International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist: Chapter 6. Cornea, External Diseases and Refractive Surgery

Basic Level Goals: PGY-2

A. Cognitive Skills

Describe the basic anatomy, embryology, physiology, pathology, microbiology, immunology, genetics, epidemiology, and pharmacology of the cornea, conjunctiva, sclera, eyelids, lacrimal apparatus, and ocular adnexa.
Describe congenital abnormalities of the cornea, sclera, and globe (e.g., Peter's anomaly, microphthalmos, birth trauma, buphthalmos).
Describe characteristic corneal and conjunctival degenerations (e.g., pterygium, pinguecula, senile plaques of the sclera, keratoconus).
Recognize the common corneal dystrophies and degenerations (e.g., map-dot-fingerprint dystrophy, Meesman dystrophy, Reis-Buckler's dystrophy, Francois syndrome, Schnyder's crystalline dystrophy, congenital hereditary stromal dystrophy, lattice dystrophy, granular dystrophy, macular dystrophy, congenital hereditary endothelial dystrophy, Fuchs' dystrophy, posterior polymorphous dystrophy, Salzmann's degeneration).
Recognize the common corneal inflammations and infections (e.g., herpes simplex, herpes zoster, syphilis, interstitial keratitis).
Understand the fundamentals of corneal optics and refraction (e.g., keratoconus).
Describe the fundamentals of ocular microbiology and recognize corneal and conjunctival inflammations and infections (e.g., Staphylococcal hypersensitivity, simple microbial keratitis, trachoma, ophthalmia neonatorum, herpes zoster ophthalmicus, herpes simplex keratitis and conjunctivitis).
Recognize the basic presentations of ocular allergy (e.g., phlyctenules, seasonal hay fever, vernal conjunctivitis, allergic and atopic conjunctivitis, giant papillary conjunctivitis).
Recognize and treat lid margin disease (e.g., Staphylococcal blepharitis, meibomian gland dysfunction).
Describe the features of, diagnose, and treat (or refer) vitamin A deficiency (e.g., Bitot's spot, dry eye, slowed dark adaptation) and neurotrophic corneal disease.
Describe the basic differential diagnosis of acute and chronic conjunctivitis or "red eye" (e.g., scleritis, episcleritis, conjunctivitis, orbital cellulitus, gonococcal and chlamydial conjunctivitis).
Describe the basic mechanisms of traumatic and toxic injury to the anterior segment (e.g., alkali burn, lid laceration, orbital fracture, etc.).
Understand the mechanisms of ocular immunology and recognize the external manifestations of anterior segment inflammation (e.g., red eye associated with acute and chronic iritis).
Describe the basic principles of ocular pharmacology of anti-infective, anti-inflammatory and immune modulating agents (e.g., indications and contraindications for topical corticosteroids, non-steroidal anti-inflammatory agents, and antibiotics).
Recognize corneal lacerations (perforating and non-perforating), pterygia that may require surgery, corneal and conjunctival foreign bodies.
Diagnose and treat corneal exposure (e.g., lubrication, temporary tarsorrhaphy).
Describe the epidemiology, differential diagnosis, evaluation and management of common benign and malignant lid lesions, including pigmented lesions of the conjunctiva and lid (e.g., nevi, melanoma, primary acquired melanosis)
Describe the epidemiology, classification, pathology, indications for surgery, and prognosis of common malpositions of the eyelids (e.g., blepharoptosis, trichiasis, distichiasis, essential blepharospasm, entropion, ectropion) and understand their relationship to secondary diseases of the cornea and conjunctiva (e.g., exposure keratopathy).
Recognize and describe the treatment for a chemical burn (e.g., types of agents, medical therapy).
Recognize and describe the etiologies of hyphema and microhyphema.
Describe the etiologies and treatment of superficial punctate keratitis (e.g., dry eye, Thygeson's superficial punctate keratopathy), blepharitis, toxicity, ultraviolet photokeratopathy, contact lens related).
Describe the symptoms and signs, testing and evaluation for, and treatment of exposure keratopathy and dry eye (e.g., Schirmer testing).
Recognize the anterior segment manifestations of systemic disease (e.g., Wilson's disease) and pharmacologic side effects (e.g., amiodarone vortex keratopathy).
Recognize, list the differential diagnosis, and evaluate aniridia and other developmental anterior segment abnormalities (e.g., Axenfeld's, Rieger's, Peters' anomalies and related syndromes).
Recognize and treat pyogenic granuloma.

