Mark W. Leitman - Manual for Eye Examination and Diagnosis

1 Cover

2 Title Page

3 Copyright Page

4 Preface

5 Introduction to the eye team and their instruments Instruments Dedicated to Andrea Kase

6 Chapter 1: Medical history Medical illnesses Medications (ocular side effects) Family history of eye disease

7 Chapter 2: Measurement of vision and refraction Visual acuity Optics Refraction Contact lenses Common problems Refractive surgery

8 Chapter 3: Neuro‐ophthalmology Eye movements Strabismus Cranial nerves III–VIII Nystagmus Common brain tumors The pupil Adie’s pupil (tonic pupil) Visual field testing Color vision Circulatory disturbances affecting vision

9 Chapter 4: External structures Lymph nodes Lacrimal system Failure of the tear to reach the puncta Obstruction at the puncta or canaliculus Tearing due to NLD obstructions Lids Lashes Phakomatoses Anterior and posterior blepharitis

10 Chapter 5: The orbit Imaging Sinusitis Exophthalmos Enophthalmos

11 Chapter 6: Slit lamp examination Cornea Corneal epithelial disease Corneal endothelial disease Corneal transplantation (keratoplasty) Conjunctiva Sclera

12 Chapter 7: Glaucoma Glaucoma vs. glaucoma suspect The iridocorneal angle The optic disk (optic papilla) Signs of nerve fiber damage Medical treatment (Table 11)

13 Chapter 8: Uvea Malignant uveal tumors Inflammation of the uvea (uveitis) Anti‐inflammatories

14 Chapter 9: Cataracts Laser‐assisted cataract surgery Some complications of cataract surgery

15 Chapter 10: The retina and vitreous Retinal anatomy Fundus examination Age‐related macular degeneration Central serous chorioretinopathy Pseudoxanthoma elasticum Albinism Retinitis pigmentosa Retinoblastoma Retinopathy of prematurity Vitreous Retinal holes Retinal detachment

16 Appendix 1: Hyperlipidemia

17 Appendix 2: Amsler grid

18 Index

19 End User License Agreement

1 Chapter 1 Table 1 Common chief complaints

2 Chapter 3Table 2 Extraocular muscles.Table 3 Nerves to ocular structures.Table 4 Types of eye‐turn.Table 5 Comparison of paralytic and nonparalytic strabismus.Table 6 Causes of small (miotic) and large (mydriatic) pupil (Fig. 125).Table 7 Visual disturbances due to compromised blood flow (Fig. 81)

3 Chapter 4Table 8 Common topical anti‐infectives.

4 Chapter 6Table 9 Superficial punctate keratitis (commonly causes photophobia).Table 10 Conjunctivitis ‐ redness more pronounced in peripheral conjunctiva (...

5 Chapter 7Table 11 Common glaucoma medications and side effects.Table 12 Common types of glaucoma.

6 Chapter 8Table 13 Common causes of an injected conjunctiva (Fig. 395).Table 14 Ocular Anti‐inflammatories (see Fig. 367).Table 15 Topical Anticholinergics.Table 16 Causes of Uveitis.

7 Chapter 10Table 17 Scheie classification of hypertensive retinopathy (see Fig. 486).Table 18 Blood sugar levels in diabetes. 6.5% is diagnostic of diabetes but i...

1 Introduction Fig 1 A seed introduced into the eye of an 8‐year‐old boy through a penetrat...

2 Chapter 1 Fig 1 Thyroid exophthalmos with exposed sclera at superior limbus, due to bu... Fig 2 CT scan of thyroid orbitopathy showing fluid infiltration of the media... Fig 3 Orbital CT scan of Graves’ orbitopathy before surgical decompression (... Fig 4 Bull’s eye maculopathy due to hydroxychloroquine in a patient with sys... Fig 5 Phenothiazine maculopathy with pigment mottling of the macula. Fig 6 Tamoxifen maculopathy with crystalline deposits (A); and (B) OCT showi... Fig 7 Tamoxifen causes cataracts. Fig 8 Besides causing maculopathy and cataracts, tamoxifen also causes cryst... Fig 9 Iris retractors are one method used to open poorly dilated pupils duri... Fig 10 Stevens–Johnson syndrome with inflammation and adhesions of lid and b... Fig 11 Irreversible darkening of a blue iris after 3 months of latanoprost (... Fig 12 (A) Prostaglandin‐analogue induced fat atrophy of the left orbit with... Fig 13 After long‐term use of prostaglandin analogue in the left eye, the pa... Fig 14 Epithelial deposits radiating from a central point in the inferior co... Fig 15 Neomycin allergy occurs in 5–10% of the population.

