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Ophthalmology Syllabus of TNPSC

Updated on: Feb 26, 2013
Ophthalmology - MS
Basic Science in Ophthalmology
Trauma and Emergency Ophthalmology
Disorders of the lids, lacrimal drainage apparatus, orbit and oculoplasty
External eye disease, sclera, cornea
Optics and refraction, contact lenses and low visual aids
Lens and Glaucoma
Uvea and Vitreo retinal diseases
Disorders of the optic nerve, visual pathway Neurophthalmology
Ocular motility, strabismus, paediatric ophthalmology.
Community Ophthalmology.

1. Basic Science in Ophthalmology

ANATOMY

The Orbit and adnexa - Osteology, Eyelids, Conjunctiva, Lacrimal gland and accessory glands, and lacrimal drainage system, Extraocular muscles (including stability and movement of eyeball), Intraorbital nerves, vessels and vascular supply, and orbital fat and fascia

Ocular anatomy - Including detailed topographical and microscopic anatomy of ocular, structures, including blood supply, particularly with respect to function and relevance to clinical disease states. Conjunctiva Cornea Sclera Limbus and aqueous outflow pathways Iris and pupil Lens and zonular apparatus Ciliary body Choroid Retina and retinal pigment epithelium and associated structures Vitreous Optic nerve

The Cranial cavity - Osteology of the skull Meninges, blood supply, nerve supply Venous sinuses Foramina and their contents Cranial fossae Pituitary gland and its relations Trigeminal ganglion Central nervous system Cerebral hemispheres and cerebellum Surface appearance Internal structure Cortical areas Ventricles Formation and circulation of cerebrospinal fluid Blood supply and venous drainage Microscopic anatomy Brain stem Midbrain Pons Medulla and fourth ventricleNuclei of cranial nerves Cranial nerves Origin, course and distribution Spinal canal including spinal cord, venous plexus, meninges, and subarachnoid space Specilised anatomy of visual system Visual pathways – visual cortex, cortical connections and associated areas Structures involved in control of eye movements Autonomic nervous system and the eye.

Head and neck anatomySpecial areas to be covered include : Nose, mouth and paranasal air sinuses Lateral wall of nose, septum, vessels and nerves, oseteology, anatomy, relations and development of air sinuses The face and scalp Muscles, nerves and vessels, temporal fossa, zygomatic arch, salivary glands and temporomandibular joint The infratemporal fossa and pterygopalatine fossa Muscles, vessels, nerves, carotid sheath, pterygopalatine ganglion General topography of the neck Posterior triangle, anterior triangle, suprahyoid region, prevertebral region, root of the neck Respiratory systemThe anatomy of the mouth, pharynx, soft palate and larynx with particular reference to bulbar palsies and tracheostomy Lympathatic drainage of the head and neck Including face

Ocular Physiology - Biochemistry of tears, aqueous and vitreous humuor Physiology and biochemistry of cornea Lacrimal system Lens metabolism Retina photoreceptors, includings vitamin A metabolism andphototransduction Retinal pigment epithelium Choroid Blood-ocular barrier

Physiology of vision - Visual acuity Accomodation Pupillary reflexes Light detection and dark adaptationColour vision Electrophysiology of the visual system Visual fields and visual pathways (including retinotopic organization) Processing of light stimuli Contrast sensitivity Eye movements StereopsisMotion detection Visual perception

GENETICS - Chromosomes and cell division Methods of genetic analysis Mendelian inheritance X-linked inheritance Mitochondrial inheritance Linkage analysis and disequilibrium and population genetics Chromosome mapping Gene mutations Oncogenes, and genetics of malignancy (including retinoblastoma) Inherited ocular disease : including for example retinitis pigmentosa, aniridia, choroidaemia, stationary night blindness, Norrie’s diseaseGenetics of ocular disorders and of general conditions which contain an ocular component Principles of gene therapy

