Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
OPHTHALMOLOGY ORAL REVALIDA
SCRIPT (CLINICALS)
Sharingan Notes | Final Chapter
Author: Rafael Fontanilla, RPh, MD
Batch 2021
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Table of Contents:
1.
2.
3.
4.
5.
6.
7.
8.
The 20 Ophthalmology Oral Revalida Cases……………………. 3
Chief Complaints in Ophthalmology and their Differentials…. 4
History Taking Mnemonic (IG CHOR | PFT) …………………….. 7
The Complete Ophthalmologic Diagnosis …………………….... 9
Must Asks in History Taking ………………………………………. 10
Complete Physical Examination …………………………………. 13
Discussion Flow …………………………………………………….. 16
Crash Course on the 10 Cases …………………………………… 17
____________________________________________________________________________________
9. Additional Cases for Batch 2021 ……………………………………….. 22
FOR EASIER UNDERSTANDING, HERE IS THE LINK FOR RECORDED VERSION OF
SHARINGAN NOTES:
https://drive.google.com/file/d/1Of9sh1IfaYg8aJe2nTH-Vg2I9IFuk-3D/view?usp=sharing
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Disclaimer:
● This reviewer is designed to serve as a script and guide for ophthalmology cases during the oral
revalida (O.R.).
● It’s main purpose is to introduce a systematic approach in diagnosing ophthalmologic cases.
● It does not contain all information regarding the cases. Supplemental reading is needed to cover
the basics and other important topics that can be asked during the oral revalida.
● All information was collected from Vaughan & Asbury along with the reviewers and transes of
various batches from the UST FMS as well as USTH PGIs.
● This is the author’s personal approach and guide to an ophtha case, so it may not work for
everyone.
Suggestions on how to use the Sharingan notes:
● Understand, don’t simply memorize.
● During your first read, just go through the notes by understanding it. Scroll down. Memorize later.
● This was designed as a visual aid for an online crash course. So it would be most effective if you
had the crash course with me. Here is the link of the recorded lecture for easier understanding:
https://drive.google.com/file/d/1Of9sh1IfaYg8aJe2nTH-Vg2I9IFuk-3D/view?usp=sharing
● Don’t let the pressure or fear take over you, remember that you are capable of giving a correct
and complete diagnosis for you have studied well.
● Enjoy the reviewer. I tried to compose it in a manner as if I am telling a story.
● Trust in your clinical eye, trust in your sharingan. Best of luck!
____________________________________________________________________________
Let’s begin with a quote: “To win a war you must know who your enemies are.” and with
that:
the first step in conquering an ophtha case during the O.R., is to familiarize yourself with
these 10 cases that can be given:
❗️
The Ten Ophthalmology Cases given during the Oral Revalida:
1. Keratitis
- Can be specified to: Bacterial | Fungal | Viral (HSV)
2. Conjunctivitis
- Can be specified to: Bacterial | Allergic | Viral
3. Cataract
4. Glaucoma
- Can be specified to: Open Angle | Angle Closure
5. Hordeolum
- Can be specified to: Internal | External
6. Error of Refraction
7. Amblyopia
8. Age-Related Macular Degeneration
9. Diabetic Retinopathy
10. Leukocoria (White Eye)
New cases for our batch:
11. Blepharitis
12. Preseptal Cellulitis
13. Foreign Bodies
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
14. Subconjunctival Hemorrhage
15. Dry Eye Syndrome
16. Uveitis
17. Retinal Detachment
18. CRAO/CRVO
19. Papillitis/Papilledema
20. Ethambutol Toxicity
21. Cataract
*Don’t memorize as of now, we’ll try to discuss how to approach them one by one later.
For one minute, I want you to briefly think of what are the possible chief complaints for each of the
diagnoses mentioned above? {proceed to next page to find out}
___________________________________________________________________________
The 9 Most Common Chief Complaints in Ophthalmology:
In ophthalmology these are the most common reasons why a patient would come to the
clinic:
1. Red eyes
2. Eyelid masses
3. Blurred vision/ Floaters/ Glares
4. Foreign body sensation
5. Eye pain
6. Tearing/ Discharge
7. Itching
8. Swelling
9. Involuntary movement
For this reviewer, we’ll focus on the top 6 CC’s.
*Note: Knowing the possible diagnoses per chief complaint will allow us to diagnose the patient and at the
same time provide possible differentials we can discuss to our panel during the discussion segment of the
oral revalida.
With this knowledge let’s try to incorporate the possible diagnoses to these chief complaints
(The ones in red bold text are the ones that belong to the 10 O.R. ophtha cases).
*Again, don’t memorize. Understand first.
Chief Complaint/ S&Sx
Red Eye
*During HPI ask about the pattern (Ciliary or
conjunctival) to differentiate conjunctivitis from keratitis
Possible Diagnosis and Differentials
Conjunctivitis - “conjunctival injection”
Keratitis - “ciliary injection”
Angle Closure Glaucoma
Uveitis
Corneal Abrasion
Subconjunctival Hemorrhage
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Eyelid Mass
*During HPI and PE look for signs of inflammation
(Rubor, calor, dolor, tumor). This will differentiate a
hordeolum from chalazion.
Blurring of Vision (BOV)
*Establish risk factors during history (Age, Diabetes,
Steroid Use, Use of prescription glasses).
* The cause of BOV is usually established during PE
Hordeolum - with signs of inflammation | pain
Chalazion - no signs of inflammation | painless
Blepharitis
Preseptal Cellulitis
Error of Refraction - Snellen’s Chart, Pinhole
Cataract - Red Orange Reflex
Age-related Macular Degeneration -Amsler
grid (+) Metamorphopsia
Diabetic Retinopathy- fundoscopy
Glaucoma - fundoscopy and tonometry
Astigmatism - pinhole testing
Strabismus (in the form of Amblyopia) - test
for extraocular muscles
Crossing of Eyes (Strabismus) → Amblyopia
Esotropia
Exotropia
White Eye (Leukocoria)
Congenital Cataract
Retinopathy of Prematurity
Retinoblastoma
Pain
Bacterial Keratitis- redness (ciliary)
Angle Closure Glaucoma - BOV
Uveitis
*Ask the patient for other sx ( the 9 CC’s)
Tearing or Discharge
*Take note of character (is it watery or is it
mucopurulent?) to distinguish the type of
conjunctivitis
Conjunctivitis
● Bacterial - Mucopurulent
● Viral and Allergic - Watery
Dry Eyes
*Take note that these conditions usually have more than 1 symptom so it is extremely important
that we illicit these other symptoms experienced by the patient during the HPI.
