Ophthalmology A Short Textbook - part 1 pptx

1.3 From left to right: Foreign body needle, glass spatula, and marres eyelid retractor.. 1.2: The patient sees only the “4” and none of the smaller symbols on the left eye chart at a di

I Ophthalmology

A Short Textbook

Gerhard K Lang, M D.

Professor and Chairman Department of Ophthalmology and University Eye Hospital Ulm Germany

Ophthalmology : a short textbook /

Gerhard K Lang ; with contributions by

J Amann [et al.] p ; cm Includes

biblio-graphical references and index.

Christopher Dedner, Tübingen

Uta Eichler, Karlsruhe

Heidi Janeczek, Göttingen

Beate Jentzen, Husberg

Mathis Kayser, Freiburg

Kerstin Lipka, Kiel

Maren Molkewehrum, Kiel

Alexandra Ogilvie, Munich

Patricia Ogilvie, Würzburg

Stefan Rose, Oldenburg

Translated by John Grossman, Berlin,

Germany

This book is an authorized translation of the

German edition published and copyrighted

1998 by Georg Thieme Verlag, Stuttgart,

Germany.

Drawings by Markus Voll, Fürstenfeldbruck

Important Note: Medicine is an

ever-changing science undergoing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar

as this book mentions any dosage or cation, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordancewith the state of knowl- edge at the time of production of the book.

appli-Nevertheless this does not involve, imply, or express any guarantee or responsibility on the part of the publishers

in respect of any dosage instructions and forms of application stated in the book.

Every user is requested to examine fully the manufacturers’ leaflets accom- panying each drug and to check, if neces- sary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of applica- tion used is entirely at the user’s own risk and responsibility The authors and pub- lishers request every user to report to the publishers any discrepancies or inaccura- cies noticed.

care-! 2000 Georg Thieme Verlag

Rüdigerstraße 14

D-70469 Stuttgart, Germany

Thieme New York, 333 Seventh Avenue

New York, N Y 10001 U.S.A

be construed as a representation by the publisher that it is in the public domain This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legisla- tion, without the publisher’s consent, is illegal and liable to prosecution This applies in particular to photostat reproduc- tion, copying, mimeographing or duplica- tion of any kind, translating, preparation of microfilms, and electronic data processing and storage.

III The Concept of the Book in Brief

Definition:The concept behind this book was to organize content and layoutaccording to a uniform structure This enhances the clarity of the presenta-tion and allows the reader to access information quickly Each chapter has itsown header icon, which is shown on every page of the chapter

Figure headings summarize the key information presented in the respectivefigure, eliminating the need for the reader to read through the entire legend.Epidemiology: In the absence of precise epidemiologic data, the authorsstate whether the disorder is common or rare wherever possible

Etiology:This section usually combines information about the etiology andpathogenesis of a disorder and in so doing helps to illuminate important rela-tionships

Symptoms and diagnostic considerations: These items are usually cussed separately The section on symptoms includes only the phenomenawith which the patient presents How and by which methods the examinerproceeds from these symptoms to a diagnosis is only discussed under diag-nostic considerations

dis-Sections highlighted with an exclamation mark contain importantfacts These may be facts that one is often required to know for exami-nations, or they may be practical tips that are helpful in diagnosing andtreating the disorder

Differential diagnosis:Wherever possible, this section discusses not onlyother possible diagnoses but also important criteria for differentiating thedisorder from others

Treatment:This section goes beyond merely documenting all possible apeutic options It also explains which therapeutic measures are advisableand offer a prospect of success The discussion of medical treatment occa-sionally includes dosage information and examples of preparations used This

ther-is done where such information ther-is relevant to cases students will encounter inpractice The trade names specified do not represent a comprehensive listing.Prognosis and clinical course: The further development of the bookdepends in no small measure on your criticism We are happy to receive anysuggestions for improvements as this will help us tailor the next edition tobetter suit yor needs Please use the enclosed postcard

V Preface

When my coworkers and I first took up the task of writing a textbook ofophthalmology that was aimed at medical students but would also be suita-ble for interns and ophthalmology residents, we did not know exactly what

we were getting ourselves into The next four years were devoted to intensivestudy of this subject We did not merely intend to design a book according tothe maxims “understand it in medical school,” “learn it for the examination,”and “use it during your internship.” Our broader goal was to give students atextbook that would kindle their interest and indeed their enthusiasm for a

