About

Editors & Authors

2ND EDITION

CHIEF AND FOUNDING EDITOR & AUTHOR

Professor Adrian T. Fung
Adrian T. Fung

BSc (Med), MBBS(Hons1), MMED (Ophthal. Sci.), MMED (Clin. Epi.) with merit, AMA(M), FRANZCO

Professor, Faculty of Medicine, Health and Human Sciences, Macquarie University
Clinical Associate Professor, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Adrian Fung is Head of the Westmead Hospital Vitreoretinal Unit and a specialist in retinal diseases. He is a Professor at Macquarie University Hospital and a Clinical Associate Professor at the University of Sydney. He holds Masters degrees in Ophthalmic Science and Clinical Epidemiology. Professor Fung has published over 100 international peer-reviewed journal articles and 7 book or book chapters. He is a Principal Investigator of the Bionic Eye Project, Golden Geographic Atrophy and Velodrome Port Delivery System trials. He is Editor for Retinal Cases and Brief Reports and Medical Retina Section Editor for Clinical and Experimental Ophthalmology. He won the RANZCO Teacher of Excellence Award in 2019 and the Macula Society Travel Grant Award in 2020.

Professor Fung is the course convenor for Ophthalmology Updates! (www.ophthalmologyupdates.com). He is an APVRS Councillor and is Chair of the RANZCO Clinical Standards Committee. He sits on the RANZCO Scientific Congress, RANZCO NSW Branch ASM, Sydney Eye Hospital Alumni, ORIA, RANZCO Clinical Standards, ANZSRS Surgical Registry, Fight Tumour Blindness and APVRS Young Ophthalmologists committees. He is a member of RANZCO, ANZSRS, ORA, AAO, ASRS, ARVO, Macula Society, Retina Society, Vit-Buckle Society, Lifeline Express International Academy, ISOO, IRGIII, IntRIS, APAO and APVRS. He is an APVRS Leadership Development Program Mentor and a RANZCO RACE Examiner.

www.dradrianfung.com.au


SENIOR EDITORS & AUTHORS

Dr Steven Yun
Steven Yun

BSc (Med), MBBS, MPhil (Med), MMed (OphthSci), FRANZCO

Conjoint Associate Lecturer, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of NSW

Dr Steven Yun is an Illawarra-based Ophthalmologist with expertise in the management of cataract, glaucoma and comprehensive ophthalmology. He received his medical training from the University of New South Wales and specialist Ophthalmology training at Sydney Eye Hospital. He was awarded the RANZCO Trevelyan-Smith scholarship to undertake a subspecialty fellowship in glaucoma and complex cataract surgery at the acclaimed Bristol Eye Hospital in the United Kingdom.

Dr Yun is widely published and has won multiple prizes presenting at local and international conferences. He was awarded a Masters of Ophthalmic Science by the University of Sydney, and a Masters of Medicine for research in retinal biology, which was funded by the prestigious Wenkart Foundation and Rebecca Cooper scholarships.

Dr Yun has a longstanding commitment to teaching the next generation of doctors and Ophthalmologists. He is a Conjoint Associate Lecturer at the University of New South Wales. One of his passions is providing volunteer medical care and these missions have taken him to Nepal, Cambodia, Vietnam and the Philippines. Dr Yun enjoys playing soccer, watching the football and cooking for his wife and daughter.

www.drstevenyun.com.au


Dr Richard Parker
Richard Parker

BMBS, MMed (OphthSc), BEHons/BCom, FRANZCO

Clinical Associate Lecturer, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Dr Richard Parker is an ophthalmic and oculoplastic surgeon.

Dr Parker completed his undergraduate studies in Sydney, followed by medical training at Flinders University, SA. He completed his general medical training at Liverpool Hospital, NSW. He completed ophthalmology training at Sydney Eye Hospital and then further training at Royal North Shore Hospital and Westmead Hospital. He completed his fellowship in oculoplastic surgery at the world-renowned Moorfields Eye Hospital, London, UK.

He holds a Masters of Medicine (Ophthalmic Science) from the University of Sydney and now is a clinical lecturer in this program. He is active in clinical research and has published in peer-reviewed journals. He has been actively involved in the training of upcoming surgeons in Australia and the UK.


