Welcome to Opthamology

Objectives

The objective of this course is to give you an overview of ophthalmology, and to equip you with some essential skills which will be useful in most fields of medicine. You will spend a two week period in The Royal Victoria Eye and Ear Hospital in groups of up to ten. Each student will be assigned a group, and should follow the timetable for their group.

Each student will be given a card containing a list of procedures, clinical conditions and skills which must be observed during the rotation. The card should be signed by each supervising consultant, lecturer or specialist registrar, and given to the examiner during the individual clinical examination at the end of the rotation.

Essential Skills

You must be able to do the following by the end of your two weeks of clinical attachment; you will be examined on at least one of these skils in your final ophthalmic exam:

1. Assess visual acuity of a child and an adult
2. Examine Eye Movements, and in particular be able to differentiate between a paralytic and non-paralytic squint
3. Examine the red reflex
4. Examine the visual fields
5. Examine pupils
6. Perform fundoscopy, in particular you should be able to examine an optic disc, and differentiate between a glaucomatous disc, optic atrophy and papilloedema, recognise diabetic and hypertensive retinopathy.

Essential Knowledge

Handbook Ophthalmology – Fifth Year Medical Students (pdf 116kb)

"Ophthalmology at a Glance" - Olver and Cassidy - Blackwell Publishing, 1st edition, 2005.

"ABC of Eyes" - P.T. Khaw and A.R. Elkington - Third Edition - BMJ Books.

"Clinical Ophthalmology" by Kanski (4th Edition)

"Ophthalmology - an illustrated colour text" - M. Batterbury and B. Bowling.

There is a small specialist library of Ophthalmology books in the Department, and these can be borrowed during your rotation by arrangement with the Department Secretary.

Please note that in Week 2, all groups move one place to the right, i.e. A becomes B etc., and Group E becomes A. Alterations to the timetable will be given to students at their first tutorial

* Students attending theatre must come to the morning theatre list at 8.30 a.m., and attend the post-operative ward round.

On the Friday of Week 2, the OSCE examination will take place. A list of times will be provided on the door of the tutorial room beside Professor Cassidy's office, please select a time for your examination by putting your name on this list. The OSCE takes place in the tutorial room.

Please consult the handout provided on the first morning of your rotation for the Orthoptics schedule. Each student will be given an individual time to attend Orthoptics either in the Eye and Ear, or AMNCH.

Overall timetable has been amended for 2008, full details will be provided at initial tutorial.

Good eye-hand co-ordination helps if you want to do micro-surgery, but there are ample opportunities for people with good medical skills to do medical ophthalmology (includes aspects of neuro-ophthalmolgoy, medical retina, glaucoma), or enjoy research interests. There are examination hurdles which are hard, and their details are available from the Ophthalmology Department.   Ms Michele Keane if you would like more information.

How to order an Ophthalmoscope

Ophthalmoscopes are available from MDI Limited, contact Pat Whelan: patwhelan@mdimedical.ie.

Introduction

This leaflet explains to you what a cataract is, what to expect before, during and after your surgery, and lists the potential complications of surgery. Most people do very well after surgery and complications are rare. However, they can occur, and it is important to be aware of what they are before you decide to proceed with your operation.

What is a cataract?

Think of your eye as being like a camera with a lens, which is crystal clear and focuses light on the back of the eye. The picture created is then transmitted to the brain along a nerve called the optic nerve, and this is how you see.

If the lens becomes cloudy in anyway, your vision becomes blurred or you may experience glare or very blurred vision in certain lighting conditions, such as a sunny day or when driving against oncoming headlights at night. Some people with cataracts feel as if they are looking through dirty glasses, they therefore keep cleaning their glasses, which of course makes no difference at all.

How is the cataract removed?

The cataract is removed through a very tiny incision (2.75mm) using a microscope, and a new lens known as an intraocular lens implant or IOL, is then inserted in its place. This operation is carried out under sterile conditions in the operating theatre. The cataract has its own covering which is called a capsule. The cataract is removed from the capsule which is left behind, as this is needed to hold the artificial lens implant in place. If you would like to watch the operation, you can do so by logging on to the Eye & Ear Hospital website which contains a video of cataract surgery being performed. The web address is www.rveeh.ie

What happens before my operation?

You will have a special scan called an A-scan to measure the best strength IOL for your eye. This is usually done on a Thursday morning in my rooms in Rathgar.

