lens from its
normal location. A partial dislocation of a lens is termed subluxated lens; a complete dislocation
of a lens is termed lens luxation or luxated lens. Lens dislocation can cause by blunt injury to the
eye, zonullar weakness. The lens may be dislocation in any direction, including posteriorly into
the vitreous cavity or anteriorly into the anterior chamber. Symptoms and signs of lens dislocation
include fluctuation of vision, impaired accommodation, monocular diplopia, iridodenesis or
phacodenesis is present.

1. Physiology and pathophysiology of pterygium, keratoconus, senile cataract, lens
dislocation
2. Definition of pterygium, keratoconus, senile cataract, lens dislocation
3. Management of pterygium, keratoconus, senile cataract, lens dislocation
SCENARIO
51
1. A 70 years old man complains of difficulty driving because of reduced vision. His best
corrected visual acuity is 20/80 OD and 20/40 OS. Progressive nearsightedness.
Problems with glare during the day.
a. What need to be asking to the patient to make the diagnosis?
b. Make the physical examination of this patient with imagination in correlation with
the story above.
c. What is the diagnosis of this case?
d. How to diagnose this kind of cases?
e. How to treated this case?
2. A 35 years old man came to the ophthalmologist and has checked his eyes. He
complained of on both eye usually be seen as a fleshy, pink growth on the white of the
eye. They occur between the eyelids ,on the right eye, in the corner of the eye, close to
the nose, extend onto the cornea.
the story above.
d. How to diagnosed this case?
e. What is the best treatment in this case?
3. A 50 years old woman came to eye emergency with complain blurred vision on left eye
after got hit by wood 5 hours ago. There’s no bleeding dan wound on her eyes. The eye
examination was visual acuity 1m counting finger, IOP was 25mmHg, lens’s position was
more toward to anterior chamber.
the story above.
d. How to diagnosed this case?
e. What is the best treatment in this case?
SELF ASSESSMENTS
1. Mention and explain about Pterygium
2. Mention and explain about Keratoconus
3. Mention and explain about Senile Cataract
4. Mention and explain about Lens Dislocation
5. Referal procedure
LEARNING RESOURSES:
4. PERDAMI: Panduan Ketrampilan dan Klinis Penyakit Mata, Jakarta, 2006
5. Buku Panduan Belajar Koas. Ilmu Kesehatan Mata. UNUD. 2017
DAY 10
MODULE
10
Title of Lecture
52
VITREORETINAL DISORDERS
By : Budhiastra MD and Ari Andayani MD
AIMS :
Describe the Signs, Symptoms, Patophysiology and Management of Vitreo Retina disorders.
LEARNING OUTCOMES
1. Diabetic Retinopathy
2. Hypertensiv Retinopathy
3. Retinal Occlusion Retinal Disease
4. Retinal Detachment
5. Age Related Macular Degeneration
CURRICULUM CONTENT
1. Fundus Examination by Funduscopy Direct, Slit lamp with lens , Fundus Camera and
OCT
2. Laser Photocoagulation
3. Anti VEGF Injection Intra Vitreal
4. Sceral Buckling dan Vitrectomy

Diabetic Retinopathy is progressive microangiopathy characteristized by small vessel
damage and occlusion. The earliest pathologic changes are thickening of the capillary endothelial
basement membrane and reduction of the number of pericytes. In term both prognosis and
treatment, it is useful to divide DR into Nonproliferative (NPDR) and Proliferative Diabetic
Retinopathy (PDR). Diabetic Macular Edema (DME) can occur in both conditions.
Hypertensive retinopathy is the retinal change in hypertension is secondary to focal
ischemia. Hypertension causes increases arterioral light reflex called copper and silver wiring.
Classification of hypertensive retinopathy according to Keith-Wagener-Baker (KW): 1.KW 1:
sclerosis, mild stenosis of arterial vessel, 2.KW 2: a-v crossing, hard exudates, 3 KW
3:hemorrhagic,soft exudates,4.KW 4:KW 3+papillaedema (optic disc edema).
Retinal detachment is separation of the sensory retina (photoreceptor and inner tissue
layers) from underlying retinal pigment epithelium (RPE) layer. RD can be divided into:
1. Rhegmatogenous retinal detachment (RRD) with retinal tear (due to myopia, aphakia,
trauma, degeneration or can be spontaneous).
2. Exudative (serous) retinal detachment with serous fluid under retina without tear,
found in hypertensive retinopathy, eclampsia.
3. Tractional retinal detachment, due to traction on vitreous body by fibrotic tissue, found
vitreous bleeding at diabetic retinopathy or trauma.
The main treatment of Rhegmatogenous detachment are Drainage, Air (gas) injection,
Cryo and Explants (DACE), but Tractional RD commonly need vitrectomy surgery.
Vascular disorders retinal occusion includes central retinal vein occlusion (CRVO), branch
retinal vein occlusion (BRVO), and central retinal arterial occlussion (CRAO), branch (BRAO).
Usually present with sudden loss of visual field and with painless visual loss. CRVO is a common
and easily diagnose retinal vascular disorders with potentially blind complication. Retinal artery
occlusion can be caused by embolism, arteriosclerosis, infection, and phlebitis. We distinguish
between ischemic and non - ischemic vein occlusion. The causes of retinal vein occlusion include
compression of the veins, arteriosclerosis, infection, phlebitis cardiovascular diseases,
hypertension and diabetes mellitus. The main treatment CRVO is anti-VEGF intra vitreal and
laser photocoagulation.
Age-Related Macular degeneration is a atrophy and degeneration of outer retina, retinal
pigment epithelium, Bruch’s membrane and choriocapillaris. The disease includes a broad
spectrum of clinical and pathologic finding that can classify into two groups: non exudative (“dry”)
53
and exudative (“wet”). The exat cause is unknown, but the incidence increased with each decade
over age 50, race usually Caucasian, sex slight female predominan, family history and a history
of cigarette smoking. The main treatment of wet is injection anti-VEGF intravitral.

1. History of Vitreo Retinal Diseases
2. Vitreo Retina Examination
3. Sign and Symptoms Vitreo Retinal Diseases.
4. Complications of Vitreo Retinal Diseases
5. Medication of Retinal Deseases
6. Treatment Vitreo Retinal Diseases by Laser Photocoagulation
7. Surgery of Vitreo Retinal Diseases by Surgery such as Screla Buckling, Cryo and
Vitrctomy.
8. Prognosis of Vitreo- Retinal Diseases.
SCENARIO
1. A 50 years old male patient complained blurry vision on both of his eyes since 2 months
prior. He has a history of hypertension, and diabetes mellitus. Redness and history of
accident was denied. From the examination, the visual acuity was 6/30, hard to be
corrected, anterior segment was normal, intraocular pressure was normal. From
funduscopy examination there were flame shaped hemorrhages on all quadrants,
exudates, microaneurysma, NVD on posterior pole.
a. What kind of anamnesis that would be needed on this patient?
b. Laboratory examination that would be needed on this patient?
c. Opthalmology examination that would be needed on this patient?
d. Explain retinal hemorrhages patophisiology on this patient
e. What would be the Predisposision factors that influence retinal hemorhages on
this case
f. What would be the differential diagnosis for this case?
g. What would be the therapy for this case?
h. How would be the follow up for this patient?
2. A 55 years old man complained blurry vision on his left eye since 3 days before. He was
diagnosed with hypertension and diabetes mellitus 3 years ago. From examination, visual
acuity was 3/60, IOP was normal, anterior segment was normal. From funduscopy
examination there were flame shaped hemorrhages on all quadrants, exudates, cotton
woll spots, the optic nerve head was not well demarcated, the vessel were bending, and
hemorrhaging.
d. Explain retinal hemorrhages patophisiology on this patient
e. What would be the Predisposision factors that influence retinal hemorhages on
this case
3. A 41 years old woman complained a sudden blurry vision on her left eye since 5 days
before. She has been wearing glasses since high school. From the examination, the
visual acuity was 1/60 and was hard to be corrected, IOP was 10 mmhg, The anterior
segment was normal, from funduscopy examination vitreous was clear and the retina was
elevated on the inferior.
54
d. Explain the patophisiology of this case
e. What would be the Predisposision factors on this case
SELF ASSESSMENTS
1. Describe definition of retinal detachment, central artery & vein occlusion vitreous
hemorrhagic, hypertensive retinophaty, and diabetic retinophaty.
2. Explain about pathogenesis of retinal detachment, central artery & vein occlusion vitreous
3. Mention classification of retinal detachment, central artery & vein occlusion vitreous
4. Mention symptoms could be found in retinal detachment, central artery & vein occlusion
vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty.
5. Mention the examination needed to make diagnosis of retinal detachment, central artery
& vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty.
6. Explain how you can establish diagnosis of retinal detachment, central artery & vein
occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty.
7. What should you do if you have a patient with retinal detachment, central artery & vein
occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic retinophaty?
8. Mention what you should tell to the patient who has history of retinal detachment, central
artery & vein occlusion vitreous hemorrhagic, hypertensive retinophaty, and diabetic
retinophaty.
LEARNING RESOURSES :
1. Vaughan, Asburhy : General Ophthalmology
2. Deborah P Langstone : Manual Diagnosis and Ocular Tretment.
3. Perdami : Panduan Ketrampilan dan Klinis Penyakit Mata, Jakarta, 2006.
4. American Academy of Ophthalmology : 2012
DAY 11
MODULE
11
Title of lecture
NEURO-OPHTHLMOLOGY DISORDERS
By AA Mas Putrawati Triningrat, MD
Aims
Describe: the sign, symptoms, patophysiology and management of neuro ophthalmology disorder
LEARNING OUTCOMES:
Can describe about Diplopia Binocular, Hemianopia: bitemporal dan Homonymous, Visual Filed
Disturbance, Edema Papil, Neuropathy Optic (Atrophy + Neuritis)
Curriculum contents.
Can describe the:
55
1. Diplopia Binocular
2. Hemianopia: bitemporal dan Homonymous
3. Visual Filed Disturbance
4. Edema Papil
5. Neuropathy Optic (Atrophy + Neuritis)
Abstract / summary of lecture

It is important to recognize that any disturbance in afferent function may result in the
same complaints of visual loss seen with pathology affecting the retina, optic nerve and visual
pathways. The optic nerve begins anatomically at optic disc but physiology and functionally within
the ganglion cell layer that covers the entire retina.
Diplopia commonly known as double vision and the most common symptoms for which
patients seek ophthalmic care. Double vision in one eye is known as monocular double vision.
Double vision continues when the unaffected eye is covered, but it should be able to see
normally when the affected eye is covered. It can be caused by an irregularly shaped cornea
(astigmatism) which is refractive error, a rare type of cataract, abnormalities of the iris, lens, or
fluid within the eye and even dry eye. Binocular diplopia is where the brain is unable to combine
the images from the right and left eyes into one picture and the double vision resolve when either
eye is covered. The double vision can be the same in all fields of gaze (comitant), or vary with
gaze direction (incomitant). Diplopia can be horizontal, vertical, oblique or torsional. It can be
caused by a number of condition. Damage which affecting the eye mucles that move the eyes or
the nerves that control movement, the diplopia can be created.
The visual field is the portion of the subject’s surrounding that can be seen at any one
time. The normal extent of field vision is 50 superiorly, 60 nasally, 70 inferiorly and 90
temporally. A Visual field defect is a loss of part of the usual field of vision, can be one or both
eyes. The lesion may be anywhere along the optic pathway, retina to occipital cortex.
Hemianopia bitemporal and homonymous is visual field disturbance that affecting visual pathway
(Chiasma opticum and tractus opticum).
Optic neuropathies typically are associated with visual field loss, most demonstrate an
afferent pupillary defect, although in case with very mild optic nerve dysfunction or with bilateral
symmetric dysfunction, the defect may not detectable. The optic disc may be abnormal or normal
in appearance; abnormal disc maybe oedematous or may show other abnormalities, such as
excavation, or atrophy. Certain causes of optic neuropathy may present in more than one way;
for example, orbital compressive or infiltrate lesions may initially demonstrate either normal,
oedematous or atrophic. Optic atrophy is a nonspecific response to optic nerve damage from any
causes since optic nerve consist of retinal ganglion cell axons, optic atrophy may be the
consequences of primary retinal disorder, such as retinitis pigmentosa, CRAO. Optic neuritis is a
disk swelling caused by inflammation at the nerve head (intraocular optic nerve). Loss of vision is
the cardinal symptom of optic neuritis and is particularly useful in differentiating papilitis from
papiledema which it may resemble on ophthalmoscopic examination. Optic neuritis may be due
to a variety of causes, but the most common is demyelinating dss, including multiple sclerosis.
Edema papil is an optic disk swelling due to raised intracranial pressure of which the most
common causes are cerebral tumour, abscess, subdural haematom, arteriovenous
malformations, subarachnoid hemorrhage acquired hydrocephalus, meningitis and encephalitis.
Self directing learning

