The American Academy of Ophthalmology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Academy of Ophthalmology designates this enduring material for a maximum of 15 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CME expiration date: June 1, 2016. AMA PRA Category 1 Credits™ may be claimed only once between June 1, 2013, and the expiration date.
BCSC® volumes are designed to increase the physician’s ophthalmic knowledge through study and review. Users of this activity are encouraged to read the text and then answer the study questions provided at the back of the book.
To claim AMA PRA Category 1 Credits™ upon completion of this activity, learners must demonstrate appropriate knowledge and participation in the activity by taking the posttest for Section 8 and achieving a score of 80% or higher. For further details, please see the instructions for requesting CME credit at the back of the book.
The Academy provides this material for educational purposes only. It is not intended to represent the only or best method or procedure in every case, nor to replace a physician’s own judgment or give specific advice for case management. Including all indications, contraindications, side effects, and alternative agents for each drug or treatment is beyond the scope of this material. All information and recommendations should be verified, prior to use, with current information included in the manufacturers’ package inserts or other independent sources, and considered in light of the patient’s condition and history. Reference to certain drugs, instruments, and other products in this course is made for illustrative purposes only and is not intended to constitute an endorsement of such. Some material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate, informed patient consent in compliance with applicable law. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise from the use of any recommendations or other information contained herein.
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Cover image: From BCSC Section 12, Retina and Vitreous. Ultra-wide-field fundus photograph from a patient with von Hippel–Lindau disease. Courtesy of Colin A. McCannel, MD.
Copyright © 2015
American Academy of Ophthalmology All rights reserved
Basic and Clinical Science Course
Louis B. Cantor, MD, Indianapolis, Indiana, Senior Secretary for Clinical Education Christopher J. Rapuano, MD, Philadelphia, Pennsylvania, Secretary for Ophthalmic Knowledge George A. Cioffi, MD, New York, New York, BCSC Course Chair
Section 8
Faculty
Robert W. Weisenthal, MD, Chair, De Witt, New York
Natalie A. Afshari, MD, La Jolla, California
Charles S. Bouchard, MD, Maywood, Illinois
Kathryn A. Colby, MD, PhD, Boston, Massachusetts
David S. Rootman, MD, Toronto, Canada
Elmer Y. Tu, MD, Chicago, Illinois
Denise de Freitas, MD, Consultant, São Paulo, Brazil
The Academy wishes to acknowledge The Cornea Society for recommending faculty members to the BCSC Section 8 committee.
The Academy also wishes to acknowledge the following committees for review of this edition:
Committee on Aging: Holly B. Hindman, MD, Rochester, New York
Vision Rehabilitation Committee: Janet S. Sunness, MD, Baltimore, Maryland
Practicing Ophthalmologists Advisory Committee for Education: Dasa Gangadhar, MD, Primary Reviewer, Wichita, Kansas; William S. Clifford, MD, Past Chair, Garden City, Kansas; Hardeep S. Dhindsa, MD, Reno, Nevada; Robert Fante, MD, Denver, Colorado; Edward K. Isbey III, MD, Asheville, North Carolina; James Mitchell, MD, Edina, Minnesota; Sara O’Connell, MD, Overland Park, Kansas; Robert E. Wiggins Jr, MD, Asheville, North Carolina
European Board of Ophthalmology: Joseph Colin, MD, PhD, EBO Chair, Bordeaux, France; MarieJosé Tassignon, MD, PhD, FEBO, EBO Liaison, Antwerp, Belgium; Massimo Busin, MD, Forlì, Italy; Beatrice Cochener-Lamard, MD, PhD, Brest, France; Sheraz M. Daya, MD, London, England, United Kingdom; Günther Grabner, MD, Salzburg, Austria; Rudy MMA Nuijts, MD, PhD, Maastricht, the Netherlands
Financial Disclosures
Academy staff members who contributed to the development of this product state that within the past 12 months, they have had no financial interest in or other relationship with any entity discussed in this course that produces, markets, resells, or distributes ophthalmic health care goods or services consumed by or used in patients, or with any competing commercial product or service.
