Ординатура / Офтальмология / Английские материалы / Practical Ophthalmology A Manual for the Beginning Ophthalmology Residents 4th edition_Wilson_1996
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Practical Ophthalmology
A MANUAL FOR BEGINNING RESIDENTS
Fourth Edition
...'i : •.> ".:>;:} Formerly titled
A Manual for the Beginning Ophthalmology Resident
Executive Editor
Fred M.Wilson II, MD
Contributing Authors
• Judith E.Gurland, MD
LatifM.Hamed,MD
Karla J.Johns,MD
KirkR.Wilhelmus,MD
Fred M.Wilson II, MD
American Academy of Ophthalmology
^
©
American Academy of Ophthalmology |
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Because diagnostic, therapeutic, and practice recommen- |
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655 Beach Street |
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dations (hereinafter "recommendations") may have |
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P.O. Box 7424 |
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changed since the publication of this book, because such |
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recommendations cannot be considered absolute or uni- |
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San Francisco, CA 94120-7424 |
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versal in their application, and because the publication |
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Clinical Education Secretaries |
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process contains the potential for error, the American |
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Academy of Ophthalmology strongly advises that the |
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Thomas A. Weingeist, MD, PhD |
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recommendations in this book be verified, prior to use, |
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Senior Secretary for Clinical Education |
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with information included in the manufacturers' package |
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Thomas J. Liesegang, MD |
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inserts or provided by an independent source and be |
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considered m light of a particular patient's clinical condi- |
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Secretary for Instruction |
. . . |
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tion and history. Caution is especially urged when using |
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Publication Task Force |
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new or infrequently used drugs. Including all indications, |
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contraindications, side effects, and alternative agents for |
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Fred M. Wilson II, MD, Chair |
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each drug or treatment is beyond the scope of this book. |
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Judith E. Gurland, MD |
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The Academy disclaims responsibility and liability |
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Latif M. Hamed, MD |
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for any and all adverse medical or legal effects, including |
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KarlaJ.Johns, MD |
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personal, bodily, property, or business injury, and for |
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Kirk R. Wilhelmus, MD |
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damages or loss of anv kind whatsoever, resulting directly |
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Margaret Robinson, Staff Liaison |
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or indirectly, whether from negligence or otherwise, |
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from the use of the recommendations or other informa- |
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Margaret Petela, Staff Liaison |
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tion in this book, from anv undetected printing errors or |
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Academy Clinical Education Staff |
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recommendation errors, or from textual misunderstand- |
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ings by the reader. The ultimate arbiter of any diagnostic |
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Kathryn A. Hecht, EdD, Vice President |
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or therapeutic decision remains the individual physician's |
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William J. Hering, PhD, Director of Programs |
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judgment. |
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Hal Straus, Director of Publications |
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Reference to certain drugs, instruments, and other |
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Margaret Robinson, Assistant Director of Programs |
products in this publication is made for illustrative pur- |
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Margaret Petela, Managing Editor |
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poses onlv and is not intended to constitute an endorse- |
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Ruth Modric, Production Manager |
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ment of such drutis. instruments, and other products. |
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Beth T. Berkelhammer, Production Editor |
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Rachel Griener, Publications Assistant |
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Production, Design, and Illustration
Metcalfe/Shuhert Design/Santa Rosa, California
Christine Gralapp, illustration
Jeanne C. Koelling, MS, illustration
Copyright © 1996 American Academy of Ophthalmology®
All rights reserved.
Library of Congress Cataloging-in-Publication Data
Practical ophthalmology r a manual for beginning residents / executive editor, Fred M. Wilson II; contributing authors, Judith E. Gurland
... [et al.]. — 4th ed.
p.cm.
