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Papilledema (Coffee Table Book Page)

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I’ve been learning more about graphic design as I hope to improve my abilities to communicate and teach. One of my self-assigned “homework” assignments was to imagine a textbook designed as a “coffee table” book. You can download this page as a PDF for free below! If you’d like me to make more documents like this, send me an e-mail or reach out to me on social media!

Integrative Reviewing And Some Other Review Ideas

As we get close to another cycle of exams, deciding on how and what to review can be more challenging than the effort of reviewing.

Realistically, there is no feasible way to cram the whole of ophthalmic knowledge in the next 1-3 months to perform well on an exam. Hopefully this time is spent reviewing and solidifying knowledge we’ve accumulated previously, and not attempting to learn concepts for the first time!

So as you gear up for this next cycle of studying, here are a few ideas on how to review:

Daily Study Calendar

Among the many crazy ideas and projects I have bouncing around in my head, I’ve wanted to develop a daily study calendar.

I’ve received a lot of feedback over the years that some of the major challenges to learning ophthalmology include the overwhelming volume and the lack of overall structure in how to study the material comprehensively. Bhullar and Venkateswaran argue this in a 2022 review article (1). While there are many general reading schedules and suggested options available (some here for free!), these still only direct the learner to textbook pages, with little instruction on how and what to study.

So although this is a massive undertaking, I started thinking of how I would design a step-by-step curriculum for a pre-ophthalmology (PGY-1) or first-year ophthalmology (PGY-2) resident. My goals were to:

  • Cover all the major topics in ophthalmology at least once

  • Span around 30-35 weeks (July 1 to OKAP in mid-March is about 37-38 weeks) to allow sufficient time for review

  • Specify learning goals for each day to direct attention to important concepts and topics

  • Allot for an average daily study time of one hour on work days, 3-4 hours on the weekends (including one day off per week for either no study or unstructured study)

  • Incorporate active learning techniques such as generation, elaboration, effortful recall, spaced repetition, and interleaving

The result is a 35-week study calendar that covers the majority of ophthalmology topics 2-3 times. This allows residents who are planning on taking exams in mid-March to start studying at the beginning of July and finish the study calendar with 2-3 weeks remaining for review.

Because learning is an iterative process, the first four weeks are structured as an “introduction to ophthalmology" and covers the afferent visual pathway, eye movements, periocular anatomy and function, and intraocular anatomy and function. These fundamentals are reviewed in subsequent weeks as we dive into most common conditions in ophthalmology (ordered anatomically), and followed by a deeper dive into the “high-yield” topics in each subspecialty.

The challenge with this approach, of course, is that the textbook correlation may be more scattered and voluminous. After all, some sections may reference almost a hundred pages of textbook in a single day, which is not a really feasible prospect.

So, as an attempt to make each day’s reading more accessible (and to the level of detail I was intending), I put together a sample section to see if this would be helpful.

Let me know what you think in the comments below! You can also reach me by email at ophthreview [at] gmail [dot] com, @ophthalmologyreview on Facebook, or @ophthreview on Twitter, Mastodon (@med-mastodon.com), or Instagram.

  1. Paramjit K. Bhullar & Nandini Venkateswaran (2023) Ophthalmology Residency in the United States: The Case for a National Curriculum, Seminars in Ophthalmology, DOI: 10.1080/08820538.2022.2152713

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Binocular (Fusion) Eye Movements

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Binocular (fusion) eye movements are synchronized eye movements that help maintain a clear and steady single image despite having two eyes, 12 extraocular motility muscles, and six cranial nerves controlling everything.

My residents often consider binocular eye movement-related problems and understanding the systems governing fusion as some of the more challenging problems encountered in ophthalmology and neuro-ophthalmology. The symptoms are often vague and difficult to describe. Furthermore, assessing and describing abnormal binocular eye movements are often subtle or challenging.

While ductions (ocular rotations) and alignment are often better conceptualized, abnormalities in binocular eye movements can be just as impactful to vision as strabismus or gaze palsy.

There are six different binocular eye movements:

  • Fixation

  • Saccades

  • Smooth pursuits

  • Vestibular-ocular reflex

  • Optokinetic system

  • Vergences

While the Basic and Clinical Science Course explains these systems in detail and shows the underlying pathways that govern each system (important for localization of lesions), I typically teach residents to consider these movements based on what the eyes are doing, what the head is doing, what the object of interest is doing, and how fast the movements are. All these movements are supranuclear (that is, the signals that control these movements are initiated before the cranial nerve nuclei are activated), so diseases that cause abnormalities in these eye movements affect cortical or brainstem structures rather than peripheral nerves or muscles.

Community Preview!

We’ve had a great first month in the Ophthalmology Review Community!

The How To Learn Ophthalmology course has launched, and all 24 lessons are ready! I still have some videos to edit/upload, but the transcripts are available for viewing.

We had an awesome live session learning how to learn concepts from the BCSC Fundamentals textbook and answered some great questions - it’s inspired this month’s live session, which will discuss how to learn from our clinical encounters.

I’m currently putting together 2 new courses for the community - a 9-module, 31-lesson course on the 8-point eye exam detailing the eye exam and practical tips for learning how to perform different parts of the eye exam, and a 4-module, 24-lesson course on visual fields.

