eBoyoek

The Little Updated

A
Pupil's
Guide to
Understanding
Ophthalmology
S e c o n d Ed it io n

J a n ic e Le d fo r d
S
I
N
L
C
O
A
R
P
O
C
S LAC K IN C O R P O R ATED
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®
 J ANICE K. (J AN) LEDFORD, COMT
EYEWRITE PRODUCTIONS
FRANKLIN, NORTHCAROLINA

SLACK
®

I N C O R P O R AT E D
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ISBN: 978-1-55642-884-5
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Library of Congress Cataloging-in-Publication Data

Ledford, Janice K.
The little eye book : a pupil's guide to understanding ophthalmology / Janice K. Ledford.
-- 2nd ed.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-55642-884-5 (softcover)
1. O phthalmology--Popular works. I. Title.
RE51.L375 2008
617.7--dc22
2008022517

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 DEDICATION
Dedicated with love to the memory of
Margaret Ruth Cole Ledford
and
Andrew Jackson (A.J.) Ledford.

JKL
 CONTENTS
Dedication .................................................................. v
Acknow ledgm ents ...................................................... ix
About the Author ....................................................... xi
Introduction ..............................................................xiii
Chapter 1. What’s In There ........................................ 1
(O cular Anatomy)
Chapter 2. How It Works ......................................... 17
(O cular Physiology)
Chapter 3. O h Say Can You See ............................... 29
(Refractive Errors, Glasses, and O ther
Delights)
Chapter 4. What Can Go Wrong ............................. 51
(Com m on Eye Disorders and Traum a)
Chapter 5. Crazy Eyes, Lazy Eyes, and ..................... 89
Getting on Your Nerves
(Strabism us, Am blyopia, and N eurology)
Chapter 6. What’s Going O n?.................................. 99
(O cular Sym ptom s and Potential
Diagnoses)
Chapter 7. Checking It O ut.................................... 107
(Basic Exam ination Techniques
and Patient Services)
Chapter 8. Checking It Further............................... 123
(O verview of O cular Tests)
Chapter 9. Fixing It ................................................ 139
(O verview of O phthalm ic Surgery)
Chapter 10. Treating It ............................................. 149
(Pharm acology)
Bibliography ............................................................ 165
Index ....................................................................... 169
 ACKNOWLEDGEMENTS, SECOND EDITION
My thanks to Al Lens, Sheila-Coyne Nemeth, Greg
Almond (Addition Technology, Inc), Cheryl Pelham,
Londa Woody, Dr. Charles Kirby, and Idari Mhadji,
MS (O ffice Manager, Eye Bank Association of America
[EBAA]). I also appreciate Dr. Roberto Pineda II, who
assisted with the first edition of this book. (He personally
acknowledged the support and help of Susannah Rowe,
MD, MPh, in that endeavor.)

ACKNOWLEDGMENTS, FIRST EDITION

In addition to my friends at SLACK Incorporated (Amy
Drummond, John Bond, and Debra Toulson), I would like
to thank Nancy Gwin, Holly Hess, Carolyn Shea, Sheila
Nemeth, Val Sanders, Dave Robie, Todd Hostetter, Linda
Sims, Patrick Caroline, Paula Parker, the late E.L. Hargis,
Leslie Hargis-Greenshields, T.D. Lundquist, Michelle
Herrin, Premier Eye Group, and Eye Sight Associates of
Middle Georgia. I would also like to acknowledge the
authors of the books in the Basic Bookshelf for Eyecare
Professionals for their hard work and dedication both to
the series and to the profession. Gratitude is also due
Bernie Calaway, President of B.I.E. Services.
Thank you to my husband of 25 years, Jim, and the
boys, T.J. and Collin, for putting up with me when dead-
lines are looming.

Janice K. (Jan) Ledford, CO MT

 ABOUT THE AUTHOR
Ja n ice K. Le d fo rd , COMT, who probably won't answer
you unless you call her Jan, has been in the field of eye
care since 1982. Through on-the-job training, self study,
and wonderful mentors, she advanced through the ranks
to obtain her certification as an O phthalmic Medical
Technologist in 1988. She currently works part-time at
the Charles George VA Medical Center in Asheville, NC,
and with Dr. Charles Kirby at both Biltmore Vision Center
and East Side O ptical, also in Asheville.
The Little Eye Book, Second Edition is her 17th book
for the eye care professional (all published by SLACK
Incorporated). She is also the coauthor of The Crystal
Clear Guide to Sight for Life (Starburst Publishers,
1996), which is written for the layperson. Journals
that have published her work include Contact Lens
Spectrum , O phthalm ology, Annals of O phthalm ology
and Glaucom a, The Journal of O phthalm ic N ursing
and Technology, Phaco and Foldables, O phthalm ology
World N ew s, and O phthalm ic Plastic and Reconstructive
Surgery. In 1993 she was awarded the Achievement in
O phthalmology by Alcon Surgical for coauthorship of the
side approach cataract technique.
Jan’s writing talents are not limited to eye care or
even to nonfiction. In addition to two novels, she has
also published and/or won awards for her short stories
and poetry.
Jan lives in the mountains of western North Carolina
with her two cats, Angel and Nadia. Her son Collin is
a college student at Southwestern Carolina Community
College in Cullowhee, NC. Her oldest son T.J. is a Master
at Arms in the U.S. Navy. Daughter-in-law Kelly and the
grands (Katie and A.J.) live in Georgia.
 INTRODUCTION
Here’s a riddle: What is the only organ of the body
that you can see into without having to cut it open or
stick a tube into it? Answer: the eye.
Little wonder, then, that we’ve learned so much about
this remarkable organ. But the more we've discovered,
the more we realize its complexities. It is the purpose of
this book to give you the basics in an easy-to-understand
way, as if you were sitting on the sofa in my living room
and we were talking. (The nice thing is that with this
book you are spared the trauma of seeing my drawings.)

Janice K. (Jan) Ledford, CO MT

 Chapter 1

What's In There
(Ocular Anatomy)

The eye is easy to understand if you think of it as a

camera. Even its anatomy is similar, although the arrange-
ment is a bit different (Figure 1-1).
* Both the camera and eye have a lens or lens sys-
tem.
* Both provide a way to collect incoming light.
* In the end, both provide an image that must be
interpreted by the brain.
But let’s start at the very beginning. The eye begins
to develop in the embryo during the second week of
pregnancy. At first it’s just a little pit in the future face,
but by the end of the second month there are specific
tissues and structures. The eyelids are fused until about

1
2 Chapter 1 .......................................................

Figure 1-1. Th e e ye works m uch like a ca m era . (Dra win g

by Ho lly Hess Sm ith . Re prin ted with perm issio n fro m
Ga yto n JL, Ledfo rd JK. The Crystal Clear Guide to Sight for
Life. La n ca ste r, PA: Sta rburst Publish ers; 19 9 6 .)

7 months. By the time birth occurs, the eyeball is very

nearly full-size and the infant can see his mother’s face
from about 10 inches away.
The eyeball (or globe) is protected in the skull by being
recessed into a depression known as the orbit (Figure 1-
2). Seven different bones contribute to the orbit, which
also provides a place of attachment for the muscles that
move the eye. A small opening (the optic foram en) at the
..................................... What's in There 3

Figu re 1-2. Th e b ony o rbit is a depressio n in th e skull in to

wh ich th e eyeba ll fits. Th e o ptic n e rve exits th e o rbit a t
the o ptic ca na l. (Reprinte d with perm ission fro m Nem eth
SC, Sh ea CA. Medical Sciences for the Ophthalm ic Assistant.
Th o ro fa re, NJ: SLACK In corpora ted; 19 8 8 .)

back of the orbit allows the optic nerve to pass through

to the brain. In cases of blunt trauma, the orbit takes the
brunt of the force. Fat in the orbit cushions the globe,
providing some protection.
There are six muscles attached to each eye, and they
provide a full range of movement (Figure 1-3). Every
muscle has its own unique action or actions, and each is
innervated by one of three cranial nerves (Table 1-1).
From the outside, the eyelids protect the globe (eye-
ball) (Figure 1-4). First, the blink reflex of the eyelids
prevents trauma to the globe by closing the eye any time
a threat is perceived. Second, each blink (every 3 or 4
seconds) spreads tears over the globe’s surface to keep
the exterior of the eye moist. Tears help protect the eye by
rinsing away bacteria and other foreign matter.
The eyelids are covered by skin (epiderm is) on the out-
side and are lined on the inside by a mucous membrane
4 Chapter 1 ............................................

Figu re 1-3 . Six extra o cula r m uscles (EOMs) a re a tta ch ed

to ea ch eye . (Ada pted from a dra wing by Ho lly Hess
Sm ith. Re prin ted with perm issio n fro m Ga yton JL, Ledfo rd
JK. The Crystal Clear Guide to Sight for Life. La nca ster, PA:
Sta rburst Publishers; 19 9 6 .)

called conjunctiva (Figure 1-5). The conjunctiva produces

mucus that helps to lubricate the eye. The conjunctiva that
lines the lid is called the palpebral conjunctiva. It is con-
tinuous with the conjunctiva that covers the white of the
eyeball (called the bulbar conjunctiva), isolating the front
exterior of the globe. (This means that nothing can “get
lost” behind the eye.) The pocket under the lids where the
bulbar and palpebral conjunctiva meet is called the the
fornix; there is an upper and a lower.
At the eyelid m argins (the area immediately behind
the lashes) are the openings of tiny m eibom ian glands,
which produce oil. This oil becomes part of the tear film,
which we will discuss in a moment. The margins of the
lids also contain hair follicles from which the lashes (for-
mally called cilia) grow.
The corner of each eye is called a canthus (see Figure
1-4); there is a nasal (nose-side or medial) and a temporal
(ear-side or lateral) canthus. The nasal canthus contains a
mound of pink tissue known as the caruncle. The caruncle
..................................... What's in There 5
Table 1-1
Th e Extra ocula r Muscles
Cranial Nerve
Muscle Action(s): 1º/2º/3º Innervation
Med ial rectus Lateral m ovem ent only III
(tow ard nose)
Lateral rectu s Lateral m ovem ent only VI
(tow ard ear)
Su perior rectu s Up-gaze/ rotate tow ard III
nose/ lateral (tow ard nose)
Inferior rectu s Dow n-gaze/ rotate tow ard III
ear/ lateral (tow ard nose)
Su perior oblique Rotate tow ard nose/ d ow n- IV
gaze/ lateral (tow ard ear)
Inferior obliqu e Rotate tow ard ear/ u p -gaze/ III
lateral (tow ard ear)
Primary action refers to the main effect that particular muscle has
on eye rotation; the secondary and tertiary actions are of lesser effect.
M uscle action depends on the orientation (direction) of the eye.

Figu re 1-4 . Th e extern a l eye. (Ada pted from a dra wing by

Ho lly Hess Sm ith.)

contains some oil glands and hair follicles. Where the

caruncle merges with the bulbar conjunctiva is a half-
moon-shaped fold of tissue called the plica sem ilunaris (or
6 Chapter 1 ............................................

Figu re 1-5 . Cro ss-se ction o f con junctiva l topogra phy.

(Reprin ted with perm issio n fro m Nem eth SC, Sh ea CA.
Medical Sciences for the Ophthalm ic Assistant. Th orofa re, NJ:
SLACK Inco rpo ra ted; 19 8 8 .)

simply, plica). At the upper and lower lid margins of the

nasal canthus are tiny openings called puncti (singular,
punctum ). The puncti drain tears from the eye.
The eye’s tear (or nasolacrim al) system is illustrated
in Figure 1-6. The tear film is composed of three layers.
The bottom layer that directly contacts the eye is mucin
created by special cells in the conjunctiva called goblet
cells. The mucin helps fill in any microscopic irregularities
on the eye’s surface, a feature that is important to clear
vision. Next is a layer of water (sometimes called the
aqueous layer, but not to be confused with the aqueous
humor inside the eye), which makes up the bulk of the
tear film. Most of this watery component comes from the
main lacrim al (or tear) gland, a two-lobed structure that
lies under the brow bone. Reflex tears (tears that result
from a stimulus such as a foreign body or bright light) and
emotional tears come from the main lacrimal gland. The
..................................... What's in There 7
Lacrimal
(tear) gland

Nasolacrimal
(tear) sac

Punctum Nasolacrimal
(tear) duct
Canaliculus

Figu re 1-6. Th e n a sola crim a l syste m . (Dra wing by Ho lly

Hess Sm ith . Reprin ted with perm ission from Ga yto n
JL, Ledford JK. The Crystal Clear Guide to Sight for Life.
La n ca ster, PA: Sta rburst Publishe rs; 19 9 6 .)

glands of Wolfing and Kraus are accessory lacrimal glands

found in the eyelid tissue. These glands also contribute to
the aqueous layer.
The watery layer is topped by a thin sheet of oil secret-
ed by the meibomian glands. The oil helps to prevent the
watery tears from evaporating too quickly. A dry eye is
not a healthy eye.
The globe can be divided into two segm ents, anterior
and posterior (Figure 1-7). The anterior segment contains
everything from the lens forward, including the external
part of the globe. The posterior segment extends from
the lens back. The anterior segment is divided into the
anterior chamber and posterior chamber. We’ll discuss
specific structures in each segment in a moment.
The “white” of the eye is properly known as the sclera.
It is a tough, fibrous tissue that helps maintain the eye’s
shape and protects the inner structures. The muscles that
move the eye attach to the sclera via tendons. O verlying
the sclera is the episclera, which contains blood vessels
8 Chapter 1 ............................................
Figure 1-7. The seg-
m ents a nd cha m bers
of the eye. (Reprinted
with perm ission from
Nem eth SC, Shea CA.
Medical Sciences for the
Ophthalm ic Assistant.
Thorofa re, NJ: SLACK
Incorpor-a ted; 19 8 8.)

that nourish the sclera. O n top of the episclera is the bul-

bar conjunctiva, as discussed previously.
The cornea is the clear covering over the colored part of
the eye (comparable to the windshield in a car). The junc-
ture where the sclera stops and the cornea starts is called
the limbus, an important landmark in eye surgery. The cor-
nea itself is a curved surface, like a glass dome. As such, it
performs the job of refracting (bending) incoming light to
start the job of focusing. The cornea actually bends light to
a greater degree than the eye’s lens (more on this later).
One of the cornea’s amazing qualities is that there are
no blood vessels in healthy tissue, because this would
..................................... What's in There 9

Figu re 1-8 . Histologica l cross-sectio n of th e co r-

nea . (Reprin ted with pe rm ission fro m Nem eth
SC, Shea CA. Medical Sciences for the Ophthalm ic
Assistant. Th o ro fa re, NJ: SLACK In co rpo ra ted;
19 8 8 .)

compromise the cornea’s clarity and thus hamper vision.

The cornea is nourished on the outside by the tears, on the
inside by the aqueous humor (described momentarily), and
through blood vessels at the limbus.
The cornea is composed of five layers (Figure 1-8).
The outermost layer is the epithelium , which is one of
10 Chapter 1 ............................................

Figu re 1-9 . Th e a n terio r segm ent o f th e eye . (Dra win g

by Lin da Sim s. Reprin ted with perm issio n fro m Ha rgis-
Green sh ields L, Sim s L. Em ergencies in Eyecare. Th o ro fa re ,
NJ: SLACK In co rpo ra ted; 19 9 9 .)

the fastest regenerating tissues in the body. If the corneal

epithelium is damaged (usually due to an abrasion or
foreign body) it can regenerate in about 24 hours with-
out scarring. However, if the deeper corneal layers are
damaged, scarring can occur that may negatively affect
vision. The next three layers of the cornea are Bow m an’s
layer, strom al layer, and Descem et’s m em brane.
The innermost layer of the cornea is the endothelium .
The endothelium cannot regenerate; you will never have
more than the number of cells you were born with. If
endothelial cells are destroyed (during surgery or other
trauma), the remaining cells spread out to cover the dam-
age. The job of the endothelium is to keep the cornea clear
by pumping fluid out of the tissue. However, severe cell
loss can cause the cornea to accumulate fluid and become
cloudy, resulting in decreased vision. The endothelium can
be evaluated with a special eye microscope (the slit lamp)
or an endothelial cell camera (specular microscopy).
Between the corneal endothelium and the iris (the
colored part of the eye) is the anterior cham ber. It is filled
with a clear fluid called aqueous hum or (or aqueous for
short). The aqueous is similar to blood plasma in com-
position, and we’ll talk about its formation in a moment.
The point where the cornea and sclera join at the eye’s
interior forms a region known as the angle (Figure 1-9).
..................................... What's in There 11
The angle is made up of a tissue meshwork (called the
trabecular m eshw ork or the trabeculum ) where the aque-
ous drains out of the eye. The trabeculum leads to the
canal of Schlem m , which in turn leads to capillaries. Thus
the aqueous is eventually carried away by the blood. If
this drainage system is faulty or becomes blocked, the
aqueous builds up inside the eye. This results in pressure
that can damage the optic nerve, a condition known as
glaucom a (see also Chapter 4, Glaucom a).
The iris is the partition between the anterior and poste-
rior chambers. It is made up of two muscles that regulate
the size of the central opening or pupil. The dilator m uscle
opens the pupil while the sphincter m uscle closes it. This
controls the amount of light entering the eye, much like
the shutter of a camera. Because of the unique innervation
of the pupil, its evaluation can give important information
regarding the nervous system as a whole.
Between the backside of the iris and the front of the
lens (sometimes called the crystalline lens) is the posterior
cham ber. It is also filled with aqueous. At the base of
the iris is a structure called the ciliary body, which con-
tinually produces the aqueous humor. (The aqueous then
flows through the pupil, into the anterior chamber, and
out the trabeculum as described previously.)
The ciliary body is continuous with the ciliary m uscle,
the structure that controls the shape of the lens. The lens
is encased in an envelope (called the capsule), which
is suspended by tiny fibers (zonules) connected to the
ciliary muscle. The ciliary muscle causes the zonules to
draw tight or to relax, thus changing the shape and focus-
ing power of the lens in order to refract (bend, or focus)
incoming light. This makes the eye the original “zoom”
camera.
Behind the lens is the posterior segment. For the most
part, this is a hollow cavity filled with a jelly-like sub-
stance known as vitreous hum or (or vitreous for short).
Unlike the aqueous, the vitreous is stable (ie, not con-
tinually being formed and drained like the aqueous).
12 Chapter 1 ............................................
The inner surface of the posterior segment is lined by
the retina, which is like the film in a camera. The retina
is made up of nine layers, including the photorecep-
tor (light-receiving) cells you may remember from high
school biology: the rods and the cones.
The rods outnumber the cones by over 20:1, and they
are scattered throughout the retina. The cones are con-
centrated mostly in a tiny specialized part of the retina
known as the m acula. The macula is 1.5 mm in diameter,
or about the size of a pin head. This is the area of fine,
central vision. The cones are responsible for color vision
as well as high-detail acuity. In the middle of the macula
is the fovea, and at the center of the fovea is the foveola
(or the foveola centralis).
The rods are used for peripheral vision and night vision
(thus lacking high detail). The cones do not function well
in the dark, and the rods take over. To illustrate this to
yourself, try the following experiment on a dark night:
find a star (a dim one may work best) and look directly
at it. It seems to disappear, because its image is falling on
the cone-rich foveola. Look a little to the side of the star
and it “reappears.” You are now seeing the star with the
dark-loving rods in the periphery of your retina.
The retina is nourished by an underlying layer of blood
vessels called the choroid. (Together, the choroid, iris,
and ciliary body are known as the uvea.) The choroid lies
beneath the sclera. There you have it... the whole eye.
Vision, however, only starts with the eyeball itself. The
globe is connected to the brain via the optic nerve and
nerve fibers and bundles that extend from it. The nerve
connects with the the back of the eye through a sieve-like
structure in the sclera known as the lam ina cribrosa. The
sheath of the optic nerve (similar to that which surrounds
the spinal cord) contains nerve fibers and blood vessels
that are vital to the health and function of the eye. The
point where the nerve enters the eye, the optic nerve
head or disk, can be seen when looking into the eye
(Figure 1-10).
..................................... What's in There 13

Figu re 1-10 . Ph otogra ph sho win g th e o cula r fun dus.

(Reprin ted fro m Len s A, La n gley T, Ne m eth SC, Sh ea
C. Ocular Anatom y and Physiology. Th o ro fa re, NJ: SLACK
In co rpo ra ted; 19 9 9 .)

The blood vessels of the fundus (the area of the eye’s

interior that is visible on examination) look like tree
branches sprouting from the nerve, but they stop just
short of the macula. If there were blood vessels in the
macular area (which sometimes occurs in disease, nota-
bly diabetes), it would impede vision.
At the center of the optic disk is a depression called
the cup. The cup is a normal structure, but it can be
enlarged by the pressure that occurs in glaucoma. This
pressure causes the cup to have a “dug out” or excavated
appearance, and the nerve fibers in the excavated area
are damaged. Since the nerve fibers spread out from the
disk in a specific pattern, such damage causes specific
patterns of visual field loss. These are mapped out by a
visual field test (see Chapter 8, Visual Field Testing).
Interestingly enough, the optic disk represents a blind
spot in your vision. This is because there are no rod or
14 Chapter 1 ............................................
cone cells on the disk. You can find your blind spot by
closing your left eye and focusing on the + below with
the right eye. Gradually bring the page closer to you until
the dot disappears. At this point (about 3 to 4 inches) the
image of the dot is falling on your optic nerve.

+ .
O f course, the eye itself is only the beginning. We’ll
explore the phenomenon of vision in the next chapter.
 Chapter 2

how it Works
(Ocular Physiology)

THE PATHOF LIGHT

When light first enters the eye (Figure 2-1), it must
pass through the tear film. The tear film is like a reflecting
mirror. If there is foreign material in the tears or if the eyes
are dry, this will blur the vision. In addition, the tears act
like a miniature lens, bending incoming light. They are
the first refractive (light-bending) surface of vision.
Next is the cornea. The cornea refracts incoming light
more than any other structure of the eye, even the crystal-
line lens. This feature is key in corneal refractive surgery
(see Chapter 9). If the surface of the cornea is irregular,
then light will not pass through unhindered. A scar, for

17
18 Chapter 2 ...........................................

1. Tear film (not shown)

2. Cornea

3. Aqueous

4. Pupil

5. Crystalline lens

6. Vitreous gel
7. Retina/macula
8. O ptic nerve

Figu re 2 -1. Th e pa th wa y o f ligh t th ro ugh th e e ye .

(Ada pte d fro m Le n s A, La n gley T, Nem eth SC, Sh ea C.
Ocular Anatom y and Physiology. Th o ro fa re, NJ: SLACK
In co rpo ra ted; 19 9 9 .)

example, could completely obscure vision if it is large

enough, or could cause distortion or glare if it is smaller.
O nce inside the eye, light passes through the aqueous.
The aqueous is normally a clear fluid, and it actually has
a tiny bit of refractive power itself. However, if the aque-
ous is muddied by blood or other debris (such as inflam-
matory cells), vision is correspondingly decreased.
After passing through the pupil, an image reaches the
lens of the eye. The shape of the lens is controlled by the
ciliary muscle and the zonule fibers. We’ll talk about how
this works (accommodation) in a minute.
Beyond the lens is the vitreous jelly. Like the aqueous,
it has little refracting power of its own and is normally
clear. But if blood or inflammatory cells leak into the
vitreous, vision will be diminished. Vision can also be
disrupted (but is generally not obstructed) by debris
such as clumps of protein in the vitreous. This causes
the phenomenon known as floaters, which patients often
describe as bugs or cobwebs in the vision.
...................................... How it Works 19
Having been focused by the cornea and lens, the ideal
situation is for the image to be cast onto the retina. It is
a common misconception that the eyes are positioned
in the head so that an image is directed onto the optic
nerve. However, the optic nerve has no light-receptor
cells. Instead, the globe is situated so that images are
focused onto the macula, the area of finest vision.
O f course, the entire retina receives input. However,
the macula has the sharpest vision. O nce received by
the rods and cones, light stimuli are jettisoned along the
nerve fibers and to the optic nerve. That’s when things
start to get even more interesting.

VISUAL PATHWAY
It will be easiest to understand this next part if you’ll
refer to Figure 2-2.
Let’s start with the right eye. Retinal nerve fibers from
the nasal half of the eye follow the inside channel of the
optic nerve. Fibers from the temporal side follow the out-
side channel. Now consider both eyes. The optic nerves
travel from each eye for about 30 to 40 mm and then
merge at a structure known as the chiasm. In the chiasm ,
the temporal fibers stay on the outside. But the nasal
fibers cross over. From the chiasm, the fibers continue on
as part of the optic tract, except that the fibers from the
nasal half of the right eye are now on the inside channel
of the left tract, and the nasal fibers from the left eye are
on the inside channel of the right tract. This fact is impor-
tant when deciphering visual field defects.
Each optic tract terminates in a structure called the
lateral geniculate body. From here the nerve fibers fan
out into what looks like a horse’s tail, the optic radiations.
These terminate in the occipital lobe of the brain (the
visual cortex), where visual interpretation takes place.
Since it is the brain that figures out what we see, it
is important to note that perceptual problems, such as
20 Chapter 2 ...........................................

