Department of Medicine - Knoxville

IM Residency Program

Area: Ambulatory - Ophthalmology

Location:  Medical Office Building B, Suite 324

Faculty:

• David J. Harris, MD
• Charles Ange, MD
• Jonathan Sowell, MD
• Herbert Glatt, MD
• Paul Froula, MD
• Bradley Pearman, MD
• Kenneth Olander, MD
• Lee McDaniel, MD

Staff Contact:

• Sabrina Walker or Tonya Burch
• Phone:     (865) 524-9871

Schedule:     

• Typically from 9 AM until 5 PM .
• The Resident is expected to attend Morning Report, Noon Conference, and resident's clinic.

Goals and Objectives:

      During the Ophthalmology rotation, the Resident should become familiar with the following topics: Eye symptoms, examination of the eye and interpretation of resulting signs, common eye disorders and their initial management by primary care physicians, systemic disorders with important ophthalmic manifestations, eye medications with important systemic side effects, and systemic medications with important ophthalmic side effects.

I.   Common Eye Symptoms – as reported by the patient

A. Visual symptoms     

•  Blurred vision

•  Double vision

a. Binocular diplopia

b. Monocular diplopia

•  Visual field disturbances

•  Dim or dark vision

•  Photopsia/flashing lights

•  Scintillating scotomas

B. Pain

•  Foreign body sensation

•  Deep eye pain

•  Pain with eye motion

•  Photophobia

•  Localized eyelid pain

•  Nausea

C. Disturbance of the appearance of the eye

•  Bulging eye

•  Eyelid mass

•  Red eye

•  Red spot on the eye

•  White pupil

•  White spot on the eye

 D. Other important history factors

• Contact lens use
• Acquaintances with red eye
• Metal-to-metal strike
• Family history

  a. Retinoblastoma

  b. Glaucoma

  c. Strabismus

  d. Retinal detachment

II.   Eye Examination

A. Visual acuity – the most important

B. Other eye examination techniques     

•  Flashlight exam of the eye and adnexae

•  Testing of ocular motility

•  Confrontation visual field test

•  Test of pupillary function         

a. Direct response

b. Consensual response

c. Equality of pupils

d. Afferent pupillary defect (Marcus-Gunn pupil)

•  Testing of the red reflex

•  Direct ophthalmoscopy

III.  Ophthalmic Signs

A. Trichiasis

B. Proptosis/exophthalmos

C. Entropion

D. Ectropion

E. Hypopyon

F. Hyphema

G. Afferent papillary defect

H. Conjunctiva       

• Generalized injection
• Ciliary injection
• Discharge

I. Ptosis

J. Corneal ulcer

K. Leukocoria

L. Rubeosis iridis

M. Preauricular adenopathy

N. Papilledema

O. Strabismus

IV.  Common Ophthalmic Diseases (* discuss initial treatment)

A. Refractive errors

•  Nearsightedness (myopia)

•  Farsightedness (hyperopia)

•  Astigmatism

•  Presbyopia

•  Refractive surgery (LASIK)

B. Eyelid disorders

•  Eyelid inflammation

a. Hordeolum*

b. Chalazion*

c. Preseptal cellulitis

d. Herpes (varicella) zoster*

•  Disorders of eyelid position

a. Entropion

b. Ectropion

c. Ptosis

d. Excess eyelid skin

•  Eyelid tumor

a. Nevus

b. Xanthelasma

c. Basal cell carcinoma

d. Squamous cell carcinoma

e. Malignant melanoma

C. Orbital diseases

•  Graves disease/thyroid ophthalmopathy

•  Orbital cellulitis

•  Dacryocystitis

•  Orbital tumors

D. Disorders of ocular motility

•  Esotropia
•  Exotropia
•  Cranial nerve palsy (III, IV, VI)

E. Conjunctival disorders

• Conjunctivitis*

  a. Viral conjunctivitis

  b. Bacterial conjunctivitis

  c. Allergic conjunctivitis

• Conjunctival lesions

  a. Pingueculum/pterygium

  b. Nevus/melanoma

  c. Subconjunctival hemorrhage*

F. Scleritis

G. Corneal diseases

• Corneal abrasion*
• Corneal foreign body*
• Corneal ulcer

  a. Bacterial/fungal

  b. Viral (herpes simplex)

• Dry Eye*

H. Cataract and cataract surgery

I. Glaucoma

• Open angle
• Narrow angle

J. Retinal disease

• Central retinal artery occlusion
• Hypertensive retinopathy
• Diabetic retinopathy
• Macular degeneration
• Retinal detachment

K. Optic nerve disorders

• Optic neuritis
• Papilledema 

L. Ocular tumors

• External

    a. Conjunctival melanoma

    b. Conjuntival squamous Neoplasia

• Intraocular

    a. Retinoblastoma

    b. Uveal melanoma

 K. Ocular trauma

• Non-penetrating trauma*
• Penetrating trauma*

  a. Blunt

  b. Sharp

• Thermal trauma
• Chemical trauma*

  a. Alkali

  b. Acid

V.  Systemic Disorders With Important Ophthalmic Manifestations

A. Endocrine disorders

• Diabetes
• Thyroid disorders

B. Immune system disorders   

• Rheumatoid arthritis

      a. Juvenile

      b. Adult

• Multiple sclerosis
• Lupus
• Sarcoidosis
• Temporal arteritis/polymyalgia rheumatica

C. Congenital disorders

• Down syndrome
• Marfan syndrome
• Neurofibromatosis

D. Trauma

• Closed head injury
• Epidural hematoma

E. Neurologic diseases

• Migraine
• Pseudotumor cerebri
• Stroke
• Brain tumor

F. Infectious disease

•  Sexually transmitted disease

    a. HIV

    b. Syphilis

    c. Chlamydia

    d. Gonorrhea

• Lyme disease
• Cat scratch disease
• Toxoplasmosis

    a. Congenital

    b. Acquired

• Bacterial endocarditis

G. Hypertension

 H. Hepatic failure/cholestasis

 I. Rosacea

VI. Eye medications with important systemic side effects

A. Topical timolol and other beta-blockers

B. Topical phenylephrine

C. Systemic acetazolamide

D. Systemic steroids

E. Systemic tetracyclines

VII. Systemic medications with important ophthalmic side effects

A. Anticholinergics

B. Topirimate

C. Tamsulosin

D. Tretinoin

E. Antihistamines

F. Sildenafil

G. Corticosteroids

H. Anticoagulants

References, Suggested Readings: Bradford , CA (Executive Editor); Basic Ophthalmology for Medical Students and Primary Care Residents, 7 th Edition. 1998. American Academy of Ophthalmology. ISBN-10 1560553618

Evaluation:   Each resident will be informally and continually evaluated based on interactions with faculty during the course of the rotation. A summative evaluation will be completed by Dr. Harris and discussed with the resident at the rotation end.