3 Chapter 2 Fig 16 Snellen chart measures the central eight degrees of vision. Fig 17 Emmetropic eye. Fig 18 A hyperopic eye often has a shorter than normal axial length creating... Fig 19 Hyperopic eye corrected with convex lens. Fig 20 Parallel rays focused by 1 D lens. Fig 21 Myopic eye. Fig 22 OCT of pathologic myopia showing: A—degeneration of macula; and B—inc... Fig 23 Myopic eye corrected by concave lens. Fig 24 Myopic astigmatism. For explanation, see text. Fig 25 Myopic astigmatism corrected with a myopic cylinder, axis 90°. Fig 26 Tomographic image of corneal astigmatism with the steepest power +47.... Fig 27 Full reading glass blurs distance vision. Fig 28 Half glasses. Fig 29 Bifocals. Fig 30 Lens case with red concave and black convex lenses. Fig 31 Trial frame.Fig 32 Phoropter dials in lenses instead of manual placement in trial frame....Fig 33 Streak retinoscope.Fig 34 Retinoscopic determination of the axis of astigmatism.Fig 35 Pupillary reflex with motion and against motion.Fig 36 Computerized autorefractor may replace retinoscopy.Fig 37 Bifocal prescription for farsighted presbyopic patient with astigmati...Fig 38 Measurement of interpupillary distance.Fig 39 Determination of bifocal segment height.Fig 40 Plastic contact lens.Fig 41 Contacts are beneficial for every sport.Fig 42 Manual keratometer.Fig 43 Manual keratometer showing circular images projected on a damaged cor...Fig 44 (A) 13.5 mm diameter. (B) 14.5 mm diameter.Fig 45 Contact lens properly overlapping limbus.Fig 46 (A) Steep base curve, 8.2 mm. (B) Flat base curve, 9.1 mm.Fig 47 Mucus deposits on contact lenses.Fig 48 Lens properly aligned on eye with center marking at 180°.Fig 49 A spectacle correction for the above eye needed an axis of 180 degree...Fig 50 Bifocal contact lens with concentric zones of alternating near and fa...Fig 51 Colored contact lenses.Fig 52 Place contact lens directly on the cornea using the tip of the index ...Fig 53 Remove lens by sliding it off cornea onto sclera and then gently pinc...Fig 54 Contact lens solutions.Fig 55 Fluorescein staining of the cornea.Fig 56 Papillary conjunctivitis with characteristic redness and small, whiti...Fig 57 Limbal injection from a tightfitting lens.Fig 58 Normal cornea. The average central thickness is 545 μm, about half th...Fig 59 Rare instance of traumatic rupture of radial keratotomy wound.Fig 60 Excimer laser used to remove a layer of central corneal stroma.Fig 61 LASIK performed with topical anesthetic.Fig 62 LASIK: a 110 μm flap of epithelium, Bowman’s membrane, and stroma is ...Fig 63 Sculpted cornea after LASIK with remaining Bowman’s membrane.Fig 64 Superficial corneal flap created with a microkeratome. Laser creation...Fig 65 LASIK surgery showing flap being lifted with spatula and laser beam o...Fig 66 Late dislocation of a LASIK flap by self‐inflicted injury.Fig 67 (A) Gray area (arrows) where epithelial cells grew under the flap. (B...Fig 68 Removal of corneal epithelium precedes excimer laser thinning of corn...Fig 69 PRK laser ablation of Bowman’s membrane and stroma after mechanical d...Fig 70 Sculpted cornea after PRK or epi‐LASIK.Fig 71 Epi‐LASIK: creation of epithelial flap with blade followed by laser a...Fig 72 Phakic 6H2 anterior chamber intraocular lens to correct refractive er...Fig 73 Tomograms of corneal topography measure 25,000 points of elevation in...Fig 74 Limbal relaxing incision at 60° (the steepest meridian) super‐imposed...Fig 75 Manual limbal relaxing incision being created on the steepest axis at...Fig 76 Femtosecond laser as an alternative to manual relaxing incision using...Fig 77A SMILE refractive surgery: Femtosecond laser creates a lenticule, whi...Fig 77B Removal of stromal lenticle. Be sure all remnants are removed.