Figu re 2 -2 . Th e visua l pa thwa y. The pa th of a n im a ge

on th e righ t side is depicted in gra y. At th e o ptic ch ia sm ,
nerve fibers from th e righ t eye (ca rryin g inform a tio n
fro m th e right visua l field) cross to th e left side a nd
jo in with n erve fibers fro m th e left eye (a lso ca rryin g
in fo rm a tio n fro m th e righ t visua l field). (Ada pte d fro m
Ch o plin N, Edwa rds R. Visual Fields. Th o ro fa re, NJ: SLACK
In co rpo ra ted; 19 9 8 .)
...................................... How it Works 21
dyslexia, occur in the brain… often in the presence of
healthy, normally functioning eyes.

Visual Field Defects

Testing of the visual field is mentioned in Chapter 8
(Visual Field Testing), but some description of the pattern
of defects seems logical here. Some patterns are typi-
cally associated with a specific disease (glaucoma, for
example) or the entire field may shrink (constriction), or
blind spots (scotom a) may exist. Evaluating the details of
visual field loss helps the physician determine what and
where the problem is (Table 2-1).
Following are a few terms you may encounter regard-
ing visual fields:
* Congruous—visual field defects of similar shape in
both eyes.
* Incongruous—field defects in both eyes that do not
match each other.
* Hemianopsia—defect affecting one hemisphere (or
half) of the visual field in one or both eyes.
* Q uadranopsia—defect affecting one quadrant (or
one quarter) of the visual field in one or both
eyes.
* Homonymous—visual field defects in both eyes
that are the same; they look like an overlay of one
another (eg, left half of field missing in each eye).
This is a congruous field, although not all congru-
ous fields are homonymous.
* Scotoma—blind spot or area where vision is
impaired or absent (at least as detectable by the
particular instrument used).
* Blind spot—if used correctly, the term refers to the
scotoma caused by the optic nerve head, which
has no light receptor cells. Some use it to refer to
any scotoma.
22 Chapter 2 ...........................................
Table 2-1
Correla tio n o f Scoto m a a n d An a to my
o f th e Visua l Pa th wa y
Characteristic of Scotom a Im plication
In one eye only Problem is in the retina or
optic nerve
N asal field of one eye only Problem is in the tem p oral
retina or ou ter channels of
the op tic nerve
Tem poral field of one eye Problem is in the nasal
only retina or inner channels of
the op tic nerve
Central, in one eye only Problem is in the m acu la or
m acu lar fibers
Enlarged blind sp ot Problem is affecting the
optic nerve
Tem poral field s of both Problem is at the chiasm
eyes w here the nasal fibers cross
Right sid e of field in both Problem is in the left op tic
eyes tract or beyond , on the left
sid e
Left sid e of field in both Problem is in the right optic
eyes tract or beyond , on the
right sid e

Note: A s a general rule, the farther from the chiasm and the closer
to the brain that a problem occurs, the more alike (congru ou s) will
be the field patterns from each eye

* Tunnel vision—situation in which little or no

peripheral vision exists; patient sees only what is
straight ahead.
...................................... How it Works 23
BINOCULAR VISION
Not only are the eyes situated to receive incoming light
on the macula, they are offset just a bit so that each eye
gets the same image from a slightly different angle. This
provides the luxury of stereo vision or stereopsis. In order
for stereopsis to exist, several things must occur. First, the
eyes must be aligned properly so they are receiving very
nearly the same image (see Chapter 5, Craz y Eyes). Next,
each eye must be functioning (binocular vision) and there
must be adequate vision in each eye. Finally, the visual
field of each eye must overlap the other to a large extent.
(There is a point in the temporal field of each eye that
does not overlap; however, the central fields do overlie
one another.) The degree of stereopsis can be measured
(see Chapter 8, Stereo Testing).
The terms stereopsis and depth perception are often
used interchangeably, but they are not the same thing.
Depth perception is a sense of the spatial relationship of
objects and is just part of stereo acuity (or seeing in three
dimensions). Even a person with only one eye (termed
m onocular) can develop depth perception with a little
practice.

COLOR VISION
The cone cells in the retina are responsible for our
color vision. Each cone has one of three different visual
pigments, making it sensitive to either red, green, or blue.
For example, purple is seen if incoming light stimulates
the red and blue cones.
When each pigment is present in normal amounts,
about 200 different color sensations are possible. 1
However, if one of the pigments is deficient or com-
pletely lacking, a color vision defect will exist. In fact, it
is possible to have defects involving one, two, or all three
24 Chapter 2 ...........................................
pigments in the same eye. Thus, a color vision defect
might be mild, moderate, severe, or absolute. Color
vision testing (see Chapter 8, Color Vision Tests) helps
determine which pigment is involved and the severity of
the deficit.
O ne might be born with a color vision defect (congen-
ital) or it might occur later (acquired). In congenital color
defects, the usual situation is where a carrier mother (who
has normal color vision herself) passes along a defective
gene to her children. If it is passed to a daughter, she too
is a symptomless carrier. However, if a son receives the
defective gene, he will exhibit the symptoms of color
blindness. In fact, about 1 in 10 men have some form of
color deficiency.2
Congenital color defects are the same in each eye,
while acquired color vision defects may occur in one eye
or both, or to a different degree in one eye as opposed
to the other. Acquired defects can frequently be traced
to medications taken by the patient, may worsen as time
goes on, and often reverse if the medication is discontin-
ued. Congenital defects never improve or worsen.

ACCOMMODATION
We have mentioned before that the lens is suspended
by zonules, the fibers that are attached both to the ciliary
muscle and the lens. When the retina receives the image
from a close object, the ciliary muscle contracts. This
causes the zonules to relax and allows the lens to thicken
(increasing in anterior/posterior diameter). This thicken-
ing makes the lens stronger (adding plus power), which
is needed to focus a close-up object. The entire process
is known as accommodation, and it occurs automatically
and nearly instantaneously (Figure 2-3). (There are other
theories as to how this works, but the above is the most
commonly accepted.)
...................................... How it Works 25

Figu re 2 -3 . Th e len s a n d cilia ry m uscle in (top) a cco m m o -

da tio n a n d (b o tto m ) rela xa tio n . (Dra win g by Ho lly Hess
Sm ith. Ada pted from Ledfo rd JK. Exercises in Refractom etry.
Th o ro fa re , NJ: SLACK In corpora te d; 19 9 0 .)

At the same time as the lens accommodates, two other

things happen: each eye moves inward slightly (conver-
gence) and the pupils get a bit smaller (miosis). Taken
together, the changes in the lens, convergence, and mio-
sis are sometimes called the accommodative reflex.
26 Chapter 2 ...........................................

Figure 2 -4 . Em m etro pia . (Dra win g by Ho lly Hess Sm ith.)

THE PERFECT EYE

In the ideal scenario, light entering the eye from a
distant object (more than 20 feet away) is refracted by the
cornea and lens so that the image is focused directly on
the macula. In this case the cornea is dome-shaped (like a
slice off a basketball), the length of the eye is perfect, and
the lens is clear and functioning. No glasses are required
for the person to see clearly. This situation is known as
em m etropia (Figure 2-4).
Emmetropia is the exception rather than the rule.
Its opposite is am etropia, popularly known as refrac-
tive errors (ie, errors in the way light is bent as it comes
through the eye). Refractive errors are the subject of the
next chapter. Evaluation of refractive errors by retinos-
copy, refractometry, and other methods is covered in
Chapter 8.

REFERENCES
1. VanBoemel GB. Special Skills and Techniques. Thorofare,
NJ: SLACK Incorporated; 1999.
2. DuBois L. Clinical Skills for the O phthalm ic Exam ination:
Basic Procedures. 2nd ed. Thorofare, NJ: SLACKIncorporated;
2006.
 Chapter 3

Oh say Can You see

(Refract ive Errors, Glasses,
and Ot her Delights)

OPTICS WITHOUT FEAR1

The subject of optics strikes dread into many hearts,
but it doesn’t need to. (And if you think we’re going to
scare you in this book, you’ve got another thing com-
ing!) The adjective optical refers to or involves “a system
through which light is transmitted.”2 Thus, the eye may be
defined as an optical system. When the eye itself does not
focus incoming light into a clear image, optical lenses are
required to do the job. Whether a lens is a natural part of
the eye (ie, the cornea or crystalline lens) or a man-made
pair of glasses or contacts, the principles of optics apply.
Read on, and fear not.

29
30 Chapter 3 ...........................................
Figu re 3 -1. An o p tica l
prism . (Dra win g by Ho lly
Hess Sm ith .)

Figu re 3-2. Ligh t is be n t

to wa rd th e ba se o f a
prism . (Dra win g by Ho lly
Hess Sm ith .)

In order to understand lenses and how they bend

(refract) light, it is easiest to start by discussing prisms. A
prism has a base and an apex (Figure 3-1). Light passing
through a prism is bent toward the prism’s base (Figure
3-2).
The two basic types of lenses used in eye care are
made of two prisms put together, either base to base or
apex to apex. A plus lens is made up of two prisms placed
base to base (Figure 3-3). Each prism of this lens bends
light toward its base. The bent rays meet, or converge, at
some distance beyond the lens. Thus, another name for
a plus lens is a convergent lens (Figure 3-4). Alternately,
it may be referred to as a biconvex lens. The crystalline
lens is a plus lens.
.............................. Oh say can you see 31
Figu re 3-3. A plus le ns
is m a de up o f two
b a se -to -b a se p rism s.
(Dra win g by Ho lly Hess
Sm ith .)

Figu re 3 -4 . Ligh t co m -
in g th ro ugh a plus le n s
is ben t in wa rd, o r co n -
ve rge d. (Dra win g by
Ho lly Hess Sm ith.)

Figure 3-5. A m inus lens

is m a de up of two a pex-
to-a pex prism s. (Dra wing
by Holly Hess Sm ith.)

A m inus lens is made up of two prisms placed apex

to apex (Figure 3-5). Each prism of the lens bends light
toward its base. The bent rays do not meet, but move out
and away (diverge) from the lens. Thus, another name for
a minus lens is a divergent lens (Figure 3-6). You may also
hear the term biconcave applied to minus lenses.
32 Chapter 3 ...........................................
Figure 3-6. Ligh t com -
in g th ro ugh a m in us
lens is sprea d a pa rt, o r
dive rged. (Dra win g by
Ho lly Hess Sm ith.)

Figu re 3 -7. A m in us
le n s do es n o t pro ject
a rea l im a ge; instea d,
the lines of the diverged
light a re extra pola ted to
m eet a t a virtua l im a ge.
(Dra wing by Holly Hess
Sm ith.)

A plus lens makes light converge to a point. It forms

a real im age that can be projected onto a screen. (If you
ever started a fire with your granny’s magnifying glass, this
will bring back a few memories!) A minus lens, because
it causes light to diverge, has no real image. However, if
the line of the divergent light rays are penciled in, it can
be seen where the nonreal, or virtual im age, would be
(Figure 3-7). Because the virtual image of a minus lens
lies in front of the lens itself (rather than behind it as in a
plus lens), it cannot be projected onto a screen.
The plus and minus lenses we have been talking about
so far focus light to a point (whether the image is real or
virtual). Since incoming light is bent the same amount in
every direction, these lenses are termed spherical. There
is one more type of lens to consider, which focuses light
.............................. Oh say can you see 33
Figu re 3 -8 . To visua lize a plus
cylin der, im a gin e a gla ss ro d cut
in h a lf. (Dra win g by Ho lly Hess
Sm ith.)

Figu re 3 -9 . In o ptics, a plus cyl-

in der is curved in o n e directio n
but n o t th e o th er. (Dra win g by
Ho lly Hess Sm ith.)

in a line instead of a point. This lens is known as a cylin-

der, which may also be in plus or minus form.
An easy way to visualize a plus cylinder is to begin
with a glass rod and then split it down the middle. The
resulting half is a cylinder (Figure 3-8). (Note that the term
“cylinder” in optics is not the same as the cylinder used in
geometry.) In the vertical meridian, this cylinder is flat. In
the horizontal meridian, it is curved (Figure 3-9). Because
of this unique shape, the cylinder bends light in a unique
way. O nly the curved side bends light, so the result is a
focused line instead of a point (Figure 3-10).
Note in Figure 3-10 that while the curve of the cylin-
der is in the horizontal meridian, the resulting focused
line of light is vertical. The direction of the focused line
is considered to be the axis of the cylinder. The cylinder’s
34 Chapter 3 ...........................................
Figure 3-10. Light en terin g
a plus cylinder is focused
in to a line o f ligh t wh ich
a ppea rs 9 0 degrees from
the lens's curved m erid-
ia n . (Dra win g by Ho lly
Hess Sm ith.)

axis is always 90 degrees from the cylinder’s curved

meridian, no matter which way the cylinder is turned.
When a cylindrical lens is used, both its power (discussed
in a moment) and axis must be noted. Cylinder axis may
be set anywhere from 1 to 180 degrees.
A minus cylinder shares many of the same charac-
teristics of the plus cylinder. Specifically, it is flat in one
meridian and curved in the other. As before, these merid-
ians are 90 degrees from each other. Figure 3-11 is a
visualization of the minus cylinder. Like a minus sphere,
the minus cylinder causes light to diverge (Figure 3-12).
Thus, there is no real image.
We have been discussing lenses in terms of their
refractive properties. Now we will look at them in terms
of their strength, or power.
The point at which a lens forms the image (whether
real or virtual) is termed the focal point of the lens. The
distance from the center of the lens to its focal point is
known as the focal length of the lens (Figure 3-13). The
focal length is determined by the power of the lens,
which is measured in diopters (D). By convention, paral-
lel light rays being refracted by a 1-D lens will have a
focal length of 1 meter. (The reason we stipulate parallel
light rays is that any light rays coming into the lens at an
angle will be refracted differently because of their angle.
In order to have a standard, we consider only those light
rays coming straight into the lens.)
.............................. Oh say can you see 35

Figu re 3 -11. Re presen ta tio n o f a m in us cylin der len s. Like

its plus co un terpa rt, it is curved in o n e m eridia n a n d fla t
in th e o th e r. (Dra win g by Ho lly Hess Sm ith .)

Fig u re 3 -12 . Ligh t

en terin g a m in us cylin -
der is diverged a lo n g
o n e m e rid ia n o n ly,
9 0 de gre e s fro m th e
le n s's curve d m e rid-
ia n . (Dra win g by Ja n
Ledfo rd.)

The stronger the lens, the greater its ability to refract

light and, thus, the shorter its focal length. All of this
can be encapsulated by saying that the dioptric power
36 Chapter 3 ...........................................

Focal Length

Figu re 3-13 . Th e fo ca l length o f a sphe rica l len s is the

dista n ce between th e cen ter o f th e len s to th e fo cused
im a ge , wh eth er rea l (a s with a plus len s, left) o r virtua l (a s
with a m in us len s, righ t). (Dra win g by Ho lly Hess Sm ith .)

of the lens equals the reciprocal of its focal length. The

mathematical formula for this is D = 1/F, where D is the
power of the lens in diopters and F is the focal length of
the lens in meters. Thus, the focal length of a 5-D lens
is 0.2 meters, and that of a 10-D lens is 0.1 meters. This
applies whether the lens is plus or minus.

Nearsightedness (Myopia)
Myopia, or nearsightedness, means that a person has
“sight at near”; far away objects are unclear. This gener-
ally occurs because the eyeball is too long or the dome
of the cornea is too steep. Incoming rays of light from an
image focus before they reach the macula, which is why
things look blurry (Figure 3-14). A minus-powered lens is
used to correct myopia. This works because a minus lens
spreads the incoming light rays apart a little. The stronger
the lens (ie, the more minus), the wider the spread. In this
way, the focal point of the image can be moved back onto
the macula (Figure 3-15).
.............................. Oh say can you see 37

Figure 3-14. Myopia (nea rsightedness). (Dra wing by Holly

Hess Sm ith.)

Figure 3-15 . Myo pia , co rre cted with a m in us len s. (Dra win g
by Ho lly Hess Sm ith .)

Farsightedness (Hyperopia)
The farsighted (hyperopic) person has “sight at a dis-
tance”; close images are blurred. In this case the eyeball is
too short or the dome of the cornea is too flat. The image
doesn’t come to a focus point soon enough (Figure 3-16).
A plus-powered lens is used to correct hyperopia because
it forces incoming light to come to a focal point sooner.
The stronger the lens, the more focusing power it has. This
pulls the image forward onto the macula (Figure 3-17).
38 Chapter 3 ...........................................

Figu re 3 -16 . Hype ro pia (fa rsigh te dn e ss). (Dra win g by

Ho lly Hess Sm ith.)

Figu re 3 -17. Hype ro pia , co rre cte d with a plus le n s.

(Dra win g by Ho lly Hess Sm ith .)

Ast igmat ism

Astigm atism is not a contagious eye disease, and
unlike myopia and hyperopia, it generally has nothing
to do with the length of the eyeball. Instead, it has to
do with the curvature of the cornea. Remember that in
emmetropia (the almost-mythical perfect eye) we said
that the cornea was spherical, rather like a slice from a
basketball? In astigmatism, the cornea is not spherical but
.............................. Oh say can you see 39

Figu re 3-18 . Fo rm s o f a stigm a tism . No te th a t th e im a ge is

stretch ed ra th er th a n co m in g to a fo cus po in t. (Dra win g
by Ho lly Hess Sm ith . Reprin ted with pe rm issio n fro m
Ga yto n JL, Ledfo rd JK. The Crystal Clear Guide to Sight for
Life. La nca ster, PA: Sta rburst Publishe rs; 19 9 6 .)

is actually more curved or steeper in one direction than

another (like a slice from a football, maybe, or the back
of a spoon). This causes the image to be stretched out
rather than focusing to a point (Figure 3-18).
There are several types of corneal astigmatism, thus it
is difficult to make a blanket statement as to how vision
will be affected. Astigmatism is resolved optically with
cylinder. This works because the axis of the cylinder
(which corrects one meridian only) can be positioned
to coincide with the direction of the astigmatism. In
addition, astigmatism can occur along with hyperopia
or myopia, requiring a plus or minus spherical lens to
be combined with the cylinder. Corneal astigmatism is
measured with an instrument called a keratometer (see
Chapter 8, Keratom etry).
40 Chapter 3 ...........................................
In some cases, the curvature of the crystalline lens
is not spherical, and this may contribute to a patient’s
refractive error. This is called lenticular astigm atism . The
amount of lenticular astigmatism may be estimated by
comparing the difference between the amount of astig-
matism measured with a keratometer (see Chapter 8,
Keratom etry) and the amount measured with refractom-
etry (see Chapter 8, Refractom etry).

Presbyopia
No one likes to talk about this one. It is a gradual
worsening of near vision caused by smoke… from birth-
day candles! That’s an old joke, but the fact remains that
presbyopia occurs with age.
When a person is born, the crystalline lens is some-
what soft and putty-like. This makes it extremely flexible,
and capable of a large degree of accommodation (focus-
ing). As we age, the lens gradually becomes more rigid.
It is also thought that the ciliary muscle begins to lose its
tone. At any rate, the lens becomes less able to focus for
near vision. We don’t usually notice this until it worsens
to a specific point… usually around age 40 to 45. Moving
the near object farther away helps bring it into focus,
which is why presbyopic patients often joke that their
arms are getting too short.
O nce again, plus lenses come to the rescue. A plus
lens restores the focusing power lost by the crystalline
lens. This plus lens can take the form of reading glasses,
a bifocal, or trifocal.

The Prescript ion for Glasses

To review, myopia is corrected with a minus sphere
lens, hyperopia with a plus sphere lens, and astigmatism
with a cylindrical lens (plus or minus, as appropriate; this
is determined by the practitioner). If astigmatism occurs
along with myopia or hyperopia, a spherocylindrical
lens (combination of sphere and cylinder) may be used.
.............................. Oh say can you see 41

Figu re 3 -19. Typica l gla sses pre scription .

In every case it is essential to note the power of lens

required to give the patient the best vision. If cylinder is
used, its axis must also be indicated.
By convention, a prescription for an optical lens
(Figure 3-19) is written:
+/- dioptric power of sphere +/- dioptric power of
any cylinder X axis of any cylinder.
For example, a patient with myopia and astigmatism
(if measured in minus cylinder) might have the following
prescription: -3.50 - 2.50 X 092.
It is often necessary to transpose a plus cylinder
prescription into minus cylinder form and vice versa.
This is done by adding the power of the sphere and
cylinder together (this yields the power and sign of the
new sphere), changing the sign of the original cylinder,
and rotating the axis by 90 degrees. (Since cylinder axis
only goes to 180 degrees, if the original axis is over 90,
you must subtract 90 to arrive at the correct axis when
42 Chapter 3 ...........................................
transposing. If the original axis is 90 or less, you may
simply add 90.)
For example, to transpose +0.75 + 0.50 X 135, first
add the sphere and cylinder powers together (+0.70 +
0.50 = +1.25). Then change the power sign of the cyl-
inder (+0.50 becomes -0.50). Since the axis is over 90,
subtract to get your new axis (135 - 90 = 045). The trans-
posed Rx is +1.25 - 0.50 X 045.
In the case of presbyopia, the power of plus sphere
required to bring close objects into focus is noted on the
prescription as an add.

THROUGHTHE GLASS LOOKING

This section discusses glasses and contact lenses. For
correction of refractive errors via surgery, see the Refractive
Surgery headings under Cornea (which includes laser
procedures and Intacs®) and Crystalline Lens (covering
intraocular lens implants [IO Ls]) in Chapter 9.

Glasses
It 's All About Your Focus
By far, the most common method of correcting refrac-
tive errors is with spectacles. After measurement by
refractometry, the practitioner can generate a prescription
for eye glasses. For the average person who is nearsighted
or farsighted, or who has astigmatism, this is usually a
simple matter. The goal of any pair of glasses for distance
is for the eye to be relaxed when wearing them, leav-
ing any available focusing power (accommodation) in
reserve for close work.
Much of the frustration comes when presbyopia
begins to be a problem, usually in a person’s 40s. The
crystalline lens inside the eye can no longer adjust for
near vision… a situation that gradually worsens for about
20 years before stabilizing. Without the full magnifying
.............................. Oh say can you see 43
power of the crystalline lens, glasses are now needed for
reading and doing close work.
A person who has not needed glasses up to this point
may be able to hop on down to the nearest drugstore and
buy a pair of over-the-counter reading glasses. Problem
solved, as long as he realizes that the glasses are for close
up only, and looking through them at distant objects will
be a disorienting, blurry mess.
The person who is nearsighted is probably already
wearing glasses (or should be!) to clear the distant vision.
In many cases, she can simply take the glasses off and
her near vision will be in focus. Alternately, a bifocal may
be added by placing a segment in the glasses lenses. The
upper part of the lens is still for distance, and the lower
segment is for near (usually about 14 inches).
A farsighted person, however, can be a special case. In
the best case scenario, the hyperope who is already wear-
ing glasses can just switch to a bifocal. But he may have
good vision at a distance without specs because there is
still some focusing power in his natural crystalline lens.
Yet this means he has been accommodating for distance
vision. Plus lenses are needed to relax accommodation,
leaving any focusing ability for up close. A segment may
be added for a further boost at near. This may be a dif-
ficult change, since the eye is not used to being relaxed at
a distance. Extra adjustment time may be needed.
Lens/Segment Types (Figure 3- 20)
Single vision glasses correct for one distance only,
usually distant but sometimes near. (O ver-the-counter
readers are single vision lenses intended to help with
close work.) A m ultifocal lens can refer to a bifocal, trifo-
cal, or no-line bi/trifocal lens, and is so called because a
range (“multi“) of focusing distances are corrected by the
same lens. A bifocal corrects for two distances, usually
distant (20+ feet) and near (14 inches). Thus, any object
that falls between these two focus points may be blurred.
A trifocal lens adds a third segment that usually corrects
44 Chapter 3 ...........................................

Figu re 3 -2 0 . Types o f lenses. a ) Sin gle visio n; b) round-

to p bifoca l; c) fla t-to p bifo ca l; d) executive trifo ca l; e)
o ccupa tion a l len s; f) pro gressive/ no -line: 1. dista nt, 2 .
inte rm edia te, 3 . n ea r.

at midrange, or 24 inches. This helps with such tasks as

computer work, reading music, seeing prices on shelves,
etc. If a person needs to see close objects while looking
up (eg, a mechanic), a segment can even be placed at the
top of the lens (often called an occupational bifocal).
A no-line or progressive lens does not have visible seg-
ments, but graduates in power down the lens so that full
distance correction is in the top (when looking straight
ahead) and the strongest near correction is near the bot-
tom (when looking down). From the top to the bottom are
.............................. Oh say can you see 45
areas of the lens that are appropriate for all ranges of the
middle ground.
The design of a progressive is the source of its greatest
advantage as well as disadvantage. The distant “sweet
spot” transitions to the near “sweet spot“ through a cor-
ridor (sometimes called the umbilicus). O n both sides of
the corridor is a “junk area“ that focuses… nothing. If
the wearer cuts her eyes to the left or right, vision will be
blurred. Thus, the wearer must learn to point her nose at
whatever she wants to see. This can be problematic until
she adjusts. It also takes practice to “learn” what part of
the lens to look through for a given distance. This eventu-
ally becomes automatic.
There are numerous materials for spectacle lenses and
frames, each with advantages and disadvantages which
are, alas, beyond the scope of this text. (Read: Go look
it up!)

