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Advantages +30D lens – High Dioptric power lens with the least
magnification of retina but the largest field of view.
- Stereoscopic, view of the retina
- Better image achieved when viewing through media - Least magnification – 60/30 = 2X
- Largest field of view – 30*2 = 60°
opacities like cataract. - Stereopsis is half that of normal, 2/4 = ½
- Ease of viewing independent of pupillary size/dilation - Used to obtain a panoramic view when detail and

status. stereopsis are not as important. Can be used with a
- Allows for magnification of image with the help of slit- small pupil. (Figure 6a)

lamp filters and magnification. +20D lens (FIg 6)–
- Image size less affected by the patient’s refractive error. - Retinal magnification – 60/20 = 3X
- “Up-close” look at the condition e.g. magnified view of - Field of view – 20*2 = 40°
- Stereopsis is 3/4th that of normal.
the macular details and neuro-retinal rim tissue - Most widely used, since it provides an adequate field
- Non-Contact: avoids potential infection transmission.
of view, stereopsis, and magnification.(Figure 6c)
Disadvantages
+14/15D lens –
- Small field of view as compared to indirect - Retinal magnification = 60/15 = 4X
ophthalmoscopy. Cannot visualise beyond the equator, - Field of view – 15*2 = 30°
hence not ideal for screening of peripheral lesions. - Stereopsis is full i.e. 4/4.
- Most useful for a detailed view of the macula or optic
- Precise patient fixation required. Not ideal when patients
cannot sit at the slit-lamp, in children and challenging disc or for determining the elevation of the retina in
situations like nystagmus. shallow retinal detachment. (Figure 6b)

b. Indirect Ophthalmoscopic Lenses: introduced by Nagel Advantages
in 1864. The condensing lens used is aspheric with one
surface less curved than the other which is kept facing - Large field with 3D stereoscopic view of the retina
the patient’s eye (indicated by silver ring).(Figure 5) and considerable depth of focus

Optical Principle - Lesser distortion of the image of retina.
- Ease of examination especially if the patient’s eye
To make the eye highly myopic by placing a strong convex
lens in front of the patient’s eye so that the emergent rays movements are present or if there are high spherical
from an area of the fundus are brought to focus as a real or astigmatic refractive errors.
inverted aerial image between the lens and the observer’s
eye.

Figure 5: Overall magnification of indirect ophthalmoscopy with different condensing lenses depends on the distance from which the aerial image is observed.
From about 40 cm, from where it is usually observed, the overall magnification is about 1.87×, with the 20 D condensing lens.Image source:Brodie SE. Optical
Instruments. In: Brodie SE, Mauger TF, Gupta PC. eds. Basic and Clinical Science Course – Clinical Optics. San Francisco: American Academy of Ophthalmology;

2020-21. p. 295-300

Powerpatient’s eye ÷ Powerfundus lens = Magnification.

Figure 6a: 30D Lens Figure 6b: 15D Lens

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Figure 6c: Commonly used lenses for Indirect ophthalmoscopy Figure 8: Optics of Hruby Lens

- Easy visualization of retina anterior to equator, b. Goldmann’s 3-mirror contact lens – Consists of a
helpful in visualising retinal peripheral degenerations central contact lens with 3 mirrors placed in the cone,
and breaks each with different angles of inclination (Figure 5).5
Helps to visualise central as well as peripheral parts
- Useful in hazy media because of its bright light and of the fundus, and even of the angle of the anterior
optical property. chamber.

Disadvantages - Provides a virtual and erect image, located near
posterior surface of crystalline lens.
- Relatively low magnification of 5x
- Visualization is difficult with very small pupils. - Can visualise the entire fundus by rotating the lens
- Patient usually more uncomfortable with intense light 360°. The 3 mirrors inclined at 59°, 67° and 73° gives
view of the anterior peripheral retina (including ora
of IO and scleral indentation. serrata and pars plana), equatorial fundus and the
- Steeper learning curve, requires extensive practice area around the posterior pole, respectively. The
central contact lens is used for posterior pole and
both in techniques and interpretation. vitreous.Figure 10a,b)

c. Concave Lens – Hruby Lens Biomicroscopy5 - Primarily used nowadays for therapeutic purposes
like retinal photocoagulation
- Plano-concave high minus lens mounted on the slit-
lamp for stability, with a dioptric power of -58.6D, Disadvantages
which neutralizes the optical power of the eye (+ 60
D). (Fig 7) Inconvenience to the patient (involves anaesthetising the
cornea and direct contact). Limited field of view requiring
- Placed 10-12 mm in front of the patient’s cornea. rotation of the lens to visualize more than a small patch of
- Provides a high resolution, virtual, erect image of the the fundus.

fundus. Image is formed 18mm in front of the patient’s
retina.
- Small field of view with low magnification; cannot
visualise the fundus beyond equator.
2. Contact Lenses = Combines stereopsis, high illumination
and magnification with the advantages of slit beam5

a. Modified Koeppe’s Lens – Posterior fundus contact
lens used to examine the posterior segment. Image
formed is virtual and erect .

Figure 7: Hruby Lens 10 Figure 9: Goldmann 3-mirror contact lens. The flat-front contact lens
essentially nullifies the power of the eye and provides an upright view of
E-ISSN: 2454-2784  P-ISSN: 0972-0200 the posterior pole. The mirrors at various angles inside enable alternative
(inverted) views of different parts of the retina and the anterior chamber

angle (gonioscopy).

100 Delhi Journal of Ophthalmology

DJO Vol. 32, No. 4, April-June 2022

Figure 10: (a) Goldmann three mirror contact lens1 and (b) its optics of the area visualised

c. Wide-field Panfundoscopic Indirect Contact lens
– Field of view – upto 130°. Real and inverted image
is produced. It is used for fundus examination and
performing laser photocoagulation.

Figure 11: Pan Fundoscopic Lens Figure 12: Krieger lens with a concave anterior surface forms a virtual erect
image in the anterior vitreous
Therapeutic Purposes
Lenses without mirror
Lenses used for Posterior Segment Lasers6,7,8
- Common Characteristics: a. Mainster: Introduced in 1986, this lens has more field
1. Concave posterior surface conforming to the corneal of view (58% greater than Goldmann) and a greater
magnification. It has a biconvex aspheric anterior lens
curvature and a flat or convex anterior surface element which produces a real and inverted image.
2. Planar mirrors allowing observation of the anterior
• Mainster Standard Lens: For focal and grid laser, from
chamber angle or peripheral retina. posterior pole to mid-periphery.
3. A prism to allow visualization of the mid-periphery of
Field of view = 90°/121°. Image magnification = 0.96X.
the retina. Laser spot magnification = 1.05X.
4. A flange to stabilize the lens and prevent blinking
5. Knurled edge to facilitate lens manipulation • Mainster Wide Field Lens: Used for panretinal
6. Laser lenses generally consist of a conical PMMA or photocoagulation in proliferative diabetic retinopathy.

aluminium shell Field of View = 118°/127°. Image magnification = 0.68X.
7. Glass anterior surface, lenticular elements and mirrors. Laser spot magnification = 1.50X.
8. Antireflection coatings applied to each optical surface
• Mainster Ultra Field PRP Lens:(Figure 13)
reducing reflected white light (from the slit lamp
source) that decreases contrast of image and laser light Widest field of view = 165°/180°. Image magnification =
(from the treatment beam) that could pose a potential 0.51X. Laser spot magnification = 1.96X.
hazard to an observer standing behind the operator.
• Mainster Focal Grid laser Lens:
Mirror Lenses Used for Focal macular or grid lasers. (Figure 14,15)
b. Rodenstock Panfudoscopic Lens: Introduced in 1969
a. Goldmann’s 3-mirror lenses (Figure 10)
b. Yannuzzi fundus lens (Krieger lens) - Has better optics by Schlegen Schlegel. Provides panoramic view and
produces a real and inverted image. Used for PRP
than a simple Goldmann fundus lens. Image produced from the posterior pole to beyond the equator without
is erect, virtual and located in the anterior vitreous. It the use of mirrors.
is used for macular photocoagulation. (Figure 12) c. Volk Lenses: Following are used as tabulated below
(Table 1).