Dr Dominic McCall
Dominic McCall

BSc(BioMed), MBBS, MMED (OphthSci), FRANZCO

Clinical Associate Lecturer, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Dominic McCall is a Sydney based general ophthalmologist with an interest in anterior segment pathology, international ophthalmology, and medical education. Dominic is a fellow of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO). He has a master’s degree in Ophthalmic Science from the University of Sydney. Dominic has a passion for teaching at all levels of medical and allied health education including the supervision/education of vocational trainees in ophthalmology in New South Wales, Australia. He was part of the RANZCO Glaucoma Syllabus committee, outlining clinical standards necessary for Australian and New Zealand Ophthalmology trainees to attain fellowship with the college and during his senior year of training was one of two registrars in charge of RANZCO’s clinical fellowship exam for Australia and New Zealand.

Dominic has an interest in international ophthalmology and the provision of reliable, high quality ophthalmic care to those who have limited access to it, including those in remote areas and developing nations. Since 2015, Dominic has been a member of the Foresight/Open Heart International ophthalmic team travelling to Santiago City in the Northern Philippines. Dominic is currently part of a small team, building and ensuring the ongoing provision of quality, regular ophthalmological care to the people of Norfolk Island off the east coast of Australia.


Ben Sim

MBBS, MPH, FRANZCO

Ben Sim is an ophthalmologist who is passionate about health education, medical photojournalism and global health and security. He specializes in oculoplastics and reconstructive surgery. Continually travelling the globe and observing how ophthalmology services are delivered in numerous healthcare settings, he hopes to use this ongoing learning experience to empower eye care practitioners and support under-resourced healthcare environments.


COPYWRITER

Dr Raymond Guan
Raymond Guan

B Sc(BioMed), MD

Raymond Guan is a junior doctor in Sydney currently undergoing general medical training at Nepean Hospital, NSW. Raymond completed his undergraduate degree in Brisbane with The University of Queensland and completed his medical education at The University of Sydney. Whilst undertaking his medical training he had the pleasure of participating in ophthalmology elective placements at Samsung Medical Centre, Seoul, South Korea and the Western Eye Hospital in London, UK. He is currently pursuing a Master of Clinical Epidemiology to expand his knowledge of statistics, research methods and population-based medicine, with a passion to better contribute back towards the medical profession through quality clinical research. Raymond has a keen interest in pursuing ophthalmology as a future career.


CHAPTER CO-AUTHOR

Adam Plant

MBBS, FRANZCO

1ST EDITION

CHIEF AUTHOR AND EDITOR

Adrian T. Fung

SECTION EDITORS

Helene Cass
Michael Chilov
Clare Fraser
James Leong
Angela Li
Daya Papalkar

Reviewers

Clinical Associate Professor Chameen Samarawickrama
Chameen Samarawickrama

BSc(Med) MBBS, PhD, FRANZCO

Clinical Associate Professor, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Associate Professor Chameen Samarawickrama is a corneal, anterior segment and refractive sub-specialist. He completed his ophthalmology training at Sydney Eye Hospital and undertook two cornea/anterior segment fellowships, first at the Royal Victorian Eye and Ear Hospital (Melbourne), followed by Moorfields Eye Hospital (London). Subsequently, he was appointed as a consultant in cornea and external eye diseases at Moorfields prior to his return to Sydney in 2016.

A/Prof Samarawickrama was named one of the ‘Top 5’ Young Scientists of 2019. He has made major contributions to ophthalmology research and is a leading clinician-scientist in his field. He was awarded his PhD from the University of Sydney. A/Prof Samarawickrama has authored over 60 publications in top-tier international journals. Over the course of his career A/Prof Samarawickrama has been awarded over $1.7million in research funding.

He is a regular speaker at international conferences and instructs ophthalmology trainees in cataract surgery and complex corneal and anterior segment reconstructions. A/Prof Samarawickrama is a consultant ophthalmologist at Westmead Hospital.


Clinical Associate Professor Clare L. Fraser
Clare L. Fraser

MBBS (Hons), MMed, FRANZCO

Clinical Associate Professor, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Associate Professor Clare Fraser trained at Sydney Eye Hospital, and did fellowships at Moorfields Eye Hospital (London, UK) and Emory Eye Center (Atlanta, USA). She has specialised in neuro-ophthalmology, strabismus and visual electrodiagnostics. She is a consultant Visiting Medical Officer at both Sydney Eye Hospital and Liverpool Hospital, and is also in private practice in Sydney. At the University of Sydney, she holds the title of Associate Professor of Neuro-ophthalmology.


Dr Elisa Cornish
Elisa Cornish

BMedSci (Hons1), MBBS, GradDipMed (OphthalSci), PhD

Clinical Senior Lecturer, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Elisa completed her BMedSci(Hons1), post graduate MBBS, GradDipMed(OphthalSci) and PhD at The University of Sydney. Her PhD was laboratory-based on The Development of the Primate Retina. Following this, she completed her FRANZCO training with the RANZCO NSW training scheme.

Since her training in Ophthalmology she has completed two Clinical Fellowships at Sydney Eye Hospital: the Professorial (Uveitis) and the Medical Retina Fellowships. As part of her training, she completed the ISCEV electrophysiology training course and spent time at Moorfields Eye Hospital in the Inherited Eye Disease and Clinical Genetics department, England. She is currently a member of the NSW Genomic Eye Multidisciplinary board, helping to interpret genomic data & genetic diagnosis with the aid of multimodal imaging and clinical expertise.


Dr Krishna Tumuluri
Krishna Tumuluri

BSc(Med), MBBS(Hons), MPH, FRANZCO

Clinical Senior Lecturer, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Krishna Tumuluri is an Oculoplastic surgeon working at Sydney Eye Hospital and Children’s Hospital Westmead and also works at two of the largest trauma centres in Sydney - Westmead and Liverpool Hospitals. He completed his Ophthalmology training at Sydney Eye Hospital and did three years of fellowship training at Moorfields Eye Hospital, London and Manchester Royal Eye Hospital UK. He is a clinical senior lecturer at University of Sydney and Macquarie University.


Dr Tanya Karaconji
Tanya Karaconji

BMedSci (Hons1) MBBS MMed (OphthalSc) FRANZCO

Clinical Lecturer, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Dr Karaconji is an adult and paediatric glaucoma surgeon and general ophthalmologist with expertise in the treatment of glaucoma conditions. Tanya is a Clinical Senior Lecturer at the University of Sydney and has published in peer-reviewed literature.


Dr Caroline Catt
Caroline Catt

BMBS, MMed, BMedSci (Hons), FRANZCO

Clinical Senior Lecturer, Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, University of Sydney

Dr Caroline Catt is a consultant ophthalmologist at The Children's Hospital at Westmead, and Liverpool Hospital NICU. She was the Professorial Senior Registrar at her training hospital of Sydney Eye Hospital and was awarded the Morin award for most outstanding Fellow during her subspeciality training at The Hospital for Sick Children in Toronto, Canada. She is a RANZCO clinical supervisor and examiner, and is a clinical senior lecturer with the University of Sydney.

www.drcarolinecatt.com.au

Dedication

2ND EDITION

To Cynthia and Aria, for reminding me what’s important in life every day.

1ST EDITION

To Joseph and Selina, for always being there for me,
To Ingrid, my best friend,
To my friends for all their support,
To my seniors who have shared their knowledge
and
To my juniors and patients, who teach me every day.

Foreword

2ND EDITION

It is always humbling when one is asked to write the foreword to a book. This book especially so because many of the contributors are ophthalmologists I know and have worked with at various stages of their career. People I am honoured to have as colleagues.

The advances in ophthalmology in the last four decades have been phenomenal and so much is possible today that would never have been dreamed of when I started my ophthalmic journey. Some basic rules, however, have not changed and one of them is the fact that a structured history and proper examination are as relevant today as they have always been.

This book is a serious update from its previous version and covers a lot more ground than before. While intended to assist and prepare the reader for the practical examinations conducted in Australia and New Zealand in their journey towards a Fellowship of the Royal Australian and New Zealand College of Ophthalmologists, this manual is equally relevant for exit examinations all over the world. In addition, the methodology of ocular and adnexal examination highlighted in the book, if adopted properly, will be relevant in clinical practice for the rest of one’s professional life.

Ophthalmic teachers, registrars, medical students and clinicians will find it a useful e-source and ready reckoner. The authors have decided to make this universally available as a web book at no cost to the user. This generous gesture will go a long way in making high quality educational materials such as this one easily accessible, affordable and will enhance educational standards worldwide.

Many hours of hard work have been put in to make the Westmead Eye Manual a reality. I would like to commend A/Prof Adrian Fung, Dr Richard Parker, Dr Ben Sim, Dr Dominic McCall, Dr Steven Yun and the many contributors for producing this high quality, practical manual which will remain a reference for eye examinations for many generations of ophthalmic practitioners for many years to come.