“small” specialty like ophthalmology and that would sustain this enthusiasmall the way through a successful examination In an age in which teaching isundergoing evaluation, we felt this was particularly important In pursuingthis admittedly ambitious goal, we were able to draw upon many years ofteaching experience This experience has shaped the educational conceptbehind this book and manifests itself in details such as the layout, which ischaracterized by numerous photographs and illustrative drawings We haveplaced special emphasis on the figures in particular These illustrations makeophthalmology come alive and hopefully will be able to imbue the readerwith some of the enthusiasm that the authors themselves have for theirspecialty

I would like to take this opportunity to offer my heartfelt thanks to myteacher, Prof Dr Dr hc G O H Naumann, Erlangen, Germany, for his sugges-tions and for the slides from the collection of the Department of Ophthal-mology and University Eye Hospital, Erlangen I would also like to offerspecial thanks to my coauthors, Dr Josef Amann, Dr Oskar Gareis, Prof Dr.Gabriele E Lang, Doris Recker, Dr Christoph Spraul, and Dr Peter Wagner fortheir harmonious cooperation and exceptional initiative in writing this book

I also thank Dr Eckhard Weingärtner for his assistance in compiling theAppendix

I would also like to extend special thanks to Dr Jürgen Lüthje and SabineBartl of Georg Thieme Verlag, whose professionalism and active and tirelesssupport were a constant source of inspiration to us all I would again like tothank Markus Voll, Fürstenfeldbruck, Germany, for his splendid illustrations

Table of Contents

1 The Ophthalmic Examination 1

(Gabriele E Lang, Gerhard K Lang)

