Manual for eye examination and diagnosis

188 Pages·2017·397.173 MB·English

by  Mark W. Leitman

Manual for
EYE
EXAMINATION
AND DIAGNOSIS
N I N T H E D I T I O N
MARK W. LEITMAN
MD
Cornea Clear, front part of the eye
Iris Colored diaphragm that regulates amount of light entering
Aqueous Clear fluid in front part of the eye
Ciliary body Produces aqueous and focuses lens
Lens Clear, refracting media that focuses light
Vitreous Clear jelly filling the back of the eye
Sclera Rigid, white outer shell of the eye
Conjunctiva Mucous membrane covering sclera and inner lids
Retina Inner lining of the eye containing light-sensitive rods and cones
Macula Avascular area of the retina responsible for the most acute vision
Fovea A pit in the center of the macula corresponding to central fixation of vision
Choroid Vascular layer between retina and sclera
Optic nerve Transmits visual stimuli from retina to brain
Zonule Fibers suspending lens from ciliary body
Cover images: Diabetic Retinopathy © Julia Monsonego,
CRA, Wills Eye Hospital and Carl Zeiss Meditec, Inc.
Upper left corner: Normal OCT angiogram
Upper right corner: Diabetic OCT angiogram showing
microaneurysms and capillary dropout (non-profusion)
Main image: cotton-wool spots, exudates, microaneurysms,
flame hemorrhages, silver-wire arterial narrowing with dot
and blot hemorrhages
Manual for
Eye Examination
and Diagnosis
Mark W. Leitman,
MD
Clinical Assistant Professor
Department of Ophthalmology and Visual Sciences
Montefi ore Hospital
Albert Einstein College of Medicine
Bronx, NY, USA
Attending Physician
St. Peter’s Medical Center
New Brunswick, NJ, USA
NINTH EDITION
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Published simultaneously in Canada
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Library of Congress Cataloging-in-Publication Data:
Names: Leitman, Mark W., 1946-, author.
Title: Manual for eye examination and diagnosis / Mark W. Leitman.
Description: Ninth edition. | Hoboken, New Jersey : John Wiley & Sons Inc.,
[2016] | Includes bibliographical references and index.
Identifi ers: LCCN 2016003738 | ISBN 9781119243618 (pbk.) | ISBN 9781119243632
(Adobe PDF) | ISBN 9781119243625 (ePub)
Subjects: | MESH: Eye Diseases--diagnosis | Diagnostic Techniques,
Ophthalmological | Handbooks
Classifi cation: LCC RE75 | NLM WW 39 | DDC 617.7/15--dc23 LC record available at http://lccn.loc.gov/2016003738
Cover image: Julia Monsenego, CRA, Wills Eye Hospital and Carl Zeiss Meditec, Inc.
A serious student is like a seed:
with so much potential it will grow
almost anywhere it lands.
Fig. I A seed introduced into the eye of an 8 year-old boy
through a penetrating corneal wound became imbedded
in the iris. Many months later, the seed became visible
when it began germinating. Courtesy of Solomon Abel,
MD, FRCS, DOMS, andArch. Ophthalmol., Sept. 1979,
Vol. 97, p. 1651. Copyright 1979, American Medical
Association. All rights reserved.