❗️
HOKAGE TIP: Before ending the HPI, always ask for the other 9 common CC’s of the
ophthalmology:
You can say “Maliban po sa [chief complaint of patient], nagkaroon po ba kayo nang:
● Red eyes (pamumula ng mata)
● Eyelid masses (bukol sa takipmata)
● Blurred vision (panlalabo ng pangingin)
● Foreign body sensation (pakiramdam na may foreign body or parang buhangin
sa mata)
● Eye pain (pananakit ng mata) - most important since it can differentiate ddx
● Tearing/ Discharge
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
●
●
●
Itching (pangangati)
Swelling
Involuntary movement
Let’s apply the what we have learned so far with some scenarios:
SCENARIO 1
Let’s say a patient comes in due to redness of the eye. On PE, you were able to ask about the
pattern of redness. Doc said it was “ciliary injection”, which confirmed your diagnosis of keratitis.
Doc wants a more specific diagnosis so he asked you “What is the causative agent/ etiology of
the patient’s keratitis?”
The good news is you were able to ask if the patient experienced other symptoms such as pain
aside from the redness. Patient mentioned that it was a painless type of eye redness.
And just with that simple question, you were able to identify that the keratitis is caused by a
virus (HSV - which is the painless type of keratitis) rather than a bacteria (painful keratitis).
SCENARIO 2
Patient comes in due to a mass found at the left eyelid. Upon seeing the patient, it appears to
you that this is either a hordeolum or chalazion. Before ending the HPI, is there anything that
you would like to ask to clinch your diagnosis?
Again the follow-up on the 9 important CC’s.
But for this case the most important of the 9 CC’s would be....
Figure 1. Pain from Naruto Shippuden
If it’s a painful mass, think of hordeolum (remember that the hordeolum is the one with
inflammatory signs such as dolor, rubor, calor, etc. Mnemonic Hordeolum Hurts)
*Since you're thinking of Hordeolum and you know that this presents with inflammation, during PE try to look for the
signs of inflammation. Doc will appreciate it if you know what you are looking for. Plus points for you.
*Remember that we can further improve this diagnosis by indicating if it is an Internal or an External hordeolum.
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
If the patient tells you that the mass is painless - it’s more likely to be a chalazion.
(Mnemonic: Chala ay walang inflammation)
____________________________________________________________________________
Before I introduce the my flow of history taking, it is important that we know how the revalida will
happen so that we can set goals:
Revalida Flow:
● History and PE
● 30 minutes to compose discussion
● Discuss your salient features
● Differentials and Clinical Impression
● Management (ADMIT)
○ ADM
■ Begin by identifying if the patient needs to be Admitted
■ If yes, then you should specify the Diet as well as the Monitoring
○ Investigatory
■ Laboratories
■ Imaging
○ Therapeutics
■ Non-pharmacologic
■ Pharmacologic
■ Preventive and Education
TIP: Your goal is to have a complete clinical impression. To do that you need a really good history and PE
because this will affect how confident you will be during the discussion part (Salient Features, Differentials,
Clinical Impression, Management) of the oral revalida.
Make a good history and PE, and everything will follow.
Let’s practice our history and PE.
____________________________________________________________________________
HISTORY TAKING OPHTHALMOLOGY
This is my system of doing history with an ophthalmologic case:
Remember that we are only allowed to have 1 BLANK sheet of paper during the OR. We must
be very familiar with the sequence of asking questions. To do this I usually begin by writing my
mnemonic “IG CHOR | PFS | PE” on the top of the paper to remind me of the sequence while I
do the introduction.
This is what the mnemonic stands for:
● Introduction and Informed Consent
● General Data
● Chief Complaint
● History of Present Illness
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
●
●
Other Symptoms (these are the other 9 CC’s that we discussed a while ago)
Review of Systems
*Here in IG CHOR our goal is to establish the diagnosis and try to think of the differentials we can discuss later as
well as gather data that would rule them out.
________
● Past Medical History
● Family History
● Social History
*Here in PFS we would establish risk factors and comorbidities that brought about the patient's condition
________
● Physical Exam
*This will be discussed thoroughly in the following pages.
Here’s an easier way of memorizing the mnemonic:
Figure 2: Visual Mnemonic for Ophthalmology Case. See it as “InstaGram CHORes | PuFS | Physical Exam”
____________________________________________________________________________
*Before we dissect the history and PE thoroughly on the next page, rest for 10 minutes.*
Figure 3. Snorlax resting and Chansey sending you care
🤗
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
____________________________________________________________________________
To know what we should ask, remember the goal: “A COMPLETE DIAGNOSIS”
Example of a complete diagnosis:
“Bacterial keratitis on left eye, Stage 2 hypertension poorly controlled,
Overweight, s/p SMILE procedure on left eye”
A “complete” diagnosis includes:
1. Primary Diagnosis:
●
●
Examples: Glaucoma, Hordeolum, Conjunctivitis, Cataract, Eye grade
TIP: make it as specific as possible using your Hx, PE, and risk factors:
* I will try to discuss these later in detail. Don’t pressure yourself to memorize them now:
○
○
○
○
○
Glaucoma → Acute Angle Closure or Open Angle Glaucoma
Hordeolum → Internal or External Hordeolum
Conjunctivitis → Bacterial, Viral, Allergic
Keratitis → Bacterial, Viral, Fungal
Cataract → Nuclear, Cortical, Subcapsular (Morphology)
→ Immature, Mature, Hypermature (Stage)
→ Congenital, Juvenile, Senile (Based on Age of onset)
❗️
Which is why AGE should always be asked. It can be part of your complete diagnosis
2. Laterality (and location if it applies)
●
Examples: Retinoblastoma, Right Eye or Internal Hordeolum on Left Upper Eyelid
3. Secondary Diagnosis/ Comorbidities with Stage and Level of Control
○
❗️
Examples: Type 2 Diabetes, Hypertension Stage 2 poorly controlled, Obesity class 2,
Grave’s Disease, COVID-19
* Remember that your chance to establish these comorbidities would be in the:
★ ROS
○
ask about symptoms that point to HTN, DM, hyperthyroidism, COVID-19
★ PFS
○
Past Medical History: look for HTN, DM, hyperthyroidism, allergies, asthma
○ Family history will also give a clue about these comorbidities as well as the
current disease of the patient (ex. Mother had glaucoma)
○ Risk of those such as smoking and alcohol intake in the Social History
★ PE
○ Establish BMI if overweight, obese I, obese II
HOKAGE TIP: Despite being only ‘secondary diagnoses” note that they should also be treated in the
“Management” part of your discussion (ex. Control the hypertension by prescribing appropriate medication as well as
advice for increased physical activity). Your panel will appreciate it if you treat the patient holistically.
4. Procedures performed on the patient (also include laterality)
● Examples: s/p SMILE procedure both eyes, s/p choroidal biopsy left eye
____________________________________________________________________________
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
____________________________________________________________________________
Let us continue by dissecting the HISTORY since we now know what a complete
impression looks like.
Remember our sequence “IG CHOR | PFS”
*Write this on top of your blank sheet of paper when doing the intro. Cross out when done.
Let’s begin:
Part 1: IG CHOR
➢ Introduction and Informed Consent
● Set the mood of your panel by beginning with a good introduction.
● Show politeness and at the same time show that you are also competent
in getting a good history and PE.
● Ensure confidentiality and proceed with general data
➢ General Data Data (NASA CORN)
○ Name:
○ Age:
■
■
○
○
○
○
Sex:
Address:
Civil Status
Occupation:
■
○
○
Importance: Can be part of the diagnosis later on as previously discussed in
cataract. (ex. Congenital or Senile Cataract)
Remember that there are a lot of ophthalmologic conditions that present at birth.
Importance: May be a risk factor. During management we can also educate on preventive
measures for protecting the eye.
Religion: Can a affect management
Nationality:
■
Importance: can be a risk factor for HTN and DM (Filipinos are more prone so this can
lead to retinopathies, management and preventive measures are needed)
➢ Chief Complaint:
➢ HPI:
○
○
○
○
○
○
○
○
O: abruptness or progressiveness
L: laterality and location (This is part of a complete diagnosis)
D
C- direction of redness (ciliary or conjunctival), characterize discharge (watery or
purulent)
A- applications to eye (foreign body, contact lenses)
R
T
S- mild pain (conj), mod to severe (keratitis)
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
➢ Other 9 CCs/SSx & Ophtha ROS:
○ Apart from the 9 common CCs als ask for:
■ Photosensitivity
■ Itching
■ Lid lag
■ Strabismus or eye crossing
➢ ROS
ROS can eat up a lot of time if we are not focused. I tried filtering out the
unnecessary questions to ask, so this includes the only MUST ASK questions.
*Most of the ROS in ophthalmology are unremarkable so here our goal is to establish
the comorbidities.
You will notice that the questions are all about Hypertension, DM, Hyperthyroidism,
COVID-19, allergies, along with some rheumatologic questions. Let's do this from head
to toe, so that we will be systematic.
○
○
○
○
○
○
○
○
○
○
○
○
○
○
General: Fever (will indicate infection), Weight loss (hyperthyroidism)
Skin: Heat intolerance, sweating (hyperthyroidism)
Head: Headache (increased ICP)
Ears: Usually unremarkable, but ask at least 1 just of the sake of their checklist
(difficulty in hearing)
Nose: loss of smell (COVID), congestion and rhinorrhea (Allergies)
Throat: Neck Masses/ Difficulty Swallowing (Hyperthyroidism), Loss of Taste
(COVID)
Pulmo: Dyspnea (COVID)
Cardio: Palpitations (hyperthyroidism), Orthopnea (Hypertension)
Gastro: Hyperdefecation, increased appetite (Hyperthyroidism)
Genitourinary - dysuria (to establish urethritis which when with conjunctivitis, it
may indicate gonococcal arthritis)
Hema: usually unremarkable
Endo Nephro - Polydipsia, polyuria, polyphagia (DM)
Rheumatologic/ Extremities: Arthritis (some rheumatologic conditions also
affect the eyes such as SLE, JRA, RA)
Neuro/Psych: usually unremarkable
Time to cross out the first half of history: IG CHOR
Let’s proceed with the 2nd half: PFS
____________________________________
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Part 2: PFS
*Again this is the part where we need to establish risk factors as well as comorbidities
➢ PMH
○
Comorbidities/ Allergies and Medications Taken
■
■
■
○
Use of Prescription Glasses/ Contact lens
■
■
○
○
Assess level of control to a more complete diagnosis
Important to take note of use of steroids since it can cause eye diseases
Asthma and Allergies are clues for allergic conjunctivitis
Ask for grade and compare later with the PE so we can upgrade or downgrade
the lenses if there are inconsistencies
Ask about how they use (especially for contact lenses) since unclean practices
may be the reason why they developed the disease
Hospitalizations, Surgery, Trauma related to the eye
If <2 years old, ask for:
■ Maternal: Rubella -> cataract
■ Birth: If premature (you can think of retinopathy of prematurity)
■ Neonatal History
➢ Family Hx
○ Ask about comorbidities: DM, HTN, Thyroid Disease (Bosyo tagalog of goiter)
○ Ask about eye conditions since there are those which are inherited:
■ Glaucoma, Cataracts, Macular Degeneration, Strabismus, Amblyopia,
Retinal Detachment
○ Family with same sx - will give a clue if infectious/ allergic
➢ Social Hx
○ Smoking - may further aggravate Grave’s Disease
○ Alcohol
Cross it out PFS!
