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I Ophthalmology A Short Textbook Gerhard K. Lang, M. D. ProfessorandChairman DepartmentofOphthalmologyand UniversityEyeHospitalUlm Germany Withcontributionsby J.Amann,M.D. O.Gareis,M.D. GabrieleE.Lang,M.D. DorisRecker,M.D. C.W.Spraul,M.D. P.Wagner,M.D. 305Illustrations Thieme Stuttgart· NewYork2000 Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. II LibraryofCongressCataloging-in-Publica- Important Note: Medicine is an ever- tionData changing science undergoing continual development. Research and clinical Lang,GerhardK. experiencearecontinuallyexpandingour [Augenheilkunde.English] knowledge,inparticularourknowledgeof Ophthalmology:ashorttextbook/ propertreatmentanddrugtherapy.Insofar GerhardK.Lang;withcontributionsby asthisbookmentionsanydosageorappli- J.Amann...[etal.].p.;cm.Includesbiblio- cation,readersmayrestassuredthatthe graphicalreferencesandindex. authors,editors,andpublishershavemade ISBN3131261617 everyefforttoensurethatsuchreferences 1.Eye-Diseases.2.Ophthalmology. areinaccordancewiththestateofknowl- I.Amann,J.(Josef)II.Title. edgeatthetimeofproductionofthebook. [DNLM:1.EyeDiseases. Nevertheless this does not involve, WW40L269a2000a] imply, or express any guarantee or RE46.L34132000 responsibilityonthepartofthepublishers 617.7–dc21 00-032597 inrespectofanydosageinstructionsand forms of application stated in the book. Everyuserisrequestedtoexaminecare- Studentcontributors: fully the manufacturers’ leaflets accom- ChristopherDedner,Tübingen panyingeachdrugandtocheck,ifneces- UtaEichler,Karlsruhe sary in consultation with a physician or HeidiJaneczek,Göttingen specialist, whether the dosage schedules BeateJentzen,Husberg mentionedthereinorthecontraindications MathisKayser,Freiburg statedbythemanufacturersdifferfromthe KerstinLipka,Kiel statementsmadeinthepresentbook.Such MarenMolkewehrum,Kiel examinationisparticularlyimportantwith AlexandraOgilvie,Munich drugsthatareeitherrarelyusedorhave PatriciaOgilvie,Würzburg beennewlyreleasedonthemarket.Every StefanRose,Oldenburg dosagescheduleoreveryformofapplica- tionusedisentirelyattheuser’sownrisk TranslatedbyJohnGrossman,Berlin, and responsibility. The authors and pub- Germany lishersrequesteveryusertoreporttothe publishers any discrepancies or inaccura- Thisbookisanauthorizedtranslationofthe ciesnoticed. Germaneditionpublishedandcopyrighted 1998 by Georg Thieme Verlag, Stuttgart, Someoftheproductnames,patents,and Germany. registereddesignsreferredtointhisbook are in fact registered trademarks or pro- DrawingsbyMarkusVoll,Fürstenfeldbruck prietarynameseventhoughspecificrefer- encetothisfactisnotalwaysmadeinthe text.Therefore,theappearanceofaname !2000GeorgThiemeVerlag withoutdesignationasproprietaryisnotto Rüdigerstraße14 be construed as a representation by the D-70469Stuttgart,Germany publisherthatitisinthepublicdomain. ThiemeNewYork,333SeventhAvenue Thisbook,includingallpartsthereof,is NewYork,N.Y.10001U.S.A legally protected by copyright. Any use, exploitation,orcommercializationoutside TypesettingbyDruckhausGötzGmbH, thenarrowlimitssetbycopyrightlegisla- Ludwigsburg tion, without the publisher’s consent, is PrintedinGermanyby illegal and liable to prosecution. This Appl,Wemding appliesinparticulartophotostatreproduc- tion,copying,mimeographingorduplica- tionofanykind,translating,preparationof ISBN3-13-126161-7 (GTV) microfilms,andelectronicdataprocessing ISBN0-86577-936-8 (TNY) 1 2 3 4 5 andstorage. Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. III The Concept of the Book in Brief . . . Definition:Theconceptbehindthisbookwastoorganizecontentandlayout accordingtoauniformstructure.Thisenhancestheclarityofthepresenta- tionandallowsthereadertoaccessinformationquickly.Eachchapterhasits ownheadericon,whichisshownoneverypageofthechapter. Figureheadingssummarizethekeyinformationpresentedintherespective figure,eliminatingtheneedforthereadertoreadthroughtheentirelegend. Epidemiology: In the absence of precise epidemiologic data, the authors statewhetherthedisorderiscommonorrarewhereverpossible. Etiology:Thissectionusuallycombinesinformationabouttheetiologyand pathogenesisofadisorderandinsodoinghelpstoilluminateimportantrela- tionships. Symptoms and diagnostic considerations: These items are usually dis- cussedseparately.Thesectiononsymptomsincludesonlythephenomena withwhichthepatientpresents.Howandbywhichmethodstheexaminer proceedsfromthesesymptomstoadiagnosisisonlydiscussedunderdiag- nosticconsiderations. Sections highlighted with an exclamation mark contain important facts.Thesemaybefactsthatoneisoftenrequiredtoknowforexami- nations,ortheymaybepracticaltipsthatarehelpfulindiagnosingand treatingthedisorder. Differential diagnosis: Wherever possible, this section discusses not only other possible diagnoses but also important criteria for differentiating the disorderfromothers. Treatment:Thissectiongoesbeyondmerelydocumentingallpossiblether- apeuticoptions.Italsoexplainswhichtherapeuticmeasuresareadvisable andofferaprospectofsuccess.Thediscussionofmedicaltreatmentocca- sionallyincludesdosageinformationandexamplesofpreparationsused.This isdonewheresuchinformationisrelevanttocasesstudentswillencounterin practice.Thetradenamesspecifieddonotrepresentacomprehensivelisting. Prognosis and clinical course: The further development of the book dependsinnosmallmeasureonyourcriticism.Wearehappytoreceiveany suggestionsforimprovementsasthiswillhelpustailorthenexteditionto bettersuityorneeds.Pleaseusetheenclosedpostcard. Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. IV Authors GerhardK.Lang,M.D. ProfessorandChairman,UniversityEyeHospital,Ulm, Germany J.Amann,M.D. Researchassistant,UniversityEyeHospital,Ulm O.Gareis,M.D. Seniorphysician,UniversityEyeHospital,Ulm GabrieleE.Lang,M.D. Director,DepartmentofMedicalRetinaandLaserSurgery, UniversityEyeHospital,Ulm DorisRecker Orthoptist,UniversityEyeHospital,Ulm C.W.Spraul,M.D. Seniorphysician,UniversityEyeHospital,Ulm