to view the notes - KayGoshtasb Kavousi

Shahrokh Kavousi, OD
Optometric Physician
Clinical Eyecare Manual
Primary Care Essentials
Review Guide
Notebook
98 – 99
Table of Contents (Search Keywords)
Clinical Significance of Common Eye Disease
and its Treatments:
Meibomianitis - 1
Seborrheic Blepharitis - 2
Bacterial Blepharitis - 3
Chalazion - 5
External- Hordeolum (Stye) - 6
Internal- Hordeolum - 7
Preseptal Cellulitis - 8
Allergic dermatitis - 9
Allergic Conjunctivitis - 11
Vernal Kerato-Conjunctivitis (VKC) - 13
Viral Conjunctivitis - 15
Epidemic Kerato-Conjunctivitis (EKC) - 16
Acute Bacterial Conjunctivitis - 17
Hyperacute Bacterial-Conjunctivitis - 19
Adult Inclusion-Conjunctivitis, (Chlamydial conjunctivitis) - 21
Superior-limbic Kerato-Conjunctivitis (SLK) - 22
Filamentary Keratitis - 23
Bacterial Keratitis (Ulcer) - 25
Marginal Keratitis (Staph. marginal infiltrates /ulcers) - 27
Fungal Keratitis - 28
Acanthamoeba Keratitis - 29
Herpes Zoster Ophthalmicus - 31
Herpes Simplex Keratitis - 33
Herpes Simplex Infection - 34
Peripheral Corneal Thinning (Differential -diagnosis) - 35
Terrien’s Marginal Degeneration - 36
Corneal Abrasion - 37
Lid Conditions: - 39
Suderiferous-Cyst, Sebaceous Cyst
Molluscum-Contagiousum
Verruca-vulgaris (Warts)
senile/Actinic-Keratosis
Kerato-acanthoma
Squamous-cell Carcinoma
Basal-cell Carcinoma
Sebaceous-cell Carcinoma
malignant-Melanoma
Hemangioma
Papilloma, Dermoid, Xanthelasma
Trichiasis
lid-Burn, lid-Laceration
Black-eye
lid-twitching (Myokymia), Blepharospasm
Myasthenia-Gravis
Sclera /epi-sclera: - 41
Diffuse anterior Scleritis
Posterior-Scleritis
Necrotizing-Scleritis
Simple epi-Scleritis
Nodular epi-Scleritis
Conjunctival ; - 42
Conj. Foreign Bodies
Conj Laceration
Conjunctival Burns
Ophthalmia neonatorum
Orbit: - 43
Orbital-Cellulitis, Orbital-Pseudotumor
Blow-out Fracture
Lacrimal-System: - 45
Dacryocystitis, Canaliculitis
Punctal-Stenosis
Rosacea (acne-rosacea) - 46
Dry-Eye Syndrome - 47
Artificial Tears: - 49
Genteal-Gel, Refresh-liquigel, Thera-tears liquid-Gel
Tears-Naturale (PF), Hypotears (PF)
GenTeal, Refresh-tears, Tears-Again
Artificial Tears, Supplements: - 51
Systane ultra
Refresh-ENDURA (PF) “OTC”
Restasis “RX”, Nature’s-Tears
Omega-3 fatty acid supplementation
Dry-Eye Treatment - 53
Dry-Eye, Therapeutic Options - 55
Red-Eye work-up - 57
Uveitis - 59
Uveitic- Syndroms - 60
Laboratory Testing in Uveitis - 61
Corneal Conditions: - 63
Map-Dot-Fingerprint Dystrophy;(EBMD)
Fuchs' Dystrophy
Lattice Dystrophy
Keratoconus
Bullous Keratopathy
Band-Keratopathy
Phylyctenule
Corneal-Burns
Sjogren’s-disease
Corneal Foreign-bodies
Cycloplegics & Mydriatics - 69
Atropine, Homatropine, Scopolamine
Cyclopentolate, Phenylephrine
Topical Antibiotic Drops - 71
Combination Antibiotic drops - 72
Topical Antibiotic Ointments - 73
Combination Antibiotic Ointments - 75
Antibiotic-Steroid Combination - 76
Steroid Pharmacology - 77
NSAID’S (non-steroidal Anti-inflammatory Agents) - 79
NARCOTICS - 81
Antiseptic - 82
Therapeutic & Diagnostic Agents - 83
Topical Anti-Histamine & Decongestant - 84
Oral Anti-Staph. Antibiotics - 85
Glaucoma Drugs - 87
Primary Open-Angle Glaucoma - 89
Acute narrow-angle Glaucoma - 91
Secondary open-angle Glaucomas - 94
Systemic Anti-Viral - 95
Grave’s Ophthalmopathy - 96
Ocular Side Effects of Systemic Medicines: - 97
Plaquenil
NSAIDS, Corticosteroids
Digoxin
Oral-Contraceptives
Anti-histamines, Phenothiazines
Lithium-Carbonate
Beta-Blockers & Diuretics
Hypo-vitaminosis
Hyper-vitaminosis
Systemic Medicines - 99
Diagnostic Pupil –Testing: - 103
Aide‟s or Tonic-Pupil
Horner‟s Pupil
Pupil-testing (Chart)
Heart –Disease ; - 105
Heart-attack or myocardial infarction
Congestive heart-failure
Cardiac arrhythimias
Stroke
Transient ischemic-attack (TIA)
Temporal Arteritis (TA)
Symptoms
A - AION
Vascular –Disease ; - 107
Pulse
BP
Carotid-artery auscultation
Heart-failure symptoms
Plaques
CABG
Diabetes: - 109
Insulin
Diabetes Symptoms
Complication of diabetes
Diabetic-nephropathy
Neuropathy
Ophthalmoplegia
Fluctuating-VA
keto-acidosis
glucose-tolerance test
hemoglobin - A1C
IDDM, type-I // NIDDM, type-II
Diabetic Retinopathy: - 117
Microaneurysms, IRMA, VEGF, vitreous-hemorrhage, NVD, NVE
cotton-wool spots, Macular-edema, Nonproliferative (NPDR)
dot-blot intraretinal hemorrhages, venous-beading, soