The Massachusetts eye and ear infirmary illustrated manual of ophthalmology

640 Pages·2009·95.012 MB·English

by  Neil J. Friedman, Peter K. Kaiser, Roberto Pineda

Introduction
I am pleased to write an introduction to the 3rd edition of the MEEI Illustrated Manual of
Ophthalmology. This edition continues the tradition of excellence forged by its authors in
the first two editions. Drs. Friedman, Kaiser, and Pineda have provided us with an acces-
sible, portable, yet comprehensive compendium that optimizes its availability for use by the
practitioner.
The new edition takes advantage of the growing importance of our most sophisticated
technologies, such as optical coherence tomography (OCT), computed tomography (CT),
and magnetic resonance imaging (MRI) while maintaining its logical organization and
clarity of description. It serves as both a valuable teaching tool and a standard reference for
the practicing clinician.
The authors, all of whom trained at Harvard Medical School as students or residents
and fellows, embody the best of the clinician–teacher paradigm. While research – basic,
translation, and clinical – moves our practice forward, the skill to imbue this knowledge to
successive generations of ophthalmologists is critical. We are grateful for their erudition,
judgment, and, above all, hard work in updating this classic text.
Joan W. Miller, MD
Henry Willard Williams Professor of Ophthalmology and Chair
Harvard Medical School
Chief of Ophthalmology, Massachusetts Eye and Ear Infirmary
10
Preface
We are delighted to present the 3rd edition of this book. Our original goal, to produce
a concise manual that covered a broad variety of ophthalmic disorders and present it in a
user friendly diagnostic atlas, has not changed. In fact, improvements to this edition, we
believe, better achieve that goal.
We have updated and expanded the format of this comprehensive ophthalmology man-
ual to make it even more accessible, instructive and useful. Specifically, new diagnoses have
been added throughout the book, and existing sections have been updated to reflect the
most current diagnostic and treatment options. Numerous sections have been completely
revised. Once again, current residents, fellows, and attending physicians have reviewed and
contributed to various chapters to ensure that the text remains relevant to a wide audience
of ophthalmologists. Moreover, we have added many new figures, including images of vari-
ous tests (i.e., CT/MRI scans, fluorescein angiography, spectral domain optical coherence
tomography (OCT), fundus autoflourescence, HRT, and visual field tests), improved the
quality of existing images, and converted all the figures to color.
In this edition, we have expanded the appendix by adding brand new tables and lists.
The existing sections, in particular the exam and medication sections, have been thoroughly
updated. The index has also been improved to make it easier to navigate the book.
We believe that this new edition retains all of its previous attributes and also incorpo-
rates important improvements to keep pace with our ever-changing field of medicine. The
book will continue to provide the type of information you are accustomed to obtaining
when referring to previous editions, and we hope it will surpass your expectations.
Neil J. Friedman, MD
Peter K. Kaiser, MD
Roberto Pineda II, MD
Contributors
The contribution of the following colleagues, who have reviewed and edited various chapters
of this text, is greatly appreciated:
Mehran Taban , MD , S umit Sharma
Cole Eye Institute
Cleveland Clinic Foundation
Cleveland, Ohio
Jason Ehrlich , M D , ATul Jain , MD, Christopher Zoumalan , MD
Department of Ophthalmology
Stanford University School of Medicine
Stanford, California
Thomas N. Hwang , M D, PhD , Timothy J. McCulley, MD ( Chapters 2, 3, 4, 7, 11)
Department of Ophthalmology
University of California at San Francisco
San Francisco, California
10
Acknowledgments
There are many people we must thank for their involvement with this project. We are par-
ticularly grateful to the faculty, staff, fellows, residents, colleagues, and peers at our various
training programs including the Bascom Palmer Eye Institute, the Cole Eye Institute, the
Cullen Eye Institute, the Massachusetts Eye and Ear Infirmary, the New York Eye and Ear
Infirmary, and Stanford University for their guidance, instruction, and support of this book.
We are indebted to those individuals who contributed valuable suggestions and revisions
to the text.
We especially acknowledge our editorial and publishing staff at Elsevier: Russell Gabbedy,
Ben Davie, and the members of their department, for their expertise and assistance in pro-
ducing this work. In addition, we are indebted to Tami Fecko, Nicole Brugnoni, Sumit
Sharma, Kaori Sayanagi, Shawn Perry, Louise Carr-Holden, Ditte Hesse, Kit Johnson, Bob
Masini, Audrey Melacan, Jim Shigley, and Huynh Van, as well as the dedicated staff of their
photography departments for all the wonderful pictures without which this book would not
be possible. We would also like to thank the many physicians whose photographs complete
the vast collection of ophthalmic disorders represented in the book.
Finally, a special heartfelt thank you to our families, including Mae, Jake, Alan, Diane,
Lisa, Maureen, Peter (PJ), Stephanie, Peter, Anafu, Christine, Roberto, Anne, Gabriela, and
Nicole, for their love, support, and encouragement.
Neil J. Friedman, MD
Peter K. Kaiser, MD
R oberto Pineda II, MD
Figure Courtesy Lines
The following figures are reproduced from Essentials of Ophthalmology, Friedman and
Kaiser, 2007, Saunders: 2-3, 2-15, 2-22, 4-1, 4-2, 4-31, 4-44, 7-17, 7-18, 7-19, 10-128,
11-29, 12-15, A-7, A-10, A-19, A-20, A-23, A-27, A-28, A-30, A-31, A-32, A-43. Table
A-2, and Table A-3.
The following figures are reproduced from Review of Ophthalmology, Friedman, Kaiser,
and Trattler, 2007, Saunders: 2-25, 2-26, 7-1, 7-5, A-14, A-16, A-17, A-21, and A-29.
The following figures are courtesy of the Bascom Palmer Eye Institute:
3-10, 4-3, 4-42, 4-52, 4-65, 5-8, 5-12, 5-25, 5-31, 5-36, 5-43, 5-60, 5-61, 5-67, 5-72, 5-74,
5-79, 6-10, 6-11, 6-12, 7-7, 7-13, 7-20, 7-21, 8-6, 8-19, 8-33, 8-35, 8-37, 9-7, 10-1, 10-5,
10-6, 10-11, 10-29, 10-31, 10-38, 10-39, 10-40, 10-44, 10-52, 10-53, 10-59, 10-61, 10-86,
10-89, 10-90, 10-99, 10-106, 10-118, 10-132, 10-133, 10-136, 10-137, 10-138, 10-139,
10-146, 10-152, 10-181, 10-182, 10-185, 10-187, 10-198, 10-199, 10-213, 10-215, 10-220,
10-222, 10-223, 10-196, 10-224, 10-227, 10-233, 10-235, 10-236, 10-237, 10-238, 10-239,
10-240, 10-241, 10-245, 10-246, 10-247, 11-15, 11-18, and 11-21.
The following figures are courtesy of the Cole Eye Institute:
1-3, 1-28, 1-32, 1-33, 1-34, 1-35, 3-3, 3-11, 3-14, 3-19, 3-22, 3-23, 3-37, 3-49, 3-52, 3-56,
3-65, 4-8, 4-19, 4-25, 4-29, 4-32, 4-39, 4-40, 4-43, 4-49, 4-54, 4-55, 4-57, 4-64, 4-67,
4-68, 5-5, 5-6, 5-11, 5-20, 5-24, 5-34, 5-35, 5-38, 5-39, 5-47, 5-53, 5-57, 5-64, 5-85, 5-90,
5-91, 5-92, 5-93, 6-13, 6-14, 7-29, 7-43, 8-4, 8-8, 8-9, 8-10, 8-11, 8-21, 8-24, 9-2, 9-6,
10-2, 10-12, 10-16, 10-17, 10-18, 10-19, 10-20, 10-22, 10-25, 10-27, 10-28, 10-32, 10-33,
10-34, 10-35, 10-41, 10-43, 10-45, 10-46, 10-47, 10-39, 10-54, 10-55, 10-56, 10-57, 10-62,
10-66, 10-67, 10-70, 10-71, 10-72, 10-73, 10-83, 10-85, 10-87, 10-88, 10-92, 10-93, 10-95,
10-96, 10-104, 10-111, 10-115, 10-116, 10-119, 10-121, 10-122, 10-123, 10-124, 10-125,
10-129, 10-130, 10-131, 10-135, 10-141, 10-143, 10-144, 10-145, 10-147, 10-148, 10-149,
10-150, 10-151, 10-158, 10-159, 10-160, 10-166, 10-167, 10-168, 10-169, 10-170, 10-171,
10-174, 10-175, 10-176, 10-177, 10-178, 10-179, 10-180, 10-184, 10-188, 10-190, 10-191,
10-193, 10-194, 10-195, 10-196, 10-197, 10-202, 10-203, 10-204, 10-206, 10-207, 10-208,
10-212, 10-217, 10-225, 10-228, 10-229, 10-234, 10-242, 10-243, 10-244, 10-248, 11-1,
11-2, 11-3, 11-4, 11-12, 11-16, 11-17, 11-22, 11-3, 11-33, 11-35, 12-3, 12-5, 12-6, 12-9,
12-10, and 12-11.