MOLECULAR AND CELL BIOLOGY - Cell organelles, recepotors and receptor signaling Plasma membrane Cytoskeleton and its relation to cell motility and contractility NucleusCell-cell communication Protein synthesis – pre – and post-transcriptional and translational controlMoelcular biology of protein synthesis

RECEPTOR PHYSIOLOGY - Secondary messengers and intracellular signaling Understanding of molecular biological techniques (also in relation to genetics) including: Polymerase chain reaction Northern and Southern Blotting In situ hybridizationExtracelluar matrix (particularly with respect to ocular structures) Collagen synthesis – types and function Proteoglycans, glycoproteins, fibronectin, laminin and glycosaminoglycans Retinal neurochemistry

PHARMACOLOGY Pharmacokinetics and pharmacodynamics Drug receptor and secondary messengers : cellular mechanisms of drug action Methods of drug delivery for ophthalmic agents, pharmacokinetics of individual

Methods - Pharmacology of : Cholinergic and adrenergic systems Drug control of intraocular pressure Serotonin Histamine Anti-inflammatory agentsAnti-infective agents Immunosuppressants Local anaesthetics Analgesics Mechanisms of drug toxicity and drugs which specifically cause ocular toxicity

MICROBIOLOGY - Principles of Infection Culture media Bacteria Gram staining and classification Exo and endotoxins Mechanisms of virulence and pathogenicity Synergic infections Antibiotics : including mechanisms of action, bacterial resistance Host defence mechanisms against bacterial infection, with particular reference to ocular defence Commensal eye flora

Viruses - Classifications Structure and replication Host defence against viral infection Antiviral agents Specific antiviral agents: mechanisms of action Laboratory methods for viral detection Viral infections of the eye

HIV AND AIDS - Classification, diagnosis, laboratory diagnosis and monitoring of HIVinfection Neuro-opthalmic opportunistic infections Anti HIV agents

Fungi - Classification: Ocular fungal infections Host factors which predispose to fungal infectionAntifungal agents

Others - Toxoplasmosis Chlamydia Acanthamoeba Helminthic infectionsAntimicrobials

PATHOLOGY CLINICAL FEATURES AND MANAGEMENT OF : Eyelid tumoursTumours of conjunctiva and cornea Uveal tumours Retinolblastoma (including genetics) Metastatic disease to the eye and orbit Orbital tumours in children and adults Cornea Inflammation, including graft rejection, dystrophies and degenerations Lens Cataract formation Uvea Inflammation Vascular disease Infection Tumours Retina Vascular disease Degenerative disease Dystophies Detachment Infection Tumours Optic nerve Vascular disease Toxic Inflammatory and neoplastic disease Phacomatoses Glaucoma Orbit Inflammations Tumours Pathological findings in the eye and orbit in systemic disease Diabetes Thyroid disease Vascular disease Pathology of infectious disease Cornea Intraocular Orbital Intracranial Vitamin metabolism and deficiency states

IMMUNOLOGY - Innate and acquired immunity Effector mechanisms of immune response Humoral immunity and antibody class and function Cellular immunity Immunity against microbes (see microbiology) T and B Cells : cluster differentiation, phenotype, T and B cell activation MHC antigens, antigen presenting cells and antigen processing Immune mechanisms of tissue damage Interleukins, complement Immunodeficiency (see microbiology) and immunosupression (see pharmacology) Organ transplantation and pathophysiology of allograft rejection

OPTICS AND REFRACTION - PHYSICAL OPTICS

Properties of light Visible light and its place in the electromagnetic spectrum Wavelength and frequency Propogation of light Wave and particle theory Fluorescene and phosphorescence Absorption and transmission of electromagnetic radiation by the eye Opthalmic hazards of different electromagnectic radiations Diffraction, Interference, Polarization, Transmission and Absorption Laser Theory History and development of lasers Properties of laser light Coherence Solid crystal lasers Gas discharge tube lasers Dye lasers Q switching Pulsed and continuous wave lasers Laser hazards and safety

GEOMETRIC OPTICS - Basics Reflection at plane and curved surfaces, the images produced and their character including ray diagrams Refraction Refractive index Critical angle Total internal reflection Prisms (including Fresnels), power and notation Lenses Spherical lenses Cardinal points, axes and principal ray diagrams Character of images produced Power and notation of lenses Magnification Thin and thick lenses and their formulae Prismatic effect of decentring lenses Principles of the pin hole Principles of the stenopaeic slit Aspheric lenses and their use in ophthalmology Cylindrical lenses and their focal characteristics Maddox rod Jackson’s cross cylinder Astimatic lenses Conoid of Sturm Circle of least confusion Confocal optics

CLINICAL OPTICS Basics Optics of the normal eye including accommodation, accommodative reserve, near synkinesis and the changes in accommodative reserve with time The schematic and reduced eyeRefractive indices of ophthalmic media including the tear film The effect of pupil diameter Use of the pinhole Visual acuity Snellen and Log MAR theory Contrast sensitivity gratings and the Peli-Robson Test Refractive error and its correction Emmetropia Myopia and hypermetropia: Prevalence, inheritance, aetiology and associations Astigmatism: Regular and irregular astimatism and principles of its correction Pinhole, stenopaeic slit and contact lens in its investigationKeratoscopic patterns in regular and irregular astigmatism Accomodative reserve and its variation with age Presbyopia Aphakia Pseudophakia Clinical refraction Retinoscopy including recognition of abnormal retinoscopy reflexes Retinoscopy and prescribing in children Cycleplegic agents, their effects and hazards Subjective refraction Pinhole and Duochrome test Interpupillary distance and back vertex distance Decentring of lenses Anisometropia and aniseikonia and the practical limits for spectacles Prescribing for presbyopia Muscle balance tests Spectacle lenses Spectacle lenses and their notation Transposition Spherical equivalent Identification of unknown lenses Recognistion of plus and minus lenses clinically Detection of prisims Neutralisation and focimetry Use of the Geneva lens measure and its limitations Aberrations of lenses and their minimization Bifocal, multifocal and varifocal lenses Best form lenses Contact lenses Classification Materials Advantages over spectacles (especially for high ametropia) Optical principles of refractive surgey Radial keratotomy Surface laser

LASIK - Principles of intracorneal rings Phakic introcular lenses Clear lens extraction Correction of high ametropia Optical advantages and disadvantages of different methods The candidates should have a detailed knowledge of : Direct and indirect ophthalmoscope Retinoscope Slit-lamp biomicroscope Applanation tonometer Operating microscope Focimeter The candidate should be familiar with the optical principles of: Slit-lamp diagnostic and therapeutic lenses Simple magnifiers Telescopic low visual aids Lensmeter Autorefractors Keratometer Endothelial specular microscope and confocal microscopy Placido’s disc and keratoscope Optical pachymetry Placido and elevation computerized corneal topography Zoom lenses Lee screen / Hess chartSynoptophore Fundus and slit-lamp cameras Scanning laser ophthalmoscope

EXTERNAL EYE AND CORNEA Eyelid General and dermatological problems and eyelid margin disease, including meibomian gland dysfunction Dry eye – causes, symptoms and managemen

2. Trauma and Emergency Ophthalmology

Essential topics/experience To have become familiar with the following :
Superficial ocular trauma: including assessment and treatment of foreigh bodies, abrasions and minor lid lacerations
Severe blunt ocular injury: management of hyphaema - recognition and initial management of more severe injury.
Severe orbtal injury: recognition and initial care of corneal and scleral wounds; recognition of acqueous leakage and tissue prolapse.
Retained intraocular foreign body; anticipation from history, confiirmation of X-ray and CT Scan.
Sudden painless loss of vision; recognition of retinal arterial occlusion, central retinal vein occlusion, acute ischaemic optic neuropathy, optic neuritis, urgency of treatment.
Severe intraocular infection; recognition and initial investigation and management of hypopyon.
Acute angle closure glaucoma; recognition and acute reduction of intraocular pressure.
Liason with Radiological department, Microbiologist, ENT and Faciomaxillary surgeons.
Practical Skills
Removal of superficial foreign bodies
Corneal epithelial debridement
Repair of minor conjunctival/lid laceration
YAG iridotomy
Eye protection and prevention of injury
Lateral canthotomy and inferior cantholysis for retrobulbar haemorrhage
Chemical/alkali burns of the conjunctiva and cornea
Drug penetration into the eye and vitreous
Use of intravitreal antibiotics, including dosage and potential complications.

3. Disorders of the lids, lacrimal drainage apparatus, orbit and oculoplasty

Essential experience
Abnormal lid position; including assessment of ectropion, entropion, ptosis, trichiasis, lagophthalmos and exposure.
Abnormal lid swelling, including chalazion, stye, retention cysts, papilloma and basal cell carcinoma.
The watering eye, including the distinction between excessive lacrimation and epiphora, blepharitis, recognition and investigation of nasolacrimal ostruction.
Orbital swelling, including dysthyroid eye disease, distinguishing intraconal from extraconal space-occupying lesions, orbital cellulitis, recognition of compressive optic neuropathy.
Liason with Neurosurgeons, ENT, Endocrinologists and orbit reconstruction Services.
Practical Skills
Use of exophthalmometer
Syringing and probing
Incision and curettage for chalazion
Wedge biopsy and removal of papilloma, etc.
Tarsorrhaphy
Electrolysis/cryotherapy for trichiasis
Surgery to involutional ectropion/entropion
Background theory/principles :- To have gained an awareness of the following
Sebaceous carcinoma of lid and squamous cell carcinoma
Cicatricial malposition of the lids
Management of ptosis and blepharospasm
Canaliculus repair
Dacryocystorhinostomy
Orbital and lacrimal tumours and their treatment
Inflammatory orbital and lacrimal diseases and their treatment
Paranasal sinus disease
Use of radiographs, MRI, CT scan
Enucleation, evisceration and fitting of prosthesis
Exenteration


4. External eye disease, sclera, cornea and anterior area

Essenstial experience
Infectious external disease, including viral, bacterial and chlamydial conjunctivitis.
The dry eye, including symptoms, assessment of reduced tear production and tear film stability and treatment.
Allergic and atopic eye disease recognition and management.
Corneal ulceration from viral and bacterial disease, marginal keratitis.
Complications of contact lens wear.
Corneal oedema, opacity and ectasia, indications for corneal transplantaion, standards of care in donor eye procurement, signs of corneal graft rejection and other complications.
Epislceritis, recognition and management.
Anterior uveitis, including classification, differential diagnosis, systemic associations, investigations and treatment.
Liaison with microbiology, immunology.
Practical skills
Conjunctival sampling and corneal scraping for microbiological investigations.
Pachometry for corneal thickness.
Keratometry and Placido’s disc.
Removal of corneal sutures.
Retrieval of donor eyes for transplantation(5)
Background theory/principles : Acanthamoeba keratitis and fungal keratitis
Cicatricial conjunctival disease.
Punctal occlusion
Corneal topography and specular microscopy
Corneal stromal dystrophies, interstitial keratitis.
Corneal biopsy, indications.
Chemical injury of the cornea and conjunctiva.
Therapeutic contact lenses and their complications.
Corneal transplantation, immunology of rejection.
Limbal stem cell transplantation.
Autoimmune corneal and scleral disease including peripheral ulcerative keratitis.
Use of immunosuppressive therapies.
Management of pterygium.
Conjunctival and uveal tumours.
Aniridia and other dysgenesis.
Fuch’s heterochromic cyclitis.


