CONTENTS Preface ........................................................................................................................................................................................ix Acknowledgments .......................................................................................................................................... x About the Executive Editors ............................................................................................................. x Introduction to Ophthalmology .................................................................................................... 1 Resources from the American Academy of Ophthalmology ..................1 Meet the Eye Care Team ...........................................................................................................................1 Eye Myths ................................................................................................................................................................... 3 1 The Eye Examination .......................................................................................................................................7 Objectives ................................................................................................................................................................... 7 Relevance ..................................................................................................................................................................... 7 Basic Information .............................................................................................................................................. 8 The Patient’s History ......................................................................................................................... 8 Ocular Anatomy ...................................................................................................................................... 9 Anatomic Aging Changes .......................................................................................................... 9 Optics ................................................................................................................................................................. 14 When to Examine ............................................................................................................................................16 Additional Tests .....................................................................................................................................16 How to Examine ................................................................................................................................................ 17 Visual Acuity .............................................................................................................................................. 17 Distance Visual Acuity Testing ........................................................................................... 17 Near Visual Acuity Testing .................................................................................................... 20 Visual Acuity Estimation in an Uncooperative Patient .................... 22 Confrontation Visual Field Testing ............................................................................. 22 Amsler Grid Testing ........................................................................................................................ 22 External Inspection .......................................................................................................................... 23 Upper Eyelid Eversion ................................................................................................................. 23 Ocular Motility Testing ................................................................................................................ 24 Pupillary Reaction Testing ..................................................................................................... 25 Anterior Chamber Depth Assessment ................................................................... 25 Intraocular Pressure Measurement ............................................................................. 26 Color Vision Testing ........................................................................................................................ 28 Fluorescein Staining of Cornea ....................................................................................... 28 Ophthalmoscopy ................................................................................................................................30 Summary of Steps in the Eye Examination ................................................................ 34 Management or Referral ...................................................................................................................... 34
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CONTENTSPainless, Acute Vision Loss Without Clear Media .....45 Painless, Acute Vision Loss With Clear Media ... Macular Degeneration ... Anatomy and Function ...
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CONTENTS
Preface ........................................................................................................................................................................................ix Acknowledgments .......................................................................................................................................... x About the Executive Editors ............................................................................................................. x
Introduction to Ophthalmology ....................................................................................................1 Resources from the American Academy of Ophthalmology ..................1 Meet the Eye Care Team ...........................................................................................................................1 Eye Myths ...................................................................................................................................................................3
1 The Eye Examination .......................................................................................................................................7Objectives ...................................................................................................................................................................7Relevance .....................................................................................................................................................................7Basic Information ..............................................................................................................................................8
The Patient’s History .........................................................................................................................8Ocular Anatomy ......................................................................................................................................9Anatomic Aging Changes ..........................................................................................................9Optics ................................................................................................................................................................. 14
When to Examine ............................................................................................................................................16Additional Tests .....................................................................................................................................16
Summary of Steps in the Eye Examination ................................................................34Management or Referral ......................................................................................................................34
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BASIC OPHTHALMOLOGY: ESSENTIALS FOR MEDICAL STUDENTSiv
Points to Remember .................................................................................................................................36Sample Problems ..........................................................................................................................................36Annotated Resources ..............................................................................................................................38
2 Acute Vision Loss ................................................................................................................................................41Objectives .................................................................................................................................................................41Relevance ...................................................................................................................................................................41Basic Information ..........................................................................................................................................42
Narrowing the Diagnosis From the History ....................................................42How to Examine ..............................................................................................................................................43
Visual Acuity Testing .....................................................................................................................43Confrontation Visual Field Testing .............................................................................43Pupillary Reactions ..........................................................................................................................43Red Reflex Evaluation and Ophthalmoscopy ...............................................44Penlight Examination ....................................................................................................................44Tonometry ...................................................................................................................................................44
How to Interpret the Findings ......................................................................................................44Acute Vision Loss Associated With Pain ............................................................44Acute Vision Loss Without Pain .....................................................................................45Painless, Acute Vision Loss Without Clear Media ...................................45Painless, Acute Vision Loss With Clear Media .............................................47Functional Disorders ..................................................................................................................... 55
Points to Remember ................................................................................................................................. 55Sample Problems ..........................................................................................................................................56Annotated Resources ...............................................................................................................................57
3 Chronic Vision Loss .........................................................................................................................................59Objectives ...............................................................................................................................................................59Relevance .................................................................................................................................................................59Basic Information ......................................................................................................................................... 60Glaucoma ................................................................................................................................................................ 60
