Now in its tenth edition, Manual for Eye Examination and Diagnosis is the leading introductory clinical textbook in the field, providing concise and practical coverage of anatomy, instrumentation, differential diagnosis and treatment of ophthalmic diseases and disorders. This accessible resource offers clear explanations of current diagnostic techniques, equipment and best practice; hundreds of full-color clinical photographs and diagrams; and step-by-step guidance on a range of key procedures. Author Mark Leitman, a practicingOphthalmology specialist with nearly five decades' experience, provides the foundational knowledge required to excel on an ophthalmology rotation. This is a must-have companion for medical students and junior doctors, trainee ophthalmologists and optometrists, optometry nurses, and ophthalmic technicians.
History includes the patient's chief complaints Table 1, medical illnesses, current medications, allergies to medications, and family history of eye disease.
Table 1 Common chief complaints Common chief complaints Causes
Persistent loss of vision 1
Focusing problems are the most common complaints. Everyone eventually needs glasses to attain perfect vision, and fitting lenses occupies half the eye care professional's day. LASIK, used to correct refractive errors, is the number one cosmetic surgery in the USA. 2
Cataracts (Fig. 7
) are cloudy lenses that commonly occur with aging. Unoperated cataracts are the leading cause of blindness worldwide. In the USA, over 3.5 million cataract extractions are performed each year. It is the number one major surgery in the USA and worldwide. 3
Thirteen percent of American adults are treated for diabetes. Another 40% are pre-diabetic. It is the leading cause of blindness in the USA in those under 65 years of age. 4
Age-related macular degeneration (AMD) (Fig. 516
) causes loss of central vision and is the leading cause of blindness in people over age 65 (Fig 515
). Signs are present in 25% of people over age 75, increasing to almost 100% by age 100. 5
Glaucoma is a disease of the optic nerve that is usually due to elevated eye pressure. It mostly occurs after age 40; affects 4% of Americans over that age, with black persons affected five times as often as whites. Peripheral vision is lost first, with no symptoms until it is far advanced. This is why routine eye exams are recommended. 6
Amblyopia affects 2-3% of children. It is due to improper use of one or both eyes in early childhood and usually resulting from eye turns (strabismus) or uncorrected refractive errors. Transient loss of vision lasting less than ½ hour, with or without flashing lights In younger patients, think of migrainous spasm of cerebral arteries. With aging, consider emboli from arteriosclerotic plaques. Simultaneous symptoms in both eyes often direct one to a brain etiology. Dry eye is also the common cause of on-off loss of vision. Floaters Almost everyone will at some time see shifting spots due to suspended particles in the normally clear vitreous. They are usually physiologic, but may result from hemorrhage, retinal detachments, or other serious conditions (Figs 556
). Flashes of light (photopsia) The retina accounts for 84% of complaints, which are usually unilateral. Simple sparks are most often due to vitreous traction on the retina (Figs 562
). Insults to the visual center in the brain (16%) are most often migrainous, but ministrokes, especially in the elderly, must be considered. Cerebral causes are often bilateral, with more formed images, such as zigzag lines. With aging a transient unilateral visual loss often viewed as a curtain coming down (referred to as amaurosis fugax) is most often due to a cholesterol embolus liberated from an arteriosclerotic plaque in the carotid artery (Figs 81
, 582 and 584-586). In older individuals transient bilateral blurring of vision is often due to decreased blood flow at the posterior circulation to the brain. A blood clot from the the heart as might occur from atrial fibrillation, a cholesterol embolus or obstruction to flow through vertebral artery in the neck should be considered. A common cause of transient blurring of vision especially in the elderly could be due to dry eye which should be considered before pursuing an extensive vascular workup. It is often associated with a gritty irritated eye relieved by artificial tears and corneal edema noted at the slit lamp (Fig. 248