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Figure 13: Mainster wide field PRP Lens Figure 14: Mainster PRP 165 Lens

Figure 15: Focal / Grid Laser Lens

In conclusion, the myriad condensing lenses remain
vital to everyday ophthalmological practice. Selecting
an appropriate lens for a particular diagnostic or
therapeutic posterior segment modality depends on the
ophthalmologist’s experience with lens, its optics and the
knowledge about new technological developments of lens
designs and therapeutic strategies.

Table 1 : Summary of features of the Lenses used for lasers Figure 16: (A to D): Volk Therapeutic Lenses 10

Type of lens Image Laser Spot Figure 17: Pediatric high index corneal contact lenses Image Source:Khurana
Magnification Magnification AK, Khurana AK, Khurana B. Optical Instruments and Techniques. In: Khurana
Volk Area centralis(FIg 16 A)
Volk PDT Lens(Fig 16 B) 1.06x 0.94x AK, 4th ed. India: Elsevier; 2018. p. 460-8
0.67x 1.5x
Volk Transequator (Fig 16 C) 0.70x 1.44x
Volk Quadraspheric (Fig 16 D) 0.51x 1.97x
0.50x 2.00x
Volk Super Quad 160 0.96x 1.05x
Mainster standard 0.68x 1.50x
0.51x 1.96x
Mainster wide field (fig 13)
Mainster ultra field PRP (fig14)

Table 2 : The table below enumerates the paediatric high index
corneal contact lenses used along-with their field of view: (Figure 17)

High index corneal contact lenses 5

Lens Use Field of View

1. ROP lens Premature infants 130 degrees

2. Standard children Paediatric to young 120 degrees
adult

3. High Fine details 30 degrees
magnification lenses

4. Portrait lens For external imaging

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References Cite This Article as: Khushboo Chawla, Shraddha Raj

1. Guyton DL, et al. Ophthalmic Optics and Clinical Refraction. Shrivastava. A Guide for Diagnostic and Therapeutic Lenses used
Baltimore: Prism Press;1999. Illustration modified by Krishna
Irsch, PhD. in Posterior Segment. Delhi Journal of Ophthalmology. 2022; Vol
32, No (4): 97 - 103.
2. Brodie SE. Optical Instruments. In: Brodie SE, Mauger TF, Acknowledgments: Nil
Gupta PC. eds. Basic and Clinical Science Course – Clinical Conflict of interest: None declared
Optics. San Francisco: American Academy of Ophthalmology; Source of Funding: None
2020-21. p. 295-300 Date of Submission: 16 May 2022
Date of Acceptance: 06 June 2022
3. Shah VA, Tripathy K, Do DV, Bhagat N, Lim JI, Karth PA.
Binocular Indirect Ophthalmoscopy. AAO EyeWiki. 2021. Address for correspondence
Available from: Khushboo Chawla, DNB

https://eyewiki.org/w/index.php?title=Binocular_Indirect_ Senior Resident Ophthalmology,
Ophthalmoscopy&oldid=75743 Guru Nanak Eye Centre,
New Delhi, India.
4. Kumar NKS. Lensopedia: Lenses in Ophthalmology. eOphtha. Email: [email protected]
2021. Available from: https://www.eophtha.com/posts/
lensopedia-lenses-in-ophthalmology

5. Walling PE, Pole J, Karpecki P, Colatrella N, Varanelli J.
Condensing Lenses: Sharpen Your Skills in Choosing and
Using. Review of Optometry. 2017. Available from: https://www.
reviewofoptometry.com/article/condensing-lenses-sharpen-
your-skills-in-choosing-and-using

6. Khurana AK, Khurana AK, Khurana B. Optical Instruments
and Techniques. In: Khurana AK, 4th ed. India: Elsevier; 2018.
p. 460-8

7. Mainster MA, Crossman JL, Erickson PJ, Heacock GL. Retinal
laser lenses: magnification, spot size and field of view. Br J
Ophthalmol 1990; 74:177-179

8. Weingeist TA, Sneed SR. Contact and non- contact lenses in
photocoagulation therapy. Laser Surgery in Ophthalmology:
Practical Applications. 1992; 2: 7-14.

9. Das T. Retinal laser optical aids. Indian Journal of
Ophthalmology.1991; 39:3: 115-117.

10. Sharma, Gitumoni & Dnb, Purkayastha & Deka, Hemlata &
Bhattacharjee, Harsha. (2008). Commonly Used Diagnostic and
Laser Lenses for Retinal Diseases-An Overview.

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DJO Vol. 32, No. 4, April-June 2022

Abstract Theme section

Slit lamp Examination Techniques

Arshi Singh1, V Krishna2

1Guru Nanak Eye Centre, Maulana Azad Medical College & assoc hosp, New Delhi, India.
2Department of ophthalmology, Moolchand Medcity hospital, New Delhi, India.

The slit lamp biomicroscope is the quintessential tool for ophthalmological examination. The instrument has seen
technological advancements with improved optics. This review aims to help the reader revise the basics of slit lamp
biomicroscopy- the assembly, optics and various examination techniques.

Delhi J Ophthalmol 2022; 32; 104-108; Doi http://dx.doi.org/10.7869/djo.779
Keywords: Slit Lamp Biomicroscope, Ophthalmic Examination Techniques, Slit Lamp Optics

Introduction beams permitted posterior segment evaluation. Bypassing
mechanism of Binstead and Stockwell permitted delinking
The slit lamp is a stereoscopic bio-microscopic device that of microscope and illumination systems, allowing them
uses a high intensity focussed beam of light which can be to move separately enabling sclerotic scatter. The first
varied in size, angle and intensity to permit visualisation commercially available slit lamp was manufactured by Haag
of fine anatomical details of ocular adnexa, anterior and Streit in 1958
posterior segments. Since its invention, it remains the most
essential and versatile ophthalmic diagnostic equipment. Design
Accessories extend its use to measuring intraocular pressure Includes the Illumination, Observation system and
(Goldman applanation tonometer), fundus examination mechanical system which keeps the two together and
(lens biomicroscopy), angle visualization (gonioscopy) and maintains parfocality.
recording (video recording device).
The basic principle is the common focal plane and the common
History axis of rotation of the microscope and the illumination
system. Their alignment is such that the microscope and the
Invention credit goes to Alvar Gullstrand (1862-1930), a light are focussed on the same point.(Figure 1)
professor of ophthalmology and physical optics in Stockholm,
who built on von Helmholtz optical imaging to device “
large reflection free ophthalmoscope” (manufactured by
Zeiss optical works), the precursor of modern day slit lamp .
Gullstrand was awarded the 1911 Nobel Prize for ‘diffraction
of light by lenses as applied to eye”.

The instrument comprising of corneal microscope and
illumination system, underwent many modifications. Initial
binocular handheld loupe was replaced by table mounted
bi-tubus corneal microscope where light was distributed
between two oculars by prisms (Abbe 1881, Koeppe 1922).
Corneal microscope was modified to introduce binocular
stereoscopic view and erect image, eye pieces adaption for
individual inter-pupillary distances and linear movements
along three directions, rotational movements in vertical and
fronto-horizontal directions by Czapski.