P.Wagner,M.D. Chiefofmedicalstaff,UniversityEyeHospital,Ulm Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. V Preface WhenmycoworkersandIfirsttookupthetaskofwritingatextbookof ophthalmologythatwasaimedatmedicalstudentsbutwouldalsobesuita- bleforinternsandophthalmologyresidents,wedidnotknowexactlywhat weweregettingourselvesinto.Thenextfouryearsweredevotedtointensive studyofthissubject.Wedidnotmerelyintendtodesignabookaccordingto themaxims“understanditinmedicalschool,”“learnitfortheexamination,” and“useitduringyourinternship.”Ourbroadergoalwastogivestudentsa textbookthatwouldkindletheirinterestandindeedtheirenthusiasmfora “small”specialtylikeophthalmologyandthatwouldsustainthisenthusiasm allthewaythroughasuccessfulexamination.Inanageinwhichteachingis undergoingevaluation,wefeltthiswasparticularlyimportant.Inpursuing thisadmittedlyambitiousgoal,wewereabletodrawuponmanyyearsof teaching experience. This experience has shaped the educational concept behindthisbookandmanifestsitselfindetailssuchasthelayout,whichis characterizedbynumerousphotographsandillustrativedrawings.Wehave placedspecialemphasisonthefiguresinparticular.Theseillustrationsmake ophthalmology come alive and hopefully will be able to imbue the reader with some of the enthusiasm that the authors themselves have for their specialty. Iwouldliketotakethisopportunitytooffermyheartfeltthankstomy teacher,Prof.Dr.Dr.hcG.O.H.Naumann,Erlangen,Germany,forhissugges- tionsandfortheslidesfromthecollectionoftheDepartmentofOphthal- mology and University Eye Hospital, Erlangen. I would also like to offer specialthankstomycoauthors,Dr.JosefAmann,Dr.OskarGareis,Prof.Dr. GabrieleE.Lang,DorisRecker,Dr.ChristophSpraul,andDr.PeterWagnerfor theirharmoniouscooperationandexceptionalinitiativeinwritingthisbook. I also thank Dr. Eckhard Weingärtner for his assistance in compiling the Appendix. IwouldalsoliketoextendspecialthankstoDr.JürgenLüthjeandSabine BartlofGeorgThiemeVerlag,whoseprofessionalismandactiveandtireless supportwereaconstantsourceofinspirationtousall.Iwouldagainliketo thankMarkusVoll,Fürstenfeldbruck,Germany,forhissplendidillustrations. Ulm,Germany,Summer2000 GerhardK.Lang Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. VI Table of Contents 1 TheOphthalmicExamination ...1 (GabrieleE.Lang,GerhardK.Lang) 1.1 Equipment ...1 1.2 History ...3 1.3 VisualAcuity ...4 1.4 OcularMotility ...5 1.5 BinocularAlignment ...6 1.6 ExaminationoftheEyelidsandNasolacrimalDuct ...7 1.7 ExaminationoftheConjunctiva ...7 1.8 ExaminationoftheCornea ...10 1.9 ExaminationoftheAnteriorChamber ...11 1.10 ExaminationoftheLens ...12 1.11 Ophthalmoscopy ...13 1.12 ConfrontationFieldTesting ...14 1.13 MeasurementofIntraocularPressure ...15 1.14 Eyedrops,Ointment,andBandages ...15 2 TheEyelids ...17 (PeterWagner,GerhardK.Lang) 2.1 BasicKnowledge ...17 2.2 ExaminationMethods ...19 2.3 DevelopmentalAnomalies ...20 2.3.1 Coloboma ...20 2.3.2 EpicanthalFolds ...21 2.3.3 Blepharophimosis ...21 2.3.4 Ankyloblepharon ...22 2.4 Deformities ...22 2.4.1 Ptosis ...22 2.4.2 Entropion ...24 2.4.3 Ectropion ...28 2.4.4 Trichiasis ...30 Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. TableofContents VII 2.4.5 Blepharospasm ...30 2.5 DisordersoftheSkinandMarginoftheEyelid ...30 2.5.1 ContactEczema ...30 2.5.2 Edema ...31 2.5.3 SeborrheicBlepharitis ...33 2.5.4 HerpesSimplexoftheEyelids ...34 2.5.5 HerpesZosterOphthalmicus ...35 2.5.6 EyelidAbscess ...36 2.5.7 TickInfestationoftheEyelids ...37 2.5.8 LouseInfestationoftheEyelids ...37 2.6 DisordersoftheEyelidGlands ...38 2.6.1 Hordeolum ...38 2.6.2 Chalazion ...39 2.7 Tumors ...40 2.7.1 BenignTumors ...40 2.7.1.1 DuctalCysts ...40 2.7.1.2 Xanthelasma ...40 2.7.1.3 MolluscumContagiosum ...42 2.7.1.4 CutaneousHorn ...42 2.7.1.5 Keratoacanthoma ...42 2.7.1.6 Hemangioma ...43 2.7.1.7 Neurofibromatosis(Recklinghausen’sDisease) ...44 2.7.2 MalignantTumors ...45 2.7.2.1 BasalCellCarcinoma ...45 2.7.2.2 SquamousCellCarcinoma ...47 2.7.2.3 Adenocarcinoma ...47 3 LacrimalSystem ...49 (PeterWagner,GerhardK.Lang) 3.1 BasicKnowledge ...49 3.2 ExaminationMethods ...52 3.2.1 EvaluationofTearFormation ...52 3.2.2 EvaluationofTearDrainage ...53 3.3 DisordersoftheLowerLacrimalSystem ...57 3.3.1 Dacryocystitis ...57 3.3.1.1 AcuteDacryocystitis ...57 3.3.1.2 ChronicDacryocystitis ...60 3.3.1.3 NeonatalDacryocystitis ...60 3.3.2 Canaliculitis ...61 3.3.3 TumorsoftheLacrimalSac ...61 3.4 LacrimalSystemDysfunction ...62 3.4.1 KeratoconjunctivitisSicca ...62 Lang, Ophthalmology © 2000 Thieme All rights reserved. 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VIII TableofContents 3.4.2 Illacrimation ...64 3.5 DisordersoftheLacrimalGland ...64 3.5.1 AcuteDacryoadenitis ...64 3.5.2 ChronicDacryoadenitis ...65 3.5.3 TumorsoftheLacrimalGland ...66 4 Conjunctiva ...67 (GerhardK.Lang,GabrieleE.Lang) 4.1 BasicKnowledge ...67 4.2 ExaminationMethods ...68 4.3 ConjunctivalDegenerationandAgingChanges ...69 4.3.1 Pinguecula ...69 4.3.2 Pterygium ...69 4.3.3 Pseudopterygium ...71 4.3.4 SubconjunctivalHemorrhage ...72 4.3.5 CalcareousInfiltration ...72 4.3.6 ConjunctivalXerosis ...72 4.4 Conjunctivitis ...74 4.4.1 GeneralNotesontheCauses,Symptoms,andDiagnosisof Conjunctivitis ...74 4.4.2 InfectiousConjunctivitis ...82 4.4.2.1 BacterialConjunctivitis ...82 4.4.2.2 ChlamydialConjunctivitis ...83 4.4.2.3 ViralConjunctivitis ...93 4.4.2.4 NeonatalConjunctivitis ...95 4.4.2.5 ParasiticandMycoticConjunctivitis ...98 4.4.3 NoninfectiousConjunctivitis ...98 4.5 Tumors ...104 4.5.1 EpibulbarDermoid ...104 4.5.2 ConjunctivalHemangioma ...104 4.5.3 EpithelialConjunctivalTumors ...105 4.5.3.1 ConjunctivalCysts ...105 4.5.3.2 ConjunctivalPapilloma ...106 4.5.3.3 ConjunctivalCarcinoma ...107 4.5.4 MelanocyticConjunctivalTumors ...108 4.5.4.1 ConjunctivalNevus ...108 4.5.4.2 ConjunctivalMelanosis ...108 4.5.4.3 CongenitalOcularMelanosis ...112 4.5.5 ConjunctivalLymphoma ...113 4.5.6 Kaposi’sSarcoma ...113 4.6 ConjunctivalDeposits ...114 Lang, Ophthalmology © 2000 Thieme All rights reserved. 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TableofContents IX 5 Cornea ...117 (GerhardK.Lang) 5.1 BasicKnowledge ...117 5.2 ExaminationMethods ...120 5.2.1 SlitLampExamination ...120 5.2.2 DyeExaminationoftheCornea ...120 5.2.3 CornealTopography ...121 5.2.4 DeterminingCornealSensitivity ...121 5.2.5 MeasuringtheDensityoftheCornealEpithelium ...121 5.2.6 MeasuringtheDiameteroftheCornea ...124 5.2.7 CornealPachymetry ...125 5.2.8 ConfocalCornealMicroscopy ...125 5.3 DevelopmentalAnomalies ...125 5.3.1 ProtrusionAnomalies ...125 5.3.1.1 Keratoconus ...125 5.3.1.2 Keratoglobus ...127 5.3.2 CornealSizeAnomalies(Microcorneaand Megalocornea) ...127 5.4 InfectiousKeratitis ...127 5.4.1 ProtectiveMechanismsoftheCornea ...127 5.4.2 CornealInfections:PredisposingFactors,Pathogens,and Pathogenesis ...128 5.4.3 GeneralNotesonDiagnosingInfectiousFormsof Keratitis ...130 5.4.4 BacterialKeratitis ...130 5.4.5 ViralKeratitis ...132 5.4.5.1 HerpesSimplexKeratitis ...132 5.4.5.2 HerpesZosterKeratitis ...134 5.4.6 MycoticKeratitis ...134 5.4.7 AcanthamoebaKeratitis ...136 5.5 NoninfectiousKeratitisandKeratopathy ...137 5.5.1 SuperficialPunctateKeratitis ...138 5.5.2 ExposureKeratitis ...140 5.5.3 NeuroparalyticKeratitis ...141 5.5.4 ProblemswithContactLenses ...141 5.5.5 BullousKeratopathy ...143 5.6 CornealDeposits,Degenerations,andDystrophies ...145 5.6.1 CornealDeposits ...145 5.6.1.1 ArcusSenilis ...145 5.6.1.2 CornealVerticillata ...145 5.6.1.3 ArgyrosisandChrysiasis ...146 5.6.1.4 IronLines ...146 5.6.1.5 Kayser-FleischerRing ...146 Lang, Ophthalmology © 2000 Thieme All rights reserved. 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X TableofContents 5.6.2 CornealDegeneration ...146 5.6.2.1 CalcificBandKeratopathy ...146 5.6.2.2 PeripheralFurrowKeratitis ...147 5.6.3 CornealDystrophies ...148 5.7 CornealSurgery ...150 5.7.1 CurativeCornealProcedures ...152 5.7.1.1 PenetratingKeratoplasty(Fig.5.18a) ...152 5.7.1.2 LamellarKeratoplasty(Fig.5.18b) ...153 5.7.1.3 PhototherapeuticKeratectomy(Fig.5.18c) ...154 5.7.2 RefractiveCornealProcedures ...155 5.7.2.1 PhotorefractiveKeratectomy(Fig.5.18d) ...155 5.7.2.2 RadialKeratotomy(Fig.5.18e) ...155 5.7.2.3 PhotorefractiveKeratectomyCorrectionof Astigmatism ...156 5.7.2.4 HolmiumLaserCorrectionofHyperopia ...156 5.7.2.5 EpikeratophakicKeratoplasty(Epikeratophakia) ...156 5.7.2.6 ExcimerLaserInSituKeratomileusis(LASIK) ...156 6 Sclera ...157 (GerhardK.Lang) 6.1 BasicKnowledge ...157 6.2 ExaminationMethods ...157 6.3 ColorChanges ...157 6.4 StaphylomaandEctasia ...158 6.5 Trauma ...158 6.6 Inflammations ...158 6.6.1 Episcleritis ...159 6.6.2 Scleritis ...161 7 Lens ...165 (GerhardK.Lang) 7.1 BasicKnowledge ...165 7.2 ExaminationMethods ...168 7.3 DevelopmentalAnomaliesoftheLens ...169 7.4 Cataract ...170 7.4.1 AcquiredCataract ...173 7.4.1.1 SenileCataract ...173 7.4.2 CataractinSystemicDisease ...179 7.4.3 ComplicatedCataracts ...180 7.4.4 CataractafterIntraocularSurgery ...180 Lang, Ophthalmology © 2000 Thieme All rights reserved. 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