Ординатура / Офтальмология / Английские материалы / Primary Care Ophthalmology_Palay, Krachmer_2005

Consulting Editors

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Contributors

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Preface

Patients frequently present to primary care practitioners for treatment of an eye problem. It is estimated that greater than half of all eye drops prescribed in the United States are prescribed by physicians other than eye care specialists. It is important that primary care practitioners be able to recognize ophthalmic disease and to treat the problem if necessary, or to refer the patient for further evaluation.

For this second edition we have made several changes and additions:

We have changed the title of the book from Ophthalmology for the Primary Care Physician to Primary Care Ophthalmology, to emphasize that it is intended for anyone involved in direct patient care, including residents, medical students, optometrists, physician assistants, nurses, and nurse practitioners.

We also have added a chapter on the “red eye.” This chapter pulls together material presented throughout the book, to emphasize that a red eye is caused by a variety of conditions, not only by conjunctivitis.

As technology changes, so does the way information is disseminated and shared. This edition of the book contains software that can be downloaded to a personal digital assistant (PDA).

The format of the second edition is the same as that of the first. Most chapters begin with a brief discussion of anatomy, followed by a more detailed description of various diseases. Each disease is described in an outline format that covers symptoms, signs, etiology, workup, differential diagnosis, and treatment. The text describes the core information of each condition, without providing unnecessary details. The highlight of the book is the more than 300 quality color illustrations that accompany the text. Most of the figures underwent a variety of modifications, such as labeling and addition of magnified insets and schematic illustrations, to augment their educational value and to emphasize desired features.

To achieve our goal of providing a practical guide to eye care, we have necessarily omitted a wealth of information that is included in the training of ophthalmologists. Many diseases that are intrinsic to the eye were excluded because the diagnosis and treatment were felt to be outside the realm of the primary care practitioner. The information in this book should not be substituted for a proper referral when necessary.

We tried to be as specific as possible when recommending treatment options. Drug dosages have been checked carefully; however, the reader is urged to consult the Physicians’ Desk Reference or other source when prescribing medications that are unfamiliar.

We hope that this book will continue to serve as a valuable reference to all practitioners involved in delivering primary eye care. We welcome your comments.

David A. Palay, M.D.

Jay H. Krachmer, M.D.

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Acknowledgments

We are extremely grateful to our many colleagues, associates, and friends who helped with the preparation of this book. We would like to credit and thank the following sources of material:

Antonio Capone Jr., M.D., Beaumont, Michigan (Figs. 10–28, 10–32, and 15–29) James Gilman, CRA, Atlanta, Georgia (Figs. 1–14 and 9–8)

Glaxo Wellcome (Fig. 1–1)

Harrington DO: The Visual Fields: A Textbook and Atlas of Clinical Perimetry (Fig. 12–1) Edward J. Holland, M.D., Cincinnati, Ohio (Fig. 5–21)

Scott Lambert, M.D., Atlanta, Georgia (Fig. 15–10)

Mark J. Mannis, M.D., Sacramento, California (Fig. 4–16) Daniel F. Martin, M.D., Atlanta, Georgia (Figs. 10–10 and 15–2) Robert A. Myles, CRA, Atlanta, Georgia (Fig. 10–27)

Maria Alexandra Pernetz, B.S., RDCS, Atlanta, Georgia (Fig. 10–17) Dante Pieramici, M.D., Santa Barbara, California (Fig. 9–5)

Spalton DJ, Hitchings RA, Hunter PA: Atlas of Clinical Ophthalmology, ed 2 (Figs. 1–5, 1–7, 1–13, 14–1, and 14–2)

Paul Sternberg Jr., M.D., Nashville, Tennessee (Fig. 10–29)

Ray Swords, CRA, Atlanta, Georgia (Figs. 10–1, 10–18, and 10–26) Keith Walter, M.D., Winston-Salem, North Carolina (Fig. 5–10)

George O. Waring III, M.D., Atlanta, Georgia (Figs. 5–20, 9–2, and 9–9) Watson PG, Ortiz JM: Color Atlas of Scleritis (Fig. 7–1)

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CHAPTER 1

General Eye

Examination

MARIA AARON • WAYNE A. SOLLEY •

GEOFFREY BROOCKER

A structured approach is crucial in the evaluation of patients with ophthalmic complaints. This chapter introduces the primary care physician to a general approach to the eye exam in adult ophthalmic patients. Adherence to these basic steps minimizes the possibility of overlooking a serious ocular problem. (See Chapter 13 for details on the pediatric eye exam.)

Related Anatomy

The cornea is located at the anteriormost aspect of the globe; along with the tear film, it is the major refracting surface of the eye (Fig. 1–1). Directly posterior to the cornea is the anterior chamber, a fluid-filled space (containing the aqueous humor) in which blood, white blood cells, or fibrin may collect in injury, inflammatory disease, and infection. The iris is a pigmented structure that lies just anterior to the crystalline lens and represents the posterior boundary of the anterior chamber. It consists of the sphincter and dilator muscles, connective tissue, and pigmented epithelium. The lens is surrounded by a thin capsule. In cataract surgery (crystalline lens extraction), the capsule usually is left intact posteriorly and houses the intraocular lens implant. The lens is supported by small filaments termed zonules that attach to the periphery of the lens capsule and anchor at the ciliary processes of the ciliary body.

Posterior to the lens is the vitreous body, a clear gel that is firmly attached to the inner eye at the area of the ora serrata (the anterior termination of the retina) and the optic nerve head (optic disc). The wall of the eye (posterior to the cornea) is composed of three layers: the sclera, choroid, and retina. The sclera is a firm collagenous layer that protects the intraocular structures, gives the globe its shape, and is the site

1

FIGURE 1–1 View of the globe, looking down on the right eye, showing major anatomic structures.

of attachment of the extraocular muscles. The choroid is a highly vascular layer forming part of the uveal tract (iris, ciliary body, and choroid) that lies just inside the sclera. The ciliary body controls accommodation, is the site of aqueous production, and lies posterior and lateral to the iris. The retina is located anterior to the choroid and posterior to the vitreous body; it is composed of photoreceptors and neural tissues. The optic nerve is a congregation of approximately 1.2 million axons from the entire retina, and it exits the globe posteriorly and slightly nasally.

The Ocular Examination

Vision

Visual acuity is the principal “vital sign” in ophthalmology. Often the status of the patient’s visual acuity is the first question the ophthalmologist asks the examining physician when consulted. Evaluating the vision should be the first step in the exam, preceding any diagnostic maneuvers (e.g., pupil examination, direct ophthalmoscopy, dilation, intraocular pressure [IOP] evaluation). The examiner measures vision using a standardized visual acuity chart (Fig. 1–2) or near acuity card (Fig. 1–3). If these tools are unavailable, the examiner can use newsprint, the patient’s chart, or an identification badge or a nameplate. The examiner monitors the patient to ensure that no