Formerly titled "A manual tor the beginning ophthalmology
resident." |
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Includes bibliographical references and index. |
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ISBN 1-56055-034-1 (pbk.) |
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1. Eye—Examination—Handbooks, manuals, etc. |
2. Ophthalmology- |
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Handbooks, manuals, etc. I. Wilson, Fred Al., |
1940- |
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II. Gurland, Judith E., 1945- |
. III. Manual |
for the beginning |
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ophthalmology resident. |
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(DNLM: |
T. Eye Diseases. |
WW 140 PK95 1996] |
. . ' : < , : : |
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RE75.M36 |
1996 |
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617.7' 0754—dc20 |
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' - |
- ; -• ; |
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D N L M / D L C |
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lor Library of Congress |
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96-41408 |
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CIP |
03 02 01 00 99 98 97 96 |
5 4 3 2 |
1 |
Contents
..'•• |
. . . |
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' - * ! |
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I' |
• ^ " • - |
Preface |
xv |
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Acknowledgments |
xvi |
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Introduction to the Practice of Ophthalmology |
1 |
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Practicing Ophthalmology |
2 |
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Responsibilities of the Resident 3 |
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Stress During Residency Training |
4 |
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Recognizing Stress and Its Sources |
5 |
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Dealing With Early Discouragement |
7 |
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Ethical Considerations |
7 |
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About This Manual 8 |
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Beyond This Manual: Lifelong Education |
9 |
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Pitfalls and Pointers |
11 |
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Suggested Resources |
12 |
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Overviewof the Ophthalmic Evaluation |
13 |
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History |
14 |
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Examination 14 |
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Ophthalmic Equipment |
15 |
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Physician Demeanor and Approach to the Patient |
17 * |
"?. |
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Medical Record Keeping |
17 |
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. . . • • . |
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Pitfalls and Pointers |
18 |
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Suggested Resources |
18 |
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History Taking 19
Goals of the History |
20 |
• ' • . ' • • |
Methods of Recording the History 21 |
;-•'"..,. |
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Components of the History 22 |
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Chief Complaint |
22 |
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Present Illness |
23 |
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iii
tv Contents
Past Ocular History |
26 |
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Ocular Medications |
27 |
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General Medical and Surgical History 27 |
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Systemic Medications |
28 |
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Allergies 28 |
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Social History |
29 |
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Family History |
29 |
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Pitfalls and Pointers |
30 |
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Suggested Resources |
30 |
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4 |
Visual Acuity Examination |
31 |
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Testing Conventions and Materials |
32 |
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Measurement Notation |
32 |
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Test Targets |
33 |
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Standard Abbreviations |
34 |
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.,: |
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Testing Procedures |
34 |
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*;;' |
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Distance Acuity Test |
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3 5 |
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Pinhole Acuity Test |
36 |
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Near Acuity Test |
3 7 |
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Other Tests of Near Vision |
38 |
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Acuity Tests for Special Patients |
38 |
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Low-Vision Testing |
39 |
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Testing Children and Special Adults |
39 |
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Variables in Acuity Measurements |
42 |
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1'ncorrectable Visual Acuity |
44 |
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Amblyopia |
45 |
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Other Tests of Sensory Visual Function |
47 |
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Contrast Sensitivity, Glare, and Color Vision Tests 48 |
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Pitfalls and Pointers |
49 |
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Suggested Resources |
50 |
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5 |
Refraction 57 |
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»A |
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((verview of Refraction |
58 |
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Overview of Ophthalmic Optics |
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Principles of Vergence |
59 |
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Types of Lenses |
60 |
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Refractive States of the |
F.ye |
64 |
Lens Notation 65 |
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Lens Transposition |
66 |
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ft
Ml
Contents
Spherical Equivalent |
67 |
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Lensometry 67 |
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Retinoscopy and Refinement |
68 |
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Instrumentation |
69 |
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Retinoscopy Technique |
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72 |
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Neutralization With a Retinoscope |
74 |
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Determining Cylinder |
77 |
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Summary of Retinoscopy Steps |
78 |
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Cycloplegic Refraction |
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Refinement 79 |
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Duochrome Test |
84 |
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Binocular Balancing |
85 |
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Near Point and Reading Add |
86 |
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Guidelines for Prescribing Glasses |
88 |
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General Prescribing Guidelines |
89 |
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Prescriptions for Myopia |
89 |
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Prescriptions for Hyperopia 90 |
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Prescriptions for Astigmatism |
90 |
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Prescriptions for Presbyopia |
91 |
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Optical Fitting Considerations |
94 |
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Pantoscopic Tilt |
94 |
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Interpupillary Distance |
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94 |
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Pitfalls and Pointers |
95 |
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Suggested Resources |
95 |
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g Ocular Motility Examination |
101 |
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Strabismus Terminology |
102 |
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Motility Terminology |
104 |
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Function of the Extraocular Muscles |