You will have received a date for your surgery once you have decided to go ahead with the operation. I will do your surgery in Mount Carmel Hospital or in the Royal Victoria Eye & Ear Hospital.

The surgery is performed as a day case procedure in most cases.

What happens when I go into hospital to have my cataract surgery?

After you have been admitted to your bed, the nurses will start to put drops in your eyes to dilate your pupils and prepare your eye for surgery. These drops may sting your eye for a few seconds after going in. This is normal and nothing to be alarmed about.

You will be one of 7 or 8 people on the list to have your surgery done, so there may be a waiting period before you are brought to theatre.

Once you arrive in the operating theatre the nursing staff will help you onto the operating table. Once you are lying in a comfortable position, some monitors will be placed on your chest and finger. These are routinely used on every patient to monitor their heart and oxygen levels during your surgery. You will also have a blood pressure cuff on your arm to monitor your blood pressure. This feels very tight during a blood pressure check, but is nothing to be concerned about.

The anaesthetist will then put a small needle in your hand or arm so that he/she can give you some medication to make you feel relaxed and to prevent you from feeling any pain during the procedure. He/she will then put some anaesthetic drops in your eye to make it become numb.

Your operation will then begin. You will notice a very bright light, and will feel me gently leaning on your forehead. You may feel some water trickling down the side of your face during the procedure. This is normal. The machine used to remove the cataract is a little noisy, but only for a minute or two. Once your operation is over, we will put a plastic shield over your eye to protect it. You are then brought to the recovery area for a short while before being transferred back to your bed.

Once you return to the ward, you will be given something to eat and drink. You will also be given two tablets to take. These are to prevent the pressure in your eye from increasing. You will be given two more of these to take 4 hours later. Once you are ready, you can go home. You will be given a prescription for eye drops which you will be using for the next 3-4 weeks. You should leave the eye shield on until the following morning. It can then be removed and kept to cover your eye at night time for the first 2-3 nights.

How should my eye feel after surgery and what can I expect to see?

Your eye will feel gritty as if there is something in it. This feeling will last for up to several weeks and at worst several months. This is normal and will eventually settle. Some people will not have this sensation. Your eye may also be watery and red. This is also normal and will eventually settle down.

Immediately after your operation your vision will be blurred, but this will begin to improve over the next few days. You will not be able to read or see close up, as you will need new glasses. These will be prescribed by your optician approximately six weeks after the operation.

All surgery has potential complications. Most people have no complications during surgery, but it is important for you to understand the possible risks involved.

Infection: 

What is blepharoplasty surgery?

Blepharoplasty surgery is a procedure by which the excessive skin on the upper or lower eyelid is removed.  This procedure can divided into a number of different types:

• Upper lid skin blepharoplasty
• Lower lid skin blepharoplasty
• Upper lid skin and fat blepharoplasty: both skin and fat are removed
• Lower lid skin and fat blepharoplasty: both skin and fat are removed
• Trans-conctuntival blepharoplasty: the lower lid excessive fat is removed in the inner part of the lid and means that there is no outward scarring on the face 

Upper lid skin blepharoplasty

This procedure involves removing excessive skin from the upper eye lid. This is conducted under local anaesthetic with sedation and pain relief being given to you intravenously by the anaesthetist. It can also be performed under general anaesthesia.  However, most people opt to have the surgery done under local anaesthesia with sedation. The procedure takes approximately 20 minutes per eye after which a double pad is placed on each eye and you are then sent back to the ward. One to two hours later, depending on the amount of bleeding during surgery, your pad is removed.  You will then be given an ice pack and you may return home at that stage.

Upper lid skin and fat blepharoplasty

This procedure is basically very similar to skin blepharoplasty except that excess fat is also removed from the upper lid.  The only extra complication here that may occur is loss of vision due to excessive pulling on the fat during the surgery, however, we take extra care during the surgery, not to put any undue pressure on the fat, however, there have been rare cases recorded, where there has been visual loss after fat blepharoplasty.  This is more common in smokers.

Lower lid skin blepharoplasty

This procedure is for the lower lid bags and involves an incision the length of your lower eye lid in the small skin crease underneath your eyelashes. This incision is extended up into one of the laugh lines at the side of your eye. Excessive skin is removed. You will have stitches which are absorbable but will be removed after two to three weeks. The procedure and the experience in the theatre are essentially the same as that for the upper lid skin blepharoplasty.  The complications are also similar except that it is extremely rare to have corneal exposure secondary to removing too much skin.