The following figures are courtesy of the Massachusetts Eye and Ear Infirmary:
1-2, 1-11, 1-8, 1-9, 1-10, 1-11, 1-12, 1-13, 1-14, 1-15, 1-16, 1-21, 1-36, 2-1, 2-2, 2-4,
2-7, 2-10, 2-11, 2-12, 2-20, 2-23, 2-24, 3-5, 3-8, 3-12, 3-13, 3-17, 3-20, 3-21, 3-24, 3-29,
3-41, 3-47, 3-48, 3-57, 3-63, 3-64, 3-68, 4-4, 4-5, 4-6, 4-9, 4-11, 4-12, 4-14, 4-15, 4-16,
4-17, 4-18, 4-20, 4-26, 4-27, 4-30, 4-33, 4-34, 4-36, 4-37, 4-38, 4-48, 4-50, 4-51, 4-56,
4-58, 4-60, 4-61, 4-62, 5-2, 5-7, 5-14, 5-15, 5-16, 5-17, 5-19, 5-21, 5-22, 5-26, 5-27, 5-28,
5-32, 5-33, 5-37, 5-40, 5-41, 5-48, 5-51, 5-52, 5-56, 5-58, 5-68, 5-70, 5-71, 5-73, 5-78,
5-80, 5-82, 5-83, 5-84, 5-86, 6-1, 6-2, 6-5, 6-8, 6-15, 7-2, 7-4, 7-6, 7-9, 7-11, 7-15, 7-22,
7-25, 7-27, 7-28, 7-31, 7-34, 7-35, 7-36, 7-37, 7-39, 7-40, 7-41, 7-42, 7-44, 8-1, 8-3, 8-5,
8-7, 8-12, 8-13, 8-15, 8-16, 8-17, 8-18, 8-22, 8-23, 8-26, 8-36, 8-38, 8-41, 9-1, 9-3, 10-4,
10-26, 10-42, 10-60, 10-63, 10-64, 10-65, 10-105, 10-112, 10-113, 10-114, 10-117, 10-126,
10-134, 10-142, 10-153, 10-154, 10-155, 10-156, 10-157, 10-161, 10-162, 10-165, 10-173,
10-183, 10-186, 10-201, 10-205, 10-214, 10-216, 10-218, 10-219, 10-221, 10-226, 11-5,
11-6, 11-7, 11-10, 11-25, 11-28, 11-34, and 12-4.
xxiv Figure Courtesy Lines
The following figures are courtesy of the New York Eye and Ear Infirmary:
3-16, 3-34, 3-39, 3-59, 4-13, 4-21, 4-35, 4-45, 4-46, 4-47, 4-53, 4-59, 4-63, 5-13, 5-42,
5-44, 5-46, 5-45, 5-49, 5-50, 5-55, 5-69, 5-88, 5-89, 7-3, 7-8, 7-10, 7-12, 7-24, 8-14, 8-25,
8-27, 8-32, 8-34, 8-40, 9-5, 9-9, 10-3, 10-8, 10-9, 10-10, 10-15, 10-21, 10-27, 10-30, 10-48,
10-58, 10-82, 10-103, 10-140, 10- 163, 10-164, 10-172, 10-183, 10-189, 10-200, 10-209,
10-210, 10-211, 11-11, and 11-20.