5.Optics and refraction, contact lens and low vision aids
Ametropia, including hypermetropia, myopia, astigmatism and their complications.
Accommodation problems, including spasm and presbyopia.
Knowledge of contact lens fitting, indications, management and complications.
Low vision aids services and rehabilitation of a low vision patient.
Practical Skills : To have undertaken (under supervision until proficient) the following :
Retinoscopy with trial lenses and subjective refraction.
Correction of refractive error by spherical, cylindrical and multi-focal lenses.
Lens neutralisation and use of focimeter.
Background theory/principles : To have gained an awareness of the following
Basis of spectacle intolerance from poor dispensing or defective prescription.
Use of log MAR charts in assessment of acuity.
Alternatives to capsular IOL fixation.
Combined cataract and glaucoma/corneal transplantion surgery.
Ectropia lentis and Marfan’s syndrome.
Contact lenses and refractive surgery.
Therapeutic contact lenses.
Fluidics and ultrasonics.
Intraocular lens design and biomaterials.


6. Disorders of lens and glaucoma


Essential topics/experience : To have become familiar with the following
Lens opacifications, including types of cataract, relationship of opacity to symptoms, contributiion to visual loss in co-morbidities, systemic associations, cataract surgery and its complications.
Pseudoexfoliation of the lens capsule, including its recognition and significance.
Calculation of intraocular lens power, according to the patient’s needs.
Glaucomatous optic neuropathy, recognition and investigation.
Glaucoma suspects, including ocular hypertension.
Rubeotic glaucoma recognition, differential diagnosis and management.
Hypotensive agents, topical and systemic drugs affecting intraocular pressure and their complications.
Glaucoma drainage surgery, indications, complications and their treatment.
Hypotony, including its causes and consequences.
Practical Skills : To have undertaken (under supervision until proficient) the following
Applanation tonometry
Assessment of peripheral and central anterior chamber depth, including pachymetry.
Assessment of irido-corneal angle structures by gonioscopy.
Methods of optic disc cup measurement.
Visual field testing, including Goldmann/kinetic perimetry and automated static perimetry.
Background theory/principles : To have gained an awareness of the following
Risk factors for primary open-angle and normal-tension glaucoma
Other secondary glaucomas, including phacolytic, pigmentary, erythroclastic, pseudo-exfoliative and silicone-oil glaucomas.
Posner Schlossman syndrome.
Chronic closed angle glaucoma.
Malignant glaucoma
Tonopen, Perkins and non-contact tonometry.
Scanning laser ophthalmoscopy and nerve fibre layer analysis
Argon laser trabeculoplasty
Prevention of glaucoma bleb failure e.g. using anti-metabolites
Drainage tubes and stents.
Cycloablation.


7. Vitreoretinal disorders


Essestial topics/experience - To have become familiar with the following
Diagnosis and management of anterior, intermediate and posterior uveitis
Flashes and floaters, complications of posterior vitreous detachment and recognition of retinal tears.
Vitreous haemorrhage, from retinal tears or neovascularization - initial management.
Retinal detachment, classification, predisposition, recognition and urgency of treatment, recognition of proliferative vitreoretinopathy.
Diabetic retinopathy, classification, screening strategies, management.
Hypertensive and arteriosclerotic retinopathy, including macroaneurysms and branch retinal vein occlusion.
Retinal vascular occlusions, recognition of ischameic and exudative responses, rubeosis.
Macular diseases, including recognition of age – related maculopathy, subretinal neovascularization, cystoid macular oedema, macular hole, related symptomatology and urgency of treatment.
Fluorescein angiography, indications, complications and interpretation.
Practial Skills : To have undertaken the following
Slit lamp examination and the use of various contact and non contact fundus lenses
Scleral indentation with indirect ophthalmoscopy.
Retinal drawing
Cryopexy and laser (via slit-lamp and indrect ophthalmoscope delivery systems) for retinal tear.
Background Theory/Principles : To have gained an awareness of the following
B-Scan ultrasound for opaque media.
Vitreoretinal surgery, including closed intraocular microsurgery, scleral buckling and internal tamponade.
Intraocular foreign body, complications and management.
Other vasoproliferative vitreoretinopathies including sickle cell retinopathy, retinopathy of prematurity, Eales’ disease.
Genetic vitreoretinal disease-Stickler syndrome, X-linked retinoschisis.
Asteroid hyalosis
choroido-retinal coloboma
Background Theory/Principles : To have gained awareness of the following
fundus imaging including scanning laser ophthalmoscopy.
Indocyanine green angiography.
Electro diagnostic tests and dark adaption.
Genetic retinal disease, retinal dystrophies, retinoblastoma.
differential diagnosis and treatment of malignant melanoma.
Macular laser photocoagulation, principles and laser safety.
Toxic maculopathy and central serous retinopathy.
Intraocular lymphoma.
Intermediate and posterior uveitis, toxoplasmosis, toxocara and sympathetic ophthalmia, retianl vasculities.
Coats’ disease, other telangiectais and the retinal phakomatoses.
AIDS-related opportunistic infections and anti-AIDS treatment