Lower lid skin and fat blepharoplasty

Again this procedure is very similar to having your lower lid skin blepharoplasty, except that excessive fat is also removed.  This procedure will have the same type of complications as upper lid skin and fat blepharoplasty.

What happens when I go into hospital to have my surgery?

After you have been admitted to your bed, the nurses will help you to get ready for your surgery. You will be one of several on the list to have your surgery done, so there may be a waiting period before you are brought to theatre.

Once you arrive in the operating theatre, the nursing staff will help you onto the operating table. Once you are lying in a comfortable position, some monitors will be placed on your chest and finger. These are routinely used on every patient to monitor their heart and oxygen levels during your surgery. You will also have a blood pressure cuff on your arm to monitor your blood pressure. This feels very tight during a blood pressure check, but is nothing to be concerned about.

The anaesthetist will then put a small needle in your hand or arm so that he/she can give you some medication to make you feel relaxed and to prevent you from feeling any pain during the procedure. He/she will then put some anaesthetic drops in your eye to make it become numb.

Your operation will then begin. You will notice a very bright light, and will feel me gently leaning on your forehead. You may feel some water trickling down the side of your face during the procedure. This is normal. Once your operation is over, we will put pads and a dressing over your eye to reduce swelling. You are then brought to the recovery area for a short while before being transferred back to your bed.

Once you return to the ward, you will be given something to eat and drink. The eye pads will be removed after one or two hours and an ice pack will be applied. Once you are ready, you can go home. You will be given a prescription for eye drops which you will be using for the next 3-4 weeks.

What should I expect post-operatively?

You’ve had surgery on your eyelids, this has involved the removal of skin and also a small amount of the muscle in your upper eyelid. This means that your “blink” will not be normal for up to three months after surgery. Hence, you may experience symptoms of dry eye for this period of time. You will be prescribed artificial teardrops to use as often as you like during the day and a gel lubricant to use at night time. This is because your eyes may not always close fully in the initial period after the operation. These symptoms will gradually resolve and you will no longer need to use the drops after a maximum of three to four months. There will be significant bruising post-operatively and possible swelling of the eyelids. This will again settle down, though everyone is different, so some people will have no swelling after a week and others will still have swelling after four or five weeks. However, swelling and bruising eventually settles and disappears. The stitches used are absorbable, however I usually remove these between two to three weeks after the operation as they can feel itchy.  You will have a very fine scar in the lid crease or skin crease, but when your eye is open, this will not be visible. It is a very fine scar and eventually it will not be noticeable at all.

What are the possible complications of skin blepharoplasty?

1. Over removal of skin which results in inability to close the eye. This can lead to extreme dryness ulceration and the need for a skin graft in severe cases.
2. Under removal of skin where you are still left with a small amount of excess skin. The upper lid is not really a complication and it is much better than having an excessive removal of skin.
3. Breakdown of the wound and need for resuturing.
4. Infection, which will require systemic antibiotics and antibiotic drops.
5. Haemorrhage. This is more common in people taking Aspirin, Plavix or Warfarin. This of course will settle down.
6. Scarring: Some people scar more than others, particularly people of African origin. This is called keloid formation.

NB:     IF YOU ARE TAKING WARFERIN PRE-OPEATIVELY, THIS MUST BE DISCONTINUED 48 HOURS PRIOR TO SURGERY, IF YOUR DOCTOR AGREES THAT THIS IS SAFE TO DO SO.

IF YOU ARE TAKING ASPIRIN OR PLAVIX, PLEASE CHECK WITH YOUR DOCTOR IF IT IS SAFE TO STOP THIS MEDICATION, AND IF SO, PLEASE STOP AT LEAST TWO IF NOT THREE WEEKS PRE-OPERATIVELY. 

YOU CAN RECOMMENCE THESE MEDICATIONS IMMEDIATELY AFTER SURGERY.