The authors and reviewers state the following financial relationships:*
Dr Afshari: National Eye Institute (S), Research to Prevent Blindness (S)
Dr Busin: Moria (L, P)
Dr Clifford: Transcend Medical (S)
Dr Cochener-Lamard: Alcon Laboratories (L), Bausch + Lomb (L), Novagali-Santen (C), PhysIOL (L), Revision Optic (L), Thea (C)
Dr Colby: Alcon Laboratories (C)
Dr Colin: Abbott Medical Optics (C), Addition Technology (C), Alcon Laboratories (C)
Dr Daya: Bausch + Lomb (C, L), PhysIOL (C), STAAR Surgical (C), Technolas Perfect Vision (C, L), Zeiss Acri.Tec (C)
Dr Gangadhar: Inspire Pharmaceuticals (C, L)
Dr Grabner: Abbott Medical Optics (C, L, S), AcuFocus (L, S), Polytech (C)
Dr Nuijts: Alcon Laboratories (L, S), ASICO (P), Bausch + Lomb (C), SensoMotoric Instruments (C, L)
Dr Rootman: Abbott Medical Optics (S)
Dr Sunness: Acucela (C), Alcon Laboratories (C), Cell Cure (C), Genentech (C), GlaxoSmithKline (C), Neurotech Pharmaceuticals (C), Novartis Pharmaceuticals Corporation (C), Ophthotech (C), Pfizer (C), Potentia Pharmaceuticals (C), ReVision Optics (C), Shire (C), Sucampo Pharmaceuticals
(C)
Dr Tassignon: Morcher GmbH (P)
Dr Wiggins: Medflow/Allscripts (C), Ophthalmic Mutual Insurance Company (C)
The other authors and reviewers state that they have no significant financial interest or other relationship with the manufacturer of any commercial product discussed in this course or with the manufacturer of any competing commercial product.
*C = consultant fees, paid advisory boards, or fees for attending a meeting; L = lecture fees (honoraria), travel fees, or reimbursements when speaking at the invitation of a commercial sponsor; O = equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers of commercial ophthalmic products or commercial ophthalmic services; P = patents and/or royalties that might be viewed as creating a potential conflict of interest; S = grant support for the past year (all sources) and all sources used for a specific talk or manuscript with no time limitation
Recent Past Faculty
Minas T. Coroneo, MD, MS
George J. Florakis, MD
Kenneth M. Goins, MD
Kristin Hammersmith, MD
James J. Reidy, MD
In addition, the Academy gratefully acknowledges the contributions of numerous past faculty and advisory committee members who have played an important role in the development of previous editions of the Basic and Clinical Science Course.