The following figures are courtesy of Warren Chang, MD: 2-8 and 2-9.
The following figures are courtesy of Cullen Eye Institute: 1-7, 5-76, and 11-14.
The following figure is courtesy of Eric D. Donnenfeld, MD: 3-6.
The following figure is courtesy of Chris Engelman, MD: 11-36.
The following figures are courtesy of Neil J. Friedman, MD: 1-6, 5-3, 5-4, 5-29, 5-62,
5-63, 5-75, 6-3, 7-14, 10-7, 11-26, 11-30, 11-31, 11-32, 12-12, 12-16, Appendix-34,
Appendix-35, Appendix-42, Appendix-44, and Appendix-45.
The following figures are courtesy of Ronald L. Gross, MD: 5-66, 6-4, 6-9, 7-23, 7-26,
7-32, and 11-22.
The following figures are courtesy of M. Bowes Hamill, MD: 4-7, 4-26, 4-28, 4-41, 4-66,
5-9, 5-10, 5-81, 7-30, and 7-33.
The following figure is courtesy of Thomas N. Hwang, MD, PhD: 11-9.
The following figures are courtesy of ATul Jain, MD: 6-6, 9-4, 10-13, and 10-14.
The following figures are courtesy of Peter K. Kaiser, MD: 2-13, 2-16, 2-19, 2-21, 9-8,
10-23, 10-24, 10-36, 10-37, 10-50, 10-51, 10-68, 10-69, 10-74, 10-75, 10-76, 10-77,
10-78, 10-79, 10-80, 10-81, 10-84, 10-91, 10-94, 10-97, 10-98, 10-100, 10-101, 10-102,
10-105, 10-107, 10-108, 10-120, 10-192, 11-16, Appendix-1, Appendix-2, Appendix-3,
Appendix-4, Appendix-6, Appendix-8, Appendix-9, Appendix-11, Appendix-12,
Appendix-13, Appendix-15, Appendix-18, Appendix-22, Appendix-24, Appendix-25,
Appendix-26, Appendix-38, Appendix-39, Appendix-40, and Appendix-41.
The following figures are courtesy of Robert Kersten, MD: 3-51, 3-62, 3-66.
The following figures are courtesy of Jonathan W. Kim, MD: 1-25, 1-26, and 3-43.
The following figures are courtesy of Douglas D. Koch, MD: 5-30, 5-65, 8-2, 8-20, 8-28,
8-29, 8-30, 8-31, 8-39, 12-8, and 12-14.
The following figures are courtesy of Andrew G. Lee, MD: 2-14, 2-17, 2-27, 7-16, 11-1,
and 11-8.
The following figures are courtesy of Peter S. Levin, MD: 1-23, 3-9, 3-30, 3-38, 3-58, 3-60,
3-61, and 3-67.
The following figure is courtesy of Thomas Loarie: 12-13.
The following figure is courtesy of Edward E. Manche, MD: 12-7.
The following figures are courtesy of Timothy J. McCulley, MD: 1-1, 1-5, 1-18, 1-20, 1-21,
1-22, 1-24, 1-30, 1-31, 3-2, 3-4, 3-25, 3-44, 3-45, and 11-24.
The following figure is courtesy of George J. Nakano, MD: 5-87.
Figure Courtesy Lines xxv
The following figures are courtesy of James R. Patrinely, MD: 1-17, 1-27, 3-18, 3-28, 3-31,
3-32, 3-33, 3-35, 3-36, 3-40, 3-42, 3-50, 3-53, 3-54, and 3-55.
The following figures are courtesy of Julian Perry, MD: 3-1 and 3-46.
The following figure is courtesy of Roberto Pineda II, MD: 5-18, Appendix-33,
Appendix-36, and Appendix-37.