1. Dr. Sorcha Ni Dhubhghaill
   “Genetic & Environmental Risk Factors in Age-Related Macular Degeneration in vitro, in vivo & Population Studies”
   PhD, awarded December 2012 by the School of Medicine, Trinity College Dublin.
2. Dr. Niamh E. Collins
   “Ocular Microtremor as a Clinical and Scientific Tool in Neurologic Disease; Validation and Application of a Generalised Discovery Protocol”
   PhD to be awarded 2013 by the School of Medicine, Trinity College Dublin.
3. Dr. Sonia Charalampidou
   “Meeting the challenges of modern cataract surgery in an era of falling thresholds and rising expectations”
   MD awarded December 2011 by the School of Medicine, Trinity College Dublin.
4. Dr. Paul F. Kenna, Professor Lorraine Cassidy
   Two current research studies:
   “An Open-Label, Phase 1b, Safety/Proof–of-Concept Study to Evaluate the Effects of Oral QLT091001 in Retinitis Pigmentosa (RP) Subjects with an Autosomal Dominant Mutation in Retinal Pigment Epithelial 65 Protein (RPE65)”
   Principal Investigators: Dr. Paul F. Kenna, Prof. Lorraine Cassidy
   Ret RP 01; Sponsor: QLT Inc, Vancouver, Canada.
   
   “Long term (3 year) ophthalmic safety and cardiac efficacy and safety of Ivabradine administered orally at the therapeutic doses (2.5/5/7.5 mg b.i.d) on top of anti-anginal background therapy, to patients with chronic stable angina pectoris” 
   CL3-16257-067; Sponsor: Institut de Recherches Internationales Servier (I.R.I.S.)“
5. Karen O'Connell, Siobhan Kelly, Katie Kinsella, Sinead Jordan, Eric Heffernan, Risteard O'Laoide, Donal O'Shea, Carmel McKenna, Lorraine Cassidy, Jean Fletcher, Cathal Walsh, Jennifer Brady, Chris McGuigan, Nial Tubridy, Michael Hutchinson
   
   Current Study: 
   Dose Related effects of vitamin D on immune responses in patients with clinically isolated syndrome and healthy control participants. An Exploratory randomized double blind placebo controlled study.

Prognostic indicators and outcome measures for surgical removal of symptomatic nonadvanced cataract
Charalampidou S, Loughman J, Nolan J, Stack J, Cassidy L, Pesudovs K, Beatty S.Arch 
Ophthalmol. 2011 Sep;129(9):1155-61. Epub 2011 May 9.

Effect on refractive outcomes after cataract surgery of intraocular lens constant personalization using the Haigis formula
Charalampidou, S., Cassidy L, Ng E, Loughman J, Nolan J, Stack J, Beatty S.
J Cataract Refract Surg. 2010 Jul, 36(7): 1081-9.

The relationship between HLA-DRB1 alleles and optic neuritis in Irish patients and the risk of developing multiple sclerosis 
Tuwir I, Dunne C, Crowley J, Saddik T, Murphy R, Cassidy L
Br J Ophthalmol. 2007 Oct, 91(10):1288-92.

Ophthalmology at a glance – an ophthalmology text for medical students
Cassidy L., Olver J.
Textbook published 2005

Should we aggressively treat congenital cataracts?
Amaya L., Cassidy L., Nischal K.
British Journal of Ophthalmology 2001.

Outcome of lens aspiration and intraocular lens implantation in children aged 5 years and under. 
Cassidy L., Rahi J., Nischal K., Russell-Eggitt I., Taylor D.
Br J Ophthalmol. 2001 May; 85(5): 540–542

Paediatric Cataract – a review
Cassidy L.
Optometry Today 2001

Vestibular Velocity Perception and Motion detection thresholds in Ophthalmoplegia. 
Cassidy L., Grunfeld E., Shallo-Hoffmann J., Acheson J., Bronstien A.
British Journal of Ophthalmology 2000.

Foramen Magnum Decompression for Transient Visual Obscurations.
Hart A., Cassidy L., Good C., Powell M., Sanders M.D. 
British Journal of Neurosurgery 2000.

Abnormal supranuclear eye movements in the child – A practical guide and major review. 
Cassidy L., Taylor D., Harris C.
Survey of Ophthalmology 2000, 44:479-506.

Reverse and converse ocular bobbing with synkinetic blinking and opsoculonus in a child with Epstein-Barr virus encephalitis after bone marrow transplant for MPS I.
Cassidy L., Taylor D., Werner K., Veys P., Harris C.
BJO 2000;84:1207-1208

Ophthalmic Complications of Childhood Medulloblastoma
Cassidy L., Stirling R., May K., Picton S., Doran R.
Paediatric Oncology 2000;34:43-47

Choroidal Folds and Papilloedema
Cassidy L., Sanders M.D.
BJO 1999;83:1139-1144 
(This is a retrospective study of 32 patients)

Congenital Cataract and Multisystem Disorders
Cassidy L., Taylor D.
Eye 1999;13:464-473.

