BACKGROUND

The first edition of Clinical Medicine in Optometric Practice was conceived amidst a storm of controversy. Two decades ago the political climate surrounding the field of eye care was fiercely antagonistic, as forces fought to suppress the right of optometrists to prescribe appropriate topical and systemic medication. With battle lines drawn in every state legislature across the nation, optometrists slowly and deliberately gained the diagnostic and therapeutic privileges that would benefit their patient population.

The increased responsibility inherent in the prescribing of topical and systemic medications mandated a familiarity with systemic disease conditions. To achieve this goal, the first edition was proposed and structured to fill the educational needs of both the optometry student immersed in a clinical medicine curriculum and the doctor in the field who sought comprehensive descriptions of systemic disease.

In 1988 Mosby identified the need for such a book. I was fortunate enough to be asked to edit and contribute to the first edition of what would become a landmark in optometric literature.

From the outset, the first edition reflected the political strife besetting the entire profession. The medical community was up in arms about this text, claiming that optometrists had no right to the information presented within its pages. During the 5 years it took to bring the book to life, several medical authors dropped out of the project due to political pressure. One editor of the first edition had a surgeon from a prominent Philadelphia-based eye hospital enter his office and threaten never to publish with Mosby again if they dared to publish Clinical Medicine in Optometric Practice. Fortunately my editor refused to cave into the pressure and the book did get published.

WHO WILL BENEFIT FROM THIS BOOK?

In the past decade, Clinical Medicine in Optometric Practice has emerged to become the best selling text on systemic conditions and the eye written exclusively for the optometrist. Copies have found their way into the hands of

students and optometrists the world over. I have been gratified to learn that the first edition has influenced the education of thousands of students and has been a valuable resource to those already in the field.

And now the second edition, conceived in a medical environment far different from the first, is poised to contribute to a second generation of students and doctors. To those familiar with the first edition, they will find a completely new and reformatted text. The book has been completely rewritten with new and indispensable information on systemic conditions that influence the eye.

To those who are seeing the book for the first time, the second edition will serve to familiarize the student and the optometrist with the ocular signs that indicate possible underlying systemic conditions. Beautiful color photographs highlight the descriptive text.

ORGANIZATION

The reader will note that the book is now divided into four parts. Part 1 discusses the medical diagnostic armamentarium available to the optometrist, from physical diagnosis to laboratory testing and radiology. Part 1 emphasizes the integration of these strategies into the optometric work-up.

Part 2 concentrates on the medical specialties that impact on eye care. Here are presented the pathogenesis and evolution of systemic disorders, which serve to sensitize the optometrist to the myriad of symptomologies indicative of underlying disease. I wanted this section of the book to help an optometrist faced with patients who are, by virtue of their history and symptomology, suspicious for systemic disease. In addition, by examining the most recent diagnostic and therapeutic regimens available, Part 2 serves as a quick reference guide for eye care practitioners and helps them gain familiarity with the medical conditions of their patients.

Part 3 addresses the most likely scenario for the eye care practitioner: the patient who presents with an ocular disorder that itself is suspicious for systemic disease. This section examines the possibility that the

VIII PREFACE

patient’s anterior or posterior segment pathology is related to a systemic condition. By identifying the eye pathology, these chapters will guide the optometrist back to the appropriate chapters in Part 2 that describe the possible associated systemic disorders.

New to the second edition, Part 4 examines the latest information on the hottest topics in optometry. These include eye care for the pregnant patient, genetics in optometry, injections, and drug side-effects.

Since the fundamental philosophy guiding Clinical Medicine in Optometric Practice is an attempt to unify primary optometry with clinical medicine, I sincerely hope that this book symbolically foreshadows an age of enlightened eye care delivery. May all our patients benefit from the knowledge contained herein.

BRUCE G. MUCHNICK, O.D.

The completion of this text is due in no small part to a great number of people who helped in its production. First and foremost, I wish to acknowledge and gratefully thank the authors of the first edition of this book. Without their expertise and invaluable contribution,

Clinical Medicine in Optometric Practice would never have become the most influential textbook in optometry history. In particular, a special thanks to some of the finest authors I ever had the pleasure to work with: Drs. Connie Chronister, David Bright, Jerry Cavallerano, Brian Mahoney, John McGreal, Leonard Messner, John Nishimoto, David Sendrowski, and Ronald Serfoss.

I wish to thank the hard-working editors at Elsevier; Ms. Christie Hart and Mr. David Stein.

Many thanks to Mr. Sam Mohr, Ms. Dione Bailey, Ms. Henrietta McBall, and Ms. Christie Milligan of the Coatesville Veterans Administration Medical Center for their assistance in producing many of the clinical procedures photographs in the text.

I must offer a special acknowledgment to Dr. Christopher Rinehart and Dr. Pierrette DayhawBarker for suggesting me as author of this text.

We stand in the shadows of optometric educators who came before us and continue to inspire us to this day. These people, our mentors, should never be forgotten. I have been most fortunate in my career to work with some of the best in our profession: Dr. Lorraine Lombardi (who despite the advent of computer technology can still draw the human brain “DaVinci-like” with two hands at the same time), Drs. Gilda and the late George Crozier, the late Dr. John Crozier (who always believed in me), Dr. Louis Catania (who gave me my first lecture assignment), Dr. Linda Casser (the most brilliant optometrist I ever had the honor of working with), Dr. Andrew Gurwood (the most dedicated optometric educator I have ever had the privilege of knowing), and the late, great Dr. Lawrence Gray. Also, special thanks go to the late Dr. Samuel Cutler, Dr. Nibondh Vacharat, Dr. Richard Sowby, and my personal mentors: Drs. Christopher Rinehart, Jeffrey Nyman, and Bernard Blaustein, who all taught me much about the history and practical aspects of optometry and medicine.

The history helps to form the clinical basis for the differential diagnosis of the patient. Every piece of information made available to the examiner must be used to create a clinical approach tailored to the patient’s own unique profile. The history may yield the presence of symptoms that indicate a disease state. If the patient is seen with a known disorder, the history may help to determine the extent and prognosis of the disease. In cases in which therapy has been instituted, the history is used to help determine the effectiveness

of past or present treatments.

Nonetheless, the history can be hampered by significant patient limitations, such as poor historical recall and inadequate explanations. In addition, poor fact gathering and inappropriate interpretation by

the examiner further complicate the gathering of information.

The ability of the patient to completely recall his or her past medical history in detail is desired but rarely achieved. The passage of time will tend to cloud even significant memories, so that a patient will have difficulty in recalling surgeries and medical treatment. For example, it is not unusual for patients who have undergone a cataract extraction to quickly forget that the procedure was ever performed. In general, elderly patients will have difficulty with historical recall. The examiner can help stimulate memories by asking which doctor the patient had seen and in which hospital the procedure was performed. To obtain information about past

4 DIAGNOSTIC PROCEDURES

medical situations, it often helps to ask the patient to attempt to visualize the memory.

The patient may inadequately describe his or her past medical history. The examiner should repeat back to the patient any information that is not logical, as this might stimulate the patient to better recall. The examiner may wish to verify certain facts with relatives, although this should be done with respect and sensitivity to the patient.

The examiner may expedite information gathering by taking a well-organized history in a non-stressful environment. Effective doctor-patient communication improves the gathering of medical information. Appropriate body posture, proper eye contact, the clear display of sympathy, and the ability to keep the patient focused on the subject are essential.

The examiner should strive to minimize interpretation of the patient’s responses when taking the medical history. A wrong interpretation may lead to faulty logic. Instead, the examiner should record the patient’s exact words in quotation marks, followed by the examiner’s logical deduction in parentheses, to minimize interpretive errors. For example, an accurate recording in quotation marks of the patient who says, “I see cobwebs moving around in my vision,” can be followed by the examiner’s interpretation of that symptom (possible floaters). Some might argue that no interpretation of the patient’s information should occur during the history, but in a practical setting this is virtually impossible. The patient often uses inflections and hand movements that cannot be adequately recorded but that might support an interpretation. The examiner should minimize interpretation to avoid false assumptions.

A reiteration and summary of the patient’s history before the examination will help to stimulate the patient’s historical memories and confirm certain facts.

Ocular manifestations of systemic disease are common; therefore the optometry examination mandates a two-part history comprised of both eye and medical information. Such a history can be complex; thus the examiner needs an organized approach. This chapter outlines the elements of the optomedical history and the integration of these elements into the optometry examination.

hood. Adolescents, who are particularly prone to risktaking behaviors, have a higher than average rate of motor vehicle injuries to the face and neck and are significantly susceptible to depression, migraine headaches, certain cancers, respiratory ailments, tobacco and alcohol use, sexually transmitted diseases, unhealthy dietary habits, and exercise-induced heart disorders. The middle-aged patient is prone to develop high blood pressure, thyroid conditions, cardiovascular disease, and Type II diabetes mellitus. Elderly patients are likely to manifest symptoms and signs of brain atrophy, certain forms of cancer, and cerebrovascular and carotid disease. Despite the tendency of some disorders to cluster in certain age groups, the examiner should use the age of the patient only as a clue in developing a differential diagnosis.

Race

Some disorders are more common in certain racial groups; thus an accurate racial determination may help in the differential diagnosis. For example, glaucoma occurs earlier and in greater frequency in the African-American population than in whites, but the prevalence of age-related macular degeneration is highest in the white population. Despite the obvious medical necessity to record race, patients may be sensitive when the subject is raised. Education may be a valuable tool to ease patient anxiety. For instance, the examiner might explain that a patient of mixed heritage may be prone to diseases that affect both races.

Sex

Most research studies on diseases and pathophysiology have traditionally included only male subjects. In recent years, medical issues involving women’s health have gained increasing attention. Significant differences between men’s and women’s health issues have become obvious. For example, during the past 60 years, cigarette smoking, which is a major risk factor in cardiovascular disease, has sharply declined in men, but not in women. This fact may explain why ischemic heart disease remains the leading cause of death in U.S. women older than 65 years.

PATIENT PROFILE Age

The accurate recording of the patient’s age is significant because of the chronological distribution of disease states. Pathology is often age-dependent, and an understanding of which disorders are most common in each age group can help the examiner in his or her differential diagnosis. For instance, hereditary and congenital disorders are often first diagnosed in child-

Occupation

Environmental and occupational hazards strongly influence eye disease. The patient’s occupation may yield clues to the causes of ocular, neurologic, and systemic manifestations. The examiner should ask the patient what type of work he or she is engaged in, ask about the timing of any symptoms related to work, and ask about exposure to environmental agents such as pesticides and chemical agents. The usefulness of a

thorough occupational history is exemplified by the case of a 19-year-old college sophomore who was seen in our clinic complaining of blurry vision and a loss of dexterity that resulted in chronic misplacement of objects. All optometry and neurology testing was normal, except for reduced visual acuities to 20/25 in both eyes. An examination of the patient’s workplace at her college chemistry lab found a fine crack in the hood designed to protect her from exposure. Replacement of the hood resulted in eventual return of normal vision and return of her normal dexterity.

REASON FOR VISIT Chief Complaint

The chief complaint is the reason for the patient’s eye examination. Although the prime motivator for the patient’s visit, the complaint may not represent or even be associated with the ultimate diagnosis. The chief complaint may seem significant to the patient, and is obviously troublesome enough to warrant an examination, but may eventually be relegated to a minor diagnosis compared with what is eventually uncovered (Box 1-1).

The examiner should never forget to address all the complaints of the patient, even if a sightor lifethreatening condition is found that is unrelated to the chief complaint. For example, a 42-year-old African-American male who was seen in our clinic complained that he had dry eyes on awakening. The confrontational visual field examination showed that the patient had a superior, bitemporal quadrantanopsia. Radiological testing revealed a pituitary

BOX 1-1

IMPORTANT HISTORICAL QUESTIONS

Describe the symptom or episode. When did the symptom first begin?

How did it first occur (how did it come on)?

How does the symptom subside (gradually vs. suddenly)? When did it last subside?

How many episodes of the symptom have occurred since the first episode?

Are the symptoms or are the episodes getting worse, better, or staying the same?

Are episodes increasing or decreasing in frequency? What, if anything, triggers the symptom?

What, if anything, relieves the symptom?

Are there any concurrent, associated symptoms? Where is the symptom located?

Has the symptom changed over time?

Have you seen a health-care professional for the symptom? Have you undergone any therapy for the symptom?

Does the symptom occur during any particular time of the day or night?

Can you do anything that changes or modifies the symptom?

tumor. Weeks later the patient returned after successful surgery, and the visual fields were normalized. The patient remarked that he still had dry eyes, however, and that his chief complaint was never addressed. Artificial tears were prescribed and were successful in ameliorating his symptoms.

Location

Every attempt should be made to isolate the location of the symptom. The examiner should record the location in unambiguous anatomical terminology. It may be difficult to pin down a precise location, because the patient may indicate a near-global area of involvement. For example, the patient with a headache may be unable to point to a precise location of the pain, and instead note that the entire head is involved.

Quality

The examiner should record the way the patient describes the characteristics of the symptoms. The description usually consists of an adjective, so that, for example, the symptom of pain is described as “sharp” or “dull.”

Severity

The severity of the symptom can be difficult to assess, because the patient may have trouble quantifying this characteristic. The examiner may wish to ask the patient to rank the severity of the symptom on a scale of 1-10, with 10 being the most severe pain the patient can imagine. The examiner should note the response as “the patient reports the pain is a 7 out of 10.” Standardized scales exist that have been accepted in the literature for various symptoms, but the inherent problem with these scales is that they assume all examiners are aware of and use these systems.

Duration

The length of time from onset to cessation of any symptom should be recorded. The duration of a single episode of the symptom should be differentiated from the frequency of the episodes since first onset. For example, a patient’s headache may have a typical duration of 2 hours, but the headaches may have occurred for many years.

Timing

The patient should be asked whether the onset of the symptom occurs at any particular time of day. In particular, the symptom may occur most commonly on awakening, and be best described as a “morning

6 DIAGNOSTIC PROCEDURES

symptom.” Other symptoms may not be noticed until later in the day or in the evening. This timing is crucial in determining a possible causative factor that is related to the patient’s life-style or to circadian rhythms.

Context

The patient should best judge the environment in which the symptom most frequently occurs. For example, a patient with dry eyes may notice the onset of symptoms only in the work environment, or a patient with headache may observe that the pain occurs only at high altitudes.

The context in which the symptom occurs can be used to help determine an underlying etiology.

symptoms, diagnoses, or treatment pertaining to each system that is reviewed.

Constitutional

This somewhat archaic term pertains to the overall health of the patient and is used to describe the general well-being of the patient.

Eye

Common abnormal ocular symptoms include blurry vision, double vision, eye pain or itch, flashes and floaters, photophobia, color vision problems, sudden or gradual vision loss, or difficulty with nighttime vision. Past diagnoses may commonly include uveitis, cataract, glaucoma, corneal infections, or retinal detachment.

Modifying Factors

The patient should try to determine what factors contribute to the onset of the symptom, modify the symptom during the episode, and help to relieve the symptom. These modifying factors may be environmental, pharmaceutical, psychological, or logistical in nature.

Associated Symptoms

Symptoms rarely occur in isolation, and the patient should be encouraged to detail any other problems that occur at the same time or within the same symptomatic episode. The examiner should attempt to determine whether these mutual symptoms are coincidental or temporally related. Associated symptoms help in the creation of a differential diagnostic list and in the determination of an underlying etiology common to at least some of the symptoms.

Ears, Nose, Mouth, and Throat

Relevant symptoms include ear pain, mouth sores, hearing loss, loss of taste, loss of smell, throat pain and throat lumps, nasal discharge or pain, and excess production of ear wax. Known diagnoses typically include infections, tumors, environmental causes, neurologic loss of senses, pharmacologically induced loss, and inflammations from systemic diseases.

Cardiovascular

Symptoms include chest pain, palpitations, difficulty breathing, easy fatigability, and arm or back pain (particularly, but not necessarily, related to exertion). Past diagnoses include angina, myocardial infarction, systemic hypertension, coronary heart disease, and valvular heart disease.

OCULAR HISTORY

The examiner should review the personal ocular history of the patient. This history includes ocular surgery, past ocular diagnosis, history of strabismus, past ocular injuries or trauma, the present spectacle and contact lens prescription and type, and the history of past ocular therapy with medications or laser. The date of the last eye examination and the name of the examining doctor will help the examiner to determine the patient’s level of compliance and to retrieve past medical records.

REVIEW OF SYSTEMS

An efficient review of the patient’s systems is necessary to explore the possible relationship between ocular symptoms and systemic disease. The reviewer should encourage the patient to recall any relevant

Respiratory

Symptoms include shortness of breath, coughing, coughing up of blood, and chest pain. The most common diagnoses include asthma, cystic fibrosis, sarcoidosis, myasthenia gravis, and chronic obstructive lung disease.

Gastrointestinal

Gastrointestinal (GI) symptoms include obstruction to solids or liquids on swallowing, nausea, vomiting (because of pregnancy or pseudotumor cerebri), indigestion, diarrhea, constipation, gastric pain, weight loss, jaundice, and abdominal swelling. Common GI diagnoses include tumors, ulcers, injury, Crohn’s disease, GI infections, drug and food allergies, inflammatory bowel diseases, and mechanical difficulties in swallowing.