106 |
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Ocular Motility Examination |
108 |
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Tests of Binocularity and Fusion |
110 |
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Stereopsis |
110 |
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Other Tests of Binocular Status |
110 |
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Tests of Alignment |
112 |
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Red Reflex Test |
112 |
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Corneal Light Reflection Test |
113 |
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Cover Tests |
115 |
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Other Considerations With Alignment Tests |
117 |
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Diagnostic Use of Prisms |
119 |
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oatents
Pitfalls and Pointers |
119 |
. .- ,....; : |
Suggested Resources |
120 |
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Pupillary Examination |
125 |
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Anatomy of Pupillary Pathways |
126 |
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Parasympathetic Pathway (Light-Reflex Pathway) |
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Near-Reflex Pathway |
128 |
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Sympathetic Pathway |
128 |
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Examination of the Pupils |
128 |
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General Pupillary Observation |
129 |
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& |
' Light-Reflex Test |
130 |
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Swinging Flashlight Test |
131 |
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Near-Reflex Test |
132 |
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Abnormal Pupils 132 |
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Iris Abnormalities |
132 |
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Relative Afferent Pupillary Defect |
134 |
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Light-Near Dissociation |
134 |
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Horner's Syndrome 135 |
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T h e Fixed and Dilated Pupil |
136 |
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Pitfalls and Pointers |
137 |
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.* |
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Suggested Resources |
138 |
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8 Visual Field Examination |
143 |
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The Visual Field |
144 |
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Screening Tests |
146 |
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Confrontation Fields Testing |
146 |
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Special Situations |
147 |
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Amsler Grid Test |
148 |
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Manual Perimetry |
148 |
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Tangent Screen Testing |
149 |
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Goldmann Perimetry |
151 |
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Automated Perimetry |
152 |
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Test Targets and Strategies |
152 |
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Patient Preparation 152 |
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Test Selection |
154 |
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Interpretation of a Computerized Printout 155 |
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Common Visual Field |
Defects |
157 |
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Eve and Shape |
158 |
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Location 159 |
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Contents |
vii |
v |
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Symmetry |
160 |
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Localizing Visual Field Defects 160 |
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Progression |
161 |
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Pitfalls and Pointers |
161 |
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2; |
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Suggested Resources |
164 |
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Q |
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External Examination 173 |
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Situating the Patient |
174 |
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General Observation |
174 |
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Inspection 175 |
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Head and Face |
178 |
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::Wiv'.:.. |
° r b i t |
178 |
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. . . |
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> ^ v : ; |
Eyelids |
181 |
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!' ' |
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Lacrimal System |
184 |
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•^i: |
;./;,•,,'.; |
Globe |
184 |
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'}ri: ;•:;••; ••:'.-.ij'r Ovl' Palpation 186 |
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" -"•:;-/; i'"•'; |
Head and Face |
187 |
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ii;^ii';[v..V:;" r |
Orbit |
188 |
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r?':;?';;!:; ; ; :" ! |
Eyelids |
189 |
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M |
';* |
Lacrimal System |
189 |
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Globe |
189 |
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';fe/',-:. :[;v |
Auscultation |
190 |
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'gV";K;|,s |
Pitfalls and Pointers |
190 |
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j ! ' |
• ' • = • ' • • • . j |
' ; • : " . ? ; • Suggested Resources |
191 |
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+ |
10 |
Slit-Lamp Biomicroscopy |
213 |
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C V.^j"••"" |
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Uses of the Slit Lamp |
214 |
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'•:'•;•:-:•'• |
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Parts of the Slit Lamp |
214 |
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.•*,. |
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T h e Viewing Arm |
215 |
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"=i |
X |
' |
. . 1i : i;.|; '• |
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^-';" • |
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T h e Illumination Arm |
216 |
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, : ? |
' 1 J |
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'•, |
.";...! "•.''.' |
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The Patient-Positioning Frame |
216 |
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.: |
],,; l: |
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'" |
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T h e Base 217 |
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• ^ v ' i ' . v ; . |
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'yPVP' |
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']'•'.''$ |
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Other Attachments |
217 |
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v : ^ ; ' , : ' ^ / |
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\" |
,[ |
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Preparing and Positioning the Patient |
217 |
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,••'.• |
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Principles of Slit-Lamp Illumination |
218 |
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>•;;•. . j • ' • ' % |
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Diffuse Illumination |
219 |
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.; |
JM |
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Direct Focal Illumination |
220 |
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'.'.•• |
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?:/;' |
i::j„f i:. ; |
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• . ' . ' . '•••'i'j, • > |
.: |
S p e c u l a r R e f l e c t i o n |
2 2 1 |
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, |
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c y ; f , i |
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r.;'-: |
!•-'••. |
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T r a n s i l l u m i n a t i o n |
2 2 2 |
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• |
..••!••••• ••••*• |
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Indirect Lateral Illumination 224 |
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Sclerotic Scatter |
224 |
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Oscillatory Illumination |
224 |