1.6 Examination of the Eyelids and Nasolacrimal Duct 7

1.7 Examination of the Conjunctiva 7

1.8 Examination of the Cornea 10

1.9 Examination of the Anterior Chamber 11

1.10 Examination of the Lens 12

1.11 Ophthalmoscopy 13

1.12 Confrontation Field Testing 14

1.13 Measurement of Intraocular Pressure 15

1.14 Eyedrops, Ointment, and Bandages 15

VII2.4.5 Blepharospasm 30

2.5 Disorders of the Skin and Margin of the Eyelid 30

2.5.1 Contact Eczema 30

2.5.2 Edema 31

2.5.3 Seborrheic Blepharitis 33

2.5.4 Herpes Simplex of the Eyelids 34

2.5.5 Herpes Zoster Ophthalmicus 35

2.5.6 Eyelid Abscess 36

2.5.7 Tick Infestation of the Eyelids 37

2.5.8 Louse Infestation of the Eyelids 37

2.6 Disorders of the Eyelid Glands 38

2.7.2.1 Basal Cell Carcinoma 45

2.7.2.2 Squamous Cell Carcinoma 47

3.2.1 Evaluation of Tear Formation 52

3.2.2 Evaluation of Tear Drainage 53

3.3 Disorders of the Lower Lacrimal System 57

3.3.3 Tumors of the Lacrimal Sac 61

3.4 Lacrimal System Dysfunction 62

3.4.1 Keratoconjunctivitis Sicca 62

Table of Contents

5.2.1 Slit Lamp Examination 120

5.2.2 Dye Examination of the Cornea 120

5.2.3 Corneal Topography 121

5.2.4 Determining Corneal Sensitivity 121

5.2.5 Measuring the Density of the Corneal Epithelium 121

5.2.6 Measuring the Diameter of the Cornea 124

5.4.1 Protective Mechanisms of the Cornea 127

5.4.2 Corneal Infections: Predisposing Factors, Pathogens, and

5.4.5.1 Herpes Simplex Keratitis 132

5.4.5.2 Herpes Zoster Keratitis 134

5.4.6 Mycotic Keratitis 134

5.4.7 Acanthamoeba Keratitis 136

5.5 Noninfectious Keratitis and Keratopathy 137

5.5.1 Superficial Punctate Keratitis 138

5.6.2 Corneal Degeneration 146

5.6.2.1 Calcific Band Keratopathy 146

5.6.2.2 Peripheral Furrow Keratitis 147

5.6.3 Corneal Dystrophies 148

5.7 Corneal Surgery 150

5.7.1 Curative Corneal Procedures 152

5.7.1.1 Penetrating Keratoplasty (Fig 5.18 a) 152

5.7.1.2 Lamellar Keratoplasty (Fig 5.18 b) 153

5.7.1.3 Phototherapeutic Keratectomy (Fig 5.18 c) 154

5.7.2 Refractive Corneal Procedures 155

5.7.2.1 Photorefractive Keratectomy (Fig 5.18 d) 155 5.7.2.2 Radial Keratotomy (Fig 5.18 e) 155

5.7.2.3 Photorefractive Keratectomy Correction of

Astigmatism 156

5.7.2.4 Holmium Laser Correction of Hyperopia 156 5.7.2.5 Epikeratophakic Keratoplasty (Epikeratophakia) 156 5.7.2.6 Excimer Laser In Situ Keratomileusis (LASIK) 156

XI7.4.5 Traumatic Cataract 180

7.4.6 Toxic Cataract 182

7.4.7 Congenital Cataract 182

7.4.7.1 Hereditary Congenital Cataracts 183

7.4.7.2 Cataract from Transplacental Infection in the First Trimester

(Vascular Pigmented Layer) 199

(Gabriele E Lang, Gerhard K Lang)