Illumination system from initial Nernst lamp (magnesium Figure 1: J. Slit lamp design includes binocular microscope & illumination system
oxide usage as an incandescent body) focussed to first to a
slit (by condensing system of lenses) and then to eye (hand A. Illumination system
held lens) was modified by mounting both slit lamp and Controls of illumination system are: Slit height variable
condensing lens on a single horizontal arm on pivoted table from 0.2 to 8 mm, Slit width variable from 20 microns to a
(Henker1916). Unavailability of Nernst lamp after 2nd world fully open aperture, variable light intensity (rheostat) to step
war, saw entry of Nitra lamp (spiral filament in nitrogen). change or continuous change.
Vogt’s invented the illumination system with slit diaphragm Angle: Variable vertical and horizontal angles.
controlling beam size. Narrowing of slit enabled thin optical Filters: Cobalt blue for enhancing fluorescence for corneal
sections, conical beams to observe the Tyndall effect. staining including contact lens fitting and Goldmann
tonometery. Red free to enhance view of blood vessels and
Coaxial rotation of illumination system and microscope nerve fibre bundles. Neutral density to reduce illumination
maintaining focus, was invented by Koeppe & Fincham in photosensitive patients. Grey filter reduces maximum
in 1923-24. Con-focality of microscope and illumination illumination for patient comfort. Yellow filter (optional)
system was introduced by indefatigable Hans Goldman enhances contrast especially with the cobalt blue filter.
in 1930’s who also introduced joystick for fine controlled Diffuser is a flip-flop attachment on light source for diffuse
movement Coaxial illumination by use of prisms to deflect illumination.

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B. Observation system/ Corneal microscope 1. Diffuse illumination: For gross examination of anterior
A telescopic system with two convex lenses separated by segment, lids, conjunctiva and cornea. A broad beam is
their focal lengths it provides magnified view. A second shown on the ocular surface by opening the light aperture
magnification is achieved using a Galilean type telescope wide. The lowest magnification is used to view more area
(concave-convex) at the examinee’s end to increase image – for preliminary examination of ocular structures. In
size. photophobic patients, neutral density filter is used. A beam
of light is slightly defocussed near the object of interest so a
Figure 2: . Schematic representation of slit lamp apparatus large area is illuminated.

Magnification can be altered by two-level Grenough Flip 2. Direct focal illumination: Slit beam is narrowed and
(flip device) and Galilean step (3-5 step magnification by vertical height is altered to include specific structure to be
rotatory device). viewed. Light is shone obliquely from temporal side and
C. Mechanical system three-dimensional view is obtained by a precise optical
Integrates illumination and observation systems as well section with magnification ranging from 5-25 times. Minute
as takes care of patient positioning. Permits simultaneous differences in media and opacities are rendered visible.
movement of illumination and observation systems, tilting Too long a vertical height would increase light scatter and
and alignment for gonioscopy, 3 mirror fundus exam. reduce contrast. Illumination is varied from broad beam
Dissociation of two permits sclerotic scatter. (parallelepiped), narrow beam (optical slit), conical or spot
The system includes forehead rest, chin rest and adjustment, (aqueous flare).
canthus alignment, head fixation band, patient handlebars,
joy stick, table height adjustment, knob for dissociating 3. Indirect lateral illumination: Light is placed on side of
illumination, and observation system. lesion to be examined. Parfocality of the observation and
illumination system is often needed to be disengaged for
Examination technique optimum observation. Light scattered in neighbourhood of
the lesion makes it stand out in softer illumination. Used
The slit lamp examination should be algorithmic to ensure for examining ghost vessels, corneal nerves, fine corneal
complete and efficient examination. Anterior segment opacities, neovascularisation, iris bleeds, sphincter changes
examination strategies: Examination under diffuse etc.
illumination, sclerotic scatter, focal examination (direct
& indirect), retro-illumination (direct & indirect), zone of 4. Sclerotic scatter: Enables detection and mapping of
specular reflection, oscillating illumination subtle corneal opacities by using principle of total internal
reflection Light normally falling on limbus travels internally
and exits at opposite limbus, resulting in a lighted limbal
ring and a dark cornea. A corneal opacity halts and scatters
light passing through the cornea highlighting its margins.
To remove parfocality of illumination and observation
system, the knob at base of illumination system or on the
horizontally placed illumination tower is loosened.

5. Retro-illumination: Lesions are examined in background
of reflected light form posterior structures like iris or fundus.
For optimal image clarity, the illumination and observation
systems are made co-axial. Useful for opaque lesions in
back of cornea like keratic precipitates and semi translucent
lesions such as vacuoles, corneal oedema and iris defects.
Softer indirect retro-illumination is useful for vacuoles and
fluid filled cavities which would stand out in the softer
surround with a darker centre.

Figure 3: a, b Diffuse illumination. c. Ray diagram showing a beam of light thrown slightly out of focus across the structure being examined so that a large area
is diffusely illuminated

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Figure 4: a, b Direct focal examination showing central anterior chamber depth; Keratic precipates.
c, d. Ray diagram showing light exactly focused on area to be inspected

Figure 5: a, b, c Indirect focal examination. Ray diagram showing light being reflected from tissue adjacent to the structure being examined.

Figure 6: a, b, Sclerotic scatter c. Ray diagram

b(Photograph courtesy Dr. Nikhil Gotmare), (Senior Resident, Cornea Services, Guru Nanak Eye Centre)

6 Zones of Specular reflection other and catoptric image of light is focussed. The irregularly

Specular reflection is an irregular reflection from a very small reflected light delineates areas of surface roughness and is

area of optical discontinuity. A monocular examination used to examine corneal endothelium, tear film and cells of

technique which high magnification of 25 times or more. lens surface.

Angle between observation and illumination systems is kept

at 30 degrees so that the angle i and r are at 15 degrees to each

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Figure7:a.Retroilluminationshowingadislocatedintraocularlenswithredfundalglow.b,c. Raydiagramsshowinglightreflectedoffastructurethatactsasamirror.

8. Examination under oscillating illumination the stained areas black. In dry eye patients, it is used to

Area to be examined is studied under alternating direct and assess lid margins for lid wiper epitheliopathy.

indirect illumination, to reveal fine scars. Magnification is c. Rose Bengal: 1.3 mg impregnated strips that stain

kept low and may be increased after localising and mapping devitalised cells and mucous strands. Used to diagnose dry

the lesion. eye syndrome, dysplastic or squamous metaplastic cells
of conjunctiva, corneal herpetic disease and meibomian
Dyes used in slit lamp examination

Various dyes are used in conjunction with diagnostic filters gland disease. It causes stinging and burning sensation on

available with the slit lamp for delineating pathological instillation and is known to be ocular toxic.

process. They are the following:

a. Fluorescein 1%: Used with cobalt blue filter for diagnosis Figure 8: a Indirect lateral illumination of subluxated lens
staining of epithelial defects, erosions, diagnosis of dry b. Retro-illumination demarcates it clearly and identifies zonular loss
eyes (tear fil break up time, meniscus height), filamentary
keratitis, aqueous leak (Seidel test), nasolacrimal duct
patency (Jones test). Also used for measuring intraocular
pressure by applanation tonometry and rigid contact lens
fitting (both static and dynamic).

b. Lissamine green 1-2%: It stains the dead, degenerated
cells unprotected by mucin or glycocalyx and mucous
strands. It is less irritating and toxic than Rose Bengal and
is better tolerated by patients. It is the preferred dye in
diagnosis of dry eyes especially kerato-conjunctivitis sicca.
Used with red-free filter, the transmitted light demarcates

Figure 9: a, b, c , d Zone of specular reflection e Ray diagram

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DJO Vol. 32, No. 4, April-June 2022

Figure 10: a. Fluorescein staining of epithelial defect in ulcer, steep fit of rigid contact lens , apical touch in keratoconus contact lens fitting