Cont act Lenses

About 40 million people in the United States wear
contact lenses.3 In the case of myopia and hyperopia and
even astigmatism, this is usually an easy matter. Optically,
the problem again occurs with presbyopia. If contacts are
worn to correct distant vision, reading glasses can be used
for near work. For patients who do not want to use glasses
at all, there are several options, including bifocal contacts
of various designs. Also popular is the monovision tech-
nique, where one eye is fit with a contact for near vision
and the other eye for distant vision. This arrangement takes
some getting used to, but is satisfactory for many. One dis-
advantage is the loss of midrange (14 inches to 20 feet).
Contact lens materials are being improved upon
constantly, providing a range of oxygen permeability,
wetability, and convenience. Disposable soft lenses are
very popular, some designed to be worn 1 day and then
discarded, and others worn for 2 to 4 weeks before
hitting the trash can. Some lenses are designated as
46 Chapter 3 ...........................................
“daily wear” (meaning that they are to be removed and
disinfected every night) while others are approved for
“extended wear” (meaning that they may be worn dur-
ing sleep). Gas-permeable contacts are more rigid (and
may last a year or more), and are meant as daily-wear
lenses only. Contact lens wearers must consult with their
eye care professional regarding what type of lens is most
appropriate.
Fitting contact lenses requires more than the usual
“complete eye exam.” In addition to a refraction, corneal
curvature must be evaluated. (See Keratom etry in Chapter
8.) The idea here is to match the curve of the contact to
the curve of the eye. The visible iris diameter (VID, the
distance from limbus-to-limbus) may also be measured to
ensure that the contact’s diameter will be appropriate.
In order to wear contact lenses safely, strict hygiene
and cleaning/wearing schedules must be followed. In
addition to hand washing, contacts that are removed and
reinserted must be disinfected. There are many cleaning
and disinfecting systems available, and the practitioner
will recommend one that is compatible with the contact
lens material being used. Proper care is key because a
contact lens is a foreign body, and as such increases the
risk of eye infections (some of which can be quite seri-
ous). See the sections Conjunctiva and Sclera and Cornea
in Chapter 4 for “what can go wrong.”

OTHER VISUAL DISORDERS

Amblyopia
Am blyopia (which laymen often refer to as “lazy
eye”) is subnormal vision in an eye and develops during
childhood. For one reason or another, the amblyopic eye
does not “learn” to see. Not only does good vision rely
on a healthy eye, but there is a nerve-generated process
.............................. Oh say can you see 47
by which the eye and brain must learn to work together.
If this process is not completed by approximately age
8, then the eye will always have subnormal vision. The
most desirable scenario is to discover amblyopia as early
as possible… in the preschool years. Then the strong eye
can be patched, forcing the weak eye to “learn” to see.
The younger the patient, the faster this process seems to
be. For more on amblyopia, see Chapter 5, Laz y Eyes.

Aphakia and Pseudophakia

When the crystalline lens is in its natural position in
the eye—just behind the pupil—the eye is said to be
phakic. If the crystalline lens is removed (cataract surgery
is the usual reason), then the eye becomes aphakic. (The
Latin prefix a- means w ithout.) An aphakic eye lacks
about 20 to 30 D of plus power needed to focus incom-
ing images. In order for the patient to see, this power
must be restored to the eye in one of three ways.
First, spectacles might be prescribed. The required
lens would be about +12.00 D strong. This means the
lenses are very thick, tend to magnify objects, are prone
to distortions at the edges, and must be aligned very care-
fully. The second option is contact lenses. In this case,
since the lens is directly on the eye, about +14.00 D are
needed. The problems of the thick spectacle lenses are
avoided, but contact lenses can carry troubles of their
own. They must be inserted and removed, as well as
cleaned properly. While most contact lens wearers have
few (if any) problems, any time you place a foreign object
on the eye, the risk of infection is increased. This leads
to the third option, an intraocular lens im plant (IO L). An
IO L is a tiny artificial lens (made of plastic, silicone, or
acrylic), usually of +20 D or so, that is placed inside the
eye, most often behind the pupil where the crystalline
lens was once located. There is no distortion as with
glasses; there is no handling as with contacts. The most
common scenario is that the IO L is placed into the eye
48 Chapter 3 ...........................................
during the same operation in which the lens is removed
(usually cataract surgery). An eye with an IO L is said to
be pseudophakic, where the Latin prefix pseudo means
“false.”

Anisomet ropia and Ant imet ropia

Usually the refractive error of the two eyes is some-
what similar, but this is not always the case. If the differ-
ence between the two eyes is 2.00 or more diopters, then
anisom etropia is present. Examples would be when the
right eye is plano (ie, 0.00 power, requiring no correction)
and the left eye is +2.50, or the right eye is -2.50 and the
left eye is -4.75.
If one eye is farsighted (hyperopic) and the other eye is
nearsighted (myopic), the situation is called antim etropia.
(In this case, a specific difference between the eyes isn’t
necessary to fit the definition, although anisometropia
may also exist if the eyes are 2.00 or more different as
well.)
Antimetropia or anisometropia can create problems
for the patient when the refractive errors are corrected.
A plus lens magnifies an image, and a minus lens mini-
fies an image. The same thing can actually occur in two
lenses of the same type (ie, both plus or both minus). For
example, a +4.00 lens will magnify an image more than
a +1.00. A -6.00 will minify an image more than a -3.75.
Thus, one eye is receiving a slightly larger and the other
a slightly smaller image size (aniseikonia). Sometimes the
brain can still fuse these two images, and other times it
cannot. In general, the greater the difference between
the refractive errors, the less likely that image fusion will
occur. If the brain sees two different images, the patient
may have double vision as well as difficulties in judging
spatial relationships.
.............................. Oh say can you see 49
REFERENCES
1. Ledford JK. Exercises In Refractom etry. Thorofare, NJ:
SLACK Incorporated; 1990.
2. Ledford JK, Hoffman J. Q uick Reference Dictionary
of Eyecare Term inology. 5th ed. Thorofare, NJ: SLACK
Incorporated; 2008.
3. Contact Lens Council. Home page. www.mycontactlenses.
org. Accessed February 26, 2008.
 Chapter 4

What Can Go Wrong

(Common Eye Disorders
and Trauma)

ITIS, OSIS, AND OMA

No, these aren’t a set of evil triplets; it’s time for a
short Latin lesson. Don’t groan; this will really help you
when it comes to identifying disorders of all sorts, not
just ocular ones.
There are several suffixes you should know:
* itis—refers to an inflammation or inflammatory
process. The prefix indicates its location (eg, kera-
titis, where “kerat” refers to the cornea).
* oma—often refers to a tumor (especially cancer-
ous), but can also refer to any disorder for which
there is no cure (eg, glaucoma).

51
52 Chapter 4 ...........................................
* osis—simply refers to an abnormal condition (eg,
ptosis).
N ote: For sim plicity’s sake, all figures are grouped in a
m ini-atlas at the end of the chapter.

TAKE A NUMBER, PLEASE

O bserved findings are often "graded" by the practi-
tioner so that, over time, any progress or regression may
be compared. Many physicians use a 0-4 system, with
0 being no evidence of a finding and 4+ being the most
advanced stage. Unfortunately, there is generally no stan-
dard of what the in-between grades actually stand for (a
teeny bit, a bit, and more of a bit, perhaps?!?), yet this
remains the rating method of choice.

SKIN AND LIDS

Disorders
Disorders of the skin around the eyes, as well as the
eyelids, include numerous lumps, bumps, and infections.
Here are the most common:
* Blepharitis—inflammation of the eyelids (Figure 4-
1). Lids appear swollen, red, and crusty, and may
itch. Can be caused by bacteria, viruses, lice, or
inflammatory conditions.
* Chalazion—inflamed oil gland in the lids (Figure
4-2). Lid has a swollen knot, which may or may not
be red and/or sore. Generally caused when the oil
gland becomes obstructed.
* Dermatochalasis—extra skin on the upper lids, usu-
ally associated with aging. May restrict the upper
temporal visual field.
............................ what Can go wrong 53
* Ectropion—an out-turned lower lid (Figure 4-3).
Palpebral conjunctiva may appear dull and meaty-
red. Corneal exposure and dryness may result.
* Entropion—in-turned lid, usually the lower (Figure
4-4). Brings lashes into contact with the globe, so
there is generally a foreign body sensation.
* Hordeolum—”proper” term for a stye, an inflamed
eyelash follicle. Lid edge is tender, swollen, and
red; lesion may have a “head” on it.
* Nevus—”proper” term for a mole. They are usually
flat and pigmented.
* Ptosis—a drooping upper lid (Figure 4-5).
* Trichiasis—lashes that grow toward and touch the
eye’s surface (Figure 4-6). Patient complains of a
foreign body sensation.

Trauma
In general, any skin laceration around the eye is
treated as elsewhere on the body… with patches,
SteriStrips™ (3M, St. Paul, MN), or stitches. But if the
lid is lacerated through-and-through and the lid margin
(edge) is involved, things can be more difficult. The edges
must be sewn together as closely to their original posi-
tion as possible. This is especially true if the lower lid is
affected, specifically in the nasal corner at the punctum
(the opening where the tears drain). If the tear-drainage
system is not sewn together properly, permanent watering
may result. The lids may also be subject to blunt trauma,
chemical burns, or thermal burns; however, a damaged
lid may mean a saved globe (eyeball), which is the whole
point of the blink reflex.
54 Chapter 4 ...........................................
TEAR SYSTEM, GLOBE, AND ORBIT
Disorders
The purpose of the tear (lacrimal) system is to lubri-
cate the eye and to drain excess tears from the eye. Thus,
the possibility of problems exists in both the excretory
and drainage components of the system. The bony orbit
protects the globe, but is not itself immune to occasional
problems. The following are the more common disor-
ders:
* Dacryocystitis—inflammation of the tear sac.
Redness and swelling occur at the inner (medial)
canthus, and is generally painful. Usually due to
bacterial infection.
* Dry eye (keratoconjunctivitis sicca)—inadequate
lubrication. Paradoxically, patients with dry eye
often complain of streaming tears. This happens
because the dry eye sends a message to the brain,
the brain sends a message to the lacrimal (tear)
gland, and the tear gland overreacts by sending too
many tears. Dry eye can lead to dry spots on the
cornea, which give the patient a foreign body sen-
sation and blurry vision. Severe dryness can lead to
scarring, infection, pain, and decreased vision. The
first line of treatment includes artificial tear drops
and ointment. In some cases the doctor may seal
off the puncti in order to retain the tears that are
produced.
* Endophthalmitis—inflammation of the eye’s inner
tissues which can destroy the eye. Due to infection
after trauma (or intraocular surgery).
* Exophthalmus—protrusion of the eyeball, often
associated with thyroid eye disease (Figure 4-7).
............................ what Can go wrong 55
* Nasolacrimal duct obstruction—usually due to
failure of a membrane in the nasolacrimal system
to open before birth; seen in 30% of newborns.
Symptoms include tearing and mattering.
* Sympathetic ophthalmia—rare inflammatory disor-
der of the uvea in the uninjured eye after a penetrat-
ing ocular injury. It usually occurs some two months
after the original injury. Symptoms may include
pain (may be slight), light sensitivity, tearing, and
blurred vision. If the physician suspects the onset of
sympathetic ophthalmia, the originally injured eye
is surgically removed and oral steroids are started in
order to stop the process and save at least one eye.

Trauma
As discussed above, any laceration of the lower lid
that involves the punctum or canaliculi (tubules in the
tear drainage system) can result in permanent watering.
Some of the inner bones of the orbit are paper-thin and
susceptible to trauma, and even the blink reflex and rigid
orbit cannot protect the globe all the time. Here are the
most important problems:
* Blowout fracture—situation in which the bones of
the orbital floor are broken, usually by blunt trau-
ma (fist, tennis ball, etc). The muscles on the lower
part of the globe may be pushed through the break
and become trapped. This limits the movement of
the eye, and the patient often complains of double
vision.
* Intraocular/intraorbital foreign body—if the eye has
been lacerated by high-velocity debris, the potential
for an intraorbital and/or intraocular foreign body
exists. Infection risk is greatest if the foreign material
is organic (plant or animal matter). Some metals are
toxic and poorly tolerated. Certain inert materials
may be retained with no adverse effects (eg, glass).
56 Chapter 4 ...........................................
* O rbital cellulitis—inflammation involving the tissue
of the orbit behind the orbital septum (a septum is
a thin dividing wall between two structures) (Figure
4-8). Because the eye is so close to the brain, there
is a risk that the infection could migrate there. Thus,
the condition can be life-threatening. Symptoms
may include redness and swelling of lids and con-
junctiva, fever, headache, pain when moving the
eye, difficulty moving the eye, and protrusion of
the eye (proptosis).

CONJ UNCTIVA AND SCLERA

Disorders
Because the conjunctiva is external, many of its dis-
orders are easy to identify. The underlying episclera and
sclera may also have problems that are unique to their
tissue:
* Conjunctivitis—inflammation of the conjunctiva,
commonly called “pink eye” (Figure 4-9). There are
several types, but all share the common symptom
of redness.
¡ Allergic—this type of conjunctivitis is associ-
ated with an allergic reaction (as in hay fever
or a response to cosmetics, etc). Symptoms
include tearing, redness, itching, and sometimes
a mucus discharge.
¡ Bacterial—in this case, the inflammation is
caused by bacteria. Symptoms include redness,
a pus-like discharge, and sometimes a gritty
sensation.
¡ Giant papillary—this is generally a response
to chronic irritation (as in contact lens wear).
Symptoms include redness, papillae (bumps)
............................ what Can go wrong 57
under the upper lid, foreign body sensation, and
itching. When full-blown, pain and itching may
be severe and mucus may accumulate.
¡ Viral—the most common type of virus that
causes conjunctivitis is the same one responsi-
ble for upper respiratory infections (adenovirus).
Symptoms may include redness, watering, and
sometimes tiny raw spots on the cornea. There
may be painful swelling of the lymph node just
in front of the ears (the preauricular node).
* Episcleritis—the episclera overlies the sclera.
Inflammation of the episclera may cause redness,
pain, and nodules that may be localized in one
area or scattered.
* Pinguecula—a benign, yellowish, fatty deposit at
the limbus usually at the 3 or 9 o’clock position
(Figure 4-10). Does not spread onto the cornea;
sometimes may become red and inflamed.
* Pterygium—a benign, flesh-colored, fibrous thick-
ening of conjunctiva that spreads onto the cornea
from the limbus (usually nasal, but sometimes tem-
poral) (Figure 4-11). A pterygium may be stable, or
it may continue to grow across the cornea. If it gets
close to the central zone, it must be removed to
prevent vision impairment.
* Scleritis—inflammation of the sclera; can cause
severe pain and tissue destruction. O ften associ-
ated with an underlying autoimmune disease.
* Subconjunctival hemorrhage—a bright, blood-red
area just under the conjunctiva caused by bleed-
ing beneath the surface (Figure 4-12). It is painless
and benign, may spread more before it clears, and
generally alarms the patient. It is equivalent to a
bruise on any other part of the body.
58 Chapter 4 ...........................................
Trauma
The conjunctiva is exposed to many types of external
trauma, including chemical burns (which should be imme-
diately irrigated for 15 minutes), thermal burns, foreign bod-
ies, and lacerations. If any of these situations also involve
the sclera, things can become much worse, especially in the
case of lacerations. If the sclera is lacerated, the choroid (a
blackish layer of blood vessels that nourish the retina) and/
or extrude through the opening. Such an iris prolapse is a
grave condition that can result in total loss of the eye.

CORNEA
Good vision depends on the clarity of the cornea, thus
many disorders of the cornea can be sight-threatening. In
addition, the cornea is rich with nerve endings, making
pain a factor even in nontraumatic disorders (notably kera-
titis and ulcers).

Disorders
* Arcus senilis—a benign, creamy white arc on the
cornea just inside the limbus; may be a complete
circle. It is generally thought to be fatty or cholesterol
deposits.
* Dystrophy—an inherited disease of the corneal tissue
that often involves the breakdown of specific corneal
layers. It usually causes corneal clouding with subse-
quent decreased vision.
* Edema—an influx of fluid into the corneal tissues
due to malfunction of the inner endothelial layer
(Figure 4-13). The swelling and haziness can cause
decreased vision and halos around lights. Edema
may be associated with certain disorders (eg, angle-
closure glaucoma, corneal dystrophy, inflammation)
and trauma.
............................ what Can go wrong 59
* Keratitis—general term meaning inflammation of the
cornea. The infectious type may be caused by bac-
teria, fungi, viruses, or protozoa. Exposure keratitis
occurs when the cornea is not protected by the eye-
lids; that is, the blink reflex is decreased or absent
and/or the lids do not completely close together.
* Keratoconus—condition in which the cornea
becomes increasingly thin and cone-shaped, caus-
ing distorted vision due to irregular astigmatism
(where the meridians are not 90 degrees from each
other, thus not correctable with cylindrical lenses).
* Neovascularization—abnormal blood vessels grow
into the corneal tissue due to lack of oxygen; often
associated with contact lens wear and corneal
infections.
* Scarring—corneal scars occur when an abrasion or
laceration goes deeper than the outer epithelial tis-
sue layer. The closer the scar is to the center of the
cornea, the more likely it is to cause visual distor-
tion and blur. If the scar is on the periphery, it may
pose no visual disturbance.
* Ulcers—epithelial breakdown with involvement
of the underlying corneal stroma; may be caused
by bacteria, fungi, protozoa, viruses, or trauma.
Scarring results when deeper corneal tissue is
involved.

Trauma
* Abrasion—a scratch on the corneal surface, which
usually abrades the epithelium (outer layer) but
may be deeper (Figure 4-14). If only the epithelium
is abraded, healing occurs rapidly within 24 to 36
hours without scarring. If deeper corneal layers are
involved, the risk of scarring increases. Symptoms
of an abrasion include foreign body sensation, light
sensitivity, and tearing.
60 Chapter 4 ...........................................
* Chemical splash—any chemical injury should be
irrigated immediately for at least 15 minutes... tap
water is fine. Alkaline materials (mortar, cement,
bleach) are more serious than acidic because an
alkali readily penetrates the tissue and causes
greater damage. By contrast, acids often result in
surface burns alone, because acids cause tissue
proteins to solidify, blocking further penetration of
the chemical.
* Foreign body—a foreign body embedded on the
corneal surface generally causes pain, redness,
tearing, and light sensitivity. If tearing and blinking
don’t dislodge the material, the physician will have
to remove it.
* Recurrent erosion—a situation in which an area
of previously damaged or abnormal corneal epi-
thelium (outer layer) adheres to the eyelid and is
pulled off when the eye is opened. Causes foreign
body sensation (typically in the morning), tearing,
and light sensitivity.

IRIS, PUPIL, AND ANTERIOR CHAMBER

Disorders
Disorders of the iris mainly involve growths that can
range from nevi (benign moles) to melanoma (malignant
cancer). Abnormalities of pupil shape are generally irregu-
larities of the pupil margin. Disorders of pupillary action,
however, are neurological in nature. The term uvea refers
to the iris, ciliary body (at the root of the iris), and choroid
(layer of blood vessels just under the retina). The anterior
chamber lies inside the eye between the iris and the cor-
nea. It is filled with aqueous, a watery fluid that flows into
it from behind the pupil. Normally the aqueous is clear,
............................ what Can go wrong 61
but in cases of infection or inflammation, cells or blood
might be seen in the anterior chamber. Following is a list
of some important abnormalities:
* Anisocoria—pupils are of unequal size.
* Argyll Robertson’s syndrome—pupil does not react
to light but does respond to near stimuli. Usually
caused by syphilis.
* Horner’s syndrome—damage to sympathetic (auto-
matic “fight or flight”) neurons. This may occur
in the brain or spinal cord (preganglionic), along
the carotid artery, or in the orbit (postganglionic).
Symptoms include a small pupil (miosis), drooped
lid (ptosis), and lack of sweating (anhydrosis) on
the affected side.
* Hyphema—blood in the anterior chamber; may
range from blood cells to completely filling the
chamber (Figure 4-15).
* Hypopyon—inflammatory cells (white blood cells,
leukocytes, or pus) in the anterior chamber; seen as
white material in front of the iris (Figure 4-16).
* Iris synechiae—adhesion of sections of iris to the
cornea (anterior synechiae) or the lens (posterior
synechiae), associated with inflammation.
* Marcus Gunn pupil (afferent pupillary defect)—an
impairment in retinal or optic nerve function
causing a dilation of both pupils when the light is
directed into the affected eye. Due to a difference
in the amount of light perceived by the two eyes,
vision is usually decreased.
* Narrow angles—inadequate space at the angle
(where the cornea meets the iris), impeding the
outflow of aqueous and potentially causing a rise
in intraocular pressure (IO P).
62 Chapter 4 ...........................................
* Uveitis—inflammation of the uvea. If only the iris
is involved, it may be termed anterior uveitis or
iritis. If the choroid is involved, the term posterior
uveitis or choroiditis may be used. Some use the
word uveitis to mean inflammation of the posterior
segment.

Trauma
If the sclera or cornea is fully lacerated, the uveal tis-
sue may prolapse through the opening. This may pull on
the iris and cause an abnormal peak in the pupil. The lon-
ger the choroid is exposed to air, the more likely it is that
endophthalmitis and possibly subsequent sympathetic
ophthalmia will occur (both defined under Tear System ,
Globe, and O rbit, in this chapter).

GLAUCOMA
Inside the front segment of the eye is a watery fluid
called the aqueous. It is constantly being formed and
drained away (Figure 4-17). This creates an intraocular
pressure (IO P), which is normally present in every eye.
If the aqueous drainage system is not adequate, the IO P
builds up inside the eye. This higher-than-normal pres-
sure is transmitted to the back of the eye, and the weak-
est spot—the optic nerve—is damaged. This scenario is
referred to as glaucoma. O ptic nerve damage first affects
peripheral vision, which may not be noticed by the
patient for a long time. This is why glaucoma is called
“the sneaky thief of sight.”
Actually, there are several types of glaucoma. The one
described above is open-angle glaucoma, the most com-
mon type. It can be caused by trauma and medications,
but mostly seems to be linked to a set of risk factors that
include family history, age (over 40), high myopia (near-
sightedness), and African ancestry. More recently it has
............................ what Can go wrong 63
been discovered that a thin central cornea also seems to
be an indicator that glaucoma is more likely to occur.
Glaucoma is diagnosed by a combination of param-
eters: 1) the presence of risk factors, 2) measurement of
IO P, 3) measurement of the visual field, 4) the appear-
ance of the interior of the eye where the aqueous drains,
and 5) an examination of the optic nerve. However,
finding an elevated IO P alone is not enough to make the
diagnosis, because some people have a higher-than-aver-
age IO P that is simply normal for them.
O pen-angle glaucoma cannot be cured, but it can and
should be treated. The preferred first line of treatment is
usually eye drops to lower IO P, of which there are several
types (see Chapter 10, Glaucom a Treatm ent). Basically,
these medications either decrease the amount of aqueous
that is formed or increase the amount of aqueous that
is drained. Surgical treatment includes laser and more
traditional methods such as the creation of an artificial
drainage path (see Chapter 9, Glaucom a Surgery).
Another type of glaucoma worth mentioning is angle-
closure glaucoma. In this case, the drainage area in the
eye is blocked off by the iris itself (Figure 4-18). Pressure
rapidly builds up, sometimes to a very high level. If not
relieved, that pressure can cause irreversible optic nerve
damage in a matter of hours. The symptoms are often
profound but can be subtle: redness around the limbus
(edge of the cornea), hazy vision and halos around lights
(caused by corneal edema, defined previously), and pain.
The pain may be quite severe, to the point where the
patient experiences nausea and vomiting. An emergency
trip to the eye doctor or emergency room is essential.
O nce pressure is relieved by medications, a simple laser
procedure called an iridotomy can virtually ensure that
another attack will not occur (Figure 4-19).
64 Chapter 4 ...........................................
CATARACT
A cataract is progressive opacification of the crystal-
line lens; it is not a growth (Figure 4-20). There are several
ways to classify cataracts.
The most usual type of classification is by the age of
the patient when the cataract is first present. Congenital,
of course, means that the cataract existed at birth. But
by far the most usual type is the senile cataract. It’s not
a very flattering name, but it means that the cataract
appeared with advancing age. As we get older, the lens
lays down more layers, sort of like a tree growing rings.
The nucleus (core of the crystalline lens) becomes more
and more compacted and eventually begins to harden
and get cloudy.
Another classification system identifies which part of
the lens is cloudy. A cataract at the nucleus is sensibly
called a nuclear cataract. This is the most common type
of all the location-classified cataracts.
An alternative classification is by the cause, since
cataracts can be precipitated by trauma (immediately or
years later), systemic medications (most notably steroids),
systemic disorders (such as diabetes), or long-standing
eye inflammation. These are the so-called secondary
cataracts.
The only treatment for a cataract is to remove the
whole cataractous crystalline lens by surgery. The lens
is broken up using ultrasonic energy (sound waves), and
the tiny lens particles are suctioned out. (There are proto-
type lasers being developed to break up the cataract, but
they are not widely available, and the eye must still be
surgically opened.) Then a plastic intraocular lens (IO L)
replacement is inserted into the eye. The IO L restores the
focusing power of the eye that is lost when the crystalline
lens is removed. The surgery is almost always performed
as an outpatient procedure.
............................ what Can go wrong 65
The crystalline lens is encased in an envelope known
as the capsule. The back of this capsule can be polished
and left in place when the cataract is removed, and it
helps hold the IO L in position. O ccasionally, the capsule
membrane will cloud over (called capsular opacifica-
tion), obscuring vision (similar to a cataract). This is easily
remedied by making a hole in the capsule with a laser
(which passes through and does not damage the IO L).
The procedure is called a Nd:YAG capsulotomy (Figure
4-21).

OTHER ABNORMALITIES OF THE LENS

Trauma or disease may cause the lens to loosen from
the fibers that support it or to become totally dislocated
(Figure 4-22). A dislocated lens may not need to be
removed, but the resulting refractive error may be prob-
lematic. If the lens totally detaches and falls back into
the posterior segment of the eye (vitreous) and does not
cause inflammation or glaucoma, it might be left there.
However, a lens that falls forward will probably cause
enough trouble (especially elevated pressure) that it will
need to be removed surgically.

VITREOUS AND RETINA

Disorders
The vitreous is actually attached to the retina, thus
many physicians speak of them together using the term
vitreoretinal. Here are some of the more common vitreo-
retinal disorders:
* Diabetic retinopathy—a collection of retinal prob-
lems specific to diabetes. (See System ic Diseases/
Conditions and the Eye in this chapter.)
66 Chapter 4 ...........................................
* Hypertensive retinopathy—a collection of retinal
problems associated with high blood pressure. (See
System ic Diseases/ Conditions and the Eye in this
chapter.)
* Macular degeneration (MD)—a progressive dete-
rioration of the macula causing an incurable loss of
central vision. It may be related to ultraviolet expo-
sure or other entities (eg, smoking), but generally
heredity is named as the cause. The patient doesn’t
become blind but may lose enough central vision to
make reading impossible. Enough peripheral vision
remains to enable the patient to get around. The
most common type, the dry (nonexudative) form,
begins in the elderly (called age-related m acular
degeneration [AMD]) and progresses slowly. In the
wet (exudative) form, abnormal, leaky blood ves-
sels grow into the macular area. Laser is sometimes
used to treat this problem. In addition, several new
medications have been developed that seem to
slow the progression of wet AMD. With either type
of MD, many physicians recommend vitamins to
help keep the retina in optimal health.
* Retinal artery occlusion—situation in which an
artery supplying the retina becomes obstructed,
halting blood flow to the tissues. If the central
(main) artery is occluded, the patient experiences
a sudden, painless loss of vision in the eye. If
a branch artery is occluded, the patient gener-
ally loses vision in only the part of the visual field
served by that branch. An arterial occlusion is an
ocular emergency, as there is a small window of
time (under 2 hours if the central artery is involved)
to begin treatment before there is permanent dam-
age (and permanent vision loss) to the eye.
* Retinal detachment—situation in which the retina
separates and pulls away from the underlying tis-
sue, resulting in blind spots and/or a curtain com-
............................ what Can go wrong 67
ing over the vision, flashes of light, and/or floaters
(Figure 4-23). The pulling may result in a tear. Tears
and detachments are repaired by laser and/or con-
ventional surgery (see Chapter 9, Retinal Surgery),
but recovery depends on what part of the retina is
affected. Detachment may occur spontaneously or
be related to trauma.
* Retinal vein occlusion—situation in which a vein
leading out of the retina becomes obstructed, slow-
ing or halting blood drainage from the tissues. The
patient experiences a sudden, painless blurring of
vision in general, or only in the area of affected
visual field. The retina still has a blood supply to
bring oxygen in. However, because the symptoms
are similar, the patient should be triaged as a pos-
sible artery occlusion. In some cases, laser is used
to treat any resulting neovascularization. The con-
dition is often seen in hypertensive patients.
* Vitreous detachment—situation in which the vitre-
ous separates from the retina (Figure 4-24). Floaters
and flashes may occur as the vitreous pulls away. It
is usually a benign condition, but occasionally the
retreating vitreous pulls some retina with it, result-
ing in a retinal hole or detachment. The most com-
mon cause is age, but vitreous detachment may
also result from high myopia (because the entire
eyeball is longer than normal) or trauma. Usually,
no treatment is necessary.

Trauma
As described above, retinal detachment can result
from trauma, even a year or so after an injury. The most
common scenario is blunt trauma, where the concussive
force of the blow is transmitted through the eye and head.
Bleeding from retinal vessels into the vitreous may also
occur during trauma. It is possible for a projectile to pen-
68 Chapter 4 ...........................................
etrate the eye and lodge in the vitreous or retina. Whether
or not to remove the foreign body depends on its location
and composition. O rganic material (plant/animal matter)
poses a significant risk for infection, and some metals (eg,
iron and copper) are toxic to the eye. However, a tiny
piece of plastic or glass that is below the line of vision
might be left alone.

OPTIC NERVE
Disorders
Because of its proximity to the brain, optic nerve dis-
orders can be serious. They include:
* Atrophy—tissue degeneration of nerve fibers, which
results in blind spots in the vision and a loss of
color perception.
* Cupping—an abnormal enlargement of the depres-
sion at the head of the nerve where it enters the
eye, caused by high IO P. It is generally accompa-
nied by irreversible nerve damage.
* O ptic neuritis—inflammation of the optic nerve
often associated with multiple sclerosis. Symptoms
may include pain with eye movement, blurry vision
that comes and goes, and blind spots.
* Papilledema (disk edema)—swelling of the optic
nerve head caused by increased pressure inside the
cranium. Symptoms include blurring that comes
and goes, double vision (if cranial nerve VI is
affected), headache, and loss of peripheral vision.

Trauma
While the optic nerve is protected by the bony orbit and
situated at the back of the eye, it is not immune to injury.
Broken bones from the orbit might lacerate the nerve. If the
............................ what Can go wrong 69
nerve’s blood flow is interrupted or the nerve is squeezed
(compressed), damage may occur. This is called traum atic
optic neuropathy. Signs of optic nerve trauma include loss
of vision, a defect in the peripheral vision, loss of color
vision, and abnormal pupillary response to light.

THE RED EYE

O ne of the most important facets of ophthalmic care
is the evaluation of the red eye. This is because some
causes of redness are sight-threatening emergencies.
O thers are self-limiting or even benign. When speaking
of the red eye, we usually think of these three entities:
conjunctivitis, iritis (anterior uveitis), and angle-closure
glaucoma (Figure 4-25 and Table 4-1).
Triage is an initial assessment of signs and symptoms
(often over the phone) and designating a priority level
to the situation. These levels usually include emergent
(to be seen immediately), urgent (to be seen the same or
next day), and elective (or routine, to be seen in the next
1 to 2 weeks). In the case of the red eye, proper triage
can be critical.
Conjunctivitis (also known as “pink eye”) is an infec-
tion of the conjunctiva (the thin, skin-like layer over the
white of the eye [sclera] and lining the lids). In general,
it almost always falls into the elective category, because
most types are self-limiting. Conjunctivitis can be caused
by allergies, bacteria, and viruses. The pupil looks nor-
mal. There may be some itching and discomfort that
may necessitate bringing the patient in sooner rather
than later. (There are a few severe types that could fall
into the urgent category, but most cases are not urgent.)
There may be a discharge, ranging from watery to thick
purulent (pus-like) material. The redness is diffuse (seen
in a general pattern over the whole eye). Vision may be a
bit blurred if there is discharge.
70 Chapter 4 ...........................................
Iritis (anterior uveitis) is an inflammation inside the eye
and is considered urgent. It may occur spontaneously,
be triggered by trauma (including planned eye surgery),
or by inflammation elsewhere in the body. The pupil is
usually smaller than normal and may have ragged edges.
There is often pain and light sensitivity. The eye may
water. The redness is generally concentrated at the limbus
(where the cornea meets the white of the eye). There may
be mild blurring of the vision.
Angle-closure glaucoma is an emergency situation. In
this case, the iris (colored part of the eye) has blocked off
the area where the eye’s internal fluid (aqueous) drains
(see Figure 4-18). With the drainage area blocked, pres-
sure builds up quickly. This pressure is transmitted to the
back of the eye, where the optic nerve can be perma-
nently damaged. Angle-closure glaucoma is generally
triggered by situations in which the pupil dilates. (This
includes the use of dilating drops in the eye care office.)
O nset is generally quick. The affected pupil is larger than
the other, may be slightly oval-shaped, and does not react
to light. There is pain, ranging from an aching in or around
the eye, to severe headache with nausea and vomiting.
The pattern of redness may be thinly distributed, with
concentration around the limbus. There is no discharge
and generally no watering. Vision is blurred because the
cornea gets hazy and edematous (due to excess fluid). This
can also cause the patient to see halos around lights.

SYSTEMIC DISEASES/CONDITIONS
AND THE EYE
People often wonder what gout, high blood pressure,
or pregnancy has to do with their eyes. Truth is, almost
any systemic disease or condition can potentially have
an effect on some part of the eye. Here are some of the
major ones:
............................ what Can go wrong 71
* AIDS (acquired immunodeficiency syndrome)—
Kaposi’s sarcoma (a cancerous growth) on lids or
conjunctiva or in the orbit, increased incidence of
infection, dry eye, swelling of blood vessels in the
retina, oozing of retinal blood vessels, inflamma-
tion of the optic nerve, nerve palsies.
* Alcoholism—defects in the visual field from toxic
deterioration or inflammation of the optic nerve,
decreased color vision, cataracts, decreased vision,
nerve palsies (rare).
* Cancer—tumors may metastasize (spread) to eye
tissues; the choroid is the most common site.
Breast and lung carcinoma are the most common
tumors to metastasize to the eye.
* Child abuse (ie, victim of)—hemorrhages of the
conjunctiva and retina, bruising and swelling
around the eye, orbital fractures, dislocation of the
lens, retinal detachment.
* Diabetes—fluctuating vision, nerve palsies, growth
of abnormal blood vessels in the retina (eg, neo-
vascularization, which can obstruct vision if the
vessels grow into the macula—the area of fine,
central vision), bleeding and leaking of retinal
blood vessels, swelling of the macula (cystoid mac-
ular edema), retinal detachment, increased risk of
glaucoma and cataracts, optic nerve damage, and
blockage of retinal blood vessels.
* Down syndrome—short and slanted eye openings,
crossed eyes, nystagmus (dancing eyes), myo-
pia, cataract, keratoconus (cornea becomes cone-
shaped).
* Elderly—cataract, macular degeneration, dry eye,
increased incidence of glaucoma and infection.
* Gout—inflammation of conjunctiva, episclera, and
sclera; elevated eye pressure (may result in glau-
72 Chapter 4 ...........................................
coma); crystal formations of uric acid in the cornea
or sclera.
* Graves’ disease (thyroid eye disease)—protrusion of
the eye(s) (proptosis), inflammation of the extraocu-
lar muscles (EO Ms), exposure of the cornea.
* Herpes simplex type 1 (same virus that causes cold
sores)—rash on eyelids, redness, light sensitivity,
tearing, pain, decreased vision, corneal ulcers.
* Hypertension (high blood pressure)—retinal blood
vessels may narrow, twist, and degenerate; bleed-
ing and leakage from retinal blood vessels; swell-
ing of the retina; swelling of the optic nerve head;
small areas of dead retinal nerve fibers.
* Hypothyroidism (advanced)—lash loss (brows and
lids), keratoconus (cornea becomes cone-shaped),
cataracts, deterioration of the optic nerve.
* Leukemia—elevated IO P, compression of the optic
nerve, protrusion of the eye, leukemic cells clog-
ging the optic nerve, bleeding from retinal blood
vessels, swelling of the retina, inflammation of the
optic nerve.
* Multiple sclerosis—inflammation of the optic nerve,
weakness (paresis) or paralysis of the EO Ms.
* Myasthenia gravis—drooped eyelid, double vision
(diplopia), weakness of the EO Ms.
* Pregnancy—changes in vision, lid droop, dark
spots on lids.
* Premature birth—retinal damage due to oxygen
use, detached retina, retinal scars, stunted develop-
ment of retinal blood vessels.
* Rheumatoid arthritis—severe dry eye; inflamma-
tion of conjunctiva, sclera, episclera, and/or uvea
(iris, choroid, ciliary body); cataract secondary to
steroid treatment.
............................ what Can go wrong 73
* Shingles (Herpes zoster ophthalmicus)—blisters on
lids and/or cornea; inflammation of the conjunc-
tiva, sclera, uvea, and optic nerve; lid paralysis;
nerve palsies; corneal swelling; glaucoma due to
inflammation.
* Smoking—dry eye, disorders of the optic nerve,
chronic inflammation of the conjunctiva, increased
risk of cataract and macular degeneration, increased
damage to the optic nerve if the patient has glauco-
ma, increased risk of retinal disease in diabetics.
* Syphilis—lesion on eyelid, inflammation of the
cornea, abnormal pupil response, swelling of the
optic disk, deterioration of the optic nerve, weak-
ness of the EO Ms.
* Vitamin A deficiency—lid swelling, dry eyes, night
blindness, corneal ulcers and tissue death, retinal
disorders.

Figu re 4-1. Bleph a ritis. (Ph oto by Pa trick Ca rolin e, FCLSA.

Reprin ted fro m Gwin N. Overview of Ocular Disorders.
Th o ro fa re , NJ: SLACK In corpora ted; 19 9 9 .)
74 Chapter 4 ...........................................

Figu re 4 -2 . Cha la zio n o f upper lid (a t a rrow). (Ph o to co ur-

tesy of TD Lin dquist, MD, Ph D. Reprinted from Ha rgis-
Green sh ields L, Sim s L. Em ergencies in Eyecare. Th o ro fa re ,
NJ: SLACK, Inco rpo ra ted; 19 9 9 .)

Figu re 4-3. Ectro pio n . (Ph oto co urtesy of EL Ha rgis, MD.

Reprin ted fro m Ha rgis-Green sh ields L, Sim s L. Em ergen-
cies in Eyecare. Th oro fa re, NJ: SLACK In co rpo ra ted; 19 9 9.)
............................ what Can go wrong 75

Figu re 4 -4 . En tro pio n . (Ph o to co urtesy o f EL Ha rgis, MD.

Reprin ted fro m Ha rgis-Green sh ields L, Sim s L. Em ergencies
in Eyecare. Tho ro fa re, NJ: SLACK Inco rpo ra ted; 19 9 9 .)

Figu re 4-5. Ptosis, right upper lid. (Ph oto fro m the a rch ives
of Prem ier Medica l Eye Gro up, ta ken by Jo hn Ca rswe ll.
Reprin ted fro m Gwin N. Overview of Ocular Disorders.
Th o ro fa re , NJ: SLACK In corpora ted; 19 9 9 .)
76 Chapter 4 ...........................................
Figure 4-6. Trichia sis.
(Ph o to co urte sy o f
Ma rk S. Bro wn , MD
a n d www.EyePla stics.
com .)

Figu re 4 -7. Exo ph th a lm us, righ t eye. (Dra win g by Ho lly

Hess Sm ith . Re prin te d with perm issio n fro m Ga yto n
JL, Ledfo rd JK. The Crystal Clear Guide to Sight for Life.
La n ca ster, PA: Sta rburst Publishe rs; 19 9 6 .)

Figu re 4 -8 . Orbita l ce llulitis. (Ph oto co urtesy o f Pa ula

Pa rker, COMT. Reprin te d fro m Ha rgis-Green sh ields L,
Sim s L. Em ergencies in Eyecare. Th orofa re, NJ: SLACK
In co rpo ra ted; 19 9 9 .)
............................ what Can go wrong 77

Figu re 4-9. Con jun ctivitis. (Ph oto co urtesy of TD Lindquist,

MD, Ph D. Reprin ted fro m Ha rgis-Gre enshields L, Sim s L.
Em ergencies in Eyecare. Th o ro fa re, NJ: SLACK In co rpo ra ted;
19 9 9 .)

Figu re 4 -10 . Pin guecula . (Ph o to by Va l Sa n ders, CRA, COT.

Reprin ted fro m Ledfo rd JK, Sa n ders VN. The Slit Lam p
Prim er. Tho ro fa re, NJ: SLACK Inco rpo ra ted; 19 9 8 .)
78 Chapter 4 ...........................................

Figu re 4 -11. Pterygium . (Ph oto by Va l Sa n ders, CRA, COT.

Reprin ted fro m Le dfo rd JK, Sa nders VN. The Slit Lam p
Prim er. Tho ro fa re, NJ: SLACK Inco rpo ra ted; 19 9 8 .)

Figure 4 -12 . Subco n junctiva l h em o rrh a ge. (Ph o to

by To dd Ho stette r, COMT, CRA, FCLSA. Reprin ted
fro m Gwin N. Overview of Ocular Disorders.
Th o ro fa re , NJ: SLACK In co rpo ra te d; 19 9 9 .)
............................ what Can go wrong 79

Figu re 4-13 . Co rn ea l edem a . (Ph oto by Va l Sa nders, CRA,

COT. Reprin ted fro m Ledfo rd JK, Sa n ders VN. The Slit Lam p
Prim er. Tho ro fa re, NJ: SLACK Inco rpo ra ted; 19 9 8 .)

Figu re 4-14 . Co rn ea l a bra sio n; n o te fin e lin ea r scra tch es

in cen ter. (Ph o to by Va l Sa n de rs, CRA, COT. Reprin te d fro m
Ledfo rd JK, Sa n ders VN. The Slit Lam p Prim er. Th o ro fa re ,
NJ: SLACK In co rpo ra ted; 19 9 8 .)
80 Chapter 4 ...........................................

Figu re 4 -15 . Hyph em a ; blo od in th e a n terio r cha m ber

(a rro w). (Pho to co urtesy o f Pa ula Pa rker, COMT. Reprin -
ted fro m Ha rgis-Green shields L, Sim s L. Em ergencies in
Eyecare. Th o ro fa re , NJ: SLACK In co rpora te d; 19 9 9 .)

Figu re 4 -16 . Hypo pyo n. (Ph o to by Va l Sa n ders, CRA, COT.

Reprin ted fro m Ledfo rd JK, Sa n ders VN. The Slit Lam p
Prim er. Tho ro fa re, NJ: SLACK Inco rpo ra ted; 19 9 8 .)
............................ what Can go wrong 81

Cornea Lens

Iris Zonules

Anterior Ciliary
chamber processes
angle

Figu re 4 -17. Sch em a tic sh o win g th e flow o f a queo us

in side th e e ye. (Dra win g by Lin da Sim s, COT. Reprin ted
fro m Ha rgis-Gre enshields L, Sim s L. Em ergencies in Eyecare.
Tho ro fa re, NJ: SLACK Inco rpo ra ted; 19 9 9 .)

Lens

Cornea

Iris

Angle

Figure 4 -18 . Sch em a tic o f a n gle-clo sure gla ucom a . In th is

ca se, co n ta ct between th e iris a n d len s blo cks a que o us
flo w. Th e iris ba se bulges fo rwa rd, o bstructin g th e a n gle.
(Dra win g by Ho lly He ss Sm ith . Reprin ted fro m Ga yto n
JL, Ledfo rd JK. The Crystal Clear Guide to Sight for Life.
La nca ster, PA: Sta rburst Publish ers; 19 9 6.)
82 Chapter 4 ...........................................

Iridotomy opening

Figu re 4-19 . A la ser iridoto my crea tes a n o pen in g in the

iris, preven tin g pressure build-up a n d th us a n o th er a n gle-
clo sure a tta ck. (Dra win g by Ho lly Hess Sm ith . Reprin ted
fro m Ga yto n JL, Ledfo rd JK. The Crystal Clear Guide to Sight
for Life. La n ca ster, PA: Sta rburst Publishers; 19 9 6 .)

Figu re 4 -2 0 . Nuclea r sclero tic ca ta ra ct. No tice cen tra l

clo ude d a re a . (Ph o to fro m th e a rch ive s o f Pre m ie r
Medica l Eye Gro up, ta ken by Jo h n Ca rswell. Reprin ted
from Gwin N. Overview of Ocular Disorders. Th o ro fa re, NJ:
SLACK In co rpora ted; 19 9 9.)
 ............................ what Can go wrong 83

Figu re 4 -21. Ca psulo to my, a n o pen in g m a de in th e cen -

ter o f th e clo udy ca psule in o rde r to restore clea r visio n
(edges of openin g a t a rrows). (Ph o to by Va l Sa n ders, CRA,
COT. Reprin ted fro m Ledfo rd JK, Sa n de rs VN. The Slit Lam p
Prim er. Th o ro fa re, NJ: SLACK In co rpo ra ted; 19 9 8 .)

Figu re 4 -2 2. Dislo ca tio n o f th e le n s. Th e edge o f th e

crysta llin e len s (a rro w) is visible th ro ugh th e pupil. (Ph o to
co urtesy o f Pa ula Pa rker, COMT. Reprinted fro m Ha rgis-
Green sh ields L, Sim s L. Em ergencies in Eyecare. Th o rofa re,
NJ: SLACK Inco rpo ra ted; 19 9 9 .)
84 Chapter 4 ...........................................

Detached retina

Figu re 4 -2 3 . Re tin a l de ta ch m e n t. (Dra win g by Ho lly

Hess Sm ith. Reprin ted from Ga yton JL, Ledfo rd JK. The
Crystal Clear Guide to Sight for Life. La n ca ster, PA: Sta rburst
Publish ers; 19 9 6 .)

Detached vitreous

Retina

Figu re 4 -2 4 . Vitreo us deta ch m en t. (Dra win g by Ho lly

Hess Sm ith . Reprin ted fro m Ga yto n JL, Ledford JK. The
Crystal Clear Guide to Sight for Life. La n ca ster, PA: Sta rburst
Publish ers; 19 9 6.)
............................ what Can go wrong 85

Conjunctivitis Iritis

Angle-closure glaucoma

Figu re 4 -2 5 . Th e red e ye, com pa rin g co n jun ctivitis, iritis,

a n d a n gle-clo sure gla uco m a . (Dra win g by Linda Sim s.
Reprinte d from Ha rgis-Green sh ields L, Sim s L. Em ergencies
in Eyecare. Th oro fa re, NJ: SLACK In corpo ra ted; 19 9 9.)
 T a b l e 4 - 1
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 Chapter 5

Crazy Eyes, Lazy Eyes, and

Getting on Your Nerves
(St rabismus, Amblyopia,
and Neurology)

CRAZY EYES (STRABISMUS)

There are six extraocular muscles (EO Ms) attached
to each eye, giving a full range of movement (Figure 5-1
and Table 5-1). Each EO M is supplied by one of three
cranial nerves. This innervation causes the eyes to be
yoked (paired) (eg, when one eye moves to the right, the
other does also). In addition, the brain “locks” the slightly
different images supplied by each eye. This helps hold the
eyes in position.

89
90 Chapter 5 ...........................................

Figu re 5 -1. Sch em a tic o f th e extra o cula r m uscles (EOMs).

(Ada pte d fro m a dra win g by Ho lly He ss Sm ith . Re prin ted
with perm issio n fro m Ga yto n JL, Ledfo rd JK. The Crystal
Clear Guide to Sight for Life. La n ca ste r, PA: Sta rburst
Publishers; 19 9 6 .)

Table 5-1
Th e Extra ocula r Muscles
Cranial Nerve
Muscle Action(s): 1º/2º/3º Innervation
Med ial rectu s Lateral m ovem ent only III
(tow ard nose)
Lateral rectu s Lateral m ovem ent only VI
(tow ard ear)
Su p erior rectu s Up -gaze/ rotate tow ard III
nose/ lateral (tow ard nose)
Inferior rectu s Dow n-gaze/ rotate tow ard III
ear/ lateral (tow ard nose)
Su p erior obliqu e Rotate tow ard nose/ d ow n- IV
gaze/ lateral (tow ard ear)
Inferior obliqu e Rotate tow ard ear/ u p -gaze/ III
lateral (tow ard ear)
Primary action refers to the main effect that particular muscle has
on eye rotation; the secondary and tertiary actions are of lesser effect.
M uscle action depends on the orientation (direction) of the eye.
........................... Crazy Eyes, Lazy Eyes 91
When all is as it should be—muscles, nerves, and brain
working together to keep the eyes straight—orthophoria
exists. (O rtho means straight.) But this is not a perfect
world. The proper term for misaligned eyes is strabism us.
If an eye is turned constantly (manifest), we call it a
tropia. We can further describe a tropia by indicating
the direction of the deviated eye (Figure 5-2): exotropia
(turned out), esotropia (turned in), hypotropia (turned
down), or hypertropia (turned up). Sometimes a tropia is
so large that it is obvious when you look at the patient,
as in Figure 5-2B through D. In other cases it might be
subtle, spotted only by someone experienced in the field
or by testing (see Chapter 7, Hirschberg Test and Chapter
8, Prism and Cover Test).
In some instances the eyes hold straight unless fusion
(where the eyes are “locked” into working together) is
interrupted. The eye turn is only brought out through
sensory deprivation (ie, covering one eye). Such a devia-
tion is termed a phoria. A phoria is described by the
direction of the deviation, in the same way as a tropia.
Thus, if an eye drifts in when covered, the condition is
called esophoria, an outward drift is exophoria, upward
is hyperphoria, and downward is hypophoria.
Tropias may be corrected by surgery (see Chapter 9,
Strabismus Surgery). O ne reason to do this is cosmetic, but
other reasons are more functional (ie, to attempt to achieve
stereopsis [see Chapter 2, Binocular Vision] or to avoid/
correct amblyopia [see next section]). Phorias are rarely
corrected surgically because a person using both eyes
simultaneously is usually able to hold the eyes straight.