). Another clue to distinguish dry eye from blood flow causes is the sometimes associated neurologic symptoms such as headache, vertigo, muscle numbness or weakness or slurred speech associated with the latter etiology. Night blindness (nyctalopia) Nyctalopia usually indicates a need for spectacle change, but also commonly occurs with aging and cataracts. Rarer causes include retinitis pigmentosa and vitamin A deficiency. Double vision (diplopia) Strabismus, which affects 4% of the population, is the condition where the eyes do not look in the same direction. This binocular diplopia disappears when one eye is covered. In straight-eyed persons, diplopia is often confused with blurry vision or caused by hysteria or a beam-splitting opacity in one eye that does not disappear by covering the other eye. Light sensitivity (photophobia) and corneal diseases (Table 9
, p. 94) Usually, a normal condition treated with tinted lenses, but could result from inflammation of the eye or brain; internal reflection of light in lightly pigmented or albinotic eyes (Figs 540
); or dispersion of light by mucous, lens, and corneal opacities, or retinal degeneration. Itching Most often due to allergy, dry eye, and lid margin infections (blepharitis) (Figs 212
). Headache Headache patients present daily to rule out eye causes and to seek direction. 1
Headache due to blurred vision or eye-muscle imbalance worsens with the use of eyes. 2
Tension causes 80-90% of headaches. They typically worsen with anxiety and are often associated with bilateral temple and neck pain. 3
Migraine often occurs in families and affects in 20% of women and 10% of men. This recurrent pounding headache, often lasting for hours, but less than a day, is sometimes accompanied by nausea, bilateral blurred vision, and flashing, zigzag lights (Fig. 141
Sinusitis causes a dull ache about the eyes and occasional tenderness over a sinus (Fig. 223
). There may be an associated nasal stuffiness and a history of allergy. 5
Menstrual headaches are cyclical. 6
Sharp ocular pains lasting for seconds are often referred from nerve irritations in the neck, nasal mucosa, or intracranial dura, which, like the eye, are also innervated by the trigeminal nerve (Fig. 108
Headaches that awaken the patient and are prolonged or associated with focal neurologic symptoms should be referred for neurologic study. Visual hallucinations These most often occur in the elderly, especially in those with dementia, psychosis, or reduced sensory stimulation, as in blindness and deafness. Many medications, including cephalosporins, sulfa drugs, dopamines used to treat Parkinson's disease, vasoconstrictors, or vasodilators should be considered. Increased tearing (epiphora) Consider increased production due to emotion and eye irritation or decreased ability of a normally generated tear to drain into the nose. (Fig. 149
Record all systemic diseases. Diabetes and thyroid disease are two that are most commonly associated with eye disease.
- Diabetes may be first diagnosed when there are large changes in spectacle correction causing blurriness. It is due to the effect of blood sugar changes on the lens of the eye.
- Diabetes is one of the common causes of III, IV, and VI cranial nerve paralysis. It is due to the closure of brainstem vessels. The resulting diplopia may be the first symptom of diabetes and often resolves by 10 weeks.
- Retinopathy due to microvascular disease (see front and back cover) may result in macular edema. It is the primary reason for blindness before age 65. Patients with diabetes should have annual eye exams, because early treatment is critical. Retinopathy is rare in children before age 15.
Autoimmune (Graves') thyroid disease
This is a condition in which an orbitopathy may be present with hyper- but also hypo- or euthyroid disease.
Fig 1 Thyroid exophthalmos with exposed sclera at superior limbus, due to bulging eye.
- It is the most common cause of bulging eyes, referred to as exophthalmos (proptosis). This is due to fibroblast proliferation and mucopolysaccharide infiltration of the orbit. A small white area of sclera appearing between the lid and upper cornea is diagnostic of thyroid disease 90% of the time (Fig. 1). This exposed sclera may be a result of exophthalmos or thyroid lid retraction due to the stimulation of Müller's muscle that elevates the lid. Severe orbitopathy may be treated with radiation, surgical decompression of the orbit (Fig. 3), or by administering steroids orally, intravenously, or by injection into the orbit. In January 2020, the FDA...