American Academy of Ophthalmology Staff
Dale E. Fajardo, EdD, MBA |
Beth Wilson, CHCP |
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Vice President, Education |
Director, CME, Programs & Acquisitions |
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Daniel Mummert |
Christine A. Arturo |
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Director, Online Education & the |
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ONE Network |
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Jasmine Chen |
Stephanie Tanaka |
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Manager, E-Learning |
Publications Manager, BCSC |
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Eric Gerdes |
D. Jean Ray |
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Interactive Designer |
Production Manager |
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Donna Scism |
Ann McGuire |
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Contents
Title Page
Copyright Page
Faculty and Disclosures
General Introduction
Visual Acuity Chart
Objectives
1 Structure and Function of the External Eye and Cornea
Anatomy
Eyelids
Conjunctiva
Lacrimal Functional Unit
The Tear Film
Cornea
Sclera
2 Examination Techniques for the External Eye and Cornea
Evaluation of Vision in the Patient With an Abnormal Cornea External Examination
Slit-Lamp Biomicroscopy Direct Illumination Methods Indirect Illumination Methods Clinical Use
Stains Fluorescein
Rose Bengal and Lissamine Green
Evaluation of the Tear Film and Tests of Tear Production Tear Composition Assays
Imaging Technologies
Impression Cytology Corneal Pachymetry
Measurement of Corneal Biomechanics Measurement of Corneal Curvature
Zones of the Cornea
Shape, Curvature, and Power Keratometry
Computerized Corneal Topography
Corneal Tomography
Indications
Additional Imaging Techniques of the Cornea and Anterior Segment
Ultrasound Biomicroscopy
Anterior Segment Optical Coherence Tomography
Confocal Microscopy
External and Slit-Lamp Photography
Specular Microscopy
Anterior Segment Fluorescein Angiography
Esthesiometry
Retinoscopy
3 Clinical Approach to Ocular Surface Disorders
Common Clinical Findings
Conjunctival Signs Corneal Signs
Clinical Approach to Dry Eye Mechanisms of Dry Eye Aqueous Tear Deficiency Evaporative Dry Eye Treatment of Dry Eye
Other Eyelid Diseases Associated With Ocular Surface Disorders Rosacea
Seborrheic Blepharitis Staphylococcal Blepharitis Hordeola and Chalazia
Structural and Exogenous Disorders Associated With Ocular Surface Disorders Exposure Keratopathy
Floppy Eyelid Syndrome
Superior Limbic Keratoconjunctivitis Recurrent Corneal Erosion
Neurotrophic Keratopathy and Persistent Corneal Epithelial Defects Trichiasis and Distichiasis
Factitious Ocular Surface Disorders Dellen
Limbal Stem Cell Deficiency
Systemic Conditions Associated With Ocular Surface Disorders Sjögren Syndrome
Ichthyosis Ectodermal Dysplasia
Xeroderma Pigmentosum Vitamin A Deficiency
4 Infectious Diseases of the External Eye: Basic Concepts and
Viral Infections
Defense Mechanisms of the External Eye
Normal Ocular Flora
Pathogenesis of Ocular Infections
Virulence
Inoculum
Host Defense
Ocular Microbiology
Diagnostic Laboratory Techniques
Specimen Collection
Staining Methods
Virology and Viral Infections
DNA Viruses: Herpesviruses
Herpes Simplex Eye Diseases
Varicella-Zoster Virus Dermatoblepharitis, Conjunctivitis, and Keratitis
Epstein-Barr Virus Dacryoadenitis, Conjunctivitis, and Keratitis
Cytomegalovirus Keratitis and Anterior Uveitis
DNA Viruses: Adenoviruses
DNA Viruses: Poxviruses
Molluscum Contagiosum
Vaccinia
DNA Viruses: Papovaviruses
RNA Viruses
5 Infectious Diseases of the External Eye: Microbial and Parasitic