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Special Techniques |
225 |
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T h e Slit Lamp as a Measuring Device |
225 |
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Gonioscopy 227 |
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Fundus Examination With the Slit Lamp |
227 |
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Goldmann Tonometry |
228 |
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Slit-Lamp Photography |
228 |
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Pitfalls and Pointers |
228 |
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Suggested Resources |
228 |
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Anterior Segment Examination |
231 |
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Overview of the .Anterior Segment Examination |
232 |
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Lacrimal Gland and Skin |
233 |
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Evelids and Eyelashes |
234 |
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Tumors |
235 |
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Blepharitis |
236 |
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Conjunctiva |
239 |
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'• |
-' • |
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Palpebral Conjunctiva |
239 |
f'WV. • |
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Limbal Conjunctiva |
244 |
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Bulbar Conjunctiva |
246 |
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Other Conjunctival Abnormalities |
249 |
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Episclera and Sclera |
250 |
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Episcleritis |
251 |
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Scleritis |
251 |
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Pigmentations |
253 |
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Involutional |
Hyaline Plaques 254 |
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Tear Film |
254 |
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Overall Wetness |
255 |
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'Fear Meniscus |
255 |
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Tear Film Breakup Lime 256 |
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Other Tear Film Abnormalities |
256 |
' " |
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Cornea 256 |
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Epithelium |
257 |
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Bowman's Layer |
258 |
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Stroma |
260 |
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Descemet's Membrane |
262 |
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Endothelium |
261 |
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Contents
Anterior Chamber |
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261 |
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Anterior Chamber Depth |
264 |
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Hare and Cell |
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265 |
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Blood and Other Foreign Matter |
265 |
;! |
;, |
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lr\s |
266 |
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Nodules |
267 |
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Neovascularization |
267 |
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Cysts and Tumors |
267 |
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:•, i |
Persistent Pupillary Membrane Remnants |
268 |
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Other Abnormalities |
268 |
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] |
^ |
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Crystalline Lens |
268 |
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I • y. |
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Cataract |
269 |
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J |
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Subluxation and Luxation 272 |
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Other Conditions |
272 |
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Retrolental Space and Anterior Vitreous |
273 |
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Cionioscopy |
273 |
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Stains |
276 |
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Fluorescein 277 |
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Rose Bengal |
279 |
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Pitfalls and Pointers |
280 |
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Suggested Resources |
280 |
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12, |
Tonometry |
285 |
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IOP Measurement Conventions and Population Means 286 |
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Types of Tonometers |
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286 |
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Applanation Tonometers |
286 |
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Indentation Tonometers |
287 |
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Cioldmann Applanation Tonometry |
288 |
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Parts of the Instrument |
288 |
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Disinfection of the Applanating Tip |
289 |
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Schiotz Indentation Tonometry 290 |
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Parts of the Instrument |
290 |
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Disinfection of the Schiotz Tonometer |
292 |
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Pitfalls and Pointers |
292 |
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Suggested Resources |
292 |
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13 Posterior Segment Examination 297
Anatomic Landmarks 2%
Pupillary Dilation 302
Instrumentation for Examination |
303 |
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Indirect Ophthalmoscope |
304 |
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Slit-Lamp Biomicroscope |
306 |
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Direct Ophthalmoscope 306 |
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Indirect Ophthalmoscopy |
307 |
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Headset Adjustment |
308 |
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1 , "J |
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. ; |
Choosing and Positioning the Condensing Lens |
309 |
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v/fs'" - |
Changing Position to View Different Fundus Areas |
3 |
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***- ' |
Sequence of the Complete Examination 313 |
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Scleral Depression |
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314 |
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Transillumination |
317 |
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Posterior Segment Examination With the Slit Lamp 317 |
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Indirect Slit-Lamp Biomicroscopy 317 |
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Hruln Lens Biomicroscopy |
319 |
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Contact Lens Biomicroscopy 320 |
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Direct Ophthalmoscopy |
321 |
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Overview of the Examination |
322 |
: |
, |
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The Fundus Record |
324 |
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Drawing the Indirect Ophthalmoscopic View |
327 |
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Drawing the Slit-Lamp Biomicroscopic View |
328 |
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Drawing the Direct Ophthalmoscopic View |
328 |
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Imaging Studies |
328 |
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Photography |
329 |
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Angiography |
329 |
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Ultrasonography |
329 |
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The Normal Fundus and Its Common Variations |
331 |
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Optic Disc |
331 |
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Posterior Pole 555 |
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Retinal Blood Vessels |
334 |
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Fundus Background |
335 |
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Peripheral Fundus |
|
335 |
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Mtreous Humor |
336 |
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Pitfalls and Pointers |
338 |
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Suggested Resources |
340 |
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14 Ophthalmic Emergencies 353
Emergency Equipment and Genera! Evaluation 354
Pediatric Evaluation 355
Ocular Trauma in the Emergency Setting 356