Contents
Preface vi 5 The orbit 70
Introduction to the eye team and their Sinusitis 72
instruments vii Exophthalmos 74
Enophthalmos 74
1 Medical history 1
Medical illnesses 3 6 Slit lamp examination and glaucoma 76
Medications 4 Cornea 76
Family history of eye disease 7 Corneal epithelial disease 77
Corneal endothelial disease 82
2 Measurement of vision and Corneal transplantation
refraction 8 (keratoplasty) 84
Visual acuity 8 Conjunctiva 89
Optics 9 Sclera 96
Refraction 11 Glaucoma 97
Contact lenses 14 Uvea 111
Common problems 18 Cataracts 128
Refractive surgery 18
7 The retina and vitreous 136
3 Neuro-ophthalmology 23 Retinal anatomy 136
Eye movements 23 Fundus examination 138
Strabismus 26 Papilledema (choked disk) 140
Cranial nerves III–VIII 31 Retinal blood vessels 142
Nystagmus 35 Age-related macular degeneration 152
The pupil 41 Central serous chorioretinopathy 156
Visual field testing 44 Pseudoxanthoma elasticum 156
Color vision 47 Albinism 158
Circulatory disturbances affecting Retinitis pigmentosa 158
vision 47 Retinoblastoma 160
Retinopathy of prematurity 161
4 External structures 51 Vitreous 161
Lymph nodes 51 Retinal holes and detachments 164
Lacrimal system 51
Lids 59 Appendix 1: Hyperlipidemia 169
Lashes 62 Appendix 2: Amsler grid 171
Phakomatoses 65
Anterior and posterior blepharitis 66 Index 172
CONTENTS v
Preface
The first edition of this book was started My special appreciation goes to Johnson
when I was a medical student 44 years ago & Johnson eye care division, which pro-
during the allotted 2-week rotation in vided a generous grant to distribute the
the eye clinic. It was published during my seventh edition to 40,000 students. I spon-
first year of eye residency with assistance sored the eighth edition, and this newest
and encouragement from my chairman, ninth edition, with distribution to 69,000
Dr Paul Henkind. At that time, all intro- medical students. Many images were
ductory books were 500 pages or more generously provided by Pfizer's website,
and could not be read quickly enough to Xalatan.com, several journals, Wills Eye
understand what was going on. With this Hospital, the University of Iowa, Monte-
in mind, each word of this 175-page prac- fiore Hospital, and many colleagues. Elliot
tical manual was carefully chosen so that Davidoff, who sat next to me in medical
students understand the refraction and school, and who is now Assistant Profes-
hundreds of the most commonly encoun- sor at the Ohio State University, surprised
tered eye diseases from the onset. They me with many unsolicited contributions,
are discussed with respect to anatomy, as did medical student, Lance Lyons.
instrumentation, differential diagnosis,
This edition has been updated with 50
and treatment in the order in which they
new images. I hope you enjoy reading it
would be uncovered during the eye exam
half as much as I enjoyed writing it. I have
and are highlighted with 551 photos and
received no monetary funding from and
illustrations.
I have no association with any company
The book is meant to be read in its entirety whose products are mentioned in this
in several hours and, hopefully, impart book.
to you a foundation on which to grow
I would appreciate any recommenda-
and enjoy this beautiful and ever-chang-
tions and images that would improve
ing specialty. The popularity of previous
the next edition. You may email me at
editions has resulted in translations into
[email protected].
Spanish, Japanese, Indonesian, Italian,
Russian, Greek, Polish, and Portuguese, MARk W. LEITMAn
and an Indian reprint.
vi PREfAcE
Introduction to the eye team
and their instruments
The eye exam depends on many sophis- them in frames (laboratory optician) or fit
ticated, and costly instruments, together them on the patient (dispensing optician).
with highly trained professionals to oper- Their training and certification is highly
ate them. variable from state to state, but often
includes 2 years at a community college.
Ophthalmologist The ophthalmologist
attended 4 years of college, 4 years of med- Ocularists (BCO, BRDO, FASO) There are
ical (MD) or osteopathic (DO) school, and no schools to teach this craft. These tech-
3 years of specialty eye residency training. nicians learn by apprenticeship. They then
They may remain general ophthalmolo- have to pass tests for certification. They
gists, but now, more often than not, spend fit the scleral shell needed after removal
an additional 1–2 years subspecializing in of an eye (Fig. 395).
corneal and external disease, vitreoret-
inal disease, cataracts, glaucoma, neu- Ophthalmic technicians Ophthalmic tech-
ro-ophthalmology, oculoplastic surgery, nicians have varying degrees of licen-
pathology, pediatric (strabismus), or uve- sure. With medical supervision, they
itis. They often employ three allied health may take medical histories; measure eye
professionals. Ophthalmologists perform pressure; do refractions and visual field
all aspects of eye care. They are the sole testing; take visual activities; teach con-
professional allowed to perform laser and tact lens fitting; and perform fluores-
other ocular surgeries. There are five lasers cein angiography to study retinal blood
of different wavelengths. Argon lasers are flow. Technicians use an optical coher-
used to treat glaucoma and retinal dis- ence tomography (OCT) instrument to
ease, most commonly diabetic retinopathy. measure each layer of the eye and the
Nd:YAG lasers are usually used to open sec- blood vessels by reflecting light off the
ondary cataracts after cataract extractions intraocular structures. This requires a
and to perform peripheral iridotomies for clear medium, as opposed to ultrasound
narrow-angle glaucoma. Excimer lasers which utilizes reflective sound waves. To
reshape the cornea in the refraction proce- appreciate the precision of ophthalmic
dure called LASIK. Femtosecond lasers may testing and procedures one must realize
replace certain manual parts of routine cat- a red blood cell is 7 μm (micrometers) in
aract extractions. Carbon dioxide lasers are diameter. OCT measures 5 μm changes
utilized for dermatologic procedures. in the retinal thickness to evaluate
edema and glaucoma loss using 30,000
Optometrist (OD) The optometrist com-
A-scans per second. A surgically created
pletes 4 years of college and 4 years of
LASIK flap is 110 μm (Figs 59 and 60)
optometry school. They perform similar
and an epi-LASIK flap (Fig. 67) is only
tasks to the ophthalmologist, with the
30 μm. A-scan ultrasound measures the
exception of surgery. They may estab-
length of the eye needed to determine
lish their own practice or work for an
the power of an intraocular lens used in
ophthalmologist. Subspecialities often
cataract surgery and B-scan ultrasound
include pediatrics and low vision.
measures individual layers. Ultrasound
Opticians (ABO, American Board of Opti- is useful with opaque media that limit
cians) Opticians grind the lenses and put direct visualization or OCT testing.
INTRODUCTION TO ThE EYE TEAM AND ThEIR INSTRUMENTS vii
Dedicated to Andrea Kase
It is impossible to perform a good eye exam without a good support team. Andrea has
enthusiastically led our team for 35 years as office manager, ophthalmic technician,
and typist of all correspondence, including the last seven editions of this book. By
encouraging me to bring my collection of rocks and other objects from nature into the
waiting room, she helped create a museum that my patients look forward to seeing.