Congratulations you have now finished the History Taking. By now, we should already have a
clinical impression and differentials that we can confirm and rule out in the PE.
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
____________________________________________________________________________
Physical Examination in Ophthalmology
Ophthalmology is a field that heavily relies on PE especially if the problem involved blurring of
vision. But a good history can almost almost be enough to make a good clinical impression.
Remember that PE should be from head to toe, but since we are only allotted 20 minutes for
both Hx and PE. We may need to do it in a focused manner. This is my flow for doing PE
(basically after GVA it’s from head to toe, same pattern with ROS):
Let’s divided it into 3 parts:
GVA Skin | Eyes HENT Pulmo Cardio Gastro Genitourinary | Hema Endocrine Rheuma/Extremities Neuro
*Basically the ones in red are the important ones.
❖ General Survey
❖ Vital signs
➢ Look for signs of hypertension, hyperthyroidism through the BP and PR
➢ Look for signs of infection using the Temperature
❖ Anthropometrics
➢ Measure BMI, it can be part of the complete diagnosis
❖ Skin
➢ Excessive sweating (for hyperthyroidism), pallor
➢ Signs of Allergy
➢ Acanthosis nigricans - DM
______________________
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
____________________________________________________________________________
❖ Complete Eye Examination
*Review the steps since the panel might ask you how it is done. Don’t memorize, I will have tables at the
end for easier memorization. Pasadahan muna natin para chill lang.
➢ Visual Acuity
■ Central - (Central BOV- Diabetic retinopathy)
● Distance: Snellen
● Near: Jaeger
■ Peripheral (via Confrontation Testing): Glaucoma (Peripheral BOV)
■ Pinhole: Astigmatism
■ Amsler Grid: (+) Metamorphopsia → Macular Degeneration
➢ External Eye Exam
* be systematic: From outer structures to inner structures. Done with slit lamp
○
○
○
○
○
○
○
○
○
Lids - look for hordeolum or chalazion
Lashes- matting or crusts (bacterial conjunctivitis), abnormal hair growth
or loss (misdirected or extra rows)
Conjunctiva- follicles - white (viral conjunctivitis), papillae - red (bacterial
or allergic conjunctivitis) masses, chemosis (conjunctivitis)
Sclera- pattern of redness
Cornea - opacities, abnormal growth
Anterior chamber - flares, blood (hyphema), pus (hypopyon)
Iris - pigmented, lesions, rubeosis
Pupils- dilated, shape (regular or irregular), reactivity to light, RAPD
(optic neuritis)
Lenses - opacities (cataract)
*In general, ask “Are there any lesions, masses, or opacification?”
➢ Extraocular Muscles and Hirschberg Test
○ Look for strabismus (common in pediatric patients)
➢ Fundoscopy
* remember: Right Eye of Patient, Right Hand, Right Eye of Examiner
○
○
○
○
○
○
○
ROR: Leukocoria
Media:
Margins: distinct or blurry
Color: Pale or pink
CD ratio: 0.3 (for evaluation of glaucoma)
Vessels: AV ratio (2:3)
Macula: exudates, drusen spots (hallmark of ARMD)
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Complete Fundoscopic Findings:
“There is (+) ROR, clear media, the optic disc is pink with distinct disk margins.
The cup to disc ratio is 0.3 with an AV ratio of 2:3. There are no signs of
hemorrhage or exudates.”
➢ Tonometry
○ Normal IOP: 10-21 mmHg; Consider glaucoma if elevated
○ Goldmann Applanation Tonometer is the gold standard
➢ Gonioscopy
○ To asses the anterior chamber
➢ Fluorescein Dye
○ Done to check for corneal abnormalities such as abrasion and the pattern
of keratitis
➢ Lymphadenopathies
○ Preauricular and submandibular lymphadenopathy suggest viral
conjunctivitis
❖ HENT
➢
➢
➢
➢
Head: headache for signs in increased ICP
Ears: usually unremarkable
Nose: Congestions or secretions that suggest allergy or COVID
Throat: Palpate thyroid gland
*Do the IPPA approach for the rest:
❖
❖
❖
❖
❖
❖
❖
❖
❖
Pulmo
Cardio: look for HTN (apex beat)
GI
GU
Hema
Endocrine:
Rheuma: Joint pains, range of motion
Extremities: Check for the hair on the toe, if none, may indicate DM
Neuro: Sensory testing to check for DM neuropathy
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
____________________________________________________________________________
Discussion Flow
●
●
●
Salient features
Differentials and Clinical Impression
Management (ADMIT)
○ ADM
■ Begin by identifying if the patient needs to be Admitted
■ If yes, then you should specify the Diet as well as the Monitoring
○ Investigatory
■ Laboratories
■ Imaging
○ Therapeutics
■ Non-pharmacologic
■ Pharmacologic
■ Preventive and Education - look at the comorbidities as well as the
occupation to treat the patient holistically
Tips on Phrasing:
Try to phrase your discussion in a way that you are sure of what you are talking about.
● Don’t use “Maybe we can give the patient …” instead “Our options for management
would include _______. The most effective would be _____”
● Don’t answer in question form “Doc, is this a form of cotton wool spots?” instead you can
say “To me this appears as cotton wool spots”.
If you don’t know the answer better to be honest but you can still show them that you know
something and that you are willing to learn.