I hope to continue adding more content, both specific to ophthalmic disease and ophthalmic skills, as I work more on building up the community. I’d love to devote more time to creating these tools and resources with more support, so consider joining the community today!

Joining will get you access to these courses and all future courses, input on resources I’m creating, live sessions, archived live sessions, and direct chat with me on any questions you might have about ophthalmology, board exams, OKAP, or even getting involved in national/international societies!

As a preview, here is one of the lessons from the How To Learn Ophthalmology course:

Join The Community!

I’ve received feedback from many people wanting me to put more time and energy into my review resources- but I’ve had a couple of things hold me back:

  • Creating helpful tools is really time-consuming! Any of my more heavily-researched articles or videos may take 15-20 hours to put together. Even shorter pieces and picmonics may take me an hour or so to make. The study guides I have on the site take about 80-100 hours to put together. Since my clinical job doesn’t afford down time to work on this, it’s hard to do this in my free time, since I don’t have much of it!

  • If I were to create something more cohesive, I’d want to connect people together too. Many of my favorite memories in training come from the hours laboring together with my co-residents, and much of my professional career would not be possible without the support and encouragement from my peers.

So it got me thinking - can we create a community of trainees that are all working together to learn ophthalmology, and also provide the useful study tools and tips that people have been asking for?

After hours of planning and work, I’m happy to share this new course/community with everyone! The course is called “How To Learn Ophthalmology.” I integrate various study strategies and proven techniques to understand the process of learning ophthalmology. Along the way, we discuss various study tools, consider various applications, and work on developing a personalized study outline and schedule. I’ve completed the transcripts of every unit (24 separate lessons). I still have a few more videos to make and edit but I wanted to let everyone know about the course!

However, the course is just the beginning! Not only will you be getting access to the course (which I’ve designed primarily for the medical student or beginning resident), I am also offering monthly live sessions where I will address study techniques, review specific topics, or walk through my techniques for studying with practice questions (or anything else that might be useful). The live sessions will be archived for viewing later, too!

You’ll also be able to communicate with fellow ophthalmology trainees and share tips and resources. If I can get at least 100 people to join the community, I should be able to drop back on my clinical duties and devote even more time to developing helpful resources. We’ve got a great group already in the community, I look forward to seeing you there!

Study Methods Preferred By Ophthalmology Learners

Background

There are a wide variety of options for learning ophthalmology now. There are more textbooks and review books available now than ever before; podcasts, YouTube channels, and many other forms of media also provide new streams of innovative content.

Over the last 6-7 years since I started Ophthalmology Review, I’ve enjoyed trying different methods of developing useful content - from directly translating my notes from residency, to creating tables and picmonics, writing review articles, etc. - I’m constantly thinking of how to teach the incredible field of ophthalmology.

However, sometimes it’s hard to know exactly what people find most useful, and what may be helpful for one person may not be for another. So in my continuous search for content ideas, I wanted to know what study tools the readers of this website find most helpful.

Ophthalmology Study Topic Checklist

Check out a new resource I’ve created - a checklist that covers over 3000+ topics in ophthalmology, with page references from the latest editions of the Basic and Clinical Science Course, Review of Ophthalmology, and Kanski’s Clinical Ophthalmology! If you’re having a hard time getting started with learning/studying ophthalmology or want a handy way of making sure you’ve covered the high-yield topics in ophthalmology, this tool may be really helpful!

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Random Topic Generator

I’m happy to announce that I’ve completed a random topic generator that covers all of the various topics discussed in the AAO’s Basic and Clinical Science Course textbooks (excluding the General Medicine volume). It’s been a while since I’ve coded to this extent so this version is very basic - I’ve included all topics listed in the BCSC (including references such as glossaries and procedure instructions), and I haven’t assigned any priorities to certain topics, which means that there is theoretically an equal chance of getting keratoconus as there is getting molecular genetics testing modalities.

Eventually I’d like to prioritize topics to a certain degree, which may also take into account stage of training (a first-year resident may need to review anatomy a lot more than a recent graduate) as well as type of knowledge (how to perform surgery is probably learned hands-on rather than from a textbook).

I’m working closely with the AAO on projects similar to this, and so eventually this project may be added to one of the resources the Academy offers. Stay tuned for more developments!

If I Had To Learn Ophthalmology From The Beginning Again...

  • I would start with a topic outline

  • I would create a realistic study schedule flexible enough to allow for adjustments

  • I would study several subjects at once instead of focusing on one topic at a time

  • I would utilize practice questions to test my previous knowledge and highlight areas of focus

  • I would utilize mnemonics and other memory tools to help remember details better

  • I would read, create, and review in short bursts instead of cramming in long sessions

  • I would devise quick reviews throughout the workday instead of trying to do it all at the end of the day

  • I would set aside time at the end of each day to reflect on the patients I saw to consider useful learning points and areas of study

  • I would use textbooks as references for study instead of reading them over and over again

  • I would create useful flashcards to review throughout the day

  • I would gamify my learning to celebrate incremental gains in knowledge

(originally posted by me on Twitter)

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Localization of Third Nerve (CN3) Palsies

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CN III Syndromes.png

Understanding the associated and not-associated features of CN3 palsies can help localize the disease. Because partial CN3 palsy is often associated with other life-threatening or highly-morbid disease, urgent neuroimaging is recommended in all cases of suspected partial CN3 palsy.