The following figures are courtesy of David Sarraf, MD and ATul Jain, MD: 10-109,
10-110, 10-230, 10-231, and 10-232.
The following figures are courtesy of Paul G. Steinkuller, MD: 1-19, 2-5, 2-6, and 12-1.
The following figures are courtesy of Christopher N. Ta, MD: 3-15, 3-26, 3-27, 4-10, 4-22,
4-23, 4-24, 5-1, 5-23, 5-54, 5-59, 5-77, 7-38, and 12-2.
Trauma 3 110
Globe Subluxation 9
Carotid-Cavernous and Dural Sinus Fistulas 10
Infections 12
Inflammation 15
Congenital Anomalies 19
Pediatric Orbital Tumors 21
Adult Orbital Tumors 26
Acquired Anophthalmia 31
Atrophia Bulbi and Phthisis Bulbi 32
Orbit
Trauma
Blunt Trauma
Orbital Contusion
Periocular bruising caused by blunt trauma; often with injury to the globe, paranasal sinuses,
and bony socket; traumatic optic neuropathy or orbital hemorrhage may be present. Patients
report pain and may have decreased vision. Signs include lid edema and ecchymosis, and
ptosis. Isolated contusion is a preseptal (eyelid) injury and typically resolves without seque-
lae. Traumatic ptosis secondary to levator muscle contusion may take up to 3 months to
resolve; most oculoplastic surgeons observe for 6 months prior to surgical repair.
Figure 1-1 • Orbit contusion
demonstrating severe eyelid ecchy-
mosis and edema, subconjuncti-
val hemorrhage and conjunctival
chemosis.
•
In the absence of orbital signs (afferent pupillary defect, visual field defect, limited extra ocular
motility, and proptosis) imaging studies are not necessarily required, but should be consid-
ered with more serious mechanisms of injury (e.g., motor vehicle accident [MVA], massive
trauma, or loss of consciousness) even in the absence of orbital signs. When indicated, orbital
computed tomography (CT) scan is the imaging study of choice.
4 Chapter 1 • Orbit
•
When the globe is intact and vision unaffected, ice compresses can be used every hour for
20 minutes during the first 48 hours to decrease swelling.
•
Concomitant injuries should be treated accordingly.
Orbital hemorrhage/Orbital Compartment Syndrome
Accumulation of blood throughout the intraorbital tissues due to surgery or trauma (retrobul-
bar hemorrhage) may cause proptosis, distortion of the globe, and optic nerve stretching and
compression (orbital compartment syndrome). Patients may report pain and decreased vision.
Signs include bullous, subconjunctival hemorrhage, tense orbit, proptosis, resistance to retropul-
sion of globe, limitation of ocular movements, lid ecchymosis, and increased intraocular pres-
sure. Immediate recognition and treatment is critical in determining outcome. Urgent treatment
measures may include canthotomy and cantholysis. Evacuation of focal hematomas or bony
decompression is reserved for the most severe cases with an associated optic neuropathy.
Figure 1-2 • Retrobulbar hemor-
rhage of the left eye demonstrating
proptosis, lid swelling, chemosis,
and restricted extraocular motility
on upgaze.
Conjunctival chemosis Lid edema
OphThalmiC EmErgEnCy
•
If orbital compartment syndrome is suspected, lateral canthotomy and cantholysis
should be performed emergently.
•
Lateral canthotomy: This procedure is performed by compressing the lateral canthus
with a hemostat, and Stevens scissors are then used to make a full-thickness incision
from the lateral commissure (lateral angle of the eyelids) posterolaterally to the lateral
orbital rim. Some advocate compression of the lateral canthal tendon prior to inci-
sion. The inferior crus of the lateral canthal tendon is then transected by elevating the
lateral lower lid margin away from the face, placing the scissors between the cut edges
of lower lid conjunctiva and lower lid skin, palpating the tendon with the tips of the
scissors, and transecting it. If the inferior eyelid is not extremely mobile, the inferior
crus has not been transected adequately and the procedure should be repeated. If the
intraocular pressure remains elevated and the orbit remains tense, the superior crus of
the lateral canthal tendon may be cut. Septolysis, blunt dissection through the orbital