● Don’t outright say “I don’t know” better to say “I am not familiar doc. However, what I
do know is that [state what you know about the topic and the importance of knowing the
answer to the question ]. I will make sure to read on it and improve my knowledge on the
matter”
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
____________________________________________________________________________
Crash Course on the 10 Cases
Let’s approach this by Chief Complaint. I will further discuss the specifics if I can:
*The ones in yellow highlight belong to the 10 revalida cases. Take not of the possible differentials so you can have a
good discussion
Table 1. Differentials for Red Eye
Differentials for Red Eye
Acute conjunctivitis
- mild pain
- watery/ purulent
discharge (depends
on cause)
- (-) BOV
- (+) conjunctival
injection
Acute Keratitis
-mod to severe pain
- watery/ purulent
discharge
- May have BOV
- (+) ciliary injection
*see table below for
etiology
Corneal Abrasion
- foreign body
sensation
- tearing
- may have BOV
- Stains with
fluorescein
*see table below for
etiology
Acute Uveitis
Acute Angle Closure
Glaucoma
- mod pain
- often with BOV
- small or irregular
pupils
- poor pupillary
reflex
- (+) ciliary
injection
- severe pain
- markedly blurred
vision
- Mid- dilated pupils/
no pupillary reflex
-(+) ciliary injection
- Marked elevated IOP
Table 2. Conjunctivitis and its types
Conjunctivitis
What to look for :
Sx: Redness, Pruritus, Pain
Signs: Conjunctival Injection, Chemosis, Discharge (character)
Bacterial Conjunctivitis
Viral Conjunctivitis
Allergic Conjunctivitis
- Purulent discharge
- check conj. for papillae (red dots)
- matting/crusting of eyelashes
- chemosis
- Watery discharge
- Check conj. for follicles (white
center)
- Watery discharge
- check conj. for papillae (red dots)
- itching, allergic rhinitis, asthma
- chemosis
Tx: Fluoroquinolones/
Aminoglycoside | Advise
handwashing and not to scratch
eyes since the other might get
infected
Tx: is supportive but antibiotics can
be given to prevent secondary
infection
Tx: Antihistamine
Rx:
Tobramycin Ophthalmic Drop
Dispense #1 bottle
Instill 1 drop to affected eye 4-6
times a day to consume
Rx: (Same as bact. conj.)
Tobramycin Ophthalmic Drop
Dispense #1 bottle
Instill 1 drop to affected eye 4-6
times a day to consume
Rx:
Cetirizine 10 mg tablet
Dispense 10 tablets
Take 1 tablet orally daily at
bedtime
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Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Table 3. Keratitis and its types
Keratitis
What to look for :
Sx: Redness, Painful/Painless, Foreign body sensation, BOV/Photophobia
Signs: Ciliary Injection, corneal opacification, corneal hypoesthesia ( HSV), Hypopyon, Ulceration
Risk: CONTACT LENSES OVERWEAR
Type is differentiated by the presence of pain and the appearance of the lesion
Bacterial Keratitis
- Painful
- Lesion: well-delineated border
- Hypopyon
Tx: Fluoroquinolones/ Topical
Fortified antibiotics
Rx:
Moxifloxacin ophthalmic drops
Dispense #1 bottle
Instill 1 drop for the first few
days, then decrease
progressively
*Prescription for Topical Fortified
Antibiotics is longer so memorize
Moxifloxacin nalang. But I’ll put it
here for completion
Rx:
Tobramycin ophthalmic drop 1
drop every hour, alternating with
Cefazolin or Vancomycin
ophthalmic drop Q1, to consume
HSV Keratitis
Fungal Keratitis
- Painless/ Corneal Hypoesthesia
- Lesion: Dendritic corneal ulcer
on fluorescein
- Painful
- Lesion: feathery/fuzzy, satellite
lesion, or endothelial plaque
Tx: topical/ oral antivirals
Topical Steroid - stromal/ endothelial
Surgical- Refer to ophtha:
● Anterior Lamellar
keratoplasty
● Lamellar Patch grafts
Tx: Discontinue STEROID USE
Topical antifungals if mild
Systemic therapy if severe
Keratoplasty/ Corneal Transplant if
unresponsive
For mild
Rx for Topical:
Acyclovir 3% ointment
Dispense #1 tube
Apply 5 times daily to consume
or
Gancyclovir eye gel
Dispense #1 tube
Apply every 4 hours for 4 days
then TID to consume
If Oral:
Acyclovir
● 400 mg 5x a day for 21
days in
immunocompetent
● 800 mg 5x a day for 21
days in
immunocompromised /
atopic
● 400 mg 2x a day for
prophylaxis for 1 year in
recurrent
Rx:
Natamycin ophthalmic susp.
Dispense #1 bottle
Instill 1 drop to affected eye every
hour
Voriconazole ophthalmic drops
Dispense #1 bottle
Instill 1 drop to affected eye every
hour
For severe:
Voriconazole 400 mg orally every
12 hours x 2 doses, 200 mg orally
twice daily
18
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Table 4. Differentials for Eyelid Masses
Differentials for Eyelid Masses
Hordeolum
- Painful, red, warm to touch
- Frequent eye manipulation
- Common in chronic
blepharitis
- ± pustule formation, ±
conjunctival hyperemia
Chalazion
- Painless, less
erythematous
- Similar in
appearance with
internal hordeolum
- May transform from
hordeolum
Blepharitis
- Irritation, burning,
itching of eyes and lid
margins
- Red-rimmed eyes
- Scaly flaky debris on
lid margins
Sebaceous Cell
Carcinoma
- from recurrent
chalazion
- Painless nodule,
diffuse lid thickening,
loss of lashes
- Confirmed on histopath
Table 5. Hordeolum in detail
HORDEOLUM: infection of the glands
What to look for :
Sx: Pain (will differentiate it from the painless chalazion)
Signs: pustule formation
Complications: Cellulitis (Preseptal or Orbital)
Types:
●
●
Internal: Meibomian
External: Zeis/ Moll (parang nasa tip ng eyelids, tapos “pointing” siya)
●
●
●
●
●
Warm compress 10-15 min four times daily
Discontinue Eye makeup
Topical antibiotic ± corticosteroids treatment (Better to use ointment)
For those with frequent hordeolum (rosacea-associated blepharitis)
Oral antibiotics
○ Cloxacillin 500 mg Q6 for 7 days
○ Co-amoxiclav 625 mg TID for 7 days
○ Clindamycin 300 mg BID for 7 days
○ Incision and drainage (I&D) – if no improvement
Tx
19
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Table 6. Blurring of Vision
Blurring of Vision
*diagnosis is usually from PE
Error of Refraction
Myopia:
“Near Long Cave”
(near sighted,
longer eyes, treat
with concave lens
Hyperopia- reverse
the mnemonic
(Far sighted, short,
convex)
Astigmatism:
cylindrical lenses
Tx: Corrective
Lenses, LASIK,
SMILE
Cataract
ARMD
Blurring of vision
Glaring
Dull Perception of
colors
Myopic Shift
Opaque lens
Poor visual acuity
(CF to HM)
> 55 y/o
Wet type - Sudden
Distortion
Dry- Gradual
Blurring
Mature cataract best
time to operate
Tx:
Phacoemulsification
IOL insertion
PE:
(+)
Metamorphopsia
Drusen Spot on
fundoscopy
-hallmark
DDx: Presbyopia
Tx:
Smoking cessation
Nutritional advice
Subretinal
neovascularization
AREDS formula:
Vit C and E, Copper,
Zinc, Carotene
Diabetic
Retinopathy
Glaucoma
Diabetes, HTN,
smoking
Optic neuropathy
Peripheral BOV
Asymptomatic
Blurring of Central
Vision
PE:
High CD ratio
High IOP
PE:
Decreased pupillary
responses
Opacification
OPEN
- painless
- gradual BOV
- B-blocker,
Acetazolamide
Microaneurysms,H
ard Exudates
non-prolif
Cotton Wool Spots
pre-prolif
Neovascularization
prolif.