Overview .......................................................................................................................................................63When to Examine ..............................................................................................................................66How to Examine ..................................................................................................................................66How to Interpret the Findings ..........................................................................................67Management or Referral ...........................................................................................................69
Cataract ......................................................................................................................................................................69Overview .......................................................................................................................................................70When to Examine ...............................................................................................................................72How to Examine ...................................................................................................................................73How to Interpret the Findings ...........................................................................................73Management or Referral ............................................................................................................74
Macular Degeneration ..............................................................................................................................74Overview ........................................................................................................................................................74When to Examine .............................................................................................................................. 77How to Examine .................................................................................................................................. 78
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COntEntS v
How to Interpret the Findings ..........................................................................................79Management or Referral ...........................................................................................................79The Visually Impaired Patient ............................................................................................80
Points to Remember ...................................................................................................................................81Sample Problems ............................................................................................................................................81Annotated Resources ..............................................................................................................................83
4 The Red Eye .................................................................................................................................................................87Objectives ............................................................................................................................................................... 87Relevance ................................................................................................................................................................. 87Basic Information ..........................................................................................................................................88
History ..............................................................................................................................................................88How to Examine ..................................................................................................................................88
Disorders Associated With a Red Eye .................................................................................91The Acute, Painful Red Eye ....................................................................................................91Acute, Nonpainful Red Eye ...................................................................................................93Chronic, Irritated Red Eye ......................................................................................................95Chronic Red Eye Without Irritation ...........................................................................96Adnexal Disease ..................................................................................................................................96
Further Interpretation of the Findings ..............................................................................97Symptoms of a Red Eye ...........................................................................................................97Signs of a Red Eye ...........................................................................................................................99Associated Systemic Problems ...................................................................................... 101Laboratory Diagnosis .................................................................................................................102
Management or Referral ....................................................................................................................102Blepharitis ..................................................................................................................................................103Stye and Chalazion ....................................................................................................................... 105Subconjunctival Hemorrhage ......................................................................................... 106Conjunctivitis ........................................................................................................................................ 106Therapeutic Warnings ...............................................................................................................107
Points to Remember ...............................................................................................................................107Sample Problems ....................................................................................................................................... 108Annotated Resources ..............................................................................................................................112
5 Ocular and Orbital Injuries ................................................................................................................113Objectives ...............................................................................................................................................................113Relevance .................................................................................................................................................................113Basic Information ......................................................................................................................................... 114
Anatomy and Function ............................................................................................................. 114When to Examine ..........................................................................................................................................117How to Examine ..............................................................................................................................................117
How to Examine and Interpret the Findings ...........................................................142Amblyopia Testing .........................................................................................................................143Strabismus Testing .........................................................................................................................145Other Tests ...............................................................................................................................................149
How to Examine ............................................................................................................................. 200Orbital Neoplasms ..........................................................................................................................201Inflammatory Processes of the Orbit ..................................................................203Vascular Malformations .........................................................................................................204
Points to Remember .............................................................................................................................205Sample Problems ......................................................................................................................................206Annotated Resources ..........................................................................................................................209
Pregnancy .............................................................................................................................................................219Sickle Cell Anemia ...................................................................................................................................220Thyroid Disease ...........................................................................................................................................220Sarcoidosis and Other Inflammatory and Autoimmune Conditions .............................................................................................................................................................221
10 Drugs and the Eye .......................................................................................................................................... 231Objectives .............................................................................................................................................................231Relevance ...............................................................................................................................................................231Basic Information .......................................................................................................................................233Topical Ocular Diagnostic Drugs ..........................................................................................234
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BASIC OPHTHALMOLOGY: ESSENTIALS FOR MEDICAL STUDENTSviii
Points to Remember ............................................................................................................................. 248Sample Problems ...................................................................................................................................... 248Annotated Resources ..............................................................................................................................251
Index ............................................................................................................................................................................253