8.5.1 Acute Iritis and Iridocyclitis 208

8.5.2 Chronic Iritis and Iridocyclitis 212

8.5.3 Choroiditis 213

8.5.4 Sympathetic Ophthalmia 214

8.6 Neovascularization in the Iris: Rubeosis Iridis 215

8.7 Tumors 216

8.7.1 Malignant Tumors (Uveal Melanoma) 216

8.7.2 Benign Choroidal Tumors 217

Table of Contents

9.2.1 Testing the Light Reflex (Table 9.1) 221

9.2.2 Evaluating the Near Reflex 223

9.3 Influence of Pharmacologic Agents on the Pupil

(Table 9.2) 224

9.4 Pupillary Motor Dysfunction 226

9.4.1 Isocoria with Normal Pupil Size 227

9.4.2 Anisocoria with Dilated Pupil in the Affected Eye 228

9.4.3 Anisocoria with a Constricted Pupil in the Affected Eye 229

9.4.4 Isocoria with Constricted Pupils 230

9.3.5 Isocoria with Dilated Pupils 231

10.2.4 Measuring Intraocular Pressure 240

10.2.5 Optic Disk Ophthalmoscopy 244

10.2.6 Visual Field Testing 246

10.2.7 Examination of the Retinal Nerve Fiber Layer 250

10.3 Primary Glaucoma 251

10.3.1 Primary Open Angle Glaucoma 251

10.3.2 Primary Angle Closure Glaucoma 265

10.4 Secondary Glaucomas 270

10.4.1 Secondary Open Angle Glaucoma 271

10.4.2 Secondary Angle Closure Glaucoma 271

XIII11.3.1 Synchysis 282

11.3.2 Vitreous Detachment 282

11.4 Abnormal Changes in the Vitreous Body 284

11.4.1 Persistent Fetal Vasculature (Developmental

Anomalies) 284

11.4.1.1 Mittendorf’s Dot 284

11.4.1.2 Bergmeister’s Papilla 285

11.4.1.3 Persistent Hyaloid Artery 285

11.4.1.4 Persistent Hyperplastic Primary Vitreous (PHPV) 285

11.4.2 Abnormal Opacities of the Vitreous Body 287

11.5 The Role of the Vitreous Body in Various Ocular Changes and

Following Cataract Surgery 293

12.2.1 Examination of the Fundus 304

12.2.2 Normal and Abnormal Fundus Findings in General 308

12.2.3 Color Vision 311

12.2.4 Electrophysiologic Examination Methods

(electroretinogram, electrooculogram, and visual evoked

potentials; see Fig 12.2 a) 312

12.3 Vascular Disorders 314

12.3.1 Diabetic Retinopathy 314

12.3.2 Retinal Vein Occlusion 318

12.3.3 Retinal Arterial Occlusion 320

12.3.4 Hypertensive Retinopathy and Sclerotic Changes 323

12.3.5 Coats’ Disease 325

12.3.6 Retinopathy of Prematurity 326

Table of Contents

12.4 Degenerative Retinal Disorders 328

12.4.1 Retinal Detachment 328

12.4.2 Degenerative Retinoschisis 333

12.4.3 Peripheral Retinal Degenerations 334

12.4.4 Central Serous Chorioretinopathy 335

12.4.5 Age-Related Macular Degeneration 337

12.7.2 Posterior Uveitis Due to Toxoplasmosis 348

12.7.3 AIDS-Related Retinal Disorders 349

12.7.4 Viral Retinitis 351

12.7.5 Retinitis in Lyme Disease 351

12.7.6 Parasitic Retinal Disorders 352

12.8 Retinal Tumors and Hamartomas 353

13.1.1 Intraocular Portion of the Optic Nerve 360

13.1.2 The Intraorbital and Intracranial Portion of the Optic

Nerve 361

13.2 Examination Methods 362

13.3 Disorders that Obscure the Margin of the Optic Disc 363

13.3.1 Congenital Disorders that Obscure the Margin of the Optic

13.3.1.6 Optic Disc Drusen 366

13.3.2 Acquired Disorders that Obscure the Margin of the Optic

Disc 367

Table of Contents

13.3.2.1 Papilledema 368

13.3.2.2 Optic Neuritis 370

13.3.2.3 Anterior Ischemic Optic Neuropathy (AION) 374

13.3.2.4 Infiltrative Optic Disc Edema 379

13.4 Disorders in which the Margin of the Optic Disc is Well

Defined 380

13.4.1 Atrophy of the Optic Nerve 380

13.4.2 Optic Nerve Pits 383

13.4.3 Optic Disc Coloboma (Morning Glory Disc) 385

13.5 Tumors 385

13.5.1 Intraocular Optic Nerve Tumors 385

13.5.2 Retrobulbar Optic Nerve Tumors 387

15.7.1.2 Dermoid and Epidermoid Cyst 420

15.7.1.3 Neurinoma and Neurofibroma 420

16 Optics and Refractive Errors 423

(Christoph W Spraul, Gerhard K Lang)

16.1 Basic Knowledge 423

16.1.1 Uncorrected and Corrected Visual Acuity 423

16.1.2 Refraction: Emmetropia and Ametropia 423

16.1.3 Accommodation 425

16.1.4 Adaptation to Differences in Light Intensity 428

16.2 Examination Methods 429

16.2.1 Refraction Testing 429

16.2.2 Testing the Potential Resolving Power of the Retina in the

Presence of Opacified Optic Media 431

16.3 Refractive Anomalies (Table 16.2) 432

XVII16.4.2 Accommodation Palsy 446

16.5 Correction of Refractive Errors 447

16.5.1 Eyeglass Lenses 447

16.5.2 Contact Lenses 451

16.5.2.1 Advantages and Characteristics of Contact Lenses 451

16.5.3 Prisms 455

16.5.4 Magnifying Vision Aids 455

16.5.5 Aberrations of Lenses and Eyeglasses 456

17 Ocular Motility and Strabismus 459

(Doris Recker, Josef Amann, Gerhard K Lang)

17.2.1.4 Vertical Deviations (Hypertropia and Hypotropia) 471

17.2.2 Diagnosis of Concomitant Strabismus 471

17.2.2.1 Evaluating Ocular Alignment with a Focused Light 471

17.2.2.2 Diagnosis of Infantile Strabismic Amblyopia (Preferential

Looking Test) 472

17.2.2.3 Diagnosis of Unilateral and Alternating Strabismus (Unilateral

Cover Test) 473

17.2.2.4 Measuring the Angle of Deviation 474

17.2.2.5 Determining the Type of Fixation 476

17.2.2.6 Testing Binocular Vision 476

17.2.3 Therapy of Concomitant Strabismus 477

18.5.3 Radiation Injuries (Ionizing Radiation) 524

18.6 Indirect Ocular Trauma: Purtscher’s Retinopathy 525

19 Cardinal Symptoms 527

(Gerhard K Lang)

Index 563

Table of Contents

Gabriele E Lang and Gerhard K Lang

1.1 Equipment

The basic equipment for the ophthalmic examination includes the following

instruments:

❖ Direct ophthalmoscopefor examining the fundus (Fig 1.1).