LAZY EYES (AMBLYOPIA)

Am blyopia is the technical term for “lazy eye.” (Patients,
however, often use the term “lazy eye” incorrectly, mean-
ing an eye that drifts [ie, strabismus].) Amblyopia is sub-
normal vision that develops during childhood.
92 Chapter 5 ...........................................

Figu re 5 -2 . Po sitio n s of the e ye in stra bism us. A. Eye s a re

stra igh t (o rth o ph o ria ). B. Righ t eye turn ed in (righ t eso tro -
pia ). C. Righ t eye turn ed up (righ t hypertro pia ). D. Righ t
e ye turn ed o ut (righ t exo tro pia ). E. Righ t eye turn ed do wn
(righ t hypotropia ; ho wever, co n ventio n ca lls fo r la belin g
up a n d do wn turn s by th e elevated eye, so th is wo uld be
pro perly term ed left hypertro pia ). (Dra win g by Ho lly Hess
Sm ith. Reprin ted with perm issio n fro m Ga yto n JL, Ledfo rd
JK. The Crystal Clear Guide to Sight for Life. La n ca ster, PA:
Sta rburst Publishers; 19 9 6 .)
........................... Crazy Eyes, Lazy Eyes 93
For good vision to develop, not only must the eye be
capable of good vision, but it must “learn” to see. In ways
that we don't understand, this critical connection takes
place in the brain rather than the eye. If the eye doesn't
learn to see by age 7 or 8, then it never will. This does not
mean that the eye is blind, just that the vision is below
normal—although it m ay be to the point of legal blind-
ness. This “age limit” is also why vision screening prior to
beginning school is so essential.
There are several causes of amblyopia. It may occur
because of congenital strabismus, where one eye is used
exclusively and the other turns in or out (or up or down).
In this case, the “unused” eye never learns to see, and
amblyopia develops. If the weaker eye is used some of the
time, the amblyopia may not be as dense (ie, severe).
O ther causes are situations in which one eye is effec-
tively covered—by a severely drooped lid or a congenital
cataract, for example. If such a problem is not detected
and corrected early on, amblyopia will develop. Another
case is where one eye has a significant refractive error that
is not corrected. In all cases, the brain ignores the blurred
vision from the weaker eye and amblyopia occurs.
Before treating the amblyopia, any underlying cause is
treated, such as strabismus surgery to straighten the eyes,
prescribing glasses, removing a cataract, etc. Treatment
for amblyopia must begin, in general, before the age of
8. The strong eye is patched, forcing the amblyopic eye
to “learn” to see. The younger the patient, the quicker this
process seems to be. With treatment, visual recovery may
be all the way to 20/20.

NEUROLOGICAL CONDITIONS
While the nerve we usually think of as being associ-
ated with the eye is the optic nerve, when we speak of
neurological conditions of the eye and lids, we mean
cranial nerves other than the optic nerve (Table 5-2).
94 Chapter 5 ...........................................
Table 5-2
Th e Cra n ia l Ne rves
Cranial Motor/
Nerve Nam e Sensory Function
I Olfactory Sensory Sm ell
II Op tic Sensory Sight
III Ocu lom otor Motor Movem ent of
eye (MR, SR, IR,
and IO), pu pil
constriction,
accom m od ation,
and u pp er lid
elevation
IV Trochlear Motor Movem ent of eye
(SO)
V Trigem inal Mixed Sensation of touch
in face, nose,
forehead, temple,
tongue, and eye;
innervation for
chewing

VI Abd u cens Motor Movem ent of eye

(LR)
VII Facial Mixed Reflex tearing,
facial exp ression,
som e taste, and
blinking

VIII Vestibu lo- Sensory H earing and

cochlear equ ilibriu m
(acou stic
nerve)
IX Glossop har- Mixed Taste and sw al-
yngeal low ing

continued
........................... Crazy Eyes, Lazy Eyes 95
Table 5-2 continued
Th e Cra n ia l Ne rves
Cranial Motor/
Nerve Nam e Sensory Function
X Vagu s Mixed Taste, heart rate,
breathing, d iges-
tion, and voice
XI Sp inal Motor Innervention of
accessory neck and shoul-
der muscles,
provides posture
and rotation of
head
XII H yp oglossal Motor Tongu e m ove-
m ent
MR=m ed ial rectu s mu scle; SR=su p erior rectu s mu scle; IR=inferior rectu s
mu scle; IO=inferior oblique m uscle; SO=superior oblique m uscle; and
LR=lateral rectu s mu scle.

A dapted from Lens A , N emeth SC, Ledford JK. Ocu lar Anatom y and
Physiology. 2nd ed. Thorofare, N J: SLA CK Incorporated; 2008.

Table 5-3 shows disorders of the cranial nerves that may

affect the eye.
Neurological conditions also include defects of the
visual field that affect the patient’s peripheral and
central vision. You might want to review Chapter 2,
Visual Pathway and Visual Field Defects. The visual field
may be tested informally by confrontation (Chapter
7, Confrontation Fields) or more formally tested and
mapped out by perimetry (Chapter 8, Visual Field
Testing). The purpose of visual field testing is to detect
and measure any defects.
96 Chapter 5 ...........................................
Table 5-3
Neurolo gica l Co n ditio n s
Clinical
Entity Features Notes
Fou rth Diagonal d ouble Also called trochlear
nerve p alsy vision (m ay nerve p alsy. May
resolve w ith head be associated w ith
tilted tow ard one head inju ry, m u ltiple
should er). sclerosis, m yasthenia
gravis, tu m or, aneu-
rysm , or d iabetes.
Treatm ent: p atch-
ing, p rism , and / or
su rgery (after 6
m onths).

N ystagm u s Blu rred or “m ov- Involu ntary, rhyth-

ing” vision, head m ic m ovem ents of
tilt or tu rn, am bly- one or both eyes.
opia. There are nearly 40
types. May be con-
genital or acqu ired .
Movem ent m ay
d ecrease or stop in
one p osition of gaze.

Seventh Partial or fu ll Also called Bell’s

nerve p alsy facial p aralysis on p alsy, facial palsy,
the affected sid e, facial nerve p alsy.
inability to close Affects orbicu -
eye on affected laris m u scle. Cau se
sid e. u nknow n. N o treat-
m ent except for cor-
neal exp osu re and
d ryness. Recovery
varies.
continued
........................... Crazy Eyes, Lazy Eyes 97
Table 5-3 continued
Neurolo gica l Co n ditio n s
Clinical
Entity Features Notes
Sixth nerve H orizontal d ou ble Also called abd u cens
palsy vision (m ay resolve nerve p alsy. May be
w ith head tu rn to associated w ith head
right or left). inju ry, hyp ertension,
m igraine, arterioscle-
rosis, viral infection,
d iabetes, and others.
Treatm ent: patching,
p rism , and / or surgery
(after 6 m onths).
Strabism u s Abnorm al eye p osi- Misalignm ent of eyes
tion. cau sed by p roblem
w ith EOMs or nerves.
Third nerve Dou ble vision Also called oculomo-
palsy (m ay resolve in tor nerve palsy. Can
right or left gaze), affect the superior
ptosis, enlarged rectus, inferior rectus,
pu p il, cyclop legia. medial rectus, inferior
oblique, and levator
muscles. May be asso-
ciated w ith diabetes,
hypertension, mul-
tiple sclerosis, head
injury, aneurysm, viral
infection. Treatment:
prisms, patching,
and/ or surgery (after
6 months).

A dapted from Ledford JK, ed. H and book of Clinical Ophthalm ology for
Eyecare Professionals. Thorofare, N J: SLA CK Incorporated; 2001.
 Chapter 6

What's Going On?

(Ocular Symptoms and
Potent ial Diagnoses)

Most of the material in this chapter is taken from The

Crystal Clear Guide to Sight for Life (Starburst Publishers,
Lancaster, PA), and has been reprinted with permission
of the publisher.
This chapter is divided into two sections. Section O ne
discusses symptoms of a visual nature. Section Two lists
physical symptoms. Symptoms are listed alphabetically.
If you don’t find a particular item, try wording it a differ-
ent way. (For example, “flashing lights” is listed as “light
flashes.”) It is important to note that any symptom may
have any number of potential diagnoses; some are more
likely than others. It is up to the eye care practitioner to
determine each patient’s diagnosis and care.

99
100 Chapter 6 ...........................................
SECTION ONE: VISUAL SYMPTOMS
* Blurry vision. Possible causes: change in glasses
prescription, cataract, blood sugar fluctuations
(diabetes), fatigue, hunger, large floater, medica-
tion side effect, angle-closure glaucoma, retinal
detachment, inflammation inside the eye, dry eyes,
hormonal disorders, migraine headaches, heart
failure, arteriosclerosis, alcohol intoxication.
* Color vision, change in. Possible causes: cataracts,
retinal or macular disease, medication side effect,
glaucoma.
* Curtain over the vision. Possible causes: vitreous
detachment, retinal detachment, hemorrhage.
* Distorted vision. Possible causes: macular degen-
eration, astigmatism, inflammation inside the eye,
retinal detachment or hole, cataract, macular
edema.
* Double vision (diplopia). Possible causes: paralysis
of one or more of the muscles that move the eye,
misaligned glasses, cataract, dislocation of an intra-
ocular lens (IO L), head trauma, dislocation of the
crystalline lens, fluid in the macula, fracture of the
bones around the eye, large difference in glasses
correction between the eyes, stroke, multiple scle-
rosis, thyroid trouble, diabetes, giant cell arteritis,
myasthenia gravis.
* Fluctuating vision (metamorphopsia). Possible
causes: diabetic blood sugar fluctuations, cataracts,
ointment or matter in the eye, dry eyes, blood ves-
sel disease.
* Glare. Possible causes: cataract, corneal scar or
dystrophy, capsule opacity after cataract surgery,
drug reaction.
............................... What's Going On? 101
* Halos (around lights). Possible causes: cataract,
mucus on the cornea, corneal edema, corneal scar,
drug reaction, exposure to intense light, dislocated
IO L, angle-closure glaucoma.
* Improvement of near vision (patient notices that
he doesn’t need reading glasses anymore). Possible
cause: cataract (myopic shift), cloudy capsule after
cataract surgery.
* Light flashes (patient perceives flashes of light,
often when in the dark and moving the eye from
one position to another). Possible causes: vitreous
detachment, retinal detachment or tear, migraine
headache, ocular migraine (without headache),
concussion.
* Light sensitivity (photophobia). Possible causes:
inflammation of cornea, inflammation inside the
eye, dilated pupil, drug reaction, migraine.
* Loss of central vision. Possible causes: macular
degeneration, central retinal artery or vein occlu-
sion, retinal tear or hole, migraine, stroke, drug
reaction, nutritional deficiency, optic neuritis, fluid
in the macula.
* Loss of depth perception. Possible causes: cataract,
difference in vision between the two eyes, loss of
vision in one eye.
* Loss of near vision. Possible causes: increasing age,
need for change in glasses, focusing spasms (in
young people), cataract, drug reaction.
* Loss of side (peripheral) vision. Possible causes:
retinal detachment, glaucoma, pituitary tumor,
stroke, retinitis pigmentosa.
* Loss of upper field of vision. Possible causes:
drooping eyelid, retinal detachment, inflammation
of the optic nerve.
102 Chapter 6 ...........................................
* Loss of vision (gradual). Possible causes: need to
change glasses, cataract, diabetes, vitamin toxicity,
drug reaction, hereditary retinal disorders.
* Loss of vision (sudden). Possible causes: retinal
detachment, hemorrhage inside the eye, blockage
of vein or artery inside eye, angle-closure glau-
coma, optic nerve trauma, ocular drug reaction,
temporal arteritis, stroke, brain injury, psychologi-
cal.
* Poor distant vision (near vision remains good).
Possible causes: uncorrected refractive error, cata-
ract.
* Poor near vision (distant vision remains good).
Possible causes: uncorrected refractive error, pres-
byopia, macular degeneration.
* Poor night vision. Possible causes: cataract, retinitis
pigmentosa, malnutrition (vitamin A deficiency),
advanced glaucoma.
* Specks before the eyes/floaters (clumps or chains of
protein and cells in the vitreous [jelly] of the eye
cast a shadow on the retina, causing the appear-
ance of specks, cobwebs, hairs, or bugs; they scoot
around as the patient looks from one direction to
another). Possible causes: vitreous detachment,
retinal detachment, retinal hemorrhage, vitreous
debris, liquification of vitreous.
* Starbursts from headlights. Possible causes: uncor-
rected astigmatism, cataract, capsule opacity after
cataract surgery, displaced IO L, corneal scar, angle-
closure glaucoma.
* Uncomfortable vision (asthenopia). Possib le
causes: eye strain, need glasses changed, glasses
need adjusting, incorrect prescription, eye muscle
imbalance.
............................... What's Going On? 103
SECTION TWO: PHYSICAL SYMPTOMS
* Burning. Possible causes: dry eyes, staring (forget-
ting to blink while reading or watching TV), allergy,
drug reaction.
* Burst blood vessel. Possible causes: straining (heavy
lifting, hard coughing or sneezing, constipation,
heaving), rubbing the eye, high blood pressure,
injury, blood disorder, vitamin C deficiency.
* Crossed/drifting eye. Possible causes: childhood
strabismus, muscle weakness, nerve palsy, head
injury.
* Crusting lids. Possible causes: low-grade lid infec-
tion (blepharitis), infection, diabetes, seborrhea,
rosacea.
* Difference in pupil size (anisocoria). Possible
causes: congenital (born with it), surgery, trauma,
inflammation inside the eye, angle-closure glau-
coma, drug reaction, optic nerve damage, Horner’s
syndrome.
* Headaches. Possible causes: sinus problems, eye
muscle imbalance, migraine, drug reaction, shin-
gles, high blood pressure, angle-closure glau-
coma.
* Itching. Possible causes: allergies (hay fever), drug
reaction, contact allergy (to make-up, lotions, etc).
* Jumping eyelid. Possible causes: excessive caffeine,
fatigue, stress, drug reaction, Parkinson’s disease,
response to eye injury or pain.
* Lid droop. Possible causes: birth defect, heredity,
loss of muscle tone, redundant skin of upper lids,
growth, injury that has damaged lid muscles, nerve
paralysis, muscular dystrophy, myasthenia gravis,
response to eye injury.
104 Chapter 6 ...........................................
* Matter/discharge. Possible causes: infection, aller-
gy, dry eye.
* Pain. Possible causes: dry eye, foreign body, eye
infection, corneal abrasion, inflammation inside
the eye, recurrent erosion syndrome, ultraviolet
burn, angle-closure glaucoma, drug reaction.
* Pressure sensation behind the eyes. Possible causes:
sinus problems, misaligned glasses, fatigue, stress,
tension, headache.
* Protrusion of the eye(s). Possible causes: thyroid
(Graves’ disease), drooping lid (lid droop of one
eye can make it look as if the other eye is pro-
truding), growth behind the eye, inflammation or
infection behind the eye (as in the sinuses), drug or
vitamin toxicity.
* Pulling sensation. Possible causes: misaligned
glasses, incorrect glasses prescription.
* Rash. Possible causes: allergic reaction to drugs or
chemicals, poison (ivy, oak, etc), shingles.
* Redness. Possible causes: allergic reaction, hay
fever and asthma, dryness, eye infection, burst
blood vessel, iritis (inflammation of iris), angle-clo-
sure glaucoma. (See also Chapter 4, The Red Eye.)
* Swelling. Possible causes: allergic reaction (hay
fever), contact allergy (make-up, lotions, etc),
fluid retention, stye, chalazion, orbital cellulitis,
redundant skin of upper lids, injury, drug reaction,
malnutrition.
* Watery eyes. Possible causes in the adult: dry eye,
allergy, infection, blocked tear duct, injury, drug
reaction. Possible causes in the infant: infection,
blocked tear duct, congenital glaucoma, injury.
 Chapter 7

Checking it Out
(Basic Examinat ion Techniques
and Pat ient Services)

HISTORY
Taking the history is the most basic of skills in any
field of medicine. It is also one of the most important,
because it determines the direction of the examination,
tests to be done, whether or not the correct diagnosis is
arrived at, the treatment plan, and even how the patient
will be billed.
History taking involves gathering the information that
the practitioner needs in order to make a diagnosis. At
a minimum, this generally includes the chief complaint
and the patient’s medical history.

107
108 Chapter 7 ...........................................
The chief com plaint is the main reason why the patient
came to the office. O btaining this information usually
involves the patient relating a set of symptoms. O nce the
symptoms are recorded, the patient is asked additional,
specific questions:
* How long has this been going on?
* Did it start suddenly or gradually?
* How severe is it?
* Is it constant, or does it come and go?
* Does anything else occur when you have this
symptom?
* Does it seem to be associated with any specific
activity?
O ther questions are asked, as appropriate:
* O ne eye, or both?
* Have you tried treating it yourself? How? Did that
seem to help?
* What seems to aggravate the problem?
* Does it seem to be getting better? Worse?
* Is there any pain or discomfort? Describe that.
Exactly where does it hurt?
* Is there any discharge? Describe it.
Familiarity with ocular symptoms is helpful in choosing
appropriate questions. For example, if the patient com-
plains of floaters, she may also have experienced flashes
of light. Chapter 6 gives details as to what symptoms may
go with what disorders. This information is also helpful
in triage, where the determination of what problems are
emergencies, urgent, or routine must be made.
The patient’s m edical history lists all the medica-
tions he is taking, including over-the-counter medicines,
patches, and injections (such as monthly allergy shots).
Some women may forget to tell you they are taking hor-
mones, and some men may forget that they are taking
.................................... Checking it Out 109
aspirin to thin their blood. Any drugs to which the patient
is allergic are also noted, as well as any major medical
disorders, including diabetes, hypertension, thyroid dys-
function, heart condition, etc.
The patient’s social history involves her living situa-
tion, hobbies, habits, etc. This could include whether or
not the patient smokes and lives alone or with someone.
Hobbies and profession are important to note because
they indicate various vision needs.
The fam ily history incorporates medical problems that
can run in the family such as diabetes, hypertension,
glaucoma, cataracts, and macular degeneration.
There are several key points for taking the history:
1. The history need not include every detail given by
the patient. The historian should listen before writ-
ing anything.
2. Corrections should be made by drawing a single
line through the mistake, writing “error,” and the
initials of the person taking the history. Using
Wite-O ut™ (BIC Corp, Milford, CT) or obliterating
anything in the patient’s chart is strictly forbidden.
3. The patient gives information in strictest confidence.
No one may discuss the patient’s case with anyone
except another person involved in that patient’s
care, or as given permission by the patient.
4. Simple questions and simple terms should be
used.

VISUAL ACUITY
Testing the patient’s visual acuity is the single most
important evaluation in eye care. It is the vital sign of
the eye. You’ve probably heard the term “20/20.” The
numerator (top number) stands for the distance from the
patient to the eye chart in feet. The denominator (bottom
number) stands for the smallest size of letters or figures
110 Chapter 7 ...........................................
(optotypes) that the patient can correctly identify. Thus,
the higher the denominator of the patient’s recorded
vision, the worse the eyesight.
20/20 is the size of the optotype that the “normal”
person can see from 20 feet away. If Patient A’s vision is
20/50, then she sees from 20 feet (the standard test dis-
tance) what “normal” Patient B can see from 50 feet away.
In other words, the smallest optotypes that Patient A can
correctly identify are larger than the 20/20 letters. In fact,
Patient B could correctly identify the 20/50 letters from
50 feet away. But Patient A can’t see the 20/50 figures if
she backs away more than 20 feet.
To test distance visual acuity, first the proper optotype
must be selected. Letters are preferred, but not everyone
knows letters. (However, just because a person is illiterate
doesn’t mean he or she doesn’t know letters.) Snellen acu-
ity (the standard eye chart) is the most common method
to test vision. Numbers may be used instead. For children
or others who can’t recognize letters or numbers, other
optotypes may be chosen if available. These include the
tumbling E (a letter E that is turned right, left, up, or down)
and the broken rings (the Landolt C chart where the letter
C is turned right, left, up, or down). The patient is asked
to identify the E’s or C’s orientation. Another option is
pictures (Allen cards).
Distance acuity is measured one eye at a time, both
with and without correction. A solid cover such as an
occluder should be used, since the patient might peek
through his fingers if using his hand. The size of the small-
est letters (indicated on the chart itself) that the patient
reads correctly are recorded. If the patient can then iden-
tify a few letters on the next row, this is written in as an
addition. For example, the patient reads all of the 20/50
letters correctly and identifies two of the 20/40 letters.
This is written as 20/50 +2 .
If the patient cannot identify the largest letter on the
chart (often a 20/400 E), she is asked to walk toward the
chart until she can recognize it. The distance from the
.................................... Checking it Out 111
chart where identification occurred is recorded and used
as the first number (ie, test distance) of the acuity fraction.
For example, the patient can see the 20/400 figure from
10 feet away. This equals 10/400. This could be converted
to 20/800 if desired.
It may not be possible to walk the patient closer to the
chart if a mirror or viewer system is used. In this case,
a card with an optotype of known size may be brought
closer to the patient until she can correctly identify it. The
numerator is the distance where the figure is first seen (as
noted above), and the second is the optotype’s size. For
example, if a 20/200 optotype is recognized at 5 feet, the
acuity would be 5/200 (or 20/800).
Alternately, the patient is asked to identify the number
of fingers held up by the examiner. (It is easiest to vary
between one, two, and five fingers.) The examiner starts
from about 1 foot from the patient and backs away until
he does not answer correctly. The maximum distance at
which the patient could accurately respond is recorded.
The test may be repeated several times at that distance
to make sure he wasn’t guessing. An example of proper
documentation would be “Counts fingers at 11 feet.”
If the patient cannot count fingers from several inches
away, the maximum distance at which he can correctly
tell whether or not the examiner’s hand is moving is
ascertained. An example would be “Hand motions at 16
inches.”
Failing hand motion, a penlight is used to find out if
the patient can tell whether or not the light is shining in
his eye. If he answers correctly, the light is directed from
different quadrants and the patient is asked if he can
identify the direction from which the light is shining. If
so, this is documented as light projection. If he can only
tell if the light is shining in his eye or not, but cannot tell
the direction, then he has light perception. A patient who
cannot see the light at all has a recorded vision of no light
perception (abbreviated as NLP).
112 Chapter 7 ...........................................
Near vision is checked with a hand-held eye chart
from 14 to 16 inches away. Each eye is checked, both
with and without correction. Like distance acuity, the last
line read correctly is recorded. Near cards usually have
20/20 equivalents printed right on them.
If a patient’s distant vision is not 20/20, it is useful to
perform a pinhole vision test. Just like it sounds, this is
the patient’s vision taken while looking through a tiny
hole (1 to 2 mm). A pinhole can be made by piercing an
index card, or one can be ordered from an optical dealer.
Each eye is checked and the results recorded as above.
If the patient’s vision is poor because of an uncorrected
refractive error, the pinhole will improve it. This method
works because the pinhole eliminates scattered light
rays, admitting only the straight-ahead light rays from the
chart. If the pinhole vision is not better than the original
measurement, the subnormal vision is most likely due
to ocular pathology. When recording pinhole vision, the
designation PH should be used (eg, PH: 20/30). The pin-
hole may be used at near as well, if desired.
Improper documentation can render the visual acu-
ity measurement unusable. The examiner m ust indicate
which eye, whether distance or near, and whether cor-
rected or uncorrected.

PUPIL EVALUATION
The pupil evaluation is probably the second most
important examination skill you need, because it pro-
vides information about the nervous system as well as the
eye. Pupil size is controlled by the dual-muscled iris (col-
ored part of the eye). The dilator muscle is responsible for
pupil enlargement, and the sphincter muscle makes the
pupil smaller. These two muscles are supplied by “oppo-
site” sets of nerves in the autonomic nervous system (an
autonomic response is automatic; we have no conscious
control over it).
.................................... Checking it Out 113
The first thing to notice about the pupils is their shape.
A penlight is used to look at each eye. Round is consid-
ered normal, although a few people have slightly oval
pupils. Pupil shape can be altered by trauma, surgery, or
congenital malformations.
Pupil size is the second criteria; it is normal for both
pupils to be approximately the same size. However, many
people have one pupil that is slightly larger than the other,
and this may even be intermittent. The penlight will prob-
ably cause the patient’s pupils to constrict, so judging size
is best done in room light. Many near vision cards have
pupil templates that can be used to estimate size.
The third step is pupillary reaction. The lights are
dimmed and the patient looks at a distant object.
(Focusing on a near object causes the pupils to constrict.)
The light is directed into each eye one at a time, and the
pupil’s reaction is noted. This is called the direct light
response. The normal pupil will initially close down
briskly when exposed to direct light, then re-open some-
what, then pulsate slightly (this pulsation is called hip-
pus). A slow or absent reaction is not normal and should
be noted. Each eye is checked independently when
evaluating the direct light response.
Now the light is swung directly from one eye to the
other, and the reaction of each eye is observed. The light
is moved rapidly, without allowing any time between
eyes. This is called the swinging flashlight test. Next, the
opposite eye is observed while performing the direct light
response on the other eye. Because of their innervation,
both pupils should do the same thing at the same time.
Thus, if the light is directed into the right eye and the
pupil gets smaller, the left pupil should get smaller, too,
even though the light isn’t shining in it. This is called the
pupils’ consensual response.
The swinging flashlight test is done principally to
detect an afferent pupillary defect, commonly known as
a Marcus Gunn pupil. In this case there is a problem with
the nerve connection between the eye and the brain. The
114 Chapter 7 ...........................................
affected pupil does not constrict when the light hits it dur-
ing the swinging flashlight test. Instead, it will dilate. This
reaction can be very subtle or extremely obvious. When
the light is moved from the affected pupil to the normal
(or more normal) pupil, the normal pupil will usually
constrict rapidly. A Marcus Gunn pupil is almost always
accompanied by subnormal vision.