Figure 11: a , Lissamine green in dry eyes (courtesy Dr. Christopher Rapuano) Cite This Article as: Arshi Singh, Krishna V Slit lamp
b. Rose Bengal stain ( courtesy Nicole C, Dry Eye flash cards. Optometry) Examination Techniques. Delhi J Ophthalmol 2022; 32 (4):
104 - 108.
References
Acknowledgments: Nil
1. Gullstrand A. Demonstration der Nernst-Spaltlampe. 37.
Versammlung der Ophthalmologischen Gesellschaft Heidelberg. Conflict of interest: None declared
Wiesbaden: Bergmann; 1911, p. 374–376.
Source of Funding: None
2. Duke Elder S . Textbook of Ophthalmology. Section 3 Diagnostic
Methods in Examination of Eye Manchester. London, CV Mosby, Date of Submission: 12 May 2022
1941, p. 233-290. Date of Acceptance: 16 June 2022

3. Berliner ML. Biomicroscopy of the Eye. Slit lamp microscopy of Address for correspondence
the living eye. New York, Hoeber PB Inc; 1949.
Arshi Singh, DNB, FICO
4. Gellrich MM. The Slit Lamp: Applications for Biomicroscopy
and Videography. Heidelberg, Springer Berlin , 2013, p 1-74 Senior Resident

5. Ledford JK and Sanders VN. The slit lamp primer. The Basic Guru Nanak Eye Centre,
Bookshelf for Eye care Professionals 2nd ed. New Jersey, Slack New Delhi, India.
Incorporated 2006 E-mail: [email protected]

6. Duke Elder S. Section 3.Examination of eye. Duke Elder. Text
Book of Ophthalmology, Manchester MH , St. Louis Mosby 1933
pg 248-255

7. Review of Ophthalmology. Approaches and Methods for
Treating Dry Eye 2021 [Internet]. Place unknown; Spiegle L,
2021 September 10. Available from: reviewofophthalmology.
com/article/approaches-and-methods-for-treating-dry-eye-2021

8. Etxebarria J. Ocular Surface Dyes. In: Benítez-del-Castillo
JM, Díaz-Valle D, Gegúndez-Fernández JA, editors. Ocular
Pharmacotherapy. (place unknown) Jaypee Digital; 2017 p. 20-
50

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Delhi Journal of Ophthalmology

DJO Vol. 32, No. 4, April-June 2022

Abstract Theme section

Tests for Potential Vision
Yashi Gupta, Priyadarshi Gupta, Ekta Shaw

Guru Nanak Eye Centre, Maulana Azad Medical college & assoc. Hospitals New Delhi, India.

Macular function tests are applied for diagnosis and follow up for macular diseases and for assessing potential
macular function in eyes with opaque media. One subset of such tests, the Potential vision tests have been devised
to assess whether patients with impaired vision have the potential to benefit from cataract surgery. Many such
tests have been described in literature namely : 1)Potential Acuity Meter 2)Laser Interferometry (retinometre,
visometre) 3)Critical Flicker Fusion Frequency. A brief overview will hereby be presented in the following article.

Delhi J Ophthalmol 2022; 32; 109-111; Doi http://dx.doi.org/10.7869/djo.780

Keywords:Macular Function Test, PAM, Laser Interferometry

INTRODUCTION an aerial image of a miniature Snellen chart with a 6 0
field of view.
We so readily use our eyes to organize and process 2. The instrument must be focussed to account for patients
information that we ignore the remarkable adjustments our ametropia.
eyes make to view the world around. The anatomical and 3. Pupil dilation is preferable as it may allow the light to be
biological processes transforming myriad of photons falling passed through less dense areas of the cataract.
on the photoreceptors is a place of great scientific curiosity 4. After dilating the pupil, the patient is asked to read the
and interest. projected Snellen’s chart. 3
5. The objective is to focus the beam onto the patient’s retina
Macular Function Tests through the cataract.The patient is encouraged to read
the lines until no other smaller lines are comprehendible
Applied for diagnosis and follow up for macular diseases and this process shall continue until the examiner is
and for assessing potential macular function in eyes with certain that the patient cannot read further lines.
opaque media. The macular function tests are classified as 6. In case a patient reads three characters of a certain line
below: then the visual acuity is established.

a) Tests in clear media Advantages
b) Tests in opaque media
1) Strong positive correlation of PAM with Snellen’s VA in
TESTS IN CLEAR MEDIA TESTS IN OPAQUE MEDIA normal retinas
a)Visual Acuity a) Maddox rod test
b)Contrast Sensitivity b) Focal ERG 2)Useful in early-moderate cataracts
c)Slit-lamp Bio microscopy c) Laser interferometry 3) High myopes with long axial lengths
d)Photo-stress test d) Potential Vision Tests 4) Predicting VA before Nd: YAG capsulotomy, macular
e)Colour vision e) VEP
f)Amsler grid f) Entoptic phenomenon hole surgery
g)Two-point discrimination
h)Microperimetry
i)FFA
j)OCT

Potential vision tests have been devised to assess whether
patients with impaired vision have the potential to benefit
from cataract surgery. Therefore, it is also important to
determine whether impairment in vision is solely due to
cataract or some other co-existing retinal, neural pathology
which might limit the results of a successful cataract surgery.
Many such tests have been described in literature namely-

1) Potential Acuity Meter
2) LaserInterferometry(retinometre,visometre,SITE-IRAS)
3) Critical Flicker Fusion Frequency

Potential Acuity Metre Test Figure 1: Potential Acuity Metre

It is a slit-lamp mounted instrument which produces a point
light source of 0.15mm diameter, in the pupillary plane
which is directed through clear areas of cataractous lens. It
was first described in 1981.

Procedure

1. An incandescent light source mounted on a slit lamp
that is set to the lowest magnification is used to generate

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DJO Vol. 32, No. 4, April-June 2022

Disadvantages hand-held interferometer may also be likewise used.
4. The patient is asked to indicate the direction of the
1) Prediction depends on patients’ activity, compliance
with examination, making adjustments to head position, fringes – vertical, horizontal or oblique.
literacy and mood. 5. If the patient is able to see the fringes, they are gradually

2) Underestimates potential acuity in severe cataracts made finer until they disappear.
3) Underestimates potential acuity in patients with Pre-op 6. The patient’s end point fringe pitch decimal reading is

VA<20/200 read off from one of the knobs and converted to Snellen’s
4) Underperforms in posterior subcapsular opacities. equivalent, using the conversion table supplied. The
5) Accuracy of PAM predictions could be reduced by circular field size can vary from 2 -8 degrees. 14

spherical aberration from peripheral parts of the optic Table 1 compares PAM with LI
media.
6) PAM overestimates retinal VA in cystoid macular Table 1 : PAM VS LI
oedema, early post-op retinal detachments, serous retinal
detachments PAM LI
7) Erratic results in patients with severe glaucomatous Field Projected- 60 Field Projected- 2-80
damage Altered By Refractive Status Unaffected By Optics Of Eye
Of Eye
Thus, PAM is a simple, slit lamp-based procedure to assess Underestimates Va In Severe Less Profound Effect
potential VA in patients with early to moderate cataracts with Cataracts Profoundly
normal retina. But cognizance of the fact should be taken to Does Not Overestimate Overestimates Va In Amblopic
not obviate the benefit from cataract surgery based solely on Patients
Accurate In Exudative Armd Accurate In Atrophic Armd
underperformance in Potential Acuity Metre testing.

Advantages

1) Good predictor in mild to moderate cataract.
2) Less influenced than Snellen’s visual acuity by: a)

clarity of media, ametropia, surface irregularities,
orientation of photoreceptors.
3) Very reliable in High myopes (AL>29mm) with
moderate cataracts.

