Ординатура / Офтальмология / Английские материалы / Ophthalmology at a Glance_Olver, Cassidy_2005

Contents

Preface 6

Acknowledgements 7

Section 1: Principles of ophthalmology

1.Introduction: what is ophthalmology? 8

2.Medical student aims 10

3.Social and occupational aspects of vision 12

Section 2: Ophthalmic history and examination

4.Taking the history and recording the findings 14

5.Visual acuity in adults 16

6.Examination of visual fields 18

7.Other visual functions 20

Section 3: Correction of refractive errors

8.Basic optics and refraction 22

9.Glasses, contact lenses and low-vision aids 24

Section 4: Basic eye examination

10.External eye and anterior segment 26

11.Posterior segment and retina 28

12.Use of eye drops 30

Section 5: Acute ophthalmology

13.The red eye 32

14.More on the red eye 34

15.Ophthalmic trauma principles and management of chemical injuries 36

16.Specific features of blunt and sharp injuries 38

17.Sudden painful loss of vision in a non-inflammed eye 40

18.Sudden painless loss of vision 42

Section 6: Gradual loss of vision

19.Gradual loss of vision 44

Section 7: Sub-specialty — Paediatric ophthalmology

20.Visual acuity in children 46

21.Strabismus (squints) 48

22.Neonates 50

23.Infants and older children 52

Section 8: Sub-specialty — Eyelid, lacrimal and orbit

24.Common eyelid lumps 54

25.Common eyelid malpositions 56

26.Lacrimal (tearing) 58

27.Basic orbital assessment 60

28.Orbital and thyroid eye disease 62

Section 9: Sub-specialty — External eye disease

29.Common conditions affecting the external eye 64

30.Common conditions affecting the cornea 66

31.Therapeutic contact lenses 68

32.Corneal and laser photorefractive surgery 70

Section 10: Sub-specialty — Corneal, refractive and cataract surgery

33.Cataract assessment 72

34.Cataract surgery 74

35.Cataract surgery postoperative care 76

Section 11: Sub-specialty — Glaucoma

36.Glaucoma— the basics 78

37.Detecting glaucoma 80

38.Medical and surgical treatment of glaucoma 82

Section 12: Sub-specialty — Vitreoretinal and medical retina

39.Retinal detachment 84

40.Retinal and choroidal anatomy and imaging 86

41.Inherited retinal dystrophies and age-related macular degeneration 88

42.Diabetic retinopathy classification and typical lesions 90

43.Diabetic retinopathy treatment 92

44.Retinal vein occlusion 94

45.Retinal artery obstruction 96

46.HIV infection and AIDS 98

Section 13: Sub-specialty—Neuro-ophthalmology

47.Pupil abnormalities 100

48.Optic nerve disease 102

49.Cranial nerve palsies and eye movement disorders 104

50.Visual fields defects 106

Appendix: Red eye 108

Index 109

Preface

This book is intended primarily for medical students and junior doctors preparing for examinations (regardless of whether they are medical or surgical). In addition we hope that general practitioners and non-ophthalmic consultants who care for patients with eye diseases will find this book invaluable in its simplicity and clarity. We have tried to create a balanced, up to date, practical book. Blackwell’s have supported our need for extensive colour pictures and diagrams which characterize this ‘visual’ subject.

Ophthalmology at a Glance took form in London around the

time that Lorraine Cassidy was about to go to Dublin to become Professor of Ophthalmology. Slowly we gathered together a team of colleagues and friends who over 2–3 years all pulled together — were cajoled? —into writing this book.As editors we have knitted together our own and their contributing work. We are incredibly grateful to everyone who made this book a reality.

Jane Olver and Lorraine Cassidy

London and Dublin, 2004

Acknowledgements

In particular we want to thank Susie Downes and her team, especially Raman Malhotra and also Damien Louis and Anne Boulton, for several of the medical retinal chapters —retinal imaging, age-related macular degeneration, retinal dystrophies, diabetic retinopathy —all vital subjects.We thank Anthony Kwan for his chapters with wonderful photos on the red eye, eye drops and additional photos of cataract surgery, Siedel positive, etc. We also want to thank Dilani Siriwardena for her enormous contribution to the Glaucoma chapters, similarly Jugnoo Rahi (social and occupatinal aspects), Bernadette MacCarry (orthoptics), Veronica Ferguson (cataract), Raj Maini and Ursula Vogt (corneal and con-

tact lenses), Suzanne Mitchell (HIV), Jonathan Barnes (arterial and venous occlusion) and Mandeep Sagoo (ocular oncology). Others helped at the beginning including Jane Leitch,and towards the end, Roger Armour, Kuki Hundal, Jod Mehta,Arosha Fernandez, Mona Loufti, Nicholas Lee, Karl Southerton, Vickie Lee, Bijan Beigi, Graham Duguid, Eamon Sharkawi, Hugh Nolan and Donal Brosnahan who baled us out with last-minute pictures we couldn’t find anywhere. The Medical Illustration Departments at the Charing Cross Hospital and the Royal Victoria Eye and Ear Hospital in Dublin were very supportive. Lastly, Lorraine’s nieces had a star role as actresses in the orthoptic department.