B. Technical/Surgical Skills

Perform external examination (illuminated and magnified) and slit lamp biomicroscopy, including drawing of anterior segment findings.
Administer topical anesthesia, as well as special topical stains of the cornea (e.g., fluorescein dye and rose bengal).
Perform simple tests for dry eye (e.g., Schirmer test).
Perform punctal occlusion (temporary or permanent) or insert plugs.
Perform simple corneal sensation testing (e.g., cotton tip swab).
Perform tonometry (e.g., applanation, tonopen, Schiotz, pneumotonometry).
Perform techniques of sampling for viral, bacterial, fungal, and protozoal ocular infections (e.g., corneal scraping and appropriate culture techniques).
Perform and interpret simple stains of the cornea and conjunctiva (e.g., culture techniques, culture media, Gram stain, Giemsa stain, calcofluor white, acid fast).
Manage corneal epithelial defects (e.g., pressure patching and bandage contact lenses).
Perform removal of a conjunctival or corneal foreign body (e.g, rust ring).
Perform primary pterygium excision.
Perform an isolated lid laceration repair.
Perform an isolated corneal laceration repair (e.g., linear laceration not extending to limbus).
Perform epilation.
Perform a lateral tarsorrhaphy.
Incise/drain or remove a primary chalazion/stye.
Perform a simple incisional or excisional biopsy of a lid lesion.
Perform irrigation of chemical burn to the eye.
Treat hyphema and microhyphema (e.g., and the complications of increased intraocular pressure and rebleeding).

Standard Level Goals: PGY-3

A. Cognitive Skills

Describe the more complex anatomy, embryology, physiology, pathology, microbiology, immunology, genetics, epidemiology, and pharmacology of the cornea, conjunctiva, sclera, eyelids, lacrimal apparatus, and ocular adnexa.
Describe the more complex congenital abnormalities of the cornea, sclera, and globe (e.g.,hamartomas and choristomas).
Describe, recognize, evaluate, and treat peripheral corneal thinning (e.g., inflammatory, degenerative, dellen-related, infectious, immunologic).
Recognize common conjunctival neoplasms (e.g., benign, malignant tumors).
Recognize and treat less common corneal or conjunctival presentations of degenerations (e.g., inflamed, atypical or recurrent pterygium, band keratopathy).
Describe the epidemiology, differential diagnosis, evaluation, and management of Bitot's spots.
Describe the differential diagnosis, evaluation, and management of Thygeson's superficial punctate keratopathy.
Understand more complex corneal optics and refraction (e.g., irregular astigmatism).
Correlate the concordance of the visual acuity with the density of media opacity (e.g., cataract) and to evaluate the etiology of discordance between acuity and findings from examination of the media.
Describe more complex ocular microbiology and describe the differential diagnosis of more complicated corneal and conjunctival infections (e.g., complex, mixed or atypical bacterial fungal, Acanthamoeba, viral, or parasitic keratitis).
Describe differential diagnosis, evaluation, and treatment of interstitial keratitis (e.g., syphilis, viral diseases, non-infectious, immunologic, inflammation).
Describe more complex differential diagnosis of the "red eye" (e.g., autoimmune and inflammatory disorders causing scleritis, episcleritis, conjunctivitis, orbital cellulitis).
Describe key features of trachoma, including epidemiology, clinical features and staging, and its complications (e.g, cicatricization), prevention (e.g., facial hygiene), and topical and systemic antibiotic treatment (especially in hyperendemic regions) and surgery (e.g., tarsal rotation).
Describe more complex mechanisms of traumatic and toxic injury to the anterior segment (e.g., long-term sequelae of acid and alkali burn, complex lid laceration involving the lacrimal system, full-thickness laceration).
Describe the differential diagnosis and the external manifestations of more complex anterior segment inflammation (e.g., acute and chronic iritis with and without systemic disease).
Describe the more complex principles of ocular pharmacology of anti-infective, anti- inflammatory and immune modulating agents (e.g., use of topical non-steroidal and steroidal agents, topical cyclosporine).
Recognize and treat corneal lacerations (perforating and non-perforating).
Recognize and treat large, recurrent, or atypical pterygia that may require surgery.
Describe and treat corneal and conjunctival foreign bodies.
Diagnose and treat severe corneal exposure (e.g., lubrication, temporary tarsorrhaphy)
Recognize and treat common and uncommon benign and malignant lid lesions.
Recognize and treat common malpositions of the eyelids (e.g., entropion, ectropion, and ptosis) as they apply to secondary corneal disease.
Recognize and treat recurrent corneal erosions.
Recognize and treat foreign body, animal, and plant substance injuries.
Recognize and treat more complex hyphemas (e.g., surgical indications).
Recognize, evaluate, and treat chronic conjunctivitis (e.g., chlamydia, trachoma, molluscum contagiosum, Parinaud's oculoglandular syndrome, ocular rosacea).
Describe the clinical features, pathology, evaluation, and treatment of ocular cicatricial pemphigoid.
Recognize, evaluate, and treat the ocular complications of severe diseases, such as chronic exposure keratopathy, contact dermatitis, and Stevens-Johnson syndrome.
Describe the epidemiology, clinical features, pathology, evaluation, and treatment of peripheral corneal thinning or ulceration (e.g., Terrien's marginal degeneration, Mooren's ulcer, rheumatoid arthritis-related corneal melt).