Tx: Control DM,
Anti-VEGF,
Vitrectomy, Laser
treatment
CLOSED (emerg)
- painful
- sudden BOV
- Redness
Tx: B-blocker,
Acetazolamide,
Laser Iridotomy
Ddx: Ocular HTN
See table 8 for amblyopia(pg 20) since it would also present as blurring of vision
Table 7. Leukocoria
Leukocoria
Congenital Cataract
Retinopathy of Prematurity
Retinoblastoma
Note age
History of Rubella
Family history of congenital cataract
Criteria for ROP screening
Premature < 30 weeks
AOG <1500 g birth weight
> 30 weeks AOG or
1500-2000 g but with
unstable clinical course
Exposure to high oxygen
concentrations (intubated)
High risk as determined by
Pediatrician
Before 3 years old
Leukocoria
Strabismus / Proptosis
Funduscopy: retinal nodule that can
appear translucent or dull white
Tx:
Surgical Tx
20
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Table 8. Amblyopia
AMBLYOPIA: a.k.a. “Lazy Eye” (think of it as the “lazy eye” refusing to fulfill its function since the other eye can do
better, so eventually the lazy eye can become a blind eye if left untreated)
What to look for :
Gen data: Check for age (since we classify strabismus occurring at infancy or <6 months as to being congenital)
Sx: Blurring of vision, (in pedia, “cross-fixation” meaning the patient uses one eye at a time to view the opposite
field)
Signs: strabismus (do Hirschberg Test, Cover-Uncover Test, Accommodation), or anisometropia via
Snellen (the left and right eye have different refractive error)
Let’s discuss a bit of strabismus since it is on of the most common causes of amblyopia
Congenital Esotropia
Note age: infancy, common in those
<6 months of age
Hallmark: Cross-fixation
Tx Goals:
1. Treat the Esotropia via:
Accommodative Esotropia
Crossing occurs at near vision
Usual age of onset: 2-3 y/o
Types:
1.
Spectacles (Fresnel Prisms) or
Strabismus surgery before 12
months
2.
2.
Treat the Amblyopia via:
Occlusion therapy/ Patching
(covering of the good eye)
Partial Occlusion til 5-6 y/o
Full-time Occlusion - for
weeks only (depending on
age of child)
Refractive Accommodative
Esotropia
- corrected by glasses
- characterized by
excessive hyperopia
Non-refractive
Accommodative Esotropia
-NOT corrected by glasses
Tx:
Intermittent Exotropia
Exotropia occurs at far vision, and
usually fuses at near vision
Amblyopia is uncommon
Sensitive to light
Treatment:
Conservative: Refraction (Fresnel
Prism) and amblyopia therapy
(despite being uncommon)
Definitive: Strabismus Surgery
Full cycloplegic refraction under 6
years old
-ENDCongratulations on finishing the final chapter of the Sharingan notes. I hope you learned a lot and that this will be of
great help not only during your oral revalida but also in your future practice. Best of luck! Unleash the Sharingan!
This reviewer wouldn’t be made possible if it weren’t for the following references:
Vaughan and Ausbury’s General Ophthalmology
UST FMS Batch Lectures and Transes 2020 and 2021
Oral Revalida Review by Arianne Balayut
21
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Sharingan Notes | The Lost Chapter
The 12 Additional Ophtha Cases for Batch 2021
1.
2.
3.
4.
5.
6.
Uveitis
Blepharitis
Preseptal Cellulitis
Dry Eye Syndrome
Cataract
Thyroid Eye Disease
7. Retinal Detachment
8. Hypertensive Retinopathy
9. Papilledema/ Papillitis
10. CRAO/CRVO
11. Ethambutol Toxicity
12. Foregin Bodies
NOTE: Due to time constraints I focused mainly on how to easily identify them during Hx and PE. We can use
Amboss/Uptodate to formulate the diagnostics and treatment.
I’ll just bring up our “Chief Complaint table” again. Highlighted in blue are the new OR cases.
Don’t be overwhelmed. Same plan: Use each one of them as differentials.
Chief Complaint/ S&Sx
Red Eye
*During HPI ask about the pattern (Ciliary or
conjunctival) to differentiate conjunctivitis from keratitis
Do a good PE of the eye for Uveitis (you will appreciate
unequal sized pupils, hypopyon)
Ask about history of trauma and sneezing (high
pressures) for Subconjunctival hemorrhage
Eyelid Mass
*During HPI and PE look for signs of inflammation
(Rubor, calor, dolor, tumor). This will differentiate a
hordeolum from chalazion.
