Contents

In sequence of eye examination

Preface viii

Introduction ix

1 Medical history 1

Medical illnesses 3 Medications 4

Family history of eye disease 6

2 Measurement of vision and refraction 7

Visual acuity 7 Optics 8 Refraction 10 Contact lenses 13

Types of contact lenses 15 Common problems 17 Refractive surgery 17

3 Neuro-ophthalmology 21

Eye movements 21 Strabismus 24

Cranial nerves II–VIII 32 Nystagmus 33

The pupil 37

Visual field testing 41 Circulatory disturbances affecting vision 44

4 External structures 48

Lymph nodes 48 Lacrimal system 48 Lids 54

Blepharoptosis (also called ptosis) 55 Lashes 57

Phakomatoses 59

Anterior and posterior blepharitis 61

5 The orbit 64

Sinusitis 65 Exophthalmos 67 Enophthalmos 68

6 Slit lamp examination and glaucoma 69

Cornea 69

Corneal epithelial disease 70 Corneal endothelial disease 74 Corneal transplantation

(keratoplasty) 75 Conjunctiva 80 Sclera 85 Glaucoma 87 Uvea 99

Anti-inflammatories 107 Sarcoidosis 107 Nematodes 110

Human immunodeficiency virus (HIV) 111

Cataracts 116

7 The retina and vitreous 123

Retinal anatomy 123 Fundus examination 125

Fluorescein angiography 126 Papilledema (choked disk) 127 Hypertensive retinopathy 131 Diabetic retinopathy (front cover) 134 Age-related macular

degeneration (AMD) 137 Vitreous 145

Retinal holes and detachments (RD) 148

Index 151

Appendix 1: Hyperlipidemia 155 Appendix 2: Amsler grid 157

The first edition of this book was started when I was a medical student 40 years ago during the allotted two-week rotation in the eye clinic. At that time, all introductory books were 500 pages or more and could not be read quickly enough to understand what was going on. With this in mind, each word of this 157-page manual was carefully chosen so as to allow the beginning eye care professional to understand the refraction and hundreds of the most commonly encountered eye diseases from the onset. They are discussed with respect to anatomy, instrumentation, differential diagnosis, and treatment in the order in which they would be uncovered during the eye exam, with 534 photos and illustrations.

It is meant to be read in its entirety in a few hours and, hopefully, impart to you a strong foundation on which to grow and enjoy this beautiful and ever-changing speciality. The popularity of previous editions has resulted in translations into Spanish, Japanese, Indonesian, Italian, Russian, Greek, Polish, Portuguese, and an Indian reprint.

My special appreciation goes to Johnson & Johnson’s eye care division, which

provided a generous grant to distribute the previous edition to 40,000 students. Many of the photographs were generously provided by Pfizer Pharmaceuticals (www.xalatan.com), several journals and many of my friends and colleagues. Elliot Davidoff, who sat next to me in medical school, and is now an assistant Clinical Professor of Ophthalmology at The Ohio State University, surprised me numerous times by sending me images without having to ask.

It is an honor to have been granted permission from so many medical and osteopathic schools to give this 8th edition to 32,000 students. I hope you enjoy reading it half as much as I enjoyed writing it. This manual is unbiased in so far as I have received no monetary funding and I have no association with any company whose products are mentioned in this book.

I would appreciate any recommendations and images which would improve the next edition. You may email me at mark.leitman@aol.com.

MARK W. LEITMAN

As the field of eye care has grown more sophisticated, a team approach by numerous allied health personnel has become essential. Certifying letters after the name indicate the person met minimal entry requirements, and will do continuing education.

Ophthalmologist Training includes four years of college, four years of medical (MD) or osteopathic school (DO) and three years of specialty eye residency training. They may remain a general ophthalmologist, but now more often than not, spend an additional 1–2 years subspecializing in cornea and external disease, vitreoretinal disease, cataracts, glaucoma, neuro-ophthalmology, oculoplastic surgery, pathology, pediatric (strabismus) or uveitis. They often employ three allied health professionals.

Optometrist (OD) After completing four years of college, these doctors attend four years of optometry school. They perform similar tasks as the ophthalmologist. They are only permitted to do laser surgery in one state and they have only some authority to prescribe oral medications in 47 states. They may establish their own practice or work for an ophthalmologist. Subspecialties often include pediatrics and low vision.

Optician (ABO) (American Board of Opticians) These technicians usually do not

determine the prescription for eye glasses, but are involved in other aspects of fitting spectacles and contact lenses. They may grind the lenses and put them in frames (laboratory optician) or fit them on the patients (dispensing optician). Their training and certification is highly variable from state to state, but often includes two years at a community college.

Ocularist (BCO, BRDO, FASO) These technicians fit ocular prostheses such as a scleral shell after removal of an eye. After five years of apprenticeship, they are eligible to test for different levels of certification.

Ophthalmic photographers (CRA) These technicians, who do anterior segment and retinal photography, ultrasound, and OCT measurements, may or may not be certified.

Office technicians, with medical supervision, may take histories, measure eye pressure, do refractions and visual fields, maintain instruments, give instruction in contact lens wear, and take visual acuities. They don’t have to be certified. If certified, their competence and training are recognized by going from entry level, Certified Ophthalmic Assistant (COA) to Certified Ophthalmic Technician (COT) and then to Certified Medical Ophthalmic Technologist (COMT).