CONFRONTATION VISUAL FIELDS

It is sometimes helpful to have a gross estimate of the
patient’s peripheral vision. Such cases include driver’s
license renewal, a positive history of glaucoma, or patient
complaints of field loss. While there are instruments that
can give a detailed map of the visual field (see Chapter 8,
Visual Field Testing), it can be tested with no equipment
at all.
In room light, the examiner sits 1 meter away from
the patient, who is not wearing glasses at this point
(Figure 7-1). (Note: to make this description easier, the
examiner will be referred to as he and the patient as she.)
The patient is instructed to cover her left eye with her
left hand—no peeking—and to look at the examiner’s
nose. The examiner closes his own right eye, because he
will be comparing the patient’s peripheral field with his
own. The examiner holds his left hand in the lower left
quadrant, at the margin of his own peripheral field. He
holds up one, two, or five fingers and asks the patient to
tell him (without looking) how many fingers he has up.
This is repeated in the upper right, then the examiner
switches to his right hand to check the upper and lower
right quadrants. The other eye is then checked. If he has
to bring his hand in toward the patient before she can
accurately detect the fingers, this is documented in the
patient’s chart. For the driver’s test, direct left and direct
right are also tested. If normal, the nasal field is generally
70 degrees and the temporal 80 degrees.
.................................... Checking it Out 115

Figu re 7-1. Perform in g con fron ta tio n visua l fields. (Ph o to

by Ma rk Arrigo n i. Re prin ted with perm issio n fro m Herrin
MP. Ophthalm ic Exam ination and Basic Skills. Th o ro fa re, NJ:
SLACK In co rpo ra te d; 19 9 0 .)

HIRSCHBERG TEST
The Hirschberg test (it is more of an evaluation than
a test) gives information regarding the eyes’ alignment. If
the eyes are straight (orthophoric; ie, there is no crossing
or strabismus) when the patient fixates on an object, both
eyes are directed to that object. Thus, if the patient is fix-
ating on a penlight, the reflection of that light should fall
on the same place in each eye. That light reflex is likely
to be decentered slightly nasal in each eye, if the eyes are
properly aligned (see also Figure 5-2).
Misalignment of the eyes is measured in prism diop-
ters (which are different from the diopters in a refraction).
The stronger the prism, the more the eye is turned.
To perform the test, the examiner sits in front of the
patient in normal room light. The patient keeps both eyes
opened and looks at the penlight, which is held about 12
116 Chapter 7 ...........................................
Fig u re 7-2 . Prism
e q u iva le n ts o f th e
Hirsch b e rg m e a su re -
m en t.

to 16 inches away. The examiner evaluates the position

of the light's reflection in each eye. If one eye is deviat-
ing, the reflex in that eye will look decentered when
compared to the other eye. The degree of misalignment
can be guesstimated by using the formula that 1 mm of
displacement (ie, from the normal, slightly nasal position)
equals 15 prism diopters. Another method of estimation is
that a reflex falling on the pupillary edge is approximately
.................................... Checking it Out 117
a 30 prism diopter deviation. If the reflex is halfway
between the pupil’s edge and the limbus, the deviation is
roughly 60 prism diopters; if the reflex is on the limbus,
this is about a 90 prism diopter turn (Figure 7-2).
The direction of the displacement is also important.
If the deviating eye is turning in, the reflex is displaced
tem poral to the eye’s visual axis (ie, the straight-ahead
“line of sight”), indicating an esotropia. If the reflex
appears displaced nasally to the eye’s visual axis, then the
eye itself is turning out: an exotropia. An up-turned eye
(hypertropia) will exhibit a reflex that is below the visual
axis, and the reflex on an eye that turns downward (hypo-
tropia) will appear above the visual axis. (See Chapter 5,
Craz y Eyes, for a discussion of terms.)

ANGLE ESTIMATION
The place where the iris and cornea meet inside the eye
is called the angle. The angle must be open in order for
aqueous fluid to drain properly out of the anterior cham-
ber. If the angle is too narrow, dilating the pupil can cause
the iris to bunch up and close the angle. The intraocular
pressure (IO P) then rises rapidly, causing an angle-closure
glaucoma attack (see Figure 4-18). Thus it is important to
evaluate the angle prior to instilling dilating drops.
The angle can be checked with a simple pen light. In
this case, the light is shown directly from the side, across
the iris surface. A narrow angle will cast a shadow on
the opposite side of the iris. An open angle will have no
shadow (Figure 7-3, top).
The best method is to use the slit lamp microscope.
The slit beam is narrowed and positioned to illuminate the
corneal thickness just at the limbus, temporally and then
nasally. If the angle is open, there is a shadow between
the cornea and iris. If the angle is narrow, this shadow
interval is smaller or absent (Figure 7-3, bottom).
118 Chapter 7 ...........................................

Figu re 7-3 . Techn iques for a ssessin g the a n gle o pen -

in g. To p: Penligh t m etho d. Bottom : Slit la m p m eth o d.
(Reprinte d with perm issio n fro m Nem eth SC, She a CA.
Medical Sciences for the Ophthalm ic Assistant. Th o ro fa re, NJ:
SLACK In co rpo ra te d, 19 8 8 .)

DOCUMENTATION
No matter how wonderful the memory of examiner or
patient, lawyers say “if it wasn’t written down, it wasn’t
done.” The results of any test must be correctly docu-
mented, as well as the diagnosis, treatment, and return
plan. Abbreviations must be standard (at least to that
clinic, lab, or office), and the notes must be legible. An
error can O NLY be corrected by drawing a single line
through it, writing the word “error” above, and initialing
.................................... Checking it Out 119

Figu re 7-4 . In stillin g o ph th a lm ic dro ps. Do no t le t the

dro pper lip co n ta ct th e lids o r la sh es. (Ph o to by Ma rk
Arrigo n i. Re prin ted with perm issio n fro m He rrin MP.
Ophthalm ic Exam ination and Basic Skills. Th o ro fa re, NJ:
SLACK In co rpo ra te d; 19 9 0 .)

by the author. Totally obliterating a mistake by erasure,

correction fluid, or scribbling is prohibited and will get
lots of attention… in court!
Log books are great for keeping track of specific tests,
such as photographs, formal visual fields, ultrasounds,
etc. Most computerized instruments provide an easy way
to keep track of patients, findings, and other data by cre-
ating an electronic record.

INSTILLING EYE MEDICATIONS

When instilling eye drops, the patient should lean his
head back, keep both eyes open, and look up. (It’s difficult
to close one's eyes while looking up!) The lower lid is gen-
tly pulled down to make a pocket, and the medication is
dropped into this pocket (Figure 7-4). The dropper tip must
120 Chapter 7 ...........................................
not contact the lid, eye, or lashes. If it does, the bottle is
considered contaminated and should be discarded.
If the patient must instill drops for himself and finds it
difficult, he might choose to lie down, close both eyes,
and put the drop into the inner corner. Then the eye is
opened, allowing the drop to run into the eye.
O intment is instilled by depositing about a 0.25-inch
ribbon (about the size of a grain of rice) into the pocket.

PATCHING THE EYE

The purpose of patching an eye is to keep it closed and
as immobile as possible. If the practitioner has requested
it, instill any medication prior to patching. The patient is
told to close both eyes. O ne sterile eye pad is folded in
half and placed on the eye. An unfolded pad is placed on
top. The patient may be asked to hold the pads in place
with one finger, leaving the assistant’s hands free to apply
the tape. (The patient should still keep both eyes closed.)
O ne piece of tape is placed over the middle of the pad,
angling from the brow (without getting any hair caught
in the tape), and across the pad. With a finger from the
other hand, the assistant pulls up on the cheek and the
tape is smoothed down. The tape angles away from the
mouth (Figure 7-5). (O ne physician friend says that if
the patient’s cheek isn’t wrinkled, the patch isn’t tight
enough!) At least four more pieces of tape are added to
secure every bit of the patch. O nce the patch is secure,
the patient is told to open the uncovered eye and asked
if the patched eye is closed. If not, the patch must be
reapplied. An eye that opens under the patch can easily
sustain a corneal abrasion.
.................................... Checking it Out 121

Figu re 7-5 . Applica tio n o f a pressure pa tch . No te tha t the

ta pe is sla n ted a wa y fro m th e pa tien t’s m o uth . (Ph o to
by Ma rk Arrigo n i. Reprin ted with perm issio n fro m Herrin
MP. Ophthalm ic Exam ination and Basic Skills. Th o ro fa re, NJ:
SLACK In co rpo ra te d; 19 9 0 .)
 Chapter 8

Checking it Further
(Overview of Ocular Tests)

This chapter presents an alphabetized list of common

eye tests, telling what they are designed to find, how
they are performed (briefly), and when they might be
indicated.
* Automated refractor—computerized instrument
that gives a read-out of a patient’s refractive error
(and often the pupillary distance and corneal
curvature as well); usually refined later with refrac-
tometry. Many offices routinely do this on each
complete eye exam.
* Biopsy—a sample of tissue or the entire growth is
surgically removed and sent to a pathology lab to
determine if it is malignant.

123
124 Chapter 8 ...........................................
* Brightness acuity test (BAT)/glare test—used to
determine how various glare/lighting situations
affect the patient’s visual acuity. May be needed
to document the necessity for cataract surgery, as
cataracts can cause significant glare problems.
* Collagen plug tear test—a tiny, dissolving pellet
of collagen is inserted into the punctum. If the
patient’s dry eye symptoms improve for the next
few days (before the collagen dissolves), then per-
manent silicone plugs may be considered.
* Color Doppler imaging (CDI)—evaluation of retinal
blood flow using ultrasound and pulsed Doppler to
measure flow velocity.
* Color vision tests—used to identify color vision
defects. If a genetic defect is suspected, both eyes
are tested at once; if acquired, then each eye is
tested alone. (See Chapter 2, Color Vision.)
¡ Arrangement (hue) test—consists of loose plas-
tic caps of graduated hues contained in a box
that has a fixed colored cap at either end. The
loose caps are scrambled, and the patient is
directed to arrange them in the box according
to graduating hue. Answers are recorded on
special grids or sheets and evaluated. The type
of defect and its severity can be discerned.
¡ Plates—the most commonly used type is the
Ishihara pseudoisochromatic plates. Each plate
presents a number made up of colored dots. The
patient is asked to identify the number (children
may be asked to trace the number). An answer
sheet is provided. Plates help identify the type
of defect, but not its severity.
* Computed tomography (CT scan/CAT scan)—ionizing
radiation is used to create cross-sectional images
of the body (usually head and orbits in eye care).
Especially useful in evaluating hard tissue (eg, bone).
................................ Checking it Further 125
* Confocal laser/microscopy—see Scanning Laser
Polarim etry and Scanning Laser Tom ography
* Contrast sensitivity test (CST)—this test documents
the patient’s ability to discriminate varying con-
trasts, which can be affected by some ocular dis-
orders (notably cataracts). The regular eye chart is
black on white; the real world has infinite degrees
of contrast. Thus, the CST gives a more realistic
idea of the patient’s vision than the eye chart. The
patient is asked to identify the direction of lines on
grids with increasingly less contrast.
* Corneal sensation—the cornea is touched to evalu-
ate the status of corneal innervation, which may
become anesthetized in certain disorders. A cor-
neal anesthesiometer may be used to give a quali-
tative measurement, or a wisp of cotton to give a
“yes or no” result.
* Corneal topography (videokeratography)—a com-
puterized instrument that creates a topographical
“map” of the corneal contour. Useful for evaluation
of many corneal disorders but especially in refrac-
tive surgery (preoperative and postoperative).
* Cover tests—strabismus evaluation in which the
patient focuses on a target while the examiner
covers an eye, watching for any movement. In
the cover-uncover test, one eye is covered then
observed for shifting as it is uncovered. In the
cross-cover test, the occluder is moved quickly
from one eye to the other. Prisms are sometimes
used with cover testing to further evaluate and/or
measure any misalignment.
* Cross cylinder—rotating lens used during refrac-
tometry to subjectively refine cylinder axis and
power when correcting for astigmatism.
126 Chapter 8 ...........................................
* Dark adaptometry—used to measure a patient’s
ability to dark adapt, which is essentially an evalu-
ation of the rod photoreceptors. A bowl-type instru-
ment (dark adaptometer) similar to a perimeter is
used. The patient is dark adapted and then asked to
indicate when lights of varying intensity are seen. It
takes about 45 minutes. Indicated when the patient
complains of night vision problems.
* Electromyography (EMG)—evaluation of individual
extraocular muscle function. After instillation of a
topical anesthetic, a thin needle is inserted into
the muscle. A computer then detects an audio
and graphic signal from the muscle; the strength/
absence of the signal indicates muscle function.
* Electronystagmography (ENG)—evaluation of hori-
zontal tracking movements of the eye.
* Electro-oculography (EO G)—evaluation of retinal
pigment epithelium function by measuring voltage
changes as the eye moves, using electrodes, poly-
graph, and alternating target.
* Electroretinography (ERG)—evaluates light response
of retina using electrodes, polygraph, and light/dark
stimulation.
* Endothelial cell count (specular microscopy)—a
photography/video set-up combined with a micro-
scope capable of visualizing the corneal endo-
thelium. Indicated in certain corneal dystrophies,
especially if intraocular surgery is planned. If the
cell count is too low, surgery may be modified or
abandoned as an option.
* Exophthalmometry—measurement of the forward
protrusion of the eye using an exophthalmom-
eter. Indicated in thyroid eye disease or any other
condition in which the eye(s) may be abnormally
protruding.
................................ Checking it Further 127
* Extraocular movement (range of motion)—the eyes
are moved into various positions of gaze (12:00,
1:30, 3:00, 4:30, 6:00, 7:30, 9:00, 10:30). If range
of motion is full (ie, neither eye is impeded due
to strabismus or other cause), then the eyes move
smoothly together to each position. O ften per-
formed during a full exam; also indicated in trauma
where muscle involvement is suspected.
* Fluorescein angiography—photographic technique
using injected fluorescein (a vegetable dye) and a
fundus camera that is equipped with special filters.
A rapid series of photographs is taken as the dye
enters the blood vessels of the eye. Indicated in
diabetes, macular degeneration, and other retinal
vascular disorders.
* Gonioscopy—a method of viewing the angle (inter-
nal area between the cornea and iris) using a
goniolens and the slit lamp microscope. Indicated
in glaucoma where the angle may be narrow,
closed, or obstructed, preventing proper drainage
of aqueous from the eye.
* Hirschberg test—gross test to determine the pres-
ence of a tropia (eg, constant strabismus). Patient
looks at a penlight while the examiner evaluates
the light reflex on the patient’s corneas. The reflex
in each eye is normally slightly nasal (see Chapter
7, Hirschberg Test).
* History—a guided series of questions designed to
determine the patient’s general and ocular health,
and the progress of any disease states. Indicated,
at least to some degree, in every ophthalmic exam
(see Chapter 7, History).
* Interferometer—used to determine the level of
visual acuity expected if a patient has a cataract
removed. A set of parallel stripes of decreasing size
are projected onto the patient’s retina. The patient
128 Chapter 8 ...........................................
is asked to indicate the direction of the lines; the
smaller the lines get, the more difficult this is.
Indicated in cases where cataract exists along with
macular degeneration, amblyopia, or other vision-
reducing disorder.
* Keratometry (K readings, K’s, ophthalmometry)—
measuring the central curvature of the cornea using
a keratometer in order to determine astigmatism.
Indicated for certain corneal diseases, fitting con-
tact lenses, post-corneal surgery, and measuring
for intraocular lens implants (IO Ls) used in cataract
surgery.
* Keratoscopy—provides a photograph showing the
reflection of a set of concentric circles on the
cornea, designating corneal shape. Indicated in
keratoconus and high astigmatism.
* Krimsky measurement—used to qualitatively mea-
sure a tropia (eg, constant eye turn). The patient
looks at a penlight. The observer uses prisms to
move the corneal reflex on the deviated eye until
it is in the same place as the fixating (straight) eye
(slightly nasal; see Hirschberg Test).
* Lensometry—reading the prescription of spectacle
lenses or contact lenses by use of a lensometer.
May be automatic or manual.
* Macular photostress test—measures how quickly
vision recovers after exposure to a bright light. The
light is shone into the eye for 10 seconds, then the
examiner times how long it takes before the patient
can identify letters on the eye chart one line above
her pretest acuity. Normal is 30 to 50 seconds.
Indicated in macular degeneration.
* Maddox rod testing—strabismus or vergence testing
in which the patient views a white light with one eye
and looks through a Maddox rod with the other. The
eye looking through the rod sees a red streak. If the
................................ Checking it Further 129
eyes are straight, the red line runs through the white
light. If the eyes deviate, then the dot and line will not
appear merged. Prisms may then be used to move the
white light until it is intersected by the streak, giving a
measurement of the strabismus.
* Magnetic resonance imaging (MRI)—uses a strong
magnetic field and radio waves to construct an
image, especially useful for soft tissue evaluation.
* Nasolacrimal evaluation—done to determine if the
nasolacrimal excretion system is open. O ne such
test involves instilling topical fluorescein dye into
the eye, then ascertaining if the dye has moved into
the nasal cavity (evidenced by blowing the nose) or
throat (the throat is viewed with a cobalt blue light),
indicating an open system. Another version involves
injecting saline into the punctum via a cannula
(blunt needle). If the saline goes into the patient’s
throat, the system is open.
* Near point of accommodation—a measurement of
the closest point at which the patient can maintain
clear focus on an accommodative target (ie, one that
stimulates the eye to focus). An accommodative tar-
get is brought closer until the patient reports blurring.
Tested while wearing distance correction, if any.
* Near point of convergence—a measurement of the
point where the patient cannot maintain conver-
gence (ie, hold the eyes together). An accommoda-
tive target is brought closer until the observer sees
one of the patient’s eyes diverge.
* O phthalmoscopy—visual examination of the retina,
including optic nerve, macula, and peripheral retina.
(Collectively, the interior area seen on ophthalmos-
copy is known as the fundus.) Performed with an
ophthalmoscope (direct or indirect). Indicated in
most full exams and in rechecks involving retinal
pathology.
130 Chapter 8 ...........................................
¡ Direct—uses a hand-held ophthalmoscope.
Provides a small field of view and 14X of mag-
nification, plus various filters and grids.
¡ Indirect—uses a head-worn binocular viewer
and a hand-held lens. Provides a large, three-
dimensional view and 2X to 4X magnification.
* O ptical coherence tomography (O CT)—evalua-
tion of ocular tissues using reflected light, yielding
cross-sectional views of the layers. O CT depicts the
thickness of cell layers, making it especially useful
in examination of the optic nerve, macula, and
retinal nerve fiber layer (RNFL). It can also be used
to visualize and measure the cornea, as well as
measure anterior chamber (AC) depth and angles.
* Pachymetry—measurement of corneal thickness
using a pachymeter (most utilize ultrasound).
Readings may be taken from various parts of the
cornea (usually the center and then several from
the limbus). Indicated in certain corneal diseases,
refractive surgery (preoperative and postoperative),
and glaucoma.
* Photography—photographs are taken to provide
a permanent record of ocular conditions. May be
necessary to show a need for surgery or to monitor
a condition over time (eg, the optic nerve in glau-
coma).
¡ External—usually uses a Polaroid™ (Polaroid
Corporation, Cambridge, MA) or 35-mm cam-
era. Indicated in external conditions, including
strabismus, growths, and eyelid positions.
¡ Retinal—a fundus camera is used to provide
photographs of the optic nerve, macula, and
periphery. Indicated in glaucoma (many doc-
tors take disk photos annually), nevi, diabetes,
hypertension, and more. If black and white film
is used and if the patient is injected with fluores-
................................ Checking it Further 131
cein dye, a fluorescein angiogram may be done
to evaluate the retina’s blood vessels (indicated
in macular degeneration, diabetes, hyperten-
sion, and other disorders).
¡ Slit lamp—35-mm camera mounted on a slit
lamp microscope. Indicated to provide magni-
fied documentation of growths, nevi, etc.
* Potential acuity meter (PAM)—used to give an esti-
mate of the level of vision a patient can expect after
cataract surgery. The instrument projects an eye
chart onto the retina, bypassing most lens opaci-
ties. Sometimes required to indicate that cataract
surgery will improve the patient’s vision, notably
when cataract coexists with macular degeneration
or amblyopia.
* Prism and cover test—a measurement of strabis-
mus. The patient views an accommodative target.
A prism is placed in front of one eye, then the
examiner alternately covers the eyes. The measure-
ment is complete when the amount of prism is
such that no eye movement occurs when the cover
is moved.
* Pupil evaluation—examination of the pupil, which
includes the size and shape of each pupil (done
by simple observation) and an evaluation of the
pupils’ reaction to light (see Chapter 7, Pupil
Evaluation).
* Refractometry—method of subjectively determin-
ing a patient’s refractive error. Most often, a
phoropter (an instrument containing many lenses
that can be moved into place with dials) is used.
Lenses are changed as the patient looks at the eye
chart and tells the examiner which lens seems to
give the best vision. May be done both undilated
and dilated. Generally performed at every full eye
exam, as well as certain rechecks and postopera-
132 Chapter 8 ...........................................
tive situations. It is not the same as a refraction,
where a licensed practitioner uses the measure-
ment and professional judgment to generate a lens
prescription.
* Retinal thickness analyzer (RTA)—evaluation of
retinal thickness using laser and a computerized
biomicroscope to generate a two- or three-dimen-
sional cross-section.
* Retinoscopy—method of objectively measuring
a patient’s refractive error using a retinoscope.
The examiner evaluates the reflection of the ret-
inoscope’s light in the patient’s pupil. Lenses are
placed in front of the patient’s eye until the reflec-
tion reaches a neutral point. Indicated for prever-
bal children and other patients who cannot be
refracted subjectively or to obtain a starting place
for refractometry. May be performed undilated and
dilated.
* Scanning laser polarimetry (SLP)—quantitative
evaluation of the RNFL using polarized light and
confocal laser to assess the RNFL’s thickness vs the
layout of axons.
* Scanning laser tomography (SLT) (also called con-
focal scanning laser ophthalmoscopy [CSLO ])—
three-dimensional evaluation of the optic nerve
head using confocal laser to assess reflectivity of
the tissues. The SLT generates the cup-to-disc ratio,
averages the thickness of the RNFL, and (in some
instruments) predicts the likelihood of the patient
developing glaucoma.
* Schirmer’s tear test (tear test, basal tear test)—used
to measure the amount of tears produced by the
eye. A strip of filter paper is placed into the lower
cul-de-sac (ie, pocket between the lid and the eye-
ball) for 5 minutes, then the amount of wetness is
measured. Can be done with or without anesthetic.
................................ Checking it Further 133
Indicated if dry eye is suspected or preoperatively
for any type of eyelid surgery.
* Slit lamp examination—microscopic evaluation of
the eye using a slit lamp microscope. Several mag-
nifications are available, and lighting is adjustable.
All external structures can be evaluated, as well as
the anterior chamber, lens, and anterior vitreous
face. The angle can be viewed if a goniolens is
used. The vitreous and fundus may be evaluated if a
Hruby lens is used. The microscope usually has an
attached applanation tonometer to measure intra-
ocular pressure (IO P) as well. Slit lamp evaluation
is performed in virtually every exam situation.
* Specular microscopy—See Endothelial cell count.
* Stereo testing—evaluation of the patient’s stereo
vision, measured in seconds of arc. Most tests
use Polaroid glasses that cause the graded test
objects to appear as if they are three-dimensional.
Patients with either poor vision in one eye or stra-
bismus cannot appreciate the stereopsis of the test
objects.
* Tonometry—method of measuring IO P in millime-
ters of mercury (mmHg) using a tonometer. There
are several models. An indentation tonometer (eg,
Schiøtz) measures the amount of indentation that
occurs when a specific weight is applied to the
corneal surface. An applanation tonometer (eg,
Goldmann) measures the amount of force needed
to flatten a specific area of the cornea. Tonometry
is indicated at every full exam and at rechecks
where the patient has glaucoma, is using topical
steroids, is postoperative, or is post-traumatic (in
many cases).
* Trial frame and lenses—the trial frame is an adjust-
able glasses frame with cells to hold corrective
lenses. The trial lenses are loose lenses that can be
134 Chapter 8 ...........................................
placed into the trial frame. This set-up is used dur-
ing refractometry if a phoropter is not available or
feasible.
* Ultrasound—sound waves are used to image or
measure the eye’s interior structures.
¡ A-scan—gives a one-dimensional read-out.
Most often used to measure the axial length of
the eye prior to cataract surgery.
¡ B-scan—gives a two-dimensional image of the
eye. Used to locate and define lesions, foreign
bodies, retinal detachments, etc.
* Visual acuity—a measurement of the patient’s
ability to see. Tested at distance and near, with
and without correction, each eye alone, and
(sometimes) both eyes together. These are gener-
ally checked at every full exam. At a minimum,
corrected distance acuity is measured at every visit
(see Chapter 7, Visual Acuity).
* Visual field testing—an evaluation of the patient’s
peripheral vision. Some tests give more information
than others; some actually quantify loss.
¡ Amsler grid—a hand-held grid used to evaluate
the central 10 to 15 degrees of vision, one eye at
a time. Indicated when the patient complains of
central vision distortions or blind spots. Patients
with macular degeneration are given a grid to
use at home.
¡ Confrontation—gross evaluation of the visual
field (see Chapter 7, Confrontation Visual Fields).
Indicated in every full exam, or when patient
complaint indicates a possible field defect.
¡ Perimetry—utilizes a hemispheric bowl (perim-
eter) to measure the visual field, in some cases
out to 80 or 90 degrees. The perimeter provides
targets of varying color (white is usually used),
................................ Checking it Further 135
size, and brightness. Each eye is tested. Annual
exams are indicated in glaucoma. O ther indi-
cations include neurological disease, retinal
disorders, and patient complaints of field loss.
¢ Automated—the size, brightness, and loca-
tion of the target is determined by a com-
puter. Specific programs may be selected as
appropriate for the situation. The test may be
printed out and stored, as well as compared
to specific databases.
¢ Manual—the size, brightness, and location
of the target is controlled by the exam-
iner. The target may be moved in from the
periphery (kinetic perimetry) or flashed on
in one location (static perimetry). Results are
recorded manually on a chart.
¡ Tangent screen—formal measurement of the
central 30 degrees of the visual field. Uses
a black screen (the patient is seated 1 meter
away) and a target. The target is colored (usually
white) and available in various sizes. While the
patient fixates on a central dot, the examiner
brings the target inward from the periphery. The
patient indicates when the target is first seen,
and this location is marked on the screen. Each
eye is tested separately. Results are transferred
to a chart for a permanent record.
* Vital signs—refers to signs that are “vital” to life:
blood pressure, respiration rate, pulse, and tem-
perature.
* Wavefront analysis—this technology is used to
evaluate the eye as an optical system, specifically
for aberrations (visual distortions caused by imper-
fections in an optical system). It is used in conjunc-
tion with laser in refractive surgery to guide the
procedure so that aberrations are reduced.
136 Chapter 8 ...........................................
* Worth 4-dot—used to evaluate strabismus, fusion,
suppression, and diplopia. The patient wears glass-
es with a red lens over the right eye and a green
lens over the left. He is then asked to comment on
the color patterns generated by a flashlight with
four colored dots.
 Chapter 9

Fixing it
(Overview of Opht halmic Surgery)

Many of the eye disorders highlighted in Chapter 4

(W hat Can Go Wrong) may be repaired surgically. This
chapter will give a brief overview of the more common
ocular surgeries.