1. Anatomy of optic nerve
2. Visual pathways
3. Extraocular muscle and Ocular movement
4. Pupillary reactivity
5. Relative afferent pupillary defect
6. Optic disc evaluation
7. Edema papil
56
8. Atrophy optic
9. Neuritis optic
10. Abnormal Visual Filed
Scenario
Case 1
Woman, 20 years old, complained about double vision and feel headache since 3 days before
admission to hospital. There are history of traffic accident particularly in eye area.
1. Mention things you should elaborate from the patien during anamnesis
2. Mention physical examination you should do for this patient
6. Explain about the management of this case
Case 2
Woman 30 years old, complained about sudden blur vision, and visual filed disturbance on her
left eye since two days before. He also complained about pain when moving her eye. On
ophthalmology examination, doctor found decreasing visual acuity (VOS 3/60).
Mention things you should elaborate from the patien during anamnesis
Mention physical examination you should do for this patient
Explain about the result from the examination
Mention differential diagnosis of the case
Which diagnosis is the most appropriate?
Explain about the management of this case
Case 3
Man 45 years old, complained about headache, nausea, vomit and disturbance visual field on
both eyes since 3 days before. On the ophthalmology examination, doctor found no disturbance
of vision, but there was edema optic nerve both eyes.
1. Mention things you should elaborate from the patien during anamnesis
2. Mention physical examination you should do for this patient
6. Explain about the management of this case
Self assessment NO
1. Describe definition of edema papil, atrophy optic, neuropathy optic, neuritis optic
2. Explain about pathogenesis of edema papil, atrophy optic, neuropathy optic,
neuritis optic
3. Mention symptom could be found in edema papil, atrophy optic, neuropathy optic,
neuritis optic
4. Mention the examination needed to make diagnosis of edema papil, atrophy optic,
neuropathy optic, neuritis optic
5. Explain how you can establish diagnosis of edema papil, atrophy optic,
neuropathy optic, neuritis optic
LEARNING RESOURSES:
57
2. American Academy of Ophthalmology, Basic and clinical science course, section 5, neuro-
ophthalmology
DAY 12
MODULE
12
Title of Lecture
OCULAR MOTILITY AND ITS DISORDERS
By Ni Made Ayu Surasmiati MD
AIMS:
Describe about eye movement and eye movement disorders
LEARNING OUTCOMES:
Can describe about eye movement and its disorders
58
CURRICULUM CONTENTS:
1. Eye movement
2. Eye movement disorders
ABSTRACT / SUMMARY OF LECTURE:

EYE MOVEMENT
Eye movement are controlled by six extraocular muscles innervated by cranial nerves III,
IV and VI. Ductions are monocular eye movements. Movement of the eye nasally is adduction;
temporal movement is abduction. Elevation and depression of the eye are termed sursumduction
(supraduction) and deorsumduction (infraduction), respectively. Incycloduction (intorsion) is nasal
rotation of the vertical meridian; excycloduction (extorsion) is temporal rotation of the vertical
meridian. Binocular eye movements are either conjugate (versions) or disconjugate (vergences).
Versions are movements of both eyes in the same direction. Dextroversion is movement of both
eyes to the right, and levoversion is movement of both eyes to the left. Sursumversion
(supraversion) and deorsumversion (infraversion) are elevation and depression of both eyes,
respectively. Convergence is movement of both eyes nasally, and divergence is movement of
both eyes temporally.
OCULAR MOVEMENT DISORDERS

Ocular position when the eye is looking straight ahead with the visual axis parallel to the sagittal
plane of the head, is called primary position. Under normal conditions, the image of the object of
regard fall simultaneously on the fovea each eye, when the eyes are in perfect alignment. Any
deviation from perfect ocular alignment is known as STRABISMUS. Orthotropia, when the eyes
properly aligned. There are many different types of strabismus. Strabismus is most commonly
described by the direction of the eye misalignment; common types of strabismus are esotropia,
exotropia, hypotropia, and hypertropia.
Esotropia
Esotropia is inward turning of the eyes (aka "crossed eyes"). Types of esotropia include infantile
esotropia, accommodative esotropia, and sixth nerve palsy. Infantile esotropia usually appears
before 6 month old. Accommodative esotropia (also called refractive esotropia) is an inward
turning of the eyes due to efforts of accommodation. It is often seen in patients with moderate
amounts of hyperopia.
Exotropia
59
Exotropia refers to outward deviation of the eyes. Exotropia may occur from time to time
(intermittent exotropia) or may be constant.
Strabismus Examination
A. Hirschberg Method – the patient fixates a light at a distance about 33 cm. decentering
of the light reflection is noted in the deviating eye.
B. Krimsky method -- uses reflections produced on both corneas by a penlight and placing
prisms in front of the fixation eye
C. Cover tes consist of four parts: (1) the cover/ uncover test (2) alternate cover test (3)
the prism alternate cover test and (4) Simultaneous prism cover test