Figure 2,3,4,5: (2) Handheld LI (3) Slit-lamp mounted LI (4) Coherent light Disadvantages
beams (5) Diagrammatic representation of Interference Fringes
1) Overestimates VA in Central macular oedema, early
Laser Interferometre post-operative retinal detachment

Laser interferometry employs the use of two coherent light 2) Overestimates VA in Geographical atrophy, macular
holes and cysts
beams for production of a three-dimensional interference
3) Miscalculates VA in Serous macular detachments,
fringe on the retina. Varying the distance between the visual field defects through fixation

4) Overestimates VA in Amblyopia
5) Unreliable in dense immature and mature cataracts
6) Underestimates visual outcome in posterior

subcapsular cataract
Laser Interferometer is thus a simple test that can be applied
to assess potential vision in patients awaiting cataract
surgery. However, the test results should be interpreted
with caution in situations mentioned above.

light beams enabled in changing the fringe width which Thus, the review of literature suggests PAM and LI are
particularly useful in moderate cataracts. Although the
correspond to different interference visual acuities with the results of both these tests may not concur in various scenarios
such as severe cataracts, retinal disorders etc but when used
Snellen equivalent from 20/660 to 20/20, independent of the together they supplement one another.

optics of the eye. Procedure Other Potential Acuity Tests
Critical Flicker Fusion Frequency (CFFF)
1. The patient should be familiarised with the possible
It is defined as frequency at which flickering light appears
fringe patterns before starting the test. to be continuous, a function of temporal visual processing.

2. The patient should not be subjected to prolonged light

testing and should be explained that scotomas may be

seen but these are to be ignored.

3. The patient is seated in front of the apparatus mounted

on a slit lamp in a dark room with dilated pupils and

broad vertical stripes in a circular field are shown. A

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DJO Vol. 32, No. 4, April-June 2022

1987;225(6):457-460.
13 Hurst M.A., Douthwaite W.A. Assessing Vision Behind Cataract

– A Review of Methods. Optom Vis Sci. 1993;70(11):903-913.
14 Faulkner W. Laser interferometric prediction of postoperative

visual acuity in patients with cataracts. Am J Ophthalmol.
1983;95(5):626-636.
15 Datiles MB, Edwards PA, Kaiser-Kupfer MI, McCain L, Podgor
M. A comparative study between the PAM and the laser
interferometer in cataracts. Graefes Arch Clin Exp Ophthalmol.
1987;225(6):457-460.
16 Faulkner W. Laser interferometric prediction of postoperative
visual acuity in patients with cataracts. Am J Ophthalmol.
1983;95(5):626-636.
17 Romo GB, Douthwaite WA, Elliott DB. Critical flicker frequency
as a potential vision technique in the presence of cataracts. Invest
Ophthalmol Vis Sci. 2005;46(3):1107-1112.
18 Shankar H, Pesudovs K. Critical flicker fusion test of potential
vision. J Cataract Refract Surg. 2007;33(2):232-239.

Figure 6: CFF Apparatus 18 Cite This Article as: Yashi Gupta, Priyadarshi Gupta Ekta Shaw
Assessing Macular Function: Seat For Highest Visual Ability With
Advantages Potential Vision Tests Delhi J Ophthalmol 2022; 32 (4): 109 - 111.
Acknowledgments: Nil
1) Useful in dense cataracts Conflict of interest: None declared
2) Sensitive indicator of retinal and optic nerve disease Source of Funding: None
3) Small macular lesions can be assessed Date of Submission: 14 June 2022
Date of Acceptance: 20 June 2022
Disadvantages
Address for correspondence
1) Overlooks small foveal lesions Priyadarshi Gupta MS,DNB,

References Senior Resident ( Retina & Uvea Services)

1 Minkowski JS, Guyton D. Potential Acuity Meter using a minute Guru Nanak Eye Centre,
aerial pinhole aperture. Rochester. 1981; 88 (Suppl): 95. New Delhi, India.
E-mail: [email protected]
2 Hurst M.A., Douthwaite W.A. Assessing Vision Behind Cataract
– A Review of Methods. Optom Vis Sci. 1993;70(11):903-913. Quick Response Code

3 Hurst M.A., Douthwaite W.A. Assessing Vision Behind Cataract Delhi Journal of Ophthalmology
– A Review of Methods. Optom Vis Sci. 1993;70(11):903-913.

4 Asbell PA, Chiang B, Amin A, Podos SM. Retinal acuity
evaluation with the potential acuity meter in glaucoma patients.
Ophthalmology. 1985;92(6):764-767.

5 Devereux CJ, Rando A, Wagstaff CM, Story IH. Potential
acuity meter results in cataract patients. Clin Exp Ophthalmol.
2000;28(6):414-418.

6 Datiles MB, Edwards PA, Kaiser-Kupfer MI, McCain L, Podgor
M. A comparative study between the PAM and the laser
interferometer in cataracts. Graefes Arch Clin Exp Ophthalmol.
1987;225(6):457-460.

7 Uy HS, Munoz VM. Comparison of the potential acuity meter
and pinhole tests in predicting postoperative visual acuity after
cataract surgery. J Cataract Refract Surg. 2005;31(3):548-552.

8 Gus PI, Kwitko I, Roehe D, Kwitko S. Potential acuity
meter accuracy in cataract patients. J Cataract Refract Surg.
2000;26(8):1238-1241.

9 Lasa MS, Datiles MB 3rd, Freidlin V. Potential vision tests in
patients with cataracts. Ophthalmology. 1995;102(7):1007-1011.

10 Devereux CJ, Rando A, Wagstaff CM, Story IH. Potential
acuity meter results in cataract patients. Clin Exp Ophthalmol.
2000;28(6):414-418.

11 Asbell PA, Chiang B, Amin A, Podos SM. Retinal acuity
evaluation with the potential acuity meter in glaucoma patients.
Ophthalmology. 1985;92(6):764-767.

12 Datiles MB, Edwards PA, Kaiser-Kupfer MI, McCain L, Podgor
M. A comparative study between the PAM and the laser
interferometer in cataracts. Graefes Arch Clin Exp Ophthalmol.

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DJO Vol. 32, No. 4, April-June 2022

Special Features

Competency-Based Medical Education for The Indian Medical
Graduate: Implementation & Assessment in Ophthalmology

Kirti Singh, Neha Rathie, Parul Jain

Guru Nanak Eye Centre, Maulana Azad Medical college & assoc. Hospitals New Delhi, India.

Competency-based medical education (CBME) curriculum has been implemented by National Medical Council from 2019 for the
Indian Medical Graduates (IMG). This competency-based curriculum focuses on skill acquisition with incorporation of soft skills
related to attitude, communication and ethics. Widespread adoption of a competency-based approach would mean a paradigm
Abstract shift in the current approach to medical education.
The current article describes rationale of CBME along with an overview of the competencies mandated in ophthalmology with
detailing of assessment module by means of logbook with incorporation of work place based assessment.