Infections
Bacteriology
Gram-positive Cocci
Gram-negative Cocci
Gram-positive Rods
Gram-negative Rods
Gram-positive Filaments
Chlamydia Species
Spirochetes
Mycology
Yeasts
Septate Filamentous Fungi
Nonseptate Filamentous Fungi
Parasitology
Protozoa
Helminths
Arthropods
Prions
Microbial and Parasitic Infections of the Eyelid Margin and Conjunctiva
Staphylococcal Blepharitis
Fungal and Parasitic Infections of the Eyelid Margin
Bacterial Conjunctivitis in Children and Adults
Parinaud Oculoglandular Syndrome
Microbial and Parasitic Infections of the Cornea and Sclera
Contact Lens–Related Infectious Keratitis
Bacterial Keratitis
Atypical Mycobacteria
Fungal Keratitis
Acanthamoeba Keratitis
Corneal Stromal Inflammation Associated With Systemic Infections
Microsporidiosis
Loiasis
Microbial Scleritis
6 Ocular Immunology
Overview of the Ocular Surface Immune Response Tear Film
Immunoregulation of the Ocular Surface Angiogenesis and Lymphangiogenesis in the Cornea
Tissue-Specific Patterns of Immune-Mediated Ocular Disease Conjunctiva
Cornea
Sclera
Diagnostic Approach to Immune-Mediated Ocular Disorders
7 Diagnosis and Management of Immune-Related Disorders of the
External Eye
Immune-Mediated Diseases of the Eyelid
Contact Dermatoblepharitis
Atopic Dermatitis
Immune-Mediated Disorders of the Conjunctiva
Hay Fever Conjunctivitis and Perennial Allergic Conjunctivitis
Vernal Keratoconjunctivitis
Atopic Keratoconjunctivitis
Ligneous Conjunctivitis
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
Mucous Membrane Pemphigoid
Ocular Graft-vs-Host Disease
Other Immune-Mediated Diseases of the Skin and Mucous Membranes
Immune-Mediated Diseases of the Cornea
Thygeson Superficial Punctate Keratitis
Interstitial Keratitis Associated With Infectious Diseases
Reactive Arthritis
Cogan Syndrome
Marginal Corneal Infiltrates Associated With Blepharoconjunctivitis
Peripheral Ulcerative Keratitis Associated With Systemic Immune-Mediated Diseases
Mooren Ulcer
Corneal Transplant Rejection
Immune-Mediated Diseases of the Episclera and Sclera
Episcleritis
Scleritis
8 Clinical Approach to Neoplastic Disorders of the Conjunctiva and Cornea
Approach to the Patient With a Neoplastic Conjunctival Lesion Management of Patients With Conjunctival Tumors
Surgical Treatment Topical Chemotherapy
Tumors of Epithelial Origin Benign Epithelial Tumors Preinvasive Epithelial Lesions Malignant Epithelial Lesions
Management of Atypical Epithelial Tumors Other Malignant Epithelial Lesions
Glandular Tumors of the Conjunctiva Oncocytoma
Sebaceous Gland Carcinoma
Tumors of Neuroectodermal Origin
Benign Pigmented Lesions Preinvasive Pigmented Lesions Malignant Pigmented Lesions
Neurogenic and Smooth-Muscle Tumors Vascular and Mesenchymal Tumors
Benign Tumors Malignant Tumors
Lymphatic and Lymphocytic Tumors Lymphangiectasia and Lymphangioma Lymphoid Hyperplasia
Lymphoma
Metastatic Tumors
9 Basic and Clinical Concepts of Congenital Anomalies of the
Cornea, Sclera, and Globe
Developmental Anomalies of the Globe and Sclera
Cryptophthalmos
Microphthalmos
Nanophthalmos
Blue Sclera
Developmental Anomalies of the Anterior Segment
Anomalies of Size and Shape of the Cornea Abnormalities of Corneal Structure and/or Clarity
Congenital Corneal Opacities in Hereditary Syndromes and Chromosomal Aberrations Secondary Abnormalities Affecting the Fetal Cornea
Intrauterine Keratitis: Bacterial and Syphilitic Congenital Corneal Keloid
Congenital Corneal Anesthesia Congenital Glaucoma
Birth Trauma
Arcus Juvenilis
10 Corneal Dystrophies and Ectasias
Corneal Dystrophies
Epithelial and Subepithelial Dystrophies
Bowman Layer Corneal Dystrophies
Stromal Corneal Dystrophies: TGFBI Dystrophies