Posterior optic Nerve Infarction After Lower Lid Blepharoplasty.
Good C.G., Cassidy L., Moseley I.F., Sanders M.D.
J Neuro-Ophthalmology 1999;19:176-179

Optic neuritis in childhood – Editorial 
Cassidy L., Taylor D.
JAPOSS 1999;3:68-69

Intraocular pressure, pulse amplitude and pulsatile ocular blood flow measurement in premature infants screened for retinopathy of prematurity.
McKibbin M., Cassidy L., Dabbs T.R., Verma D.
Eye 1999;13:266-267

A Study of Fibroblastic Growth Factor Basic and Platelet Derived Growth Factor levels in Vitreoretinal Disorders
Cassidy L., Barry P., Duffy J., Kennedy S.
Br J Ophthalmol 1998; 82:181-185

Orbital Glial Hamartoma and Anophthalmia in Dandy-Walker Syndrome.
Cassidy L., Suoliotti A., Cassels-Brown A.
Neuro-Ophthalmology 1998;19:107-111.

Primary Adenocarcinoma of the Ethmoid Sinus Presenting as Proptosis.
Cassidy L., Franks A., Cassels-Brown A.
Ophthalmologica 1998; 167:17-18

Effect of Accommodation on Intraocular Pressure in Glaucoma
Cassidy L., Delaney Y., Fitzpatrick P., Blake J. 
Irish Journal of Medical Science, Volume 167, Number 1, 17-18.

A Case of Bilateral Optic Nerve Sheath Meningioma.
Cassidy L., Moriarty P., Kennedy S.
Eye 1997; 11:564-569

Ophthalmic Presentation and Sequelae of Childhood Medulloblastoma
Cassidy L., May K., Stirling R., Doran R. 
Transactions of the European Strabismological Association 1997; 24:267-272

An entirely internal approach to primary phakic rhegmatogenous retinal detachment
Cassidy L., Barry P.
Abstract published in the Irish Journal of Medical Science – Proceedings, May 1995, p.2

Carotid Stump Syndrome and Retinal Ischaemia
Cassidy L., Grace P., Bouchier-Hayes D.
Eur J Vasc Surg, 1992; 6: 368-370

Nystagmus and other involuntary eye movements
Cassidy L.
Ophthalmology series of Fundamentals of Clinical Ophthalmology
Chapter 8, p. 160-172

Ocular myopathies, myasthenia gravis and cranial nerve palsies
Cassidy L.
Ophthalmology series of Fundamentals of Clinical Ophthalmology:
Chapter 6, p. 119-145

Scleral salvage techniques for covering porous polyethylene sphere implants
Cassidy L., Barras C., Olver J.
Abstract published in the European Society of Ophthalmic Plastic and Reconstructive Surgery Abstract Book

The volume replacement attained from stacked porous polyethylene orbital floor implants.
Cassidy L., Olver J.
Abstract published in the European Society of Ophthalmic Plastic and Reconstructive Surgery Abstract Book

The place for punctual plugs in facial palsy
Cole C., Cassidy L., Olver J.
Abstract published in European Society of Ophthalmic Plastic and Reconstructive Surgery Abstract Book

Healon vs Viscoat
Cassidy L., Power W., Collum L. Hillary
Abstract published in the Irish Journal of Medical Science, Vol. 160, No.8, p. 259.

Head of Discipline
Professor Lorraine Cassidy

Tutor
Dr. Sarah Yacoub

Clinical Lecturer
Dr. Sorcha ni Dhubhghaill

Discipline Contact

Discipline Secretary - Michele
T: +353 1 634 3649

Where to go:

The Royal Victoria Eye and Ear Hospital is on Adelaide Road, accessed from Leeson Street Bridge on the East side.

Department Office and Lecture Room are located on the Lower Ground Floor - the porters will direct you from Reception.

Theatres are on the first floor - please report to Sister in charge, she will direct you to changing rooms.

Out-Patients is on lower ground floor - take stairs down from reception level, and walk straight on to central clinic area.

Casualty Department is on lower ground floor - access through out-patients.

Ophthalmic Wards - public wards are on the ground floor on the right hand side from reception. If you are going to a ward to see patients, please introduce yourself to sister in charge of a senior staff nurse before seeing patients. You will be told which patients you may see, and can take them to the examination room to check vision etc. if it is free and if the patient is agreeable.