❖ Focused light(Fig 1.1) for examining the reaction of the pupil and the

ante-rior chamber

❖ Aspheric lens(Fig 1.1) for examining the anterior chamber.

❖ Eye chart for testing visual acuity at a distance of 5 meters (20 feet)

(Fig 1.2).

Basic diagnostic instruments for the fundus, pupil, and anterior chamber.

Fig 1.1 From left to right: direct

ophthalmoscope, aspheric lens, andfocused light

Snel-❖ Binocular loupesfor removing corneal and conjunctival foreign bodies.

❖ Desmarres eyelid retractor and glass rod or sterile cotton swab for eyelid

❖ Sterile buffer solutionfor primary treatment of chemical injuries

❖ Antibiotic eyedrops for first aid treatment of injuries, sterile eye compresses, and a 1 cm adhesive bandage for protective bandaging.

An ophthalmologist should be consulted following any emergencytreatment of eye injuries

1 The Ophthalmic Examination

Basic diagnostic equipment for removing corneal foreign bodies and eyelid eversion.

Fig 1.3 From left to right: Foreign

body needle, glass spatula, and marres eyelid retractor

Des-1.2 History

A complete history includes four aspects:

1 Family history Many eye disorders are hereditary or of higher incidence in

members of the same family Examples include refractive errors, bismus, cataract, glaucoma, retinal detachment, and retinal dystrophy

stra-2 Medical history As ocular changes may be related to systemic disorders,

this possibility must be explored Conditions affecting the eyes includediabetes mellitus, hypertension, infectious diseases, rheumatic disorders,skin diseases, and surgery Eye disorders such as corticosteroid-inducedglaucoma, corticosteroid-induced cataract, and chloroquine-inducedmaculopathy can occur as a result of treatment with medications such assteroids, chloroquine, Amiodarone, Myambutol, or chlorpromazine (seetable in Appendix)

3 Ophthalmic history The examiner should inquire about corrective lenses,

strabismus or amblyopia, posttraumatic conditions, and surgery or eyeinflammation

1.2 History

4 Current history What symptoms does the patient present with? Does the

patient have impaired vision, pain, redness of the eye, or double vision?When did these symptoms occur? Are injuries or associated generalizedsymptoms present?

1.3 Visual Acuity

Visual acuity, the sharpness of near and distance vision, is tested separatelyfor each eye One eye is covered with a piece of paper or the palm of the handplaced lightly over the eye The fingers should not be used to cover the eye

because the patient will be able to see between them (Fig 1.4).

The general practitioner or student can perform an approximate test of

visual acuity The patient is first asked to identify certain visual symbols

referred to as optotypes (see Fig 1.2) at a distance of 5 meters or 20 feet (test of

distance vision) These visual symbols are designed so that optotypes of a tain size can barely be resolved by the normal eye at a specified distance (thisstandard distance is specified in meters next to the respective symbol) Theeye charts must be clean and well illuminated for the examination Thesharpness of vision measured is expressed as a fraction:

cer-Examining visual acuity.

Fig 1.4 The palm of the hand is

placed lightly over the eye to cover it

to allow testing of the distance andnear vision in the opposite eye

1 The Ophthalmic Examination

actual distance

standard distance ! visual acuity.

Normal visual acuity is 5/5 (20/20), or 1.0 as a decimal number, where the

actual distance equals the standard distance

An example of diminished visual acuity (see Fig 1.2): The patient sees

only the “4” and none of the smaller symbols on the left eye chart at a distance

of 5 meters (20 feet) (actual distance) A normal-sighted person would be able

to discern the “4” at a distance of 50 meters or 200 feet (standard distance).Accordingly, the patient has a visual acuity of 5/50 (20/200) or 0.1

The ophthalmologist tests visual acuity after determining objective

refraction using the integral lens system of a Phoroptor, or a box of individuallenses and an image projector that projects the visual symbols at a defineddistance in front of the eye Visual acuity is automatically calculated from the

fixed actual distance and is displayed as a decimal value Plus lenses (convex lenses) are used for farsightedness (hyperopia or hypermetropia), minus lenses (concave lenses) for nearsightedness (myopia), and cylindrical lenses for astigmatism