Occluded retinal arteriole

Vision is central to the way we live; our social world, education, mobility and ability to communicate all depend on clear vision. The eyes and the face are important for interpersonal communication –

‘the eyes are the window of the soul’. Economically, many occupations are dependent on precise visual requirements

What is ophthalmology?

Ophthalmology is a large subject for a very small area: it is the medical and surgical care of the eye, the adjacent adnexal and periocular area and the visual system. It encompasses the upper and mid face, eyebrows and eyelids, lacrimal system and orbit, as well as the globe and eye muscles, optic nerve and nervous connections all the way back to the visual cortex. Many medical conditions have ocular features as their first presentation, e.g. in diabetes, cardiovascular disease, rheumatology, neurology, endocrinology and oncology. There is overlap with maxillofacial, plastic, otolaryngology and neurosurgery and strong links with dermatology with Mohs’ micrographic surgery for excision of periocular skin tumours. There are links with neuroradiology and pathology. It combines medical and surgical skills and uses minimally invasive microsurgery and lasers as well as delicate plastic surgical techniques.

Type of patients

Predominantly the very young and the elderly. Also, middle-aged patients with thyroid eye disease, diabetes or inherited disorders. Ophthalmic trauma affects particularly the young adult. Very few eye patients become ill and die. Most remain ambulatory and are seen as out patients or have day-case surgery.

Team

General practitioners, eye casualty officers, hospital ophthalmologists, medical physicists, optometrists, orthoptists and ophthalmic nurse practitioners, all collaborate in the investigation and management of ophthalmic patients.

Sub-specialties

The eye can be subdivided into several sub-specialty areas. Some ophthalmologists practice general ophthalmology alone; although most have a significant sub-specialty interest. Sub-specialties include:

•Paediatric ophthalmology and strabismus

•Oculoplastic, lacrimal and orbital (including oncology).

•External eye disease including contact lenses.

•Cornea and refractive surgery, cataract.

•Glaucoma.

•Vitreoretinal surgery.

•Medical retina.

•Neuro-ophthalmology.

•Intraocular microsurgery.

How to get into ophthalmology

Good eye–hand coordination helps if you want to do microsurgery and there are ample opportunities for people with good medical skills to practice medical ophthalmology,including neuroophthalmology, medical retina and glaucoma, or to conduct ophthalmic research. Examination hurdles are hard. Details of Basic SpecialistTraining and Higher SpecialistTraining curricula are obtainable from the Royal Colleges. Getting Part 1 MRCOphth helps you obtain your first Senior House Officer (SHO) post. Do Part 2 and 3 whilst an SHO in Basic Surgical Training (BST) (2 years minimum in recognized posts).You have to attend the Royal College of Ophthalmologists’ Basic Microsurgical Skills course

before you are allowed to do intraocular surgery. A certificate of eligibility is required from one of the Royal Colleges before entering Higher Surgical Training (HST) (4.5 years duration), which provides experience in all the sub-specialties. There is exit assessment before being awarded the Fellowship in Ophthalmology (FRCOphth, FRCSEd(Ophth)) and Certificate of Completion of Specialist Training (CCST) necessary to be placed on the Specialist Register. Advanced Subspecialist Training (ASTO) towards the end of HST offers further sub-specialty training. Training will be shortened with the introduction of Foundation Training and a subsequent unified training grade.

Membership examination: MRCOphth, MRCSEd

Part 1 Basic sciences. General physiology and pharmacology. Ocular anatomy, physiology, embryology, pharmacology. No clinical experience in ophthalmology needed to sit.

Part 2 (i) Optics and refraction. (ii) Assessment of clinical methods. One year’s experience as SHO required. The practical refraction is the hardest part.

Part 3 Clinical ophthalmology including microbiology, histopathology, medical and neurology clinical examination. Eighteen months’ experience as SHO required. The medical and neurology parts are the most difficult.

Colleges

•Royal College of Ophthalmologists: www.rcophth.ac.uk

•Royal College of Surgeons of Edinburgh: www.rcsed.ac.uk

•Irish College of Ophthalmologists: www.seeico.com

Education website

• Good basic anatomy and histology: www.lib.berkeley.edu/OPTO/ eyeanat.html

Eye associations

•American Academy Ophthalmology: www.aao.org

•American Associated Ophthalmic Plastic and Reconstructive Surgery: www.asoprs.org

•American Association Paediatric Ophthalmology and Strabismus: www.aapos.org

•Association for Research Vision and Ophthalmology: www.arvo.org

•British Oculoplastic Surgery Society: www.bopss.org

Further reading

1The Wills Eye Manual. Office and Emergency Room Diagnosis and Treatment of Eye Disease. Douglas J. Rhee and Mark F. Pyfer.

2Clinical Anatomy of the Eye. Richard S. Snell and Micheal A. Lemp.

3Ophthalmology. An Illustrated Text. M. Batterbury and B. Bowling.

4ABC of Eyes. P.T. Khaw and A.R. Elkington.

5Pocket Book of Ophthalmology. Philip I. Murray and Alistair Fielder.

KEY POINTS

•Ophthalmology is multidisciplinary.

•Interfaces with medicine.

•Involves microsurgery.