Delhi J Ophthalmol 2022; 32; 112-118; Doi http://dx.doi.org/10.7869/djo.781

Keywords: Competency-based Medical Education (CBME), Assessment, Logbook, Undergraduate curriculum, Teaching-Learning methods

Introduction application. In ophthalmology it entails 4 weeks of clinical
posting during 2nd year.
Rationale of CBME
Medical education focus is to train graduates to become •Integrated Teaching learning: Both horizontal and vertical
effective health care providers. Erstwhile medical education integration (inter and intra disciplines), bridge gaps between
was based on time bound, subject-centred curriculum with theory & practice. Ophthalmology can link with community
most assessments being summative, with inherent little medicine and ENT for horizontal integration. Vertical
opportunity for feedback. Both teaching–learning activities integration is feasible with pharmacology, microbiology and
and assessment focused more on acquiring knowledge and clinical specialities of medicine, paediatrics, gynaecology.
not on skill acquisition, nor on patient doctor communication
nor attitude. Competency-based Medical Education seeks •Self-directed learning: An important teaching learning
to redress this with focus on basic clinical skills required tool Self‐Directed Learning (SDL) is the “process in which
to practice including soft skills related to communication, individuals take the initiative, with or without the help of
doctor–patient relationship, ethics, and professional others, in diagnosing learning needs, formulating learning
conduct. goals, identifying human and material resources for learning,
choosing/ implementing learning strategies, and evaluating
Competency is defined as “the ability to do something learning outcomes”.2 The Graduate Medical Education
successfully and efficiently,” and CBME is an approach to 2019 document lists life‐long learning as one of the roles of
ensure that the Indian Medical Graduate (IMG) develops the Indian Medical Graduate (IMG) to continuously equip
competencies required to fulfil patients’ health requirements themselves with relevant knowledge and skills in the ever
thereby preparing students for actual professional evolving world of medicine. To inculcate SDL, the logbook
practice. Teaching–learning activities become more skill- includes details of SDL activities undertaken by the student
based, involving more clinical, hands-on experience and followed by subsequent reflections on the same.
assessment focuses on outcomes or competencies achieved.
Time constraints are an issue, as continued training until •Skill Certification: CBME curriculum with focus on
desired competency is achieved, could be difficult to fit in outcomes, emphasizes skill development. Acquisition of
during the prescribed course. essential/ desirable and certifiable skills, during simulated
or clinical posting has to be combined with documentation
Work placed based assessment (WPBA) measures working of process.
of a health care professional while performing duties.
Proposed by Norcini et al in 2007 it comprises of three •Electives: This is to provide immersive learning experiences
essential components namely direct observation, conduction to explore career stream, discipline or research project related
at work place and contextual with constructive, immediate or unrelated streams of interest. As per CBME curriculum,
feedback.1 Mini clinical examination (Mini CEX), Directly 8 weeks of electives is reserved after 7th semester (post
observed procedural skills (DOPS), Case based discussion 3rd Prof exam Part I and prior to commencement of III rd
(CBD) are few of the WPBA methods. Formative assessments MMBS Part II). Of these 8 weeks, 4 weeks is for clinical and
largely work-based form the backbone of CBME and need 4 weeks for pre / para clinical, with choices given to student.
to be performed frequently with qualitative feedback from Ophthalmology is part of Block II of electives envisaging
teachers. Structured logbook required for this, is detailed in supervised posting followed by formative assessment. At
this article least 75% attendance is mandatory.

Key aspects of CBME •AETCOM (Attitude, Ethics and Communication): This
•Early Clinical exposure (ECE): This aims to create an module is designed on the fundamental principle that a
opportunity for correlation learning in Phase I with clinical person's attitude influences behaviour and determines

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DJO Vol. 32, No. 4, April-June 2022

doctor patient relationship. Emphasis on empathetic C. Knowledge Based Competencies
communication and guiding principles on professionalism
and ethics are the basic tenets of this module. S.no Competency Competency

(I) CompetenciesinOphthalmology(CBMEcurriculum) 1 OP1.1 Describe the physiology of vision

The competencies have been divided as per domain in 2 OP1.2 Define, classify and describe types and methods
table below and need to be taught using different teaching
learning methods to accommodate the total hours. of correcting refractive errors

A. SKILL BASED: certifiable competencies (OP* -ophthalmology) 3 OP1.4 Enumerate indications and describe principles of

refractive surgery

4 OP1.5 Define, enumerate the types and the mechanism

by which strabismus leads to amblyopia

S.no Competency no Competency 5 OP2.1 Enumerate the causes, describe and discuss the
aetiology, clinical presentations and diagnostic
1¤ OP *1.3¤ Demonstrate the steps in performing the visual features of common conditions of lid & adnexa
including Hordeolum externum/ internum,
acuity assessment for distance vision, near vision, blepharitis, pre-septal cellulitis, dacryocystitis,
hemangioma, dermoid, ptosis, entropion, lid lag,
colour vision, the pin hole test and the menace and lagophthalmos

blink reflexes

2¤ OP2.2¤ Demonstrate the symptoms &clinical signs of

common conditions of the lid and adnexa including 6 OP2.4 Describe aetiology, clinical presentation. Discuss

Hordeolum externum / internum, blepharitis, complications and management of orbital

pre-septal cellulitis, dacryocystitis, hemangioma, cellulitis

dermoid, ptosis, entropion, lid lag, lagophthalmos 7 OP2.5 Describe clinical features on ocular examination

3¤ OP2.3¤ Demonstrate under supervision clinical procedures and management of a patient with cavernous

performed in the lid including: bells phenomenon, sinus thrombosis

assessment of entropion/ ectropion, perform

the regurgitation test of lacrimal sac. Massage 8 OP2.6 Enumerate causes and describe differentiating
features, and clinical features and management of
technique in cong. dacryocystitis, and trichiatic cilia proptosis

removal by epilation

4¤ OP3.1¤ Elicit document and present an appropriate history 9 OP2.7 Classify various types of orbital tumours.

in a patient presenting with a “red eye” including Differentiate symptoms and signs of presentation

congestion, discharge, pain of various types of ocular tumours

5¤ OP3.2¤ Demonstrate document and present the 10 OP2.8 List investigations helpful in diagnosis of orbital
tumors. Enumerate indications for appropriate
correct method of examination of a “red eye” referral

including vision assessment, corneal lustre, pupil

abnormality, ciliary tenderness

6¤ OP3.8¤ Demonstrate correct technique of removal 11 OP3.3 Describe aetiology, pathophysiology, ocular
of foreign body from the eye in a simulated
features, differential diagnosis, complications and
environment
management of various causes of conjunctivitis

7¤ OP3.9¤ Demonstrate the correct technique of instillation of 12 OP3.4 Describe aetiology, pathophysiology, ocular

eye drops in a simulated environment features, differential diagnosis, complications and

8¤ OP4.8¤ Demonstrate technique of removal of foreign body management of trachoma.

in the cornea in a simulated environment 13 OP3.5 Describe aetiology, pathophysiology, ocular

9¤ OP6.6¤ Identify and demonstrate the clinical features features, differential diagnosis, complications and
and distinguish and diagnose common clinical
management of vernal catarrh
conditions affecting the anterior chamber
14 OP3.6 Describe aetiology, pathophysiology, ocular

10¤ OP7.3¤ Demonstrate the correct technique of ocular features, differential diagnosis, complications and
examination in a patient with a cataract
management of pterygium

11¤ OP8.3¤ Demonstrate the correct technique of a fundus 15 OP3.7 Describe aetiology, pathophysiology, ocular

examination and describe and distinguish the features, differential diagnosis, complications and

funduscopic features in a normal condition and in management of symblepharon

conditions causing an abnormal retinal exam 16 OP4.1 Enumerate, describe and discuss types and causes

12¤ OP9.1¤ Demonstrate the correct technique to examine extra of corneal ulceration

ocular movements ( Uniocular & Binocular) 17 OP4.2 Enumerate and discuss differential diagnosis of
infective keratitis
13¤ PY10.20 Demonstrate testing of visual acuity, colour and

(physiology)¤ field of vision in volunteer/ simulated environment 18 OP4.3 Enumerate causes of corneal oedema

B. Affective Competencies - it may or may not be certified 19 OP4.4 Enumerate causes and discuss management of
dry eye
S.no Competency no Competency

1¤ OP4.10¤ Counsel patients and family about eye donation in 20 OP4.5 Enumerate causes of corneal blindness

a simulated Environment 21 OP4.6 Enumerate indications and types of keratoplasty

2¤ OP6.10¤ Counsel patients with conditions of the iris and 22 OP4.7 Enumerate indications and describe methods of
anterior chamber about their diagnosis, therapy tarsorraphy

and prognosis in an empathetic manner in a 23 OP4.9 Describe and discuss importance and protocols
simulated environment involved in eye donation and eye banking