If the patient cannot discern the symbols on the eye chart at a distance of 5meters (20 feet), the examiner shows the patient the chart at a distance of 1meter or 3 feet (both the ophthalmologist and the general practitioner useeye charts for this examination) If the patient is still unable to discern anysymbols, the examiner has the patient count fingers, discern the direction ofhand motion, and discern the direction of a point light source

1.4 Ocular Motility

With the patient’s head immobilized, the examiner asks the patient to look in

each of the nine diagnostic positions of gaze: 1, straight ahead; 2, right; 3,

upper right; 4, up; 5, upper left; 6, left; 7, lower left; 8, down; and 9, lower

right (Fig 1.5) This allows the examiner to diagnose strabismus, paralysis of

ocular muscles, and gaze paresis

Evaluating the six cardinal directions of gaze (right, left, upper right,

lower right, upper left, lower left) is sufficient when examining paralysis ofthe one of the six extraocular muscles The motion impairment of the eyeresulting from paralysis of an ocular muscle will be most evident in thesepositions Only one of the rectus muscles is involved in each of the left andright positions of gaze (lateral or medial rectus muscle) All other directions ofgaze involve several muscles

1.4 Ocular Motility

Evaluating the nine diagnostic positions of gaze.

Fig 1.5 This examination allows the examiner to diagnose strabismus, paralysis of

ocular muscles, and gaze paresis

1.5 Binocular Alignment

Binocular alignment is evaluated with a cover test The examiner holds a

point light source beneath his or her own eyes and observes the light tions in the patient’s corneasin the near field (40 cm) and at a distance (5 m)

reflec-The reflections are normally in the center of each pupil If the corneal reflection

is not in the center of the pupil in one eye, then a tropia is present in that eye

Then the examiner covers one eye with a hand or an occluder (Fig 1.6) and

tests whether the uncovered eye makes a compensatory movement

Compen-satory movement of the eye indicates the presence of tropia However, therewill also be a lack of compensatory movement if the eye is blind The covertest is then repeated with the other eye

If tropia is present in a newborn with extremely poor vision, the baby willnot tolerate the good eye being covered

1 The Ophthalmic Examination

Evaluation of binocular alignment.

Fig 1.6 The

ex-aminer coversone eye of thepatient with thehand to test ifthe uncoveredeye makes acompensatorymovement indi-cating presence

of tropia

1.6 Examination of the Eyelids and Nasolacrimal Duct

The upper eyelid covers the superior margin of the cornea A few millimeters

of the sclera will be visible above the lower eyelid The eyelids are in direct

con-tact with the eyeball

Stenosis of the nasolacrimal duct produces a pool of tears in the medial angle of the eye with lacrimation (epiphora) In inflammation of the lacrimal sac, pressure on the nasolacrimal sac frequently causes a reflux of mucus or pus from the inferior punctum.Patency of the nasolacrimal duct is tested by

instilling a 10% fluorescein solution in the conjunctival sac of the eye If thedye is present in nasal mucus expelled into paper tissue after two minutes,the lacrimal duct is open (see also p 53)

Due to the danger of infection, any probing or irrigation of thenasolacrimal duct should be performed only by an ophthalmologist

1.7 Examination of the Conjunctiva

The conjunctiva is examined by direct inspection The bulbar conjunctiva isdirectly visible between the eyelids; the palpebral conjunctiva can only beexamined by everting the upper or lower eyelid The normal conjunctiva issmooth, shiny, and moist The examiner should be alert to any reddening,secretion, thickening, scars, or foreign bodies

Eversion of the lower eyelid The patient looks up while the examiner pulls

the eyelid downward close to the anterior margin (Fig 1.7) This exposes the

conjunctiva and the posterior surface of the lower eyelid

1.7 Examination of the Conjunctiva

up while the aminer pulls theeyelid downwardclose to the ante-rior margin.

ex-Examination of the upper eyelid (simple eversion).