1. Definition of binocular single vision.
2. Definition of conjugate and vergence movement
3. Definition of Orthophoria, Heterotropia, Heterophoria
4. Describe muscle action and field of action of Extra ocular muscle
SCENARIO
A 6 years old girl complain blurred vision and eye discomport. From the visual acuity examination
of the right eye is 6/30 with correction ∫ -2.25 visual acuity improve 6/12 and the left eye the
visual acuity 6/6. Hirschberg test result that the corneal light reflex on the right eye fall in the
medial side at limbus
b. What is the choice of medical treatment of this case?
c. How about Hirschberg test?
d. What is the complication of uncorrected refractive error?
e. What is the treatment of amblyopia?
SELF ASSESSMENT:
1. Mention and explain about type of strabismus
2. Management of strabismus,
LEARNING RESOURSES:
3. Deborah PL: Manual Diagnostic & Ocular Treatmentt.
5. Wright, KW. Handbook of Pediatric Strabismus and Amblyopia, 2006
60
\
Day 13
MODULE
13
Title of Lecture
COMMUNITY OPHTHALMOLOGY
By Ni Made Ari Suryathi, MD
AIMS:
Describe the health measure and disease, vision 2020, prevention blindness,focus eye health
program in community.
LEARNING OUTCOMES:
Know and can calculate prevalence, incidence, prevalensi odd, incidens odd from
one work sheet of data.
Understand about prevention of blindness, vision 2020 and eye care program in
community.
CURRICULUM CONTENTS
4. Health measure and disease
5. Prevention of blindness
6. Vision 2020
7. Eye care program
61
The most commonly used measures of disease burden are prevalence and incidence.
Prevalence is the proportion of the population with the condition of interest. (A common mistake
is to use the term ‘‘prevalence rate’’ rather than ‘‘prevalence.’’ Since prevalence is a proportion,
not a rate, the term ‘‘prevalence rate’’ is incorrect and should be avoided.) Prevalence is the
probability of being a case in a population at a given point in time and useful for assessing why
people already have disease .
Incidence is the probability of becoming a case in a population at risk during a specified time
period and useful for assessing why people will get disease

Health measure and disease
Prevalence, Incidence
Prevalence Odd, Incidence Odd
Five causes of blindness
Prevention of blindness
Vision 2020
Eye care program in community
LEARNING TASK
Cataract and Ages
Objectives
At the end of the practical students should be able to:

Understand the distinction between prevalence and incidence
Understand the need for denominators when measuring disease frequency
Calculate and interpret different measures of disease frequency (prevalence,
cumulative incidence, incidence rate, odds)
Understand the concepts of relative risk and risk difference
QUESTION 1: CATARACT AND TROPICAL CLIMATE
Ages is one of risk factor of senile cataract. The table below shows example cataract in years
by ages in “District A” for men and for women with total population 5.000.
TABLE 1: SENILE CATARACT BY AGES FOR MEN AND WOMEN
Ages (years) Matur Senile Cataract

Women Men
41- 45 46 50
46 - 50 59 60
51- 55 64 69
56 – 60 70 72
62
61-65 75 77
65 – 70 78 79
>70 85 81
Question 1a: Describe the association between ages and matur senile cataract.
Question 1b: Discuss possible explanations for this association between ages and mature
senile cataract.
Question 1c: Discuss prevalence of cataract in men and women over 50 years old.
Question 1d: Discuss prevalence odd of cataract in each men and women over 60 years old
SELF ASSESSMENTS
Mentions and explain about prevalence and incedence

Mention and explain about :
Vision 2020
Prevention of blindness
Five causes of blindness
Focus Eye Care Program in Community
LEARNING RESOURSES:
3. The Epidemiology of Eye Diseae: Gordon J Johnson
4. Epidemiology and Statistics for the Ophthalmologist
63
Study Guide
The Visual System and Disorders
PRACTICUM DAN BASIC CLINICAL SKILL STUDY GUIDE
I. BASIC CLINICAL SKILL VISUAL PHYSIOLOGY STUDY GUIDE
A. GOAL
The goals of the study are to enchand the knowledge and the student skill for examination
of:
1. Visual acuity (visus)
2. Visual field
3. Pupil reflex, consensual reflex and pupil reflex during accomodation.
4. Organic and functional color blindness
5. Cornea arch
B. EQUIPMENT USE:
1. Optotype snellen
2. Perimeter
3. flashlight
4. Ishihara chart and wall thread
5. Keratoskope placido
C. WORK METHOD:
1. VISUAL ACUITY, (Snellen chart)

a. Hang the Snellen chart at the wall at eye height during sitting
b. Ask the subject sit on the chair which 6 meter distance from the Snellen chart
c. For examination of the right eye, close the left eye with the left hand.
d. Ask the subject to read the letter on the chart, begin with the upper to the
lower raw, without any mistake
e. Repeat this test to the other eye, with same method.
f. Visual acuity (visus) is calculatefrom the formula: V = d/D, where V= visual
acuity, d= the distance of subject from Snellen chart, and D= the distance
that normal person can be read correctly (this is write at the Snellen chart).
g. Must be remember that the value from d/D, can’t be to simplified.
Learning task: Comprehend the influence of aging process to the visual

acuity, what is the cause that problem?
2. VISUAL FIELD (use perimeter)

a. The equipment for visual field test is perimeter. Place the perimeter on the
laboratory table
b. Ask the subject sitting face to the perimeter, and close one eye which is note
test. If the right eye would be tested, close the feft eye and visepersa.
c. Palace the subject chic on the chic support and ajust the height so the lower
margin of their eye and the eye level equal to the center of perimeter.
d. Fit he perimeter fist so the perimeter arc on the plane surface
e. Ask the subject to focus their sight to the centre of perimeter during the
examination.
f. Take the sign tool (white) and move it along the perimeter arc from side to the
center , and stop when the subject begin sea it, and read the number at the
perimeter arc, and than write on the form.
Udayana University Faculty of Medicine, MEU 64

Study Guide
g. Repeated again that method after move the perimeter arc 30 degree clock
wise direction
h. Do it to the other eye with the same method.
Learning task: comprehend the difference of visual field of right and left eye.
What is the mono and binocular vision?.
3. PUPIL REFLEX, CONSENSUIL REFLEX and PUPIL REFLEX DURING