Black lines
Clinical Professor Nitin Verma AM,OTL,CStJ

President, RANZCO
Honorary Consul for Timor Leste
Hospitaller St. John, Australia
Clinical Professor University of Tasmania
Clinical Associate Professor University of Sydney

1ST EDITION

It is a privilege to be asked to write the foreword for this timely and extremely useful book “Ophthalmic Clinical Examination”, which has been written by my former Senior Registrar Adrian Fung, and edited by a large number of Ophthalmology Registrars who have trained at Sydney Eye Hospital. Additionally, there are contributions from consultant ophthalmologists and from other disciplines.

This book fills a much-needed gap in the ophthalmic education literature. Ophthalmology is an extremely practical hands-on specialty, which depends critically on the ability to carefully and thoroughly examine the eye.

As ophthalmologists, we are fortunate that ocular pathology and abnormalities can be seen, photographed and imaged in many ways to facilitate diagnosis. Despite this, the core of our clinical acumen revolves around our ability to perform an efficient, detailed and accurate ocular examination. This book addresses techniques of physical examination in a meticulous, carefully thought out and well illustrated manner. It is detailed enough for those completing their training, whilst approachable enough for those learning the basics.

I would recommend this book without hesitation to all eye trainees. Ophthalmology residents, registrars, fellows, and even consultants and attendings will find many useful tips and reminders.

Enjoy this wonderful compendium of ophthalmic examination techniques.

Black lines
Professor Peter McCluskey

Director, Save Sight Institute
Professor of Clinical Ophthalmology
Sydney Eye Hospital

Preface

2ND EDITION

It has been over ten years since I first wrote “Ophthalmic Clinical Examination”. The book was designed to summarise the steps ophthalmologists need to perform when examining a patient. I’m proud that it has become such a success and loved by trainees around the world.

The second edition of this text represents a significant update of the original text. My primary original motivation was twofold: to incorporate advances in ophthalmic knowledge and technology and to involve the next generation of authors to share their expertise. Since the majority of the authors have trained at Westmead Hospital, Sydney, it was only natural to call this Second Edition “Westmead Eye Manual”. Critically, the manuscript will be available online so that it is accessible to anyone, anywhere.

All the chapters have been updated and reviewed by both recent graduates and senior consultants. A new Uveitis chapter has been added to consolidate the approach required when an inflammatory ocular disorder is encountered. The chapter on Preparing for the Examination has been extensively revised. Consent Scripts have been added for a wider range of procedures, and a new Clinical Trials Summary chapter has been added to give readers a concise summary of the trials that, in the authors’ opinion, are most important in informing current practice.

The aim of this text remains unchanged: to consolidate the experience of the authors’ into a single volume that can be help ophthalmologists improve their clinical examination skills. Although it will be extremely useful for trainees preparing for their examinations, it is much more than that. Qualified and training ophthalmologists, medical students, orthoptists, optometrists, ophthalmic nurses, neurologists, emergency physicians and general practitioners will all benefit from the summaries of examinations, lists and examples of diagnoses, and clinical reasoning, contained herein.

I hope that you find clinical ophthalmology as exciting as I do and hope this “book” can help you to make the lives of our patients that little bit better.

Adrian T Fung, 2021

1ST EDITION

This book has been written for anyone interested in ophthalmic clinical examination. My aim has been to write a book with sufficient detail for a general ophthalmologist, whilst being approachable enough for those with minimal ophthalmic experience. It has particularly been targeted at residents/registrars who are about to sit their exit clinical examinations, including the:

  • Royal Australian and New Zealand College of Ophthalmology (RANZCO) Advanced Clinical Examination (RACE)
  • Fellow of Royal College of Ophthalmology (FRCOphth) Part 2 (practical component) Examination;
  • Fellow of the Royal College of Surgeons of Edinburgh Ophthalmology (FRCSEd (Ophth)) Part 3 (clinical skills certificate) and Part 4 (final) Examinations
  • Fellow of Royal College of Physicians and Surgeons of Glasgow Ophthalmology (FRCSGlas (Ophthalmology)) Part 3 (structured oral and clinical) Examination
  • Associate Fellowship of the Royal College of Surgeons in Ireland Ophthalmology (AFRCSI Ophth.) Part 3 (clinical) Examination
  • and the American Board of Ophthalmology Oral Examination

Despite this, junior residents and registrars, medical students, orthoptists, ophthalmic technicians, optometrists, nurses, family physicians and ophthalmologists wanting revision will all find it useful. This book has been designed to be concise enough for trainees to carry with them in clinics. It is not intended to be a comprehensive textbook on ophthalmic disease and management, for which several excellent texts already exist.