3¤ OP7.5¤ To participate in the team for cataract surgery

4¤ OP7.6¤ Administer informed consent and counsel patients

for cataract surgery in a simulated environment

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DJO Vol. 32, No. 4, April-June 2022

24 OP5.1 Define, enumerate and describe aetiology, S.no Competency Competency
1 no.
associated systemic conditions, clinical features 2 Explain effect of pituitary tumours on visual
3 AN30.5 pathway
complications indications for referral and AN31.3
4 AN31.5 Describe anatomical basis of Horner's
management of episcleritis 5 syndrome
6 AN41.1
25 OP5.2 Define, enumerate and describe aetiology, 7 AN41.2 Explain anatomical basis of oculomotor,
AN41.3 trochlear and abducens nerve palsies along
associated systemic conditions, clinical features, 8 PY10.17
9 with strabismus
complications, indications for referral and 10 PY10.18
PY10.19 Describe & demonstrate parts and layers of
management of scleritis PA36.1 eyeball

26 OP6.1 Describe clinical signs of intraocular inflammation Describe anatomical aspects of cataract,
glaucoma & central retinal artery occlusion
and enumerate the features that distinguish
Describe position, nerve supply and actions of
granulomatous from non-granulomatous intraocular muscles

inflammation. Identify acute iridocyclitis from Describe and discuss functional anatomy
of eye, physiology of image formation,
chronic condition
physiology of vision including colour vision,
27 OP6.2 Identify and distinguish acute iridocyclitis from Refractive errors, colour blindness, Physiology
chronic iridocyclitis
of pupil and light reflex
28 OP6.3 Enumerate systemic conditions that can present
as iridocyclitis and describe their ocular Describe and discuss physiological basis of
manifestations lesion in visual pathway

29 OP6.4 Describe and distinguish hyphema and hypopyon Describe and discuss auditory & visual evoke
potentials
30 OP6.5 Describe and discuss angle of anterior chamber
and its clinical correlates Describe etiology, genetics, pathogenesis,
pathology, presentation, sequelae and
31 OP6.7 Enumerate and discuss aetiology, clinical complications of retinoblastoma

distinguishing features of various glaucoma’s

associated with shallow and deep anterior

chamber. Choose appropriate investigations and

treatment for patients with above conditions.

32 OP6.8 Enumerate and choose appropriate investigation

for patients with conditions affecting Uvea

33 OP6.9 Choose correct local and systemic therapy for 11 PH1.58 Describe drugs used in Ocular disorders

conditions of the anterior chamber and enumerate 12 IM24.15 Describe and discuss etio-pathogenesis,
their indications, adverse events and interactions clinical presentation, identification,

34 OP7.1 Describe surgical anatomy and metabolism of the functional changes, acute care, stabilization,

lens management and rehabilitation of vision and

35 OP7.2 Describe and discuss etio-pathogenesis, stages of visual loss in elderly

maturation and complications of cataract

36 OP 7.4 Enumerate types of cataract surgery and Knowledge Based Competencies: Integration with

describe steps intraoperative and postoperative – Anatomy (AN), Physiology (PY), Pathology (PA),

complications of extracapsular cataract extraction Pharmacology (PH), & General Medicine (IM)
surgery

37 OP8.1 Discuss aetiology, pathology, clinical features and Source: National Medical Commission UG-Curriculum-Vol-

management of vascular occlusions of retina III.pdf - NMC 3

38 OP8.2 Enumerate indications for laser therapy in https://www.nmc.org.in/wp-content/uploads/2020/01/UG-

39 OP8.4 treatment of retinal diseases (including retinal Curriculum-Vol-III.pdf accessed on 18 /6/2022
detachment, retinal degenerations, diabetic
retinopathy & hypertensive retinopathy) (II) Ophthalmology Teaching/ Learning programme in

Enumerate and discuss treatment modalities in concordance to CBME is summarized below:

management of diseases of the retina Teaching learning methods would be chosen according to

40 OP8.5 Describe and discuss correlative anatomy, student patient ratio. Suggested are:

aetiology, clinical manifestations, diagnostic tests, • For Knowledge based competencies:

imaging and management of diseases of the optic

nerve and visual pathway Lecture, Small group Teaching (SGT), Structured

41 OP9.2 Classify, enumerate the types, methods of case presentations like One minute Preceptor (OMP) 4

diagnosis and indications for referral in a patient • For Skill based competencies:
with heterotropia / strabismus
DOAP (Directly observed assisted performance), Peyton
42 OP9.3 Describe role of refractive error correction in
a patient with headache and enumerate the 4 step approach5 Small group teaching (SGT), Skill lab,

indications for referral Simulated patient

43 OP9.4 Enumerate, describe and discuss causes of • For Affective domain: Movies, Role play sessions,
Shadowing, Theatre of oppressed, Brainstorming sessions
avoidable blindness and the National Programs

for Control of Blindness (including vision 2020)

44 OP9.5 Describe evaluation and enumerate the steps S.no Competency Competency Suggested Date Remarks by
Faculty
involved in stabilisation, initial management and no method of Completed

indication for referral in patient with ocular injury T/ L

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DJO Vol. 32, No. 4, April-June 2022

Teaching Sessions, Teaching/ Learning Methods & Duration (hours)

Large Group Small group teaching SGT/ SDL AETCOM Total Clinical/Field Posting

Teaching Practical’s /Tutorials Module 3.2
Need to be
incorporated 100 hours PHASE 2 - ECE during 2nd year 4 weeks duration
PHASE 3 - during 3rd year 4 weeks duration
3rd 30 hours 60 hours 10 hours
Professional Part I 30 hours 60 hours 10 hours 100 hours Total : 8 weeks

Total

(III) Assessment: Logbook Glossary:
Attempt at Competency
Name: F: First or only
Batch: R: Repeat
Roll No.: Re: Remedial
Year of Admission:
E-mail ID: Rating
Mobile No.: B: Below expectation
University Registration No.: M: Meets expectation
E: Exceeds expectation

LOGBOOK CERTIFICATE Decision of faculty:
This is to certify that the candidate Mr/ Ms...................................., C: Completed
Reg No. ..........................., admitted in the year....................................in the................ R: Repeat
....................................................Medical College, Batch roll no..................................... Re: Remedial
...and university registration no
.............................................has satisfactorily completed / has not completed all I. Clinical Case Presentations: Phase II: 2 Case presentations required
assignments /requirements mentioned in this logbook for MBBS course in the
subject of Ophthalmology during the period from S.no. Patient Name.......................... Age/ Sex .....................
......................................................... to.................................................................
She / He is / is not eligible to appear for the summative (University) assessment Diagnosis
as on the date given below.