8. Disorders of the optic nerve and visual pathways-Neurophthalmology

Essential topics/experience : To have become familiar with the following
Swollen optic disc, differential diagnosis, recognition and evaluation of papilloedema, ischaemic optic neuropathy (arteritic and non-arteritic), acute optic neuritis and congenital optic disc anomalies.
The atrophic optic disc, recognition and differential diagnosis, clinical evaluation of optic nerve function.
Visual pathway disorders, identification of site and nature of lesion from history, examination and investigations, transient ischaemic attacks.
Examination of cranial nerve plasies particularly III, IV, VI, VII and V nerve
Practical Skills : To have undertaken (under supervision until proficient) the following
Goldmann visula fields
Examination of the cranial nerves
Temporal artery biopsy
Background theory/principles : To have gained an awareness of the following
Benign intracranial hypertension
Compressive optic neuropathy
Optic nerve glioma
Chiasmal lesions
Visual evoked responses
Neuro-imaging including CT, MRI and carotid doppler
Carotid endarterectomy
Multiple sclerosis and its ophthalmic manifestations
Higher cortical dysfunction, including the visual agnosias.


9. Strabismus and paediatric Ophthalmology

Essential Topics/experience : To have become familiar with the following
Concomitant strabismus, screening strategies, epicanthus, accommodative aspects, interpretations of orthoptic report, indications for surgery.
amblyopia, anisometropic, stimulus-deprivation, strabismic prevention and treatment using occlusions.
Incomitant strabismus, cranial nerve plasies including diabetic mononeuropathies, significance of painful third nerve palsy and of pupil sparing, prediction of post operative diplopia.
the approach to infants, children and their parents.
Ophthalmia neonatorum, diagnosis and management.
Congenital nasolacrimal obstruction; recognition and management
Ametropia in children, significance and treatment
The apparently blind infant, normal and delayed visual maturation
Paediatric cataract surgery and paediatric glaucoma.
Practical Skills : To have undertaken (under supervision until proficient) the following
Eye movement evaluations
Cover test (including alternate and prism)
Stereo tests
Cycloplegic refraction
Horizontal muscle surgery
Synoptophore examination
Background theory/ Principles : To have gained an awareness of the following
Nystagmus
Ocular motility syndromes (duane’s, brown’s)
Use of botulinum toxin
Ocular myopathies and the neuromuscular junction
Supranuclear eye movement disorders
Fresnel prisms
Oblique muscle, vertical muscle and adjustable suture surgery
Electromyography.
Assessment of vision in children, fixation, preferential looking, single and linear optotype tests.
Cycloplegic refraction and prescribing for children.
Fundoscopy in children.
Ocular albinism Cognenital nystagmus
Congenital glaucoma, diagnosis and management.
Congenital cataract, diagnosis and management including prevention of amblyopia.
Leucocoria, differential diagnosis including retinoblastoma.
Retinopathy of prematurity, screening and treatment.
Paediatric neurological diseases.
Ophthalmic signs of child abuse
Orbital Cellulitis presenting in children.
Orbital tumours in children, including rhabdomyosarcoma.


10. Community Ophthalmology.
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