Fig 1.8 The patient relaxes and

looks down The examiner places aswab superior to the tarsal region ofthe upper eyelid, grasps the eyelashes

of the upper eyelid between thethumb and forefinger, and everts theeyelid using the swab as a fulcrum

Eversion of the upper eyelid Simple eversion (Fig 1.8) The patient is asked to

look down The patient should repeatedly be told to relax and to avoid tightlyshutting the opposite eye This relaxes the levator palpebrae superioris andorbicularis oculi muscles The examiner grasps the eyelashes of the uppereyelid between the thumb and forefinger and everts the eyelid against a glassrod or swab used as a fulcrum Eversion should be performed with a quicklevering motion while applying slight traction The palpebral conjunctiva canthen be inspected and cleaned if necessary

1 The Ophthalmic Examination

Full eversion with retractor.To expose the superior fornix, the upper eyelid is

fully everted around a Desmarres eyelid retractor (Figs 1.9a and b) This

method is used solely by the ophthalmologist and is only discussed here forthe sake of completeness This eversion technique is required to remove for-eign bodies or “lost” contact lenses from the superior fornix or to clean theconjunctiva of lime particles in a chemical injury with lime

Examination of the upper eyelid and superior fornix (full eversion with retractor).

Figs 1.9 a and b In this case, the

ex-aminer everts the eyelid around a marres eyelid retractor In contrast tosimple eversion, this procedure allowsexamination of the superior fornix inaddition to the palpebral conjunctiva.1.7 Examination of the Conjunctiva

Des-a

b

Examination of the anterior portion of the eye.

Fig 1.10 The

examiner ates the eyeusing a focal lightsource and loupemagnification

evalu-1 The Ophthalmic Examination

Blepharospasm can render simple and full eversion very difficultespecially in the presence of chemical injury In these cases, the spasmshould first be eliminated by instilling a topical anesthetic such as oxy-buprocaine hydrochloride eyedrops

1.8 Examination of the Cornea

The cornea is examined with a point light source and a loupe (Fig 1.10) The

cornea is smooth, clear, and reflective The reflection is distorted in the

pres-ence of corneal disorders Epithelial defects, which are also very painful, willtake on an intense green color after application of fluorescein dye; cornealinfiltrates and scars are grayish white Evaluating corneal sensitivity is alsoimportant Sensitivity is evaluated bilaterally to detect possible differences inthe reaction of both eyes The patient looks straight ahead during the exami-nation The examiner holds the upper eyelid to prevent reflexive closing and

touches the cornea anteriorly (Fig 1.11) Decreased sensitivity can provide

information about trigeminal or facial neuropathy, or may be a sign of a viralinfection of the cornea

Evaluation of corneal sensitivity.

Fig 1.11 Corneal sensitivity can be

evaluated with a distended cottonswab The patient looks straightahead while the examiner holds theupper eyelid and touches the corneaanteriorly

1.9 Examination of the Anterior Chamber

1.9 Examination of the Anterior Chamber

The anterior chamber is filled with clear aqueous humor Cellular infiltrationand collection of pus may occur (hypopyon) Bleeding in the anterior cham-ber is referred to as hyphema

It is important to evaluate the depth of the anterior chamber In a

cham-ber of normal depth, the iris can be well illuminated by a lateral light source

(Fig 1.12) In a shallow anterior chamber there will be a medial shadow on the

iris The pupillary dilation should be avoided in patients with shallow rior chambers because of the risk of precipitating a glaucoma attack Olderpatients with “small” hyperopic eyes are a particular risk group

ante-Dilation of the pupil with a mydriatic is contraindicated in patients with a

shallow anterior chamber due to the risk of precipitating angle closureglaucoma

1 The Ophthalmic Examination

1.10 Examination of the Lens

The ophthalmologist uses a slit lamp to examine the lens The eye can also be examined with a focused light if necessary.

Direct illumination will produce a red reflection of the fundus if the lens is clear and gray shadows if lens opacities are present The examiner then illuminates the eye laterally with a focused light held as close to the eye as possible and

inspects the eye through a +14 diopter loupe (see Fig 1.10) This examination

permits better evaluation of changes in the conjunctiva, cornea, and anteriorchamber With severe opacification of the lens, a gray coloration will be vis-ible in the pupillary plane Any such light-scattering opacity is referred to as acataract