Stromal Dystrophies: Non-TGFBI Dystrophies
Endothelial Dystrophies
Ectatic Disorders
Keratoconus
Pellucid Marginal Degeneration
Keratoglobus
11 Systemic Disorders With Corneal Changes
Disorders of Carbohydrate Metabolism
Mucopolysaccharidoses
Diabetes Mellitus
Disorders of Lipid Metabolism and Storage
Hyperlipoproteinemias
Hypolipoproteinemias
Sphingolipidoses
Mucolipidoses
Disorders of Amino Acid Metabolism
Cystinosis
Tyrosinemia
Alkaptonuria
Disorders of Protein Metabolism
Amyloidosis
Disorders of Immunoglobulin Synthesis
Noninflammatory Disorders of Connective Tissue
Ehlers-Danlos Syndrome
Marfan Syndrome
Disorders of Nucleotide Metabolism
Gout
Porphyria
Disorders of Mineral Metabolism
Wilson Disease
Hypercalcemia
Hemochromatosis
Corneal and External Disease Signs of Systemic Neoplasia
Enlarged Corneal Nerves
Appendix
12 Clinical Approach to Depositions and Degenerations of the Conjunctiva, Cornea, and Sclera
Degenerative Changes of the Conjunctiva
Age-Related (Involutional) Changes Pinguecula
Pterygium
Conjunctival Concretions Conjunctival Inclusion Cysts Conjunctivochalasis
Conjunctival Vascular Tortuosity and Hyperemia Degenerative Changes in the Cornea
Age-Related (Involutional) Changes Epithelial and Subepithelial Degenerations Stromal Degenerations
Endothelial Degenerations Scleral Degenerations
Drug-Induced Deposition and Pigmentation Corneal Epithelial Deposits
Stromal and Descemet Membrane Pigmentation Endothelial Manifestations
13 Clinical Aspects of Toxic and Traumatic Injuries of the Anterior Segment
Injuries Caused by Temperature and Radiation Thermal Burns
Ultraviolet Radiation
Ionizing Radiation Chemical Injuries
Alkali Burns
Acid Burns
Management of Chemical Injuries
Toxic Keratoconjunctivitis From Medications Pathogenesis
Clinical Presentation Management
Animal and Plant Substances
Insect Injuries
Vegetation Injuries
Concussive Trauma
Subconjunctival Hemorrhage
Corneal Changes
Traumatic Mydriasis and Miosis
Traumatic Iritis
Iridodialysis and Cyclodialysis
Traumatic Hyphema
Nonperforating Mechanical Trauma
Conjunctival Laceration
Conjunctival Foreign Body
Corneal Foreign Body
Corneal Abrasion
Perforating Trauma
Evaluation
Management
Surgical Trauma
Corneal Epithelial Changes From Intraocular Surgery
Descemet Membrane Changes During Intraocular Surgery
Corneal Endothelial Changes From Intraocular Surgery
Conjunctival and Corneal Changes From Extraocular Surgery
14 Treatment of Ocular Surface Disorders
Surgical Procedures of the Ocular Surface Limbal Transplantation
Autologous Conjunctival Transplantation Pterygium Excision
Mucous Membrane Grafting Conjunctival Flap Conjunctival Biopsy Conjunctivochalasis Excision
Therapeutic Interventions for Corneal Disease Superficial Keratectomy and Corneal Biopsy
Management of Descemetocele, Corneal Perforation, and Corneal Edema Corneal Tattoo
Tarsorrhaphy
15 Clinical Approach to Corneal Transplantation
Corneal Transplantation
Eye Banking and Donor Selection
Criteria Contraindicating Donor Cornea Use Surgical Approach to Corneal Disease
Preoperative Evaluation and Preparation
Penetrating Keratoplasty
Surgical Technique for Penetrating Keratoplasty
Combined Procedures
Intraoperative Complications
Postoperative Care and Complications
Control of Postoperative Corneal Astigmatism and Refractive Error
Diagnosis and Management of Graft Rejection
Pediatric Corneal Transplantation
Corneal Autograft Procedures
Keratoprosthesis
Lamellar Keratoplasty
Anterior Lamellar Transplantation
Surgical Technique
Postoperative Care and Complications
Endothelial Keratoplasty
DSEK Surgical Technique and Complications
Descemet Membrane Endothelial Keratoplasty
Basic Texts
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