Blurring of Vision (BOV) or Loss of Vision
*Establish risk factors during history (Age, Diabetes,
Steroid Use, Use of prescription glasses, TB drug
intake).
* The cause of BOV is usually established during PE
For the new cases, rely on fundoscopy and ishihara
test
Possible Diagnosis and Differentials
Uveitis - “ciliary injection”; Unequal pupils
Subconjunctival Hemorrhage - “small spot of
blood”
Keratoconjunctivitis Sicca “ciliary injection”,
with dry eye symptoms
Conjunctivitis - “conjunctival injection”
Keratitis - “ciliary injection”
Angle Closure Glaucoma
Blepharitis
Preseptal Cellulitis
Hordeolum - with signs of inflammation | pain
Chalazion - no signs of inflammation | painless
Hypertensive Retinopathy - fundoscopy
CRAO/CRVO - fundoscopy; sudden PAINLESS loss
of vision
Retinal Detachment - fundoscopy
Ethambutol Toxicity - ishihara test (pages with
red-green)
Error of Refraction - Snellen’s Chart, Pinhole
Cataract - Red Orange Reflex
Age-related Macular Degeneration -Amsler
grid (+) Metamorphopsia
Diabetic Retinopathy- fundoscopy
Glaucoma - fundoscopy and tonometry
Astigmatism - pinhole testing
22
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Strabismus (in the form of Amblyopia) - test
for extraocular muscles
Proptosis/Ptosis
Hx: Family history of thyroid disease or cancer
Thyroid Eye Disease - (+) for hyperthy sx
Orbital Tumor - with family history of eye
malignancy
Hemorrhage
Crossing of Eyes (Strabismus) → Amblyopia
Esotropia
Exotropia
White Eye (Leukocoria)
Cataract Congenital Cataract
Retinopathy of Prematurity
Retinoblastoma
PE is the same for all of the (-) Red Orange Reflex
Differentiate them by asking about risk factors: Age,
steroid use
Pain
Uveitis
Foreign Body
Bacterial Keratitis- redness (ciliary)
Angle Closure Glaucoma - BOV
*Ask the patient for other sx ( the 9 CC’s)
Tearing or Discharge
*Take note of character (is it watery or is it
mucopurulent?) to distinguish the type of
conjunctivitis
Conjunctivitis
● Bacterial - Mucopurulent
● Viral and Allergic - Watery
Papillitis vs Papilledema
Grave’s Ophthalmopathy
Approach: Look for signs and symptoms of hyperthyroidism, exophthalmos, and lid retraction
History:
● Hyperthyroid symptoms (palpitations, weight loss,
etc.)
● Smoking as risk factor
● Rule out orbital CA using family history
PE:
●
●
●
Exophthalmos
Lid Retraction
Conjunctival Injection
●
TSH and Free T4
Dx:
Treatment:
● Eye protection
● Address hyperthyroidism (thionamides)
● Smoking cessation
● IV steroids if severe soft tissue inflammation
● Surgery
23
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
NOTE: Try to refer to the old notes for differentials that will suit your case well.
Continuation of Differentials for Red Eye
Acute Uveitis
Subconjunctival
Hemorrhage
Keratoconjunctivitis Sicca
CC: redness or eye pain
Approach: Rely on your PE to
differentiate it from keratitis.
CC: redness
Approach: Gather risk factors during
History, confirm with PE
History:
- moderate eye pain (anterior
uveitis)
- no pain (posterior uveitis)
- often with BOV
- PHOTOSENSITIVITY
REMEMBER: THIS IS BENIGN
CC: redness or pain or dryness
Approach: Get exposures and try to
rule in Sjogren’s if with dry mouth. Do
Schirmer test to evaluate eye
dryness
History:
- Painless
- Etiology (ask about):
● Hypertension/DM
● Trauma
● Coagulopathies
History:
- pain
- PMHx: Sjogerns
- Diet: Vit A deficiency
- History of prolonged
watching of TV
PE:
- red focal region
Diagnostics:
- Clinical/Slit lamp
PE:
- same with conjunctivitis
- Schirmer test <15 mm
- check for dry mouth to
consider Sjogren Syndrome
Treatment:
- Reassurance (will resolve in
2-3 weeks)
Diagnostics:
- Clinical
Schirmer test
PE:
- (+) ciliary injection
- (+) Hypopyon
- small or irregular pupils
- poor pupillary reflex
Diagnostics:
- Slit Lamp is sufficient
Treatment:
- Glucocorticoids (but make
sure patient doesn’t have
glaucoma/cataract)
Treatment:
- Artificial Tears
Continuation of Differentials for Eyelid Masses
Blepharitis
Examine the eyelids well:
Redness, scaly, crusts, irritable,
itchy
History:
Preseptal Cellulitis
Check for eye movement to
differentiate from orbital cellulitis
History:
- Hx of URTI or rhinosinusitis
- Irritation, burning, itching of
eyes and lid margins
- Red-rimmed eyes
- Scaly flaky debris on lid margins
Diagnosis: Clinical
Treatment:
Orbital Cellulitis
Look for the cardinal signs of orbital
cellulitis: proptosis, diplopia,
ophthalmoplegia (paralyzed eye
muscles)
History:
- Hx of URTI or rhinosinusitis
PE:
- no involvement of extraocular
muscles (good eye movement)
- eyelid swelling and erythema
- fever and chemosis are less
common
PE:
- with involvement of extraocular
muscles (LIMITED EYE
MOVEMENT)
- Cardinal Signs of Orbital Cellulitis:
24
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
- Eyelid margin hygiene
proptosis, diplopia and
ophthalmoplegia
Diagnosts: Clinical/ CT to confirm
Treatment: (refer to Amboss/UptoDate)
- Oral antibiotics and close follow-up
(Amoxi-clav or Clinda)
- eyelid swelling and erythema
-fever and chemosis are more
common
Diagnosis: Clinical/ CT to confirm
Treatment: (refer to Amboss/UptoDate)
- Empiric IV antibiotic
Hypertensive Retinopathy:
Approach in History:
● CC: may be BOV or patient may just
come in due to high blood pressure
● ROS normal; Ask about DM to rule this
out during your discussion for
differentials
● Your PE will confirm your diagnosis.