There is no single method for examining an eye. The approach herein has provided a practical, simple and time efficient method for the author, but in no means is it the only way. I encourage you to use this book as a guide, and perfect your own clinical ophthalmic examination technique.

Adrian T Fung, 2010

Acknowledgements

This book would not have been possible without the assistance of the following people, who generously donated their expertise, time and resources:

  • Westmead Hospital, Sydney for their Support
  • The Royal Australian and New Zealand College of Ophthalmologists for their support. In particular: Nitin Verma, Kiran Sindhu, Maria Moon, Justin Mora, David Andrews
  • The University of Sydney
  • Macquarie University Hospital
  • The Sydney Eye Hospital Foundation and Save Sight Institute for assistance in funding the medical diagrams and illustrations (1st Edition)
  • Professor Peter McCluskey (Director, Save Sight Institute), Dr Justin Playfair (President, Sydney Eye Hospital Foundation) and Dr Pauline Rumma (Director of Clinical Services, Sydney Eye Hospital) for their support. Professor Peter McCluskey also for contributing photos of patients that we have managed together
  • The Royal Prince Alfred Hospital Ophthalmology (Dr Simon Liew) and Audio-Visual (Imelda Brewster, Anthony Butler) Departments for assistance with diagrams
  • Marcus Cremonese for assistance with illustrations
  • George Jang for assistance with the cover
  • Professor John Grigg for the following photos: Follicles, papillae, keratoglobus, leucocoria, pterygium, Bulls eye maculopathy (Batten disease), choroidal folds and crystalline retinopathy
  • Dr Ross Fitzsimmons and Kristen Saba for the tables on strabismus and accommodative exotropia and the following photos: Accommodative esotropia, Duane syndrome, and CNIV palsies
  • Professor Gerard Sutton for corneal topographic images
  • Gordon Sanderson for assistance with the refraction chapter
  • Dr Raf Ghabrial for the following images: Lacrimal gland pleomorphic adenoma, entropion, melanoma of the lower eyelid and mechanical ectropion
  • Dr Simon Taylor for comments on the ptosis, ectropion and entropion chapters
  • Dr John Gregory-Roberts and the Retinal Unit, Sydney Eye Hospital for permission to use OCT and fundus fluorescein angiography images
  • Associate Professor Alex Hunyor for the following images: Bullous rhegmatogenous retinal detachment, proliferative vitreoretinopathy, high-water marks, B-scans (vitreous haemorrhage with tear, choroidal effusion, suprachoroidal haemorrhage, posterior scleritis with serous retinal detachment)
  • Associate Professor Samantha Fraser-Bell for the following image: Bulls eye maculopathy (Stargardt disease)
  • Dr Michael Chilov for the following images: Thyroid orbitopathy (CT), CMO (FFA), Diabetic retinopathy (FFA), CNV (OCT)
  • Dr David Maberley for the following image: Sub-macular haemorrhage
  • Dr Ridia Lim for the following images: OCT of optic discs, glaucomatous optic disc, inferotemporal retinal nerve fibre layer defect, retinal nerve fibre layer (Drance) haemorrhage, End-stage glaucomatous field, clover-leaf artefact field, inferior hemifield defect, enlarged blindspot
  • Li Qi (Deborah) Rong for the following Humphrey Visual Fields: Superior quadrantinopia, homonymous hemianopia, bitemporal hemianopia, and superior altitudinal hemifield defect
  • Raj Devasahayam for confocal microscopy images
  • Radiology Department, Royal Prince Alfred Hospital Sydney for some of the CT and MRI images
  • Dr Jason Yeo for advice on the radiology chapters
  • Chantelle Palmer
  • Dr Mitchell Lawlor for advice on photography
  • Drs Simon Skalicky, Matt Simunovic and Dov Hersh for modelling photos in visual fields to confrontation and B-scan ultrasonography
  • All the patients who generously consented to publication of their image

          

All rights reserved. No part of this publication which includes all images and diagrams may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the authors, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.

Vitreoretinal Surgery Online
This open-source textbook provides step-by-step instructions for the full spectrum of vitreoretinal surgical procedures. An international collaboration from over 90 authors worldwide, this text is rich in high quality videos and illustrations.

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