SKIN AND LIDS

Probably the most common type of eyelid surgery is
removal of growths (tumors that could be either benign or
malignant). These are often excised (surgically removed)
or biopsied (a portion of the growth is removed) and sent
to pathology (lab that determines malignancy). If a large
amount of tissue is removed, the surgeon may do a graft

139
140 Chapter 9 ...........................................
(transplant tissue from another part of the patient’s body)
or a flap (skin adjacent to the wound is moved over) to
repair the damage. A growth may also be removed by
cautery (burned) or cryotherapy (freezing), but these
leave no tissue for pathology.
Trichiasis (ingrown lashes) may be treated with epila-
tion (mechanical removal), cryotherapy, or electrolysis
(weak electric current). Ectropion (out-turned lid) is treat-
ed by tissue removal or tightening (removing a wedge of
skin from the lid and sewing the edges together, pulling
the lid tight against the eyeball). Entropion (in-turned lid)
may be quick-fixed with sutures or more permanently by
tissue tightening, surgery that pulls the tarsus (dense col-
lagen) in the lid toward the outer corner (lateral canthus).
The tension keeps the lid from flipping back in. Extra
eyelid skin is surgically removed in a blepharoplasty. If
the brow has begun to droop as well, a brow lift may be
performed at the same time.

TEAR SYSTEM
If there is a blockage in the tear drainage system, a
probe (fine metal wire) may be passed through the punc-
tum (opening in the lid) and into the drainage canal. If a
blockage is encountered, the probe is pushed through.
Sometimes a silicone tube (stent) is pulled through the
punctum, through the canal, and into the nose to keep
the canal open and operational. The tube is usually left
in place for 6 months or more. More recently, a balloon
catheter (similar to that used in cardiac treatment) has
been used to stretch the canal without the need for a
stent.
............................................... fixing it 141
CORNEA
The cornea (clear covering over the front of the eye)
is the first tissue that light passes through on its way to
the retina. It acts as a lens to help focus images, thus it
must be clear and smooth in order for vision to be crisp.
This makes any corneal surgery a delicate and exacting
procedure.

Corneal Transplant
If the cornea is so diseased, scarred, or distorted that
vision is severely reduced, a corneal transplant may
be indicated to restore vision. The cornea is the most
commonly transplanted tissue in the United States (over
40,000 cases per year). The diseased corneal tissue (either
just specific layers of the cornea or an entire "button" of
cornea) is removed and replaced with donor tissue (from
someone who has died and donated the eyes), similar
to exchanging a car windshield. This tissue is sewn into
place. Recovery from corneal transplant is slow, taking
up to a year.

Refract ive Surgery

Corneal refractive surgery is the alteration of the cor-
nea’s shape in order to correct nearsightedness, farsight-
edness, and/or astigmatism. There are several methods,
but none of those mentioned here can correct presbyopia
(the loss of near vision that occurs with age).
Radial keratotomy (RK) and astigm atic keratotomy (AK)
correct nearsightedness and astigmatism respectively.
Both procedures involve numbing (topically anesthetiz-
ing) the cornea and then making near full-thickness inci-
sions into the cornea. The surgeon determines the number,
placement, and depth of the incisions prior to surgery by
evaluating the patient’s refractive error, corneal thickness,
and corneal shape. The incisions flatten the cornea in an
attempt to cause images to be focused on the retina.
142 Chapter 9 ...........................................
Laser refractive surgery is the procedure that most
people are hearing about now, billed as LASIK (laser-
assisted in situ keratomileusis), LASEK (laser-assisted
subepithelial keratectomy), and epi-LASIK (or E-LASIK,
epithelial laser-assisted in situ keratomileusis). These can
be used to correct nearsightedness, farsightedness, and/or
astigmatism. After applying anesthetic drops to the eye,
a thin corneal flap is cut. An ultraviolet laser, known as
the excimer laser, is used to reshape the corneal tissue
under the lifted flap, then the flap is put back into place.
The reshaping process is determined, as in RK and AK,
by careful measurements of the patient’s cornea and
refractive error. This information is entered into the laser’s
computer program, which then gives the surgeon details
on how to best proceed.
Photorefractive keratectomy (PRK) is another laser
surgery for the correction of myopia, hyperopia, and/or
astigmatism. In PRK, the corneal surface layer is removed
and the underlying tissue is altered without the creation of
a flap. O therwise, the procedure is very similar to LASIK.
Intacs®(Addition Technology Inc, Sunnyvale, CA) are
tiny plastic curved pieces that are placed into the corneal
tissue (Figure 9-1). After a numbing drop, a tunnel is
surgically created for the Intac piece. Two are inserted in
each cornea. The rings act to flatten the cornea, and are
designed to correct 1 to 3 D of myopia (with less than 1
D of astigmatism). The procedure takes about 15 minutes
per eye.

GLAUCOMA SURGERY
Glaucoma occurs when the pressure inside the eye
(created by the formation and drainage of the watery
aqueous fluid) causes irreversible damage to the optic
nerve. The goal in surgery is to increase the drainage of
fluid from the eye, reducing the pressure. In some cases,
laser treatment may be used to lower intraocular pres-
............................................... fixing it 143

Figure 9-1. Ph o togra ph of In ta cs ® , rin gs im pla n ted in to

th e corn ea to co rre ct re fra ctive erro rs. (Im a ge of Inta cs ®
courtesy of Additio n Tech no logy Inc, www.a ddition tech -
n o logy.com .)

sure (IO P) in a procedure known as laser trabeculoplasty.

The trabeculum is the network-like area inside the angle
of the eye (where the cornea and iris meet) where the
aqueous drains. The laser actually burns tiny areas of the
trabeculum. It is believed that when these areas heal, the
scar tissue pulls the trabecular openings farther apart and
increases aqueous drainage.
A surgical trabeculotomy is done by making an open-
ing in the sclera (white of the eye) and creating an exte-
rior drainage site known as a bleb. (A bleb is not an open
hole; it is covered by conjunctiva, the membrane that
normally lies over the sclera.) In some individuals, the
bleb scars over and is no longer effective. In these cases
a drainage im plant may be used. The implant consists of
a plastic ring to hold the bleb open and a tiny tube run-
ning from the bleb to the eye’s interior, through which
the aqueous flows.
144 Chapter 9 ...........................................
While most types of glaucoma cannot be cured, angle-
closure glaucoma (ACG) (see Chapter 4, Glaucom a,
and Figure 4-18) can be resolved by laser treatment.
ACG occurs when the iris blocks aqueous from drain-
ing through the angle. (The mechanism of this varies;
basically the iris bulges over the angle.) The YAG laser,
a long-wavelength laser, is used to create a hole in the
iris (iridotomy), forming a passage for aqueous from the
posterior to the anterior chamber even if the angle is
blocked.

CRYSTALLINE LENS
Cat aract Surgery
In the past, one had to wait to have cataract surgery
until the cataract reached a certain stage (often referred
to as “ripe”). Now, surgery is usually indicated when the
cataract interferes with the person’s activities of daily liv-
ing. Current technology allows a cataract (cloudy crystal-
line lens) to be removed at any point. After anesthetizing
the eye, a small incision is made in the sclera or cornea.
The surgeon then uses fine instruments to open the lens
capsule that encases the cataract. An ultrasonic probe is
inserted, and sound waves are used to break the cataract
into small fragments. (This process is known as phaco-
em ulsification.) The pieces are then suctioned out of the
eye. Finally, an intraocular lens (IO L) is placed inside
the eye, ideally into the capsular bag. The proper power
of the IO L (measured in diopters) is calculated before
surgery using the desired refractive error, keratometry
readings, axial length, and a computer program. O nce
the IO L is in place, the procedure is over; usually stitches
are not needed. The entire surgery (not counting prep,
recovery, etc) can take as little as 15 minutes.
............................................... fixing it 145
Refract ive Surgery
IO Ls were originally developed to replace the crys-
talline lens after cataract surgery. New IO Ls have been
developed that are used strictly for reducing refractive
errors while leaving the crystalline lens in place (termed
phakic IO Ls). There are several types, including lenses
that can be placed in front of the iris or behind it. If the
crystalline lens is not cataractous but removed for refrac-
tive correction using a traditional IO L, the extraction
procedure is a clear lensectomy.

STRABISMUS SURGERY
Surgical repair of misaligned eyes generally falls into
two categories: recession and resection. In muscle reces-
sion, the muscle is detached at the insertion point (where
it attaches to the eye) and stitched to the sclera (white of
the eye) at a new place farther back. This acts to loosen
the muscle. A resection involves detaching the muscle,
trimming it so it is slightly shorter, and restitching it to
the same spot. This effectively tightens the muscle. The
amount to move or trim a muscle is determined before
surgery by carefully measuring the amount of eye devia-
tion with prisms.

RETINAL SURGERY
The retina contains the light receptor cells and nerve
fibers vital to good vision. In disorders such as diabetes
and high blood pressure, laser treatm ent may be used to
seal off leaky blood vessels. Laser may also be used to
stop new blood vessel growth found in macular degen-
eration and diabetes. Some retinal tears can be treated by
laser, but others require intraocular surgery as well.
146 Chapter 9 ...........................................
In the case of larger retinal tears and detachments,
laser is performed around each tear, then a scleral buckle
(a band of silicone rubber) is sutured externally to the
sclera (white of the eye). This pushes the sclera inward,
where it reattaches with the retina. Sometimes gas or air
may be injected into the eye to further push the retina
and sclera together.

ENUCLEATION
Unfortunately, it sometimes becomes necessary to
enucleate (surgically remove) an eye. Such a situation
might occur if the globe is traumatized beyond repair or
if an already blind eye becomes painful. The procedure
is usually done under general anesthesia because of
the emotional stress that the patient is undergoing. The
conjunctiva (membrane covering the white of the eye)
is detached and the globe is taken out. O nce the eye is
removed, a synthetic implant is placed into the socket
and the conjunctiva is sewn over it. The function of the
implant is to provide volume in the orbit. O nce the eye
socket has healed, a prosthesis (false eye) can be fit by a
specialist.
 Chapter 10

Treating it
(Pharmacology)
MEDICATIONS FOR THE EYE
Diagnost ics
Diagnostic medications are, as their name implies,
used to help diagnose ocular conditions. Some of them
may be used for other purposes as well, which will be
mentioned here.
The diagnostic medication most used in examining
the external eye is fluorescein dye. When a blue light is
directed onto fluorescein, the fluorescein takes on a yel-
low-greenish glow. For external use, the fluorescein is
provided in drop form, usually combined with a topical
anesthetic. Filter-paper strips impregnated with fluorescein
are also available; these are moistened with sterile water

149
150 Chapter 10 ..........................................
or topical anesthetic and touched to the eye. O nce on the
eye, fluorescein will stain in any de-epithelialized areas (ie,
areas that have lost the outer epithelium). These areas glow
when the blue light is turned on, making the dye invalu-
able for diagnosing corneal and conjunctival abrasions, as
well as other surface disorders of the cornea.
Fluorescein is also used to diagnose retinal problems. In
this case, the dye is injected through a vein in the patient’s
arm. A special camera with a blue exciter filter is used to
photograph the dye as it enters the blood stream of the eye.
This technique is used especially in diabetics, where blood
vessel abnormalities and leakages often occur.
Indocyanine green is another injectable dye used to
evaluate the blood vessels of the iris and retina. It is more
visible through pigmented tissues than fluorescein dye,
making evaluation of the choroid easier.
Trypan blue is a US Food & Drug Administration-
approved dye used to highlight the capsule of the crystal-
line lens during cataract surgery, making the membrane
easier for the surgeon to see.
Rose bengal is another external ocular dye. It stains
tissue that has degraded (or devitalized), assisting with
the diagnosis of dry eye and other disorders.
Anesthetics are used to eliminate sensation, usually for
the control of pain. In ophthalmology, all forms of anes-
thesia are used. General anesthesia, where the patient is
totally asleep, is indicated in some surgeries. However,
most surgeries (including minor surgeries) can be done
using a local anesthetic, where the medication is injected
into the specific area being treated (eg, eyelids). Some sur-
geries and all office testing can be done using just a topi-
cal anesthetic, commonly known as a “numbing drop.”
Tetracaine and proparacaine are the most popular.
Another class of diagnostic medications dilates
(enlarges) the pupil and allows the examiner a better
view of the eye’s lens, vitreous, and retina. These are the
mydriatic agents. The most common clinical mydriatic
agent is phenylephrine.
............................................ Treating it 151
Table 10-1
Effect a n d Recovery o f Dila tio n Dro ps
Tim e of Maxim um Tim e to
Diagnostic Drug Dilation Recovery
Phenylephrine 30 to 60 m inu tes 3 to 5 hours
Tropicam id e/ hyd ro- 15 to 60 m inu tes 2 to 4 hou rs
xyam phetam ine
Atropine 30 to 40 m inu tes 7 to 10 d ays
H om atropine 40 to 60 m inu tes 1 to 3 d ays
Scopolam ine 20 to 30 m inutes 3 to 7 d ays
Cyclopentolate 30 to 60 m inu tes 24 hou rs
Tropicam id e 20 to 40 m inutes 3 to 6 hou rs

Tim e of Maxim um Tim e to

Diagnostic Drug Cycloplegia Recovery
Atropine 60 to 180 m inu tes 6 to 12 d ays
H om atropine 30 to 60 m inu tes 1 to 3 d ays
Scopolam ine 30 to 60 m inutes 3 to 7 d ays
Cyclopentolate 25 to 75 m inu tes 6 to 24 hou rs
Tropicam id e 20 to 35 m inutes und er 6 hou rs

A similar set of drugs, the cycloplegics, not only dilate

the pupil but paralyze the ciliary muscle (which controls
the ability of the lens to focus). They provide a large
pupil through which to look but have an additional use
in refractometry (measuring for glasses). In this case, the
idea is to eliminate (temporarily) the eye’s own ability to
focus so that all the focusing can be done with the lenses.
This enables the examiner to determine a true measure-
ment. This technique is frequently employed in children.
The most commonly used cycloplegic agent in this case
is cyclopentolate.
Regardless of which dilating drop is used (and some-
times a combination is given), practitioners want to know
how long it’s going to take to have full effect. Patients
want to know when it’s going to wear off. Table 10-1
reviews this information. (Note: other sources of informa-
tion may list slightly different times.)
152 Chapter 10 ..........................................
Table 10-2
An tim icro bia ls
Antibiotics Antivirals Antifungals
Bacitracin Acyclovir Am p hotericin B
Erythrom ycin Fam ciclovir N atam ycin
Flu oroqu inolones Foscarnet Voriconazol
Gentam icin Ganciclovir
N eom ycin (only in Id oxu rid ine
com bination) Triflurid ine
Polym ixin B (only
in com bination)
Su lfacetam id e
Tobram ycin
Trim ethoprim /
polym ixin B

A potential side effect of dilating the pupils can be an

acute angle closure glaucoma attack. This is covered in
Chapter 4 under Glaucom a (see Figure 4-18) and Chapter
7 under Angle Estim ation (see Figure 7-3).

Ant imicrobials
Antimicrobials are used to battle infection. Specifically,
antibiotics fight bacteria, antivirals fight viruses, and anti-
fungals fight fungi. Each of these is available in some
form of eye medication (Table 10-2). It is common for
antibiotic medications to contain a mixture of antibiotics.
This is done to increase the chances of treating the patient
effectively, as some bacteria are resistant to certain anti-
biotics. Antibiotics are also sometimes combined with
anti-inflammatory agents (see next section).
............................................ Treating it 153
Table 10-3
An ti-In fla m m a to ries
Steroids NSAIDs
Dexam ethasone Brom fenac
Fluorom etholone Diclofenac
Lotep red nol Flu rbip rofen
Med rysone Ketorolac
Pred nisolone N ep afenac
Rim exolone

Ant i-Inflammatories
Inflammation can be a side effect of disease or injury.
The purpose of anti-inflammatory drugs is to quiet the
inflammation so that healing can take place. The two
major classes of anti-inflammatory agents are steroids
and nonsteroidal anti-inflammatory drugs (NSAIDs).
Steroids are potent suppressors of ocular inflammation.
However, steroid eye drops have three major side effects.
They can increase intraocular pressure (IO P), causing
glaucoma. They may also cause cataracts. Finally, they
immunosuppress the eye, increasing the risk of infection.
It is important to note, however, that IO P usually returns
to normal once the steroid is discontinued, and topical
steroids are generally used for a time period that is too
short to cause a cataract. Steroids are often combined
with antibiotics to provide a bacteria-fighting, inflamma-
tion-quieting medication.
N SAIDs quiet the inflammation without the side
effects of steroids (Table 10-3).

Glaucoma Treat ment

Glaucoma is a disorder in which the optic nerve is
damaged by excessive pressure in the eye. The high
pressure usually occurs when there is inadequate aque-
154 Chapter 10 ..........................................
ous drainage. Initial treatment of glaucoma is almost
always by use of eye drops. These drugs act by increas-
ing aqueous drainage or decreasing aqueous produc-
tion. O ccasionally, an oral medication may be used.
If topical and/or oral drugs fail to control the pressure,
surgery is generally considered (see Chapter 9, Glaucom a
Surgery).
Beta-blockers are the group of drugs most frequently
prescribed for glaucoma. They include timolol, levobuno-
lol, metipranolol, carteolol, and betaxolol. Beta-blockers
act by decreasing aqueous production. Most beta-block-
ers can have side effects on the heart and lungs, and
cannot be used by patients with cardiovascular and
respiratory diseases. Betaxolol is associated with fewer
such side effects.
O ther glaucoma medications include the carbonic
anhydrase inhibitors (CAIs) of which there are two
topicals (dorzolamide and brinzolamide) as well as oral
forms (including dorzolamide). These act by decreasing
aqueous production, as does the combined beta-blocker/
CAI (dorzolamide/timolol). The alpha agonsists (apraxoni-
dine and brimonidine) act to both decrease aqueous pro-
duction and increase outflow. The prostaglandin analogs
(travoprost, latanoprost, bimatoprost) and the adrenergic
drug dipivefrin all lower pressure by increasing outflow.
The m iotics are not used as much any more, but these
drops increase aqueous drainage by constricting the
pupil, thus stretching out the drainage area at the base of
the iris (colored part of the eye). Pilocarpine is the most
commonly used medication in this class.
Whatever the treatment chosen, it is important for the
patient to understand the medication’s purpose, dosage,
and possible side effects. Some patients discontinue the
drops because they “don’t make the eye feel any better,”
but most people cannot feel elevated pressure. It is prob-
ably best to give the patient a written medication sched-
ule. When the drops are late or skipped, it means that the
pressure is allowed to rise for that time period. Eventually,
............................................ Treating it 155
elevated pressure can result in permanent vision loss…
and potential blindness.

Ot her Ocular Medicat ions

Lubricants are used to moisten. There are lubricant
drops and ointments, usually called “artificial tears” and
“tear ointment” by the general public. A thicker drop/gel
is also available. All are sterile, some are preservative-
free. Lubricants are the first line of defense in the treat-
ment of dry eye. Although not a lubricant, the prescrip-
tion medication Restasis® (Allergan, Irvine, CA) purports
to increase tear production that has been reduced by
ocular inflammation.
Vasoconstrictors (also called ocular decongestants)
are used to constrict the blood vessels of the external eye
in order to “get the red out.” Phenylephrine, naphazo-
line, oxymetazoline, and tetrahydrozoline are examples.
While useful in reducing the redness and irritation
associated with mild allergies, frequent use is not recom-
mended because these drugs can have a “rebound” effect
of actually increasing redness if used too often. They also
tend to cause dryness.
Antihistam ines are used to treat allergic reactions
to reduce itching, redness, swelling, and watering.
Sometimes antihistamines are combined with vasocon-
strictors.
Mast cell stabilizers are also used to treat allergies, but
they do not give rapid relief; instead they are intended to
use before symptoms start (eg, a number of days prior to
doing yard work or cleaning a dusty attic).
Macular degeneration m edications are used to treat
the wet form of age-related macular degeneration (AMD).
These drugs are injected into the eye, where they act to
prevent growth and leakage from new, abnormal blood
vessels in the macula or to block the abnormal vessels
themselves. Lucentis™ (Genentec, San Francisco, CA) and
Macugen ™ (O SI Eyetech Pharmaceuticals, Melville, NY)
156 Chapter 10 ..........................................
are two such drugs. Another AMD treatment, Visudyne ™
(Novartis, East Hanover, NJ), is injected intravenously and
then activated by ophthalmic laser.

EFFECTS OF SYSTEMIC MEDICATIONS

ON THE EYE
Many ocular side effects of systemic medications have
been reported (Table 10-4). Although most of these occur-
rences are not dangerous, some are potentially vision-
threatening. Thus patients taking these drugs should be
monitored on a routine basis. Some medications can
affect visual acuity, color vision, eye movement, or pupil-
lary response. O thers can cause glaucoma, cataracts, reti-
nal degeneration, or optic nerve damage. These problems
emphasize the importance of a careful medication history
and the need for health professionals to recognize these
drug-related ocular complications.