DO NOT FORGET TO DO
FUNDOSCOPY!
Fundoscopic Findings:
● Cotton-wool spots
● Retinal hemorrhages
● Microaneurysms
● AV nicking
● Papilledema and Optic Atrophy
● Decreased AV ratio (since the arteries are constricted normal AV is 2:3)
Other important to note in PE: (so we can differentiate it from papillitis)
● Normal pupillary light reflex
● Bilateral affectation
Differentials
Here your differentials are based on the Fundoscopic Findings
●
●
DM Retinopathy:
○ Ruled in due to the hemorrhages (can also have the cotton wool spots)
○ Rule this out in the history (3P’s, acanthosis, Past Medical and Family History
of DM)
Optic Neuritis
○ Ruled in since papilledema in HTN retinopathy looks like PAPILLITIS of optic
neuritis
○ Ruled out by differentiating Papilledema vs Papillitis
Papilledema
Bilateral
Intact Pupillary light reflex
Papillitis
Unilateral
Depressed (since there is inflamed optic n.)
25
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Diagnostics and Treatment: (Refer to AMBOSS/UpToDate)
● Manage Hypertension
● Screening
CRAO vs CRVO
Basically they will both present with painless sudden loss of vision. The only way to differentiate
them is via fundoscopy.
History:
● CRAO: usually >60 y/o
● CRVO: usually >80 y/o (but this is still more common)
● Gather risk factors to support your Dx:
○ CRAO is due to an embolus
○ CRVO HTN, DM, smoking
PE:
●
RAPD
○ (+) for CRAO and Ischemic type of CRVO
○ (-) for BRAO and Non-ischemic CRVO
● Fundoscopic Findings:
CRAO: look for the pathognomonic “Cherry Red Sport”
CRVO: diffuse hemorrhage on all 4 quadrants “pizza” or “blood and thunder” appearance
DIfferentials
You can use Hypertensive/DM retinopathy as your third differential since they may be painless and at
the same time they present with hemorrhages as well.
Treatment:
CRAO: Eyeball massage, carbogen therapy, decrease IOP (surgical therapy)
CRVO: Anti-VEGF, Steroids, Panretinal photocoag if ischemic CRVO (perform RAPD to confirm)
26
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
Cataract
Diagnosis is Clinical: Rely on your PE
History:
● Glares/ Halos around lights
PE:
●
●
●
Reduced visual acuity (measure to see if
surgery is indicated)
Painless
Bilateral
Diagnosis:
● Clinical
Treatment
● Extracapsular Cataract Extraction/
Phacoemulsification
● Indication of Surgical Tx: (+) visual disturbances
Foreign Body
Approach: ask about the mechanism of injury, PE
will reveal the foreign body.
History:
● Mechanism of injury
● Type of foreign body
(glass/metal/chemical)
PE:
●
●
Do not remove the foreign body ->
expulsion of contents; protect the eye with
a cup
Look for signs of open globe injury:
○ Hyphema
○ Visual acuity: hand movement or light perception
○ Hypotony (<6mmHg IOP)
○ Distorted appearance
○ Tear drop
○ Loss of ROR - vitreous hemorrhage
○ RAPD may be positive if optic nerve is affected
Treatment:
● Analgesics for pain
● NPO and antiemetics to prevent vomiting -> increases IOP
● Start antibiotics
● Tetanus Immunization
● Imaging depending on nature of foerign body (Do not use MRI if metallic)
● Refer to ophthalmology for surgery.
27
Sharingan Notes | Final Chapter | Rafael R. Fontanilla, RPh, MD
AGAIN MEMORIZE THIS:
❖ Complete Eye Examination
*Review the steps since the panel might ask you how it is done. Don’t memorize, I will have tables at the
end for easier memorization. Pasadahan muna natin para chill lang.
➢ Visual Acuity
■ Central - (Central BOV- Diabetic retinopathy)
● Distance: Snellen
● Near: Jaeger
■ Peripheral (via Confrontation Testing): Glaucoma (Peripheral BOV)
■ Pinhole: Astigmatism
■ Amsler Grid: (+) Metamorphopsia → Macular Degeneration
➢ External Eye Exam
* be systematic: From outer structures to inner structures. Done with slit lamp
○
○
○
○
○
○
○
○
○
Lids - look for hordeolum or chalazion, blepharitis
Lashes- matting or crusts (bacterial conjunctivitis,blepharitis), abnormal
hair growth or loss (misdirected or extra rows)
Conjunctiva- follicles - white (viral conjunctivitis), papillae - red (bacterial
or allergic conjunctivitis) masses, chemosis (conjunctivitis)
Sclera- pattern of redness
Cornea - opacities, abnormal growth
Anterior chamber - flares, blood (hyphema), pus (hypopyon)
Iris - pigmented, lesions, rubeosis
Pupils- dilated, shape (regular or irregular), reactivity to light, RAPD
(optic neuritis)
Lenses - opacities (cataract)
*In general, ask “Are there any lesions, masses, or opacification?”
➢ Extraocular Muscles and Hirschberg Test
○ Look for strabismus (common in pediatric patients)
➢ Fundoscopy
* remember: Right Eye of Patient, Right Hand, Right Eye of Examiner
○ ROR: Leukocoria
○ Media:
○ Margins: distinct or blurry
○ Color: Pale or pink
○ CD ratio: 0.3 (for evaluation of glaucoma)
○ Vessels: AV ratio (2:3)
○ Macula: exudates, drusen spots (hallmark of ARMD)
Look for hemorrhages and cherry red spots for CRAO and CRVO
28