ACCOMMODATION (use flashlight)
a. Ask the subject sitting on the chair and relax
b. Beam of light to the right eye of the subject with flashlight, and look at the
change of pupil diameter of the right eye (if the pupil diameter is smaller, it
mean pupil reflex positive).
c. Repeat it again but now look the change of pupil diameter of the left eye
(consensual reflex, If the diameter of left eye is smaller, it mean consensual
reflex positive)
d. Ask the subject to watch the examiner’s fingers from distance around 50 cm
and than moving it approach the subject (focusing the eyes or
accommodation), and the examiner watching the changes of pupil
diameter .During accommodation the pupil diameter should be smaller.
Learning task: describe the mechanism of pupil reflex and consensual reflex.
Why the pupil diameter change to smaller during accommodation?
4. ORGANIC AND FUNCTIONAL COLOR BLINDNESS (use Ishihara chart

and wall thread).
4.1. Organic visual blindness:
a. Ask the subject to select many color of wall thread and collect it with
same color. The examiner write the incorrect color.
b. Ask the subject to read the Ishihara chart, and write their mistake, use
the guide of the Ishihara chart.
4.2. Functional color blindness.

a. Ask the subject to watch the white sky through the green or red glass for view
minute, and than ask them to watch the wall thread or read the Ishihara
chart.
b. The subject difficult to choose the wall thread or read the Ishihara chart. It is
functional color blindness.
Learning task: Describe the mechanism of organic or functional color

blindness.
5. CORNEA ARCH (use keratoskope placido)

a. Ask the subject to sit down back to the light, and place the
keratoskope placido 20 cm front of the subject.
b. Ask the subject always watch the keratoskope placido during
examination, and the examiner watch the cornea of the subject
through the hole at the center of keratoskope palcido. The image of the
keratoskope placido can be watch at front surface of the cornea in
form of black circle.
c. If the image form is full and concentric circle, it mean the surface of
cornea is normal

Study Guide
d. If the image form is crooked on one side and difference to the other
side, it mean the front surface of the cornea is abnormal.
Learning task: what is call astigmatism? what is to correct it?
STUDY GUIDE BASIC CLINICAL SKILL OPHTHALMOLOGY
CONTENTS:
1. Subjective visual examination

2. External inspection:
 Eyelid
 Conjunctiva
 Sclera
 Lachrymal apparatus
 Pupil
 Light reflex and convergence
 Cornea
 Camera Oculi Anterior
 Iris
 Lens
3. Intra Ocular Pressure
 Palpation
 Tonometry Schiotz
4. Therapeutic Skill
 Eyelid eversion
 Eye drops installation
 Eye ointment installation
 Applying eye dressing
 Removal conjunctiva foreign body
 Removal corneal foreign body (with cotton bud)
I. SUBJECTIVE VISUAL EXAMINATION
Eye Examination:
• Visual Acuity
• Visual field examination with confrontation test, perimetry (kinetic and static)
• Dark adaptation – measurement of least luminance required to produce a visual
sensation
• Contrast sensitivity – is measurement of the smallest distinguishable contrast, it is
assessment of quality of vision
• Colour vision –with lantern test (Edridge green lantern) and Isochromatic charts
Subjective examination of the function of eye
Definition-
It is defined as the measurement of the smallest retinal image which can be appreciated
with reference to its shape and size. it is actually measure of form sense.
• Central or direct vision
• Distance vision with Snellen test type
• Near vision with Snellen test type or Jaeger’s test type
• The principal of assessment is measurement of spatial resolution of the eye i.e. an

estimation of ability of eye to discriminate between two points.

Study Guide
DISTANCE VISION
Two distant points can be visible as separate only when they subtend an angle of 1 minute
at the nodal point of eye.
Principle
• Each individual letter subtends an angle of 5 minutes and each component of letter
subtends an angle of 1 minute at the nodal point of eye from the distance in meters
written as numerical.
• Snellen chart is having different number of letters in different rows and the letter at
top line should be read clearly at distance of 60 m. similarly the letters at subsequent
lines as are read at 36, 24,18,12,9,6,5mts respectively
• Numerical convention is used for recording visual acuity. In fraction, the numerator is
the distance at which the patient is sitting from chart and the denominator is the
distance at which person (with normal vision) should be able to read the last line that
person is able to read.

Study Guide
Procedure of testing
• Patient is seated at the distance of 6 meters from Snellen’s chart (distance of 6 mts
is taken as at this distance it is assumed that the rays are almost parallel and patient
exert minimum accommodation)
• The chart should be properly illuminated at minimum of 20 feet candles. Patient is

asked to wear trial frame. It is adjusted according to patient inter pupillary distance.
• Ask the patient to read with one eye from the top letter while the contra lateral eye is
closed gently with the patient palm or with occulder in the trial frame.
• Now patient is asked to reads the Snellen’s chart from top letter to smaller letter, and
depending upon the smallest line that the patient can read from distance of 6mt. His
vision is recorded as 6/6, 6/9, 6/12,6/18, 6/24, 6/36, 6/60.
• But if patient is not able to see the top line from 6mts he is asked to count the
examiner finger at 5,4, 3, 2, 1 mts (or reverse, from 1 to 5 mts) and noted as
5/60,4/60,3/60,2/60,1/60 respectively (or CF=counting finger 1m, CF 2m, CF 3m,CF
4m, CF 5m)
• If patient not able to count examiner finger close to face then examiner waves or
moves his hand in about 25 cm from the patient eye and asks patient whether he is
able to see hand movement or not. Visual acuity then recorded as HM+ or 1/300
• When patient cannot distinguish hand movements, the examiner use penlight in front
of the patient eye (± 20 – 25cm) and notes whether the patient can perceive light or
not. If he perceive light it is noted as LP (light perception) +ve otherwise as LP-ve.
The examiner then reflect the penlight from four directions (nasal, superior,
temporal, inferior) and asked the patient to mention the direction of the light.
• Record accordingly if present patient perceive light from all directions it is marked
as PR (Projection of rays ) present or else mark as absent or defective. The test is
repeated for the other eye in similar fashion
Pin hole test