Signature of Faculty Signature and seal Student Presenter ................................................................................
Name and Designation Head of Ophthalmology department Date.........................................................................................................
Place:
Date : Signature and seal Diagnosis
Dean of the College Principal/ Teacher’s Remarks
Reflections by student
General Instructions Faculty signature

1. The logbook is a record of academic & co-curricular activities II. Clinical Case Presentations Phase III: 2 Case presentations required
of designated student during ophthalmology posting
2. Logbook records various activities like overall participation & S.no. Patient Name.......................... Age/ Sex .....................
performance, attendance, completion of selected competencies.
Reflections of student need to be documented Diagnosis
3. The student is responsible for maintaining his/ her logbook
and getting entries verified by concerned faculty regularly. Student Presenter ................................................................................
4. Logbook must be verified by department & college, prior to Date.........................................................................................................
submitting application of students for University examination.
Diagnosis
S.no. Contents Page no.
Teacher’s Remarks
I Clinical case presentations
Reflections by student
II Competencies
Faculty signature
III Self -Directed learning
Skill Based competencies; Assessment
IV Integrated Learning Sessions
Assessment methods again would be chosen according to
There are 4 weeks of clinical posting in Second Professional and 4 weeks student patient ratio.
Suggested are:
in Third professional Part 1 • For Knowledge based competencies:
Written (Long questions, short answer questions), Objective
Rotation Phase Duration From To Faculty structured clinical examination (OSCE), Multiple choice
questions (MCQ)
(weeks) signature
• For Skill based competencies:
1st ECE (4th sem) 4 DOPS (Direct observation of procedural skills),

2nd III 4 Mini CEX, Case based discussion, Critical incident
( 3rd Prof Part I ) technique, Bed side clinics, Viva, Multisource feedback
Sent up • For Affective domain: Reflections, Portfolio,
Internal Brainstorming sessions
Assessment

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DJO Vol. 32, No. 4, April-June 2022

OP1.3 Demonstrate steps in performing visual acuity OP3.2 Demonstrate document and present correct method
assessment for distance vision, near vision, colour vision, of examination of a “red eye” including vision assessment,
pin hole test , menace and blink reflexes corneal lustre, pupil abnormality, ciliary tenderness

Date Attempt at Rating Decision Faculty Date Attempt at Rating Decision Faculty
completed competency (B/M/E) of Faculty signature completed competency (B/M/E) of Faculty signature
(C/R/Re) (C/R/Re)

OP2.2 Demonstrate symptoms &clinical signs of common OP3.8 Demonstrate correct technique of removal of foreign
conditions of lid and adnexa including Hordeolum body from eye in a simulated environment
externum/ internum, blepharitis, preseptal cellulitis,
dacryocystitis, hemangioma, dermoid, ptosis, entropion, lid Date Attempt at Rating Decision Faculty
lag, lagophthalmos completed competency (B/M/E) of Faculty signature
(C/R/Re)

Date Attempt at Rating Decision Faculty
completed competency (B/M/E) of Faculty signature
(C/R/Re)

OP3.9 Demonstrate the correct technique of instillation of
eye drops in a simulated environment

Date Attempt at Rating Decision Faculty
completed competency (B/M/E) of Faculty signature
(C/R/Re)
OP2.3 Demonstrate under supervision clinical procedures
performed in lid including: bells phenomenon, assessment
of entropion/ ectropion, perform the regurgitation test of
lacrimal sac. Massage technique in cong. Dacryocystitis &
trichiatic cilia removal by epilation

Date Attempt at Rating Decision Faculty OP4.8 Demonstrate technique of removal of foreign body
completed competency (B/M/E) of Faculty signature in cornea in a simulated environment
(C/R/Re)

Date Attempt at Rating Decision Faculty
completed competency (B/M/E) of Faculty signature
(C/R/Re)

OP3.1 Elicit document and present an appropriate
history in a patient presenting with a “red eye” including
congestion, discharge, pain

Date Attempt at Rating Decision Faculty OP3.9 Demonstrate the correct technique of instillation of
completed competency (B/M/E) of Faculty signature eye drops in a simulated environment
(C/R/Re)
Date Attempt at Rating Decision Faculty
completed competency (B/M/E) of Faculty signature
(C/R/Re)

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DJO Vol. 32, No. 4, April-June 2022

OP4.8 Demonstrate technique of removal of foreign body PY10.20 Demonstrate testing of visual acuity, colour and
in cornea in a simulated environment field of vision in volunteer/ simulated environment

Date Attempt at Rating Decision Faculty Date Attempt at Rating Decision Faculty
completed competency (B/M/E) of Faculty signature completed competency (B/M/E) of Faculty signature
(C/R/Re) (C/R/Re)

OP6.6 Identify and demonstrate clinical features and I Self Directed Learning
distinguish , diagnose common clinical conditions affecting
anterior chamber

Date Attempt at Rating Decision Faculty Phase II - 3-4 such SDL can be incorporated 6
completed competency (B/M/E) of Faculty signature Self- directed learning
(C/R/Re) Topic:
Objectives:
OP7.3 Demonstrate correct technique of ocular Task:
examination in a patient with a cataract Methodology:
Faculty
signature Reflections: Self Directed Learning

Date Attempt at Rating Decision s.no. Competency no.....................................................................
completed competency (B/M/E) of Faculty Competency detail:..............................................................
(C/R/Re)
Student Presenter..............................................Date...........................
What Happened?
So what?
What Next?
Faculty signature

OP8.3 Demonstrate correct technique of a fundus Integrated Learning Sessions
examination & describe and distinguish funduscopic
features in normal condition and in conditions causing an Summary of Integrated Learning Sessions
abnormal retinal exam
S.no Competency no. Topic Departments Date
involved

Date Attempt at Rating Decision Faculty
completed competency (B/M/E) of Faculty signature
(C/R/Re)

OP9.1 Demonstrate the correct technique to examine extra Marking scheme
ocular movements (Uniocular & Binocular)
The marking varies depending on different universities. For
Date Attempt at Rating Decision Faculty Delhi University it is as follows:
completed competency (B/M/E) of Faculty signature Internal / Formative assessment (FA): 35% marks to be
(C/R/Re) obtained by student in theory and practical to quality for
sitting in university exam.
Summative assessment (Ophthalmology paper in 3rd
Professional MMBS Part I):
Theory (60) and Practical (40). Of which 50% marks must
be obtained by student in theory and practical separately
for passing. Around 20% of FA is added to the summative
assessment.

E-ISSN: 2454-2784  P-ISSN: 0972-0200 117 Delhi Journal of Ophthalmology

DJO Vol. 32, No. 4, April-June 2022

References

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(9):855-871.

2. Premkumar K, Vinod E, Sathishkumar S. et al. Self-directed
learning readiness of Indian medical students: a mixed method
study. BMC Med Educ 18, 134 (2018). https://doi.org/10.1186/
s12909-018-1244-9

3. Medical Council of India, Competency based Undergraduate
curriculum for the Indian Medical Graduate Vol III: 81-87 , UG-
Curriculum-Vol-III.pdf - NMC
https://www.nmc.org.in/wp-content/uploads/2020/01/UG-
Curriculum-Vol-III.pdf accessed on 18 /6/2022

4. Gatewood E, De Gagne JC. The one-minute preceptor model: A
systematic review. J Am Assoc Nurse Pract. 2019 Jan;31(1):46-57

5. Nikende C, Huber J, Stiepak J et al. Modification of Peyton’s four-
step approach for small group teaching – a descriptive study.
BMC Med Educ 14, 68 (2014). https://doi.org/10.1186/1472-6920-
14-6

6. Singh T, Aulakh R, Gupta P, Chhatwal J, Gupta P. Developing
a competency-based undergraduate logbook for pediatrics:
Process and lessons. Postgrad Med 2022, 68 (1) : 31-34

Cite This Article as: Kirti Singh, Neha Rathie, Parul Jain,
Competency-Based Medical Education for The Indian Medical
Graduate: Implementation & Assessment in Ophthalmology
Delhi J Ophthalmol 2022 32 (4) 112-118.

Acknowledgments: Nil

Conflict of interest: None declared

Source of Funding: None

Date of Submission 04 June 2022
Date of Acceptance: 20 June 2022

Address for correspondence

Kirti Singh, MD, DNB, FRCS,

FAIMER, DoHA

Dir Professor of Ophthalmology
& Director GNEC State Nodal Officer
NPCB, Guru Nanak Eye Center ,
Maulana Azad Medical College
& assoc hosp.Ranjit Singh Marg,
New Delhi, India.
Email: [email protected]

E-ISSN: 2454-2784  P-ISSN: 0972-0200 118 Quick Response Code
Delhi Journal of Ophthalmology

DJO Vol. 32, No. 4, April-June 2022

E-ISSN: 2454-2784  P-ISSN: 0972-0200 119 Delhi Journal of Ophthalmology