REFERENCE
Physicians’ Desk Reference for O phthalm ology. 36th ed.
Montvale, NJ: Medical Economics Co; 2008.
............................................ Treating it 157
Table 10-4
System ic Me dica tio n s a n d th e Eye *
Potential Ocular Side
Drug/ Drug Group Effect(s)
ACE inhibitors (cap top ril; Blu rred vision, inflam m a-
H TN , CH F, d iabetic neu - tion of conju nctiva/ lid s,
ropathy) hem orrhage (su bconju nc-
tiva, retina), sw elling/ d is-
coloration of lid s
Am iod arone (Cord arone ®, Corneal d ep osits, light
Pacerone®; heart regu lator) sensitivity, halos/ glare,
blu rred vision, skin p ig-
m entation, blepharitis/
conju nctivitis, inflam m a-
tion of op tic nerve
Am p hetam ines Increased IOP

Antibiotics Inflam m ation of conju nc-

Baclofen (mu scle sp asm s)
Bisp hosp honates
(Fosam ax®; osteop orosis)
Canthaxanthine (herbal)
Canthaxanthine (Rivera ®,
Orobronze ®; tanning
agent, p hotosensitive skin
d isord ers)
tiva, nod u les on insid e of
lid s
Blu rred vision
Blu rred vision, anterior
u veitis, irritation/ p ain,
red ness, tearing, light sen-
sitivity, ep iscleritis, sw ell-
ing of lid s/ orbit
Crystalline d ep osits in
retina
Macu lar cond itions/ d ep os-
its

*A bbreviation key can be found at the end of the table on page 163.

continued
158 Chapter 10 ..........................................
Table 10-4 continued
Syste m ic Medica tio ns a n d the Eye
Drug/ Drug Group
Celecoxib (Celebrex®;
inflam m ation/ pain of RA
and OA)
Cham om ile (herbal)
Chem otherap eu tic agents
(cancer)
Chlorp rom azine
(Thorazine®; antip sychotic)
Datura (herbal)
Digitalis (Lanoxin ®,
Digoxin ®; heart regulator)
Echinacea p u rp u rea
(herbal)
Erectile d ysfu nction agents
(Viagra ®, Levitra ®, Cialis ®)
Estrogen (birth control,
horm onal rep lacem ent)
Potential Ocular Side
Effect(s)
Blu rred vision, irritation of
conju nctiva, conju ntivitis
Allergic inflam m ation of
conju nctiva
Conju nctivitis, inflam m a-
tion, sw elling
Pigm ent d ep osits (lens, cor-
nea, conju nctiva, retina)
Pupil d ilation
Cone cell toxicity (w ith
resu ltant yellow -tinged or
“frosty” vision)
Inflam m ation of conju nctiva
Im p aired color vision (tran-
sient), blurred vision, pain,
red ness, light sensitivity,
pu pil d ilation, sud d en loss
of vision in one or both eyes
(d u e to blood vessel obstru c-
tion)
Corneal sw elling, nystagmu s
(rhythm ic jerking motions of
eyes), sw elling of optic d isk,
sw elling of retina, changes in
patterns of retinal blood ves-
sels, d ry eye
continued
............................................ Treating it
Table 10-4 continued
Syste m ic Medica tio ns a n d the Eye
Drug/ Drug Group
Etham bu tol hyd rochlorid e
(Myam bu tol®; treatm ent of
tu bercu losis)
Ethanol (beverage)
Ginkgo biloba (herbal)
Gold salts (arthritis)
H yd roxychloroquine
(Plaqu enil®; RA, lu p u s)
Ibu p rofen (N SAID for
p ain/ inflamm ation)
Isoniazid (treatm ent of
tuberculosis)
Licorice (herbal)
159
Potential Ocular Side
Effect(s)
Inflammation of optic nerve
(with associated symptoms of
decreased vision, color vision
disturbance, visual field
defect), macular degeneration
If u sed d uring p regnancy,
can cau se abnorm ally sm all
eyeballs, ep icanthu s (fold
of skin over nasal canthu s),
abnorm ally sm all op ening
betw een lid s
H em orrhage (anterior cham -
ber/ hyp hem a, retina)
Dep osits in cornea, conju nc-
tiva, and lens; nystagm u s
(rhythm ic jerking m otions
of eyes)
Deposits in cornea; d eposits
in RPE (m ay resu lt in night
vision and central vision
loss), retinop athy, blu rred
vision
Color vision d istu rbance,
visual field d istu rbance,
op tic nerve inflam m ation
Macu lar d egeneration
Ocu lar m igraine-typ e sym p -
tom s (jagged -ed ged , flashing
area that m oves from p erip h-
eral to central vision)
continued
160 Chapter 10 ..........................................
Table 10-4 continued
Syste m ic Medica tio ns a n d the Eye
Drug/ Drug Group
Lithiu m (bip olar d isord er)
Mariju ana (sed ative/ nar-
cotic)
Methylphenid ate (Ritalin ®,
Concerta ®; ADH D, narco-
lepsy)
Minocycline (type of tet-
racycline antibiotic; infec-
tion)
N ap roxen (N SAID for
p ain/ inflamm ation)
N iacin (supp lem ent)
N SAIDs (inflam m ation,
p ain)
Penicillamine (Dep en ®;
cystine [am ino acid ] in
u rine, RA, Wilson’s d is-
ease)
Potential Ocular Side
Effect(s)
Ocu lar p rotru sion; eyes
“lock” in position, usu ally
u p -gaze, for m inu tes or
hou rs; shock-like m u scle
tw itch
Ocular red ness, d ecreased
tearing, low ered IOP, color
vision d istu rbance
Dilated p u pil w ith
d ecreased accom m od a-
tion (and resu ltant blurred
vision), low ered IOP
Scleral p igm entation (p er-
m anent), m yop ia (tem p o-
rary)
Op tic nerve inflam m ation,
visual field d istu rbance,
corneal op acity, sw elling
arou nd eye
Sw elling of m acu la,
d ecreased vision, d ry eye,
sw elling and d iscoloration
of lid s, p rotru sion of eye,
lash loss, keratitis
Increased IOP
Paralysis of EOMs (w ith
resultant d ou ble vision),
d rooped eyelid
continued
............................................ Treating it
Table 10-4 continued
Syste m ic Medica tio ns a n d the Eye
Drug/ Drug Group
Phenobarbital (Donnatal®;
sed ative)
Phenytoin (Dilantin ®; epi-
lep sy/ seizu res)
Pred nisone (steroid ; asth-
m a, arthritis)
Prop ranolol (Ind eral®;
angina, H TN , m igraine,
other)
Qu etiap ine (Seroqu el®;
schizop hrenia, bip olar
d isord er)
161
Potential Ocular Side
Effect(s)
N ystagm u s (rhythm ic
jerking m otions of eyes),
paralysis of EOMs, d ifficu lty
converging eyes, tiny or
d ilated pupils
N ystagm u s (rhythm ic jerk-
ing m otions of eyes), p araly-
sis of EOMs (w ith resu ltant
d ou ble vision), change in
color vision, light sensitivity.
If taken d u ring p regnancy,
can cau se fetal und erd e-
velopm ent of op tic nerve,
strabism us, d rooping eyelid ,
ep icanthu s (fold of skin
over nasal canthu s), w id ely
sp aced eyes
Posterior su bcap su lar
cataract, increased IOP (w ith
resu ltant nerve d am age and
visual field changes), pup il
d ilation, angle-closu re glau -
com a
Im p aired relaxation of
m u scles (inclu d ing those
affecting the eye), m ay
conceal ocu lar sym ptom s of
hyp othyroid ism
Cataract
continued
162 Chapter 10 ..........................................
Table 10-4 continued
Syste m ic Medica tio ns a n d the Eye
Drug/ Drug Group
Retinoid s (Accu tane ®; skin
d isord ers, leukem ia)
Rifam p in (antibiotic;
Rifad in ®; tubucu losis, lep -
rosy)
Statins (decrease choles-
terol)
Su lfonam id es (antibiotics
and nonantibiotic/ d iu ret-
ics)
Su lind ac (Clinoril®; inflam -
m ation/ pain of OA/ RA)
Tam oxifen (N olvad ex®;
breast cancer)
Tamsulosin (Flomax®;
benign prostate hypertro-
phy)
Topiram ate (Topam ax®
[su lfonam id e]; seizu res,
m igraine)
Potential Ocular Side
Effect(s
Disord ers of m eibom ian
gland s, p erm anent d ry eye,
ocular irritation, color vision
changes, cornea/ lens op aci-
ties, inflam m ation of op tic
nerve, blu rred vision
Conju nctival red ness, d is-
charge, increased tearing,
d iscolored tears, m acu lar
d egeneration
Ocular hem orrhage (retina,
vitreou s, subconju nctiva,
other)
Sw elling of ciliary bod y
(w ith resu ltant p rolonged
accom m od ation/ ind uced
m yopia [1 to 5 D], and poten-
tial angle closu re)
Corneal inflam m ation,
Stevens-Johnson synd rom e
Crystals in retina, cataract,
color vision changes
Flop p y iris synd rom e (intra-
op erative com p lication)
Acu te glau com a (w ith associ-
ated sym ptom s of pain, red -
ness, elevated IOP, blu rred
vision, etc), eyelid spasm s,
u veitis, retinal hem orrhage
continued
............................................ Treating it 163
Table 10-4 continued
Syste m ic Medica tio ns a n d the Eye
Potential Ocular Side
Drug/ Drug Group Effect(s)
Tricyclic antid ep ressants Myd riasis/ cycloplegia,
(Elavil®; d ep ression) angle-closu re glaucom a,
d ry eye

N ote: This list is not intended to be all-inclusive. The reader is

encouraged to further research regarding specific medications.

ACE=angiotensin converting enzyme; ADH D=attention d efecit/ hyperac-

tive d isord er; CH F=congestive heart failu re; EOMs=extraocu lar m u s-
cles; H TN =hyp ertension; IOP=intraocu lar p ressu re; OA=osteoarthritis;
RA=rheu matoid arthritis; RPE=retinal p igm ent ep itheliu m.

A dapted in part from Fraunfelder FW. Ocular toxicology. In: Physicians’

Desk Reference for Op hthalm ic Med icines. 36th ed. M ontvale, N J: M edical
Economics Company; 2008.
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Choplin N, Edwards R. Visual Fields. Thorofare, NJ:
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 Index
A-scan, 134 aqueous humor, 9, 10, 11, 18, 60-
accommodation, 24-25, 129 61
and refractive errors, 40, 42, 43 flow of, 11, 81
afferent pupillary defect, 61, and intraocular pressure, 11, 61,
113-114 62, 63, 142-144
AIDS (acquired immunodefi- arcus senilis, 58
ciency syndrome), 71 Argyll Robertson’s syndrome, 61
alcoholism, 71 arthritis, 72
allergy, 56, 155 astigmatism, 36-40, 59, 125, 128.
alpha agonists, 154 See also cylinder
amblyopia (lazy eye), 46-47, axis, 33-34, 41, 42
91, 93
ametropia, 26. See also refrac- B-scan, 134
tive errors beta-blockers, 154
Amsler grid, 134 bifocal(s), 43-44, 45
anatomy, 1-14. See also specific binocular vision, 23
structure biopsy, 123
anesthetic(s), 150 blepharitis, 52, 73
angle(s), 10-11, 61, 143, 144 blepharoplasty, 140
evaluation of, 117-118, 127, blind spot, 13-14, 21, 22
130, 133 blink(ing), 3, 53, 94
angle-closure glaucoma, 63, 69, blood vessels, retinal, 12, 13.
70, 81, 85, 86 See also neovascularization
mechanics of, 63, 70, 81, 117 blowout fracture, 55
symptoms of, 63, 70, 86 Brightness Acuity Test (BAT),
treatment of, 63, 144 124
aniseikonia, 48 burning (symptom of), 103
anisocoria, 61
anisometropia, 48 cancer, 71
anterior chamber, 7, 8, 10, 60, canthus, 4
61, 80 capsule (of lens), 11, 65, 83, 144,
anterior segment, 7, 8, 10 150
antibiotic(s), 152, 157 capsulotomy, 65, 83
anti-inflammatory medications, carbonic anhydrase inhibitors
153 (CAIs), 154
antimetropia, 48 cataract, 64-65, 82
aphakia, 47-48 surgery of, 64-65, 144
aqueous (layer of tear film). See tests regarding, 124, 127-128,
tears 131, 134

169
170 Index .............................................................
types of, 64
cellulitis, 56, 76
chalazion, 52, 74
chiasm, 19, 20, 22
chief complaint, 107-108
child abuse, 71
choroid, 12, 58, 62, 71
choroiditis, 62
ciliary body, 11, 12, 60
ciliary muscle, 11, 18, 40, 151
collagen plug, 124
color Doppler imaging (CDI),
124
color vision, 12, 23-24, 100
defects of, 23-24
testing, 124
computed tomography (CT scan/
CAT scan), 124
confocal laser/microscopy. See
scanning laser polarimetry,
scanning laser tomography
cone(s), 12, 14, 23
confrontation visual field test-
ing, 114-115, 134
conjunctiva, 3-4, 5, 6, 56-58, 143
conjunctivitis, 56-57, 69, 77
contact lens(es), 45-46, 47, 56-
57, 59
contrast sensitivity test, 125
converge/convergence, 25, 30,
31, 129
cornea, 17-18
abrasion of, 10, 59, 79
anatomy of, 8-10
central thickness, 63, 130, 141
disorders of, 53, 54, 58-59
edema of, 58, 70, 79
and red eye, 86
and refractive errors, 26, 36,
37-38. See also astigmatism
surgery of, 141-142
tests of, 123, 125, 126, 128,
130, 150
trauma of, 59-60
corneal implant (Intacs®), 142,
143
corneal topography, 125
corneal transplant, 141
cover test(s), 125, 131
cranial nerve(s), 5, 89, 90, 93-
95
cross cylinder, 125
crossed eyes. See strabismus
crystalline lens. See lens, crys-
talline
CT/CAT scan, 124
cup/cupping (of optic disk), 13,
68, 132
cycloplegia, 151
cylinder, 33-34, 35, 39, 41-42.
See also cross cylinder
dacryocystitis, 54
dark adaptometry, 126
depth perception, 23
dermatochalasis, 23
detachment. See retinal d., vitre-
ous d.
development, of eye, 1-2
diabetes, 65, 71
diagnostic medications, 149-152
dilation, pharmaceutical, 150-152
diopter(s), 34, 35, 36, 115
discharge, 86, 104, 108
disk. See optic disk
disorders. See also specific dis-
order
of anterior chamber, 60-62, 81.
See also red eye
of conjunctiva/sclera, 56-57,
76-78
of cornea, 58-59, 78, 79
of cranial nerves, 96-97
of lens, 55-57, 82-83. See also
cataract
of optic nerve, 68
of retina/vitreous, 65-67, 84
of skin/lids, 52-53, 73-76
of tear system/globe/orbit, 54-
55, 76
visual, 46-48. See also refrac-
tive error(s)
................................................................. index 171
distance vision, 110-111 flashes, 67, 101
diverge/divergence, 31, 32 floaters, 18, 67, 102
documentation, 112, 118-119 fluorescein, 127, 129, 130-131,
“grading” of findings, 52 149-150
double vision (diplopia), 48, 96, focal length, 34-36
97, 100 focal point, 34
Down syndrome, 71 foreign body, 55, 60, 68, 86
dry eye, 54, 124, 132-133 fracture(s), 55, 71
dystrophy (corneal), 58 fundus, 13, 129
fusion, 91
ectropion, 53, 74, 140
edema, geniculate body. See lateral
corneal, 58, 70, 79 geniculate body
disk, 68 glare, 18, 100, 124
elderly, 66, 71 glare test, 124
electromyography (EMG), 126 glasses, 40-41, 42-45. See also
electronystagmography (ENG), lens(es), optical
126 glaucoma, 11, 13, 62-63. See
electro-oculography (EO G), 126 also intraocular pressure
electroretinography (ERG), 126 angle-closure, 63, 70, 81, 85,
embryology, 1-2 86, 117, 144
emmetropia, 26 evaluation/testing, 127, 130,
endophthalmitis, 54, 62 132, 133, 135
endothelial cell count, 10, 126 medication for, 153-155
endothelium (corneal), 10, 126 open-angle, 62-63
entropion, 53, 75, 140 surgical treatment of, 63, 81,
enucleation, 146 82, 142-144
episclera, 7-8, 57 globe (eyeball), 2-4, 7, 12
episcleritis, 57 disorders/trauma of, 54, 55, 56
epithelium, corneal, 9-10, 59, 60 goiniolens/gonioscopy, 127, 133
examination. See also specific gout, 71-72
tests Graves’ disease, 72
basic, 107-118 halos, 101
special tests, 123-136 headache(s), 70, 103
exophthalmometry, 126 hemorrhage(s), 57, 78
exophthalmus, 54, 76 Herpes (virus), 72, 73
extraocular muscle(s), 55, 89-90, high blood pressure. See hyper-
126, 127. See also strabismus tension
anatomy of, 2, 3, 4, 5, 7 Hirschberg test, 115-117, 127
surgery of, 145 history (patient), 107-109, 127,
eyelid(s), 1-2 156
anatomy of, 3-4 hordeolum (stye), 53
disorders of, 52-53, 73-76, 103 Horner’s syndrome, 61
surgery of, 139-140 hyperopia (farsightedness), 37-
38, 48, 142
farsighted(ness). See hyperopia hypertension, 66, 72
172 Index .............................................................
hyphema, 61, 80
hypopyon, 61, 80
hypothyroid, 72
image(s). See also focal point;
lens(es), optical; vision
real/virtual, 32, 34, 36
size, 48
indocyanine green, 150
Intacs®, 142, 143
interferometer, 127-128
intraocular lens implant (IO L),
47-48, 64, 65, 128, 145
intraocular pressure (IOP), 11, 86
elevated, 61, 70, 117, 153
in glaucoma, 13, 62, 63, 142,
153-154
measurement of, 133
iridotomy, 63, 82, 144
iris, 11, 12, 70, 82, 117, 144
disorders/trauma, 60, 61, 62.
See also iritis
iritis, 62, 70, 85, 86
itching, 103
keratitis, 59, 86
keratoconjunctivitis sicca, 54.
See also dry eye
keratoconus, 59
keratometer/keratometry, 128
keratoscopy, 128
ke ra to to m y/ke ra te c to m y/ke r-
atomileusis. See refractive
surgery
Krimsky measurement, 128
laceration, 53, 55, 58, 59
lacrimal (tear) gland, 6-7, 54
laser,
capsulotomy, 65
evaluation techniques using,
132
glaucoma, 63, 82, 142-143, 144
refractive, 142
retinal, 66, 67, 145-146, 156
lashes (cilia), 4, 53, 130
LASIK, 142
lateral geniculate body, 19, 20
lazy eye. See amblyopia
lens, crystalline, 11, 18, 40, 144-
145
disorders/trauma, 47-48, 64-65,
83. See also cataract
and vision, 11, 24-25, 40, 42.
See also accommodation
lens, gonio. See gonio lens
lens(es), optical, 30-36. See also
contact lens(es), cylinder,
minus lens, plus lens
intraocular. See intraocular
lens implant
in refractometry, 125, 131-132,
133-134
in spectacles, 43-45
lensectomy, clear, 145
lensometer/lensometry, 128
leukemia, 72
light, path of, 17-19
limbus, 8, 9, 46
lubricants, 155
macula, 12, 13, 19
macular degeneration, 66, 127,
128, 131, 134, 155-156
macular photostress test, 128
Maddox rod testing, 128-129
Magnetic Resonance Imaging
(MRI), 129
Marcus Gunn pupil, 61, 113-114
mast cell stabilizers, 155
medications. See ocular medica-
tions and systemic medica-
tions
meibomian glands, 4,7
minus lens(es), 31, 32, 36, 37, 40,
48. See also cylinder
miosis, 25, 61
miotic(s), 154
monovision, 45
multifocal (lens). See bifocal,
trifocal (lens)
multiple sclerosis, 68, 72
................................................................. index
muscles. See extraocular muscles
myasthenia gravis, 72
mydriatic/mydriasis, 150, 151
myopia/myopic (nearsightedness),
36-37, 48, 62, 67
correction of, 36, 37, 39, 40, 142
nasolacrimal system, 6-7, 55, 129
near point
of accommodation, 129
of convergence, 129
near vision, 40, 42, 101, 102, 112
nearsighted(ness). See myopia
neovascularization, 59, 67, 71
nerve, optic. See optic nerve
nerve fibers (retinal), 13, 19, 20
nerve palsies, 96, 97
neurology, 60, 93-97
nevus/nevi (mole), 53, 60
night vision, 12, 102, 126
no-line bi/trifocal lens, 43, 44-45
nonsteroidal anti-inflammatories
(NSAIDs), 153
nystagmus, 96
occipital lobe (of brain), 19, 20
ocular medications
diagnostics, 149-152
for glaucoma, 153
for infection, 152
for inflammation, 153-155
instillation of, 119-120
other, 155-156
ocular physiology, 17-26
of accommodation, 24-25
of binocular vision, 23
of color vision, 23-24
path of light, 17-19
of refractive errors, 36-40
visual pathway, 19-22
ocular side effects (of systemic
medications), 156, 157-163
ocular symptoms, 99-104
ocular trauma. See trauma
open-angle glaucoma, 62-63
173
op hth almosco pe/o ph thalmo s-
copy, 129-130, 132
optic cup. See cup/cupping
optic disk, 12, 13-14, 68, 130.
See also cup/cupping
optic nerve, 3, 12, 19, 94
disorders/trauma, 22, 68-69
and glaucoma/intraocular pres-
sure, 11, 70, 142
optic neuritis, 68
optic radiations, 19, 20
optic tract, 19, 20, 22
optical coherence tomography
(O CT), 130
optics, 29-36
optotype(s), 109-110, 111
orbit, 2-3, 55, 56, 76, 146
orthophoria, 91, 92, 115, 116
pachymetry, 130
palsy (nerve), 96-97
papilledema, 68
patch, 47, 93, 120-121
path of light, 17-19
perimetry/perimeter, 32-33
peripheral vision, 12, 22, 62, 66,
101, 114. See also visual field
phacoemulsification, 144
pharmacology, 149-156
phoria, 91
photography/photograph, 126,
127, 130-131
photophobia, 86, 101
photoreceptor cells, 12, 126
photorefractive keratectomy
(PRK), 142
pinguecula, 57, 77
pinhole, 112
“pink eye”. See conjunctivitis
plus lens(es), 30, 31, 32, 36, 38,
40, 43, 48
posterior chamber, 7, 8, 11
posterior segment, 7, 8, 11
Potential Acuity Meter (PAM),
131
174 Index .............................................................
pregnancy, 72
prematurity, 72
presbyopia, 40, 42-43, 141
prescription (for glasses), 40-42,
132
pressure, intraocular. See intra-
ocular pressure
pressure, sensation of, 104
prism(s)
optical, 30-31
in strabismus measurement,
115, 116, 128, 129, 131
progressive add lens. See no-line
bi/trifocal lens
protrusion, of eye (exophthal-
mus), 54, 56, 104, 126
pseudophakia, 47-48
pterygium, 57, 78
ptosis (drooping), of eyelid, 53,
75, 93, 103
pulling, sensation of, 104
puncti/punctum, 6, 53, 54, 124,
140
pupil, 11, 60, 61, 62. See also
dilation and cycloplegia
disorders of, 60, 61, 62
evaluation of, 112-114, 131
reaction of, 25, 61, 112, 113-
114
and the red eye, 69, 70, 85, 86,
90
shape of, 60, 62
size of, 61, 103
range of motion, 127
rash, 104
recurrent erosion, 60
red eye, 69-70, 85, 86
refraction, of light, 132. See also
lenses (optical)
refraction, measurement, 132.
See also refractive errors and
refractometry
refractive error(s), 26, 36-40, 47-
48. See also specific refractive
error
refractive surgery, 141-142, 143,
145
refractometry, 131-132, 151
refractor/phoropter, 123
retina, 12, 19
detachment of, 66-67, 84, 146
disorders of, 65-68
evaluation of, 126, 129-130, 150
surgery of, 145-146
retinal thickness analyzer (RTA),
132
retinopathy, 65, 66
retinoscope/retinoscopy, 132
rheumatoid arthritis, 72
rod(s), 12, 13, 19, 126
rose bengal, 150
scanning laser polarimetry (SLP),
132
scanning laser tomography (SLT)
132
scar, corneal, 10, 59
Schirmer’s tear test, 132-133
sclera, 7-8, 10, 12, 57-58, 146
scleritis, 57
scotoma, 21, 22
shingles, 73
side effects (of medications),
152, 153, 154, 156, 157-163
slit lamp (microscope), 10, 117,
118, 131, 133
smoking, 66, 73
specular microscopy. See endo-
thelial cell count
shpere/shperical (lens), 32, 40, 41,
42
stereo vision, 23, 133
steroid(s), 64, 153
strabismus, 89-91, 92, 97, 103
measurement of, 115-116, 129-
130, 131
tests regarding, 125, 127, 133,
136
stye. See hordeolum
subconjunctival hemorrhage, 57,
78
................................................................. index 175
surgery of optic nerve, 68-69
cataract, 64-65, 144 of retina/vitreous, 67-68
corneal, 141-142, 143 of skin/lids, 53
enucleation, 146 of tear system/globe/orbit, 55-
for glaucoma, 63, 142-144 56
refractive, 141-142, 143, 145 triage, 69, 108
retinal, 67, 145-146 trial frame/trial lenses, 133-134
skin/lids, 139-140 trichiasis, 53, 76, 140
strabismus, 145 trifocal(s), 40, 43-44
tear system, 140 tropia, 91, 92, 116-117, 127, 128
swelling, 104 trypan blue, 150
swinging flashlight test, 113-114
sympathetic ophthalmia, 55, 62 ulcer, corneal, 59
symptoms. See also specific dis- ultrasound, 124, 130, 134
order uvea, 12, 55, 60, 62
physical, 103-104 uveitis, 62, 69, 70
visual, 100-102
synechiae, 61 vasoconstrictors (ocular decon-
syphilis, 61, 73 gestants), 155
systemic disorders, 70-72. See vision
also specific disorder color. See color vision
systemic medications, 156, 157- disturbances of, 100-102, 157-
163 162
physiology of, 1, 2, 12, 17-21,
tangent screen, 135 23, 91, 93
tear film. See tears testing of. See visual acuity
tear system, 6-7, 53, 54, 55, 129. visual acuity, 109-112, 134
See also nasolacrimal system visual cortex (of brain), 19
tear test(s), 132-133 visual field
tears, 3, 6-7, 9, 17, 53 defects of, 13, 21-22, 95
artificial, 155 testing of, 114-115, 134-135
thyroid, 54, 72, 126 visual pathway, 19-22
tonometer/tonometry, 133 visual pigment(s), 23-24
topography, corneal, 125 vital signs, 135
trabecular meshwork/trabecu- vitamin(s), 66, 73
lum, 11, 143 vitreous humor, 11, 18, 65, 133
transposition (of lens power), detachment of, 67, 84
41-42
trauma watering, 53, 55
of anterior chamber, 62, 80 wavefront analysis, 135
of conjunctiva/sclera, 58 Worth four-dot, 136
of cornea, 59-60, 79
of lens, 65, 83 zonules, 11, 24
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