Method
• Place the pin hole occluder in front of the eye with reduced vision
• Ask the patient to move their eye and head until some letters can be read on the
letter chart
• Ask the patient to read the lowest line of letters he can see looking through the
pinhol
Interpretation
• If patient vision is improved with pin hole it means the poor acuity is due to refractive
errors. (eg. 6/12 PH 6/6 means visual acuity 6/12 can be improved with pinhole until
6/6)
• If static acuity means may be due to structural or organic cause.(eg.6/12 NI PH =

non improved PH means the visual acuity still 6/12 with non improvement with pin
hole)

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• If reduced the poor visual acuity may be due to corneal opacity or lenticular opacity
occupying papillary area or macular pathology.
Charts for testing near vision are :

1) Snellen near vision chart
2) Jaeger chart
3) Roman test type
Method of recording near vision

• Ask the patient to sit with his back to the light
• If the patient is using glasses for distance the same number will be put on the trial
frame. Occlude one eye with an occulder
• Ask the patient to hold the near vision by his right hand at a distance of 25 to 33
cms.
• Note the near vision as per the letter read
• Repeat the test for the other eye.
II. EXTERNAL INSPECTION
1. Eyelids
Eyelids conditions
 Diffuse swollen or edema, usually found in nephritic syndrome, heart
disease, anemia, dacryoadenitis and hyperthyroid..
 Eyelid swollen with sharp edge in chalazion, tumor.
 Blepharospasm, happened on corneal erosin, anterior uveitis, acute
glaucoma. Essential Blepharospasm did not result from organic disorders
and usually happened billateraly. Blepharospasm could also be found at
psychiatric patient with hysteria.
 Echymosis, the color of the eyelid changes as a result of blood extravatation
after trauma.
 Ectropion, is turning outward of the eyelids, could be found in elderly, paralise
of the muscles, cikatriks and other.
 Entropion, turning inward of the eyelids.In Trachomas patient the entropion
usually happen in upper eyelids. Entropion could also happen due to parese
of the muscles, cikatriks and senile condition.
 Lagoftalmos: inabillity to close the eyelids completely.
 Redness, inflamation, squama, tumour Merah, radang, keropeng (skuama),
tumor.
 Pseudoptosis, difficulties to open the eyelids as if it is drooping. Happen on
enophthalmos, phtisis bulbi, chalazion or the other eyelids tumour, eyelids
edema and blepharochalazis.
 Ptosis, drooping eyelids. Usually happen in elderly with history of intraocular
surgery, Myasthenia gravis, Horner Syndrome, N III palsy, botulinum toxin
injection
 Cikatriks, scar on the eyelids
 Trikiasis, silia atau bulu mata tumbuh salah arah sehingga dapat merusak
kornea. Trikiasis dapat disebabkan blefaritis dan entropion.
 Xantelasma, penimbunan deposit berwarna kekuning-kuningan pada
kelopak, terutama nasal atas dan bawah. Xantelasma biasanya dihubungkan

Study Guide
dengan hiperlipidemia dan dapat tanpa hiperlipidemia seperti pada histiosis

dan retikulohistositoma.
Abnormality of lower eyelids:

 Similar with upper eyelids
 Swollen of lacrimal sac, redness and sometimes pus came out when it be
pushed.
 Madarosis.
Inerpalpebral Fissure
 Normal
 Narrow or small, if there is eyelids edema, blepharitis, ptosis, pseudoptosis,
blepharophymosis
 Wide or bigger, happened in hyperthyroid or intraocular tumour.
Eyelids margin
 Complete cilia
 Trichiasis
 Meibomian gland punctum secretion
 Redness, pain and ulceration
2. Conjunctiva
Upper Tarsal Conjunctiva
Can be checked by eversion the upper eyelids using finger or cotton tip applicator.
Abnormality of the conjunctiva:
 Cobble stone follicles, deposite of macrophages and lymphoid cells under the
conjunctiva. Dome shaped appearance, about 1 mm. Most follicles can be
seen in forniks area because in this area consist of a lot of lymphoid tissues.
 Membrane, inflammatory cells beyond the conjunctiva that will be bleed
iwhen excised. This membrane usually appears like mass surrounding tarsal
or bulbar conjunctiva. It is consists of necrotic tissues, penetrated to the
deeper layer and greyish, usually can be found in patient with bacteria
conjunctivitis or rarely happened on viral conjunctivitis.
 Pseudomembrane, membranes that not get bleed if excised. Happened in
ocular pemphygoid and Steven Johnson Syndrome.
 Papillae, tiny dome shaped nodule that consist of hyperemic central core
blood vessels of the conjunctiva that protrude up and perpendicular to the
tarsal plate surrounded by edema and inflammatory cells
 Giant Papillae, polygonal shaped, flat and coukd be found in vernal
conjunctivitis, superior limbic keratitis, and iatrogenic conjunctivitis.
 Cicatriks, in trachoma usually the direction of the cicatriks is parallel with
eyelids margin.
 Simblepharon, stickyness of tarsal and bulbar conjunctiva and kornea. Can
be found in chemical trauma or Steven Johnson Syndromes
 Hordeolum or Stye
 Chalazion.
Inferior tarsal conjunctiva Konjungtiva tarsal inferior

The abnormalities could be:

Study Guide
 Cobble stone follicles.

 Papil.
 cicatriks
 Hordeolum or Stye.
 Chalazion.
Bulbar conjunctiva
The abnormalities could be:
 Discharge
 Conjunctival Injection, vasodilatation of superior conjunctival arteries
 Cilliary Injection, vasodilatation of pericorneal arteries or anterior cilliaris
arteries.
 Episcleral injection, vasodilatation of episcleral vessels
 Subconjunctival bleeding.
 Flickten, inflammatory surrounded with neovascularization on conjunctiva
 Simblepharon.
 Degeneration plaque
 Pinguecula, conjunctival degeneration plaque in palpebral fissure area,
triangular shape in nasal and temporal cornea
 Pterygium, proliferation of fibrous tissues process with neovascularization on
conjunctiva, triangular shape with the apeks toward the cornea
 Pseudopterygium.
 Flickten, inflammatory cells and neovascularization on the cornea.
3. Sclera
Abnormalities that coulb be found in sclera:
 Local or diffuse episcleral injection.
 Nodulle.
4. Lacrimal Apparatus
The abnormalities includes:
 Epifora.
 Stenosis or obstruction of lacrimal punctum
 Lacrmal sac inflammation Peradangan di sakus lakrimal.
 Yellowish discharge or pus in lacrimal punctum
5. Pupil
Pupil abnormalities:
 Isokoria, similarities of shape and size of pupil in both eyes
 Anisokoria, the size of both pupil is different, found in monocular granuloma
uveitis and Afferent pupillary defect
 Midriasis, happened as a results of parasympatolitik drugs (atropine,
skopolamine) atau sympatomimetik (adrenaline and cocaine).
 Miosis, happened in miotic spastics (meningitis, ensephalitis dan ventrikel
haemorraghe), morfine and antikolinesterase intoxication. In miotic paralitic
or simpatic parese as Horner syndrome, miosis, ptosis dan anhidrosis were
the Trias.