B. Technical/Surgical Skills

Perform more advanced techniques, including keratometry, keratoscopy, endothelial cell count and evaluation, specular microscopy, and pachymetry.
Perform stromal micropuncture.
Perform application of corneal glue.
Assist in more complex corneal surgery (e.g., penetrating keratoplasty and phototherapeutic keratectomy).
Perform more advanced tests for dry eye (e.g., modified Schirmer tests, Examination of tear break-up time, fluorescein dye testing, rose bengal dye).
Perform more complex pterygium excision, including conjunctival grafting.
Perform more complex lid laceration repair.
Perform manual superficial or lamellar keratectomy.
Perform more complex corneal laceration repair (e.g., stellate perforating laceration).
Repair simple lacerations of the lacrimal drainage apparatus (e.g., perform intubations and primary closure).

Advanced Level Goals: PGY-4

A. Cognitive Skills

Describe the most complex anatomy, embryology, physiology, histopathology, microbiology, immunology, genetics, epidemiology, and pharmacology of the cornea, conjunctiva, sclera, eyelids, lacrimal apparatus, and ocular adnexa.
Describe the most complex and less common congenital abnormalities of the cornea, sclera, and globe (e.g., cornea plana, keratoglobus).
Recognize common and uncommon corneal and conjunctival neoplasms, dystrophies and degenerations (e.g., lattice dystrophy).
Understand the most complex corneal optics and refraction (e.g., post-keratoplasty).
Describe less common and rare ocular infections and describe the differential diagnosis of the most complicated corneal and conjunctival infections (e.g., amoebas, leishmaniasis, nematodes).
In non-endemic areas, describe the basic features of onchocerciasis.
In endemic areas, define the etiology, vector (e.g., black fly), and incidence, diagnostic features (e.g., microfiliariae, keratitis, iritis), diagnosis (e.g., skin snip test), course and prognosis, treatment (e.g., ivermectin, nodulectomy), and prevention (e.g., vector control, environmental and behavioral changes) of oncocerciasis.
Describe the most complex differential diagnosis of the ''red eye" (e.g., pemphigoid, pemphigus, Stevens Johnson syndrome).
Diagnose and treat the most complex traumatic and toxic injuries to the anterior segment (e.g., total lid avulsion, severe alkali burn).
Describe the differential diagnosis and the external manifestations of the most complex or uncommon anterior segment inflammations (e.g., syphilitic keratouveitis).
Describe the most complex principles of ocular pharmacology of anti-infective, anti-inflammatory and immune modulating agents (e.g., combination therapies of antiviral and anti-inflammatory agents).
Recognize and treat complex corneal lacerations (e.g., lacerations extending beyond the limbus).
Diagnose and treat the most severe corneal exposure cases (e.g., conjunctival flap).
Understand ocular surface transplantation, including conjunctival autograft/flap, amniotic membrane transplantation, limbal stem cell transplantation.
Understand the surgical indications (e.g., Fuchs' dystrophy, aphakic/pseudophakic bullous keratopathy), surgical techniques, and recognition and management of postoperative complications (especially immunologically-mediated rejection) of corneal transplantation (e.g, penetrating, lamellar).
Understand the preoperative Examination, patient selection, surgical management, and postoperative care of refractive surgical techniques, including keratotomy (radial, astigmatic), photoablation (photorefractive, phototherapeutic, LASIK), corneal wedge resection, thermokeratoplasty, intracorneal rings, phakic intraocular lens and clear lens extraction.

B. Technical/Surgical Skills

Perform and interpret the most advanced corneal techniques (e.g., pachymetry, endothelial microscopy, computerized corneal topography).
Understand and perform specialized and complicated contact lens fitting (e.g., post-keratoplasty).
Perform more complex corneal surgery (e.g., penetrating or lamellar keratoplasty, keratorefractive procedures and phototherapeutic keratectomy).
Repair complex entropion and ectropion.
Perform a thin conjunctival flap (e.g., Gunderson flap).
Perform other complex conjunctival surgery (e.g., autograft, stem cell transplant).
Perform basic non-laser refractive surgery techniques (e.g., relaxing keratotomy).
Manage and treat more complex neoplasms of the conjunctiva (e.g., carcinoma, melanoma).