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 Hippus, also known as pupillary athetosis, is spasmodic, rhythmic, but

irregular dilating and contracting pupillary movements between the sphincter
and dilator muscles
 Pupil occlusion, pupil covered by inflammatory tissues in front of the lens
 Seklusi pupil, the whole pupil is attached to anterior lens
 Leukokoria, white pupil or whitish reflex of the pupil. Can be found in
cataract, retrolental fibroplasia, endophthalmitis, vitreous hyperplasia, high
myopia, retinal detachment andretinal tumour as retinoblastoma
 No pupil reaction, can be found in intoxication of mydriatics and miotic drug,
sphincter pupil rupture, posterior sinekia, blind
Light reflex and convergence

 Positive light reflex, miotic effect when pupil get exposed to the light
 Negative light reflex, happened on sphincter pupillae rupture, no Light
perception patient, parasympatic abnormalities, drug induced angd posterior
synekia
 Convergence reflex consist of accommodation, miosis and convergence if
there is a changes focus from far point to near point.
Kornea
Abnormalities of the cornea:

 Normal corneal diameter is 12 mm
 Macrocornea: diameter of the corena is larger than normal
 Microcornea: diameter of the cornea is smaller than normal
 Arkus senilis, whitish or grey ring in outer segement of cornea
 Corneal edema, the cornea is unclear and thickened, happened in congenital
glaucoma as well as acute glaucoma, after intra ocular surgeries, endothelial
decompensation, trauma and corneal infection
 Erosion, corneal epithelial detachment, give rise to positive fluourescein test
 Infiltrat, deposit of inflammatory cells on the cornea that makes cornea
unclear and positive placido test
 Pannus, inflammatory cells with neovascularization, usually at the superior
limbal area of the cornea, happened in trachoma, contact lens warpage,
flicten, superior limbic keratoconjunctivitis and corneal burn
 Corneal Ulcer, loss half of corneal layer due to necrosis in infection or allergic
condition
 Corneal Xerosis, the dryness of the corneal surface and unclear cornea.
 Keratomalasia, softened and protruded cornea
 Cicatriks, scar on the cornea, consist of nebula, macula and lecoma
 Leukoma adheren, cornea is attached to the iris
 Corneal Staphyloma, protrusion of the cornea due to corneal ulcer or cornea
become thin with exposed uvea in the back of the cornea
 Keratik presipitat, inflammatory cell in the corneal endothel
6. Anterior Chamber
Abnormalities:
 Shallow anterior chamber in lens dislocation, iris tumour, anterior synekia, iris
bombe due to pupillary block and acute glaucoma

Study Guide
 Deep anterior chamber, in aphakia, myopia, congenital glaucoma and angle

resession
 Flare, deposit of inflammatory cells and fibrin in anterior chamber
 Hipopion, the deposit of inflammatory cells in lower part of anterior chamber.
7. Iris
Abnormalities:
 Coloboma
 Aniridia
 Iris atrophy
 Rubeosis iridis, neovascularization in the iris
 Anterior Synekia, attachment of the iris with cornea
 Posterior Synekia, attachment of the iris to the lens
8. Lens
Abnormalities:
 Cataract, clouding of the lens
 Lens dislocation, changes in lens position from its normal position, can be
subluxated or luxated to anterior or posterior
II. TONOMETRI
1.PALPATION TONOMETRI
Basic: intra ocular pressure measurement by examiner finger
Instrument: examiner finger tekanan bola mata dengan jari pemeriksa.
Technique
 The patient close his eyes Penderita memejamkan mata with down gaze
 One of the pointing finger pushed the eyeball while the other finger constantly hold
the eyeball, and the other finger hold the forehead and patient chin.
Interpretation
 The eyeball soft enough when it is pushed by finger (N = normal palpation)

 N+1, N+2, N+3 atau N-1, N-2, N-3 is the notation that show the higher or lower
intraocular pressure
 If the intraocular pressure is higher than normal the glaucoma is suspicious

Study Guide
Notes
This methods can be used if tonometry is not available or the tonometry could not be used
in some eye condition such as cicatriks on the cornea, irregular cornea and corneal
infection. This methods need more practical skill because of subjective interpretation.
Beware of oculo cardiac reflex if the eyeball being pushed innapropiatelly.
2. SCHIOTZ TONOMETRI
The Schiotz tonometer was once the most widely used tonometer. It is used much less often
in today’s office setting, but still serves as an accurate, inexpensive, portable, autoclavable
instrument for use in the operating room or in nonophthalmologic or nonoptometric settings.
The instrument is a simple mechanical device that employs a weight to press a freely
moving plunger against the cornea, indenting it. The amount of indentation produced by this
weight is read from a scale with a needle indicator moved by the plunger. The plunger must
move freely within the cylinder of the tonometer, so the instrument must be kept
scrupulously clean. Any debris or oils from the hands can accumulate in the cylinder and
affect the movement of the plunger.
The Schiotz tonometer. (Courtesy of Sklar Instruments.)
Cleaning the Tonometer

The entire instrument must be carefully cleaned between each patient to avoid the possible
spread of infection. The instrument is made entirely of metal, so it can withstand steam
sterilization and noncorrosive chemical disinfection. However, it is more common to clean

Study Guide
the tonometer with isopropyl alcohol.
Calibrating the Schiotz

A metal test block is provided with every instrument. It is in the corner of the storage box
and should be wiped clean before use. The calibration is checked by resting the tonometer
perpendicularly on the test block. The needle should indicate zero on the left end of the
scale. If it does not, a small screw at the base of the needle can be loosened to rezero the
needle. The needle itself should be perfectly straight because bending it will give a false
reading.
The instrument is placed on the test block to test calibration. (Photo by Mark
Arrigoni.) (Reprinted from Herrin
MP. Ophthalmic Examination and Basic Skills. Thorofare, NJ: SLACK Incorporated;
1990.)
Performing Schiotz Tonometry

The patient must be reclining so that the eyes are looking straight up at the ceiling. A drop of
anesthetic is instilled in each eye. The patient is instructed to relax and keep both eyes open
and positioned straight ahead; a target placed on the ceiling is helpful. The tonometer
should already have been cleaned and tested.
A right-handed assistant should hold the tonometer in the right hand using the 2 curved
arms attached to the side of the cylinder. The scale mount rotates easily and should be
turned so that the scale is facing the assistant. The left hand is used to gently hold the lids
of the patient’s right eye apart, anchoring them against the orbital rim so that no pressure is
applied to the globe.
An alternative hand position is to hold the upper lid with the left hand and the lower
Lids with the small finger of the right hand. In either case, the hand holding the tonometer
can rest on the patient’s cheek or forehead for stability. The tonometer is gently lowered
onto the eye so that the footplate rests on the central cornea and the instrument is
perpendicular. The cylinder is then lowered slightly, so that the tonometer is resting on the
eye and the assistant is providing only lateral support. The cylinder should neither lift up nor
press down on the footplate at this point. Looking straight at the scale, the needle position is
noted. If the scale is not directly facing the assistant, an erroneous reading will be made.
The tonometer is quickly lifted straight up off. Because the plunger indents the cornea, any
movement of the tonometer while it is on the eye may cause an abrasion. The scale

Study Guide
readings do not indicate IOP in mm Hg but must be converted according to a table provided
with the instrument. The scale readings are inversely proportional to the IOP; lower numbers
indicate higher pressures. The standard weight on the plunger is 5.5 gm, and 2 additional
weights (2.0 and 4.5 gm) may be added to this for a total of 7.5 and 10.0 gm, respectively. If
the scale reading is less than 3 (ie, the IOP is more than 25), the next weight is added, and
the measurement is taken again. If the 7.5 weight still gives a reading of less than 3, then
the third weight is added, and the measurement is retaken. Along with the IOP, the assistant
should also document the weight used.
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

Study Guide
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

Study Guide
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.

Study Guide
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 (taken from 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

Study Guide
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
 Tilting slightly at 15-25° lateral to the patient, move forward as you direct the light
beam into the pupil. The optic disc should be within view as you are about 1-2
inches from the patient’seye. 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 2nd
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

Study Guide
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
F. Please demonstrate how to remove foreign body from the conjunctiva and cornea
G. Please demonstrate how to examine the posterior segment using direk
ophthalmoscope

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BLOCK

VISUAL SYSTEM AND DISORDERS

TIME TABLE CLINICAL SKILL 12

MEETING OF STUDENT REPRESENTATIVES 22

FORMAT OF ARTICLE REVIEW 23

TOPICS OF ARTICLE REVIEW 25

PRACTICUM AND BASIC CLINICAL SKILL GUIDES 65

1. Able to know and understand anatomy of the eye structures

1. Anatomy, histology and physiology of the eye.

COORDINATOR : dr. I Wyn Eka Sutyawan Sp.M

1 dr. Putu Budhiastra, Sp.M (K)

No Name Dept No Telp

1 dr. Putu Budhiastra, Sp.M (K) Ophtalmology 085238238999

English Class (Class B)

BLOCK : VISUAL SYSTEM AND DISORDER

NO DAY LEARNING OUTCOME EDUCATIONAL LEARNING METHOD OF

08.00- dr. I Md Agus

Lecture 1 dr. Yuliana

Lecture 2 Class room dr. Ratna

Lecture 3 Class room Prof Sutjana

10.00- dr. Yuliana , dr. Ratna

14.00- Basic Clinical Skill

3 08.00- Lecture 5 Classroom Prof. Jawi

11.00-11.50 Student Project

14.00- Basic Clinical Skill

11.00-11.50 Student Project

Visual Acuity Class room

10.00-10.50 dr. Eka Sutyawan,

08.00- Lecture 13 dr. AAA Sukartini

10.00-10.50 dr. Ari Andayani,

Lecture 23 Classroom dr. Ari Suryathi

10.00-10.50 dr. Surasmiati,

13 08.00- Presentasi SP Class room Team Lecture

08.00- dr. I Md Agus

Lecture 2 Class room dr. Ratna

Lecture 3 Class room Prof Sutjana

14.00- Basic Clinical Skill

13.00- Basic Clinical Skill Team Lecture

09.00- Lecture 10 dr. Eka

Lecture 12 dr. Ratna

10.00-10.50 dr. Eka Sutyawan,

08.00- Lecture 13 dr. AAA Sukartini

7 Lecture 14 Classroom dr. Laksmi Utari

11.00-11.50 Student Project

10.00-10.50 dr. AAA Sukartini

13.00-13.50 Basic Clinical Skill

9 11.00-11.50 Student Project

10 08.00- SGD Discroom Facilitator

11 11.00-11.50 Student Project

10.00-10.50 dr. Surasmiati,

Basic Clinical Skill Blok Visual

MID BLOCK MEETING

The Prerequisites of Final Examination:

Format of Article Review

TOPIC OF ARTICLE REVIEW

Note. Student presentation: at class room (4.01)

Note. Student presentation: at class room (4.01)

Time Table of Consultation

No Point of Discussion Date Supervisor Sign

No Item Assessment Range Score (%) Score

Article Review Assessments Form

No Item Assessment Range Score (%) Score

1. Describe about the position of bones that construct the walls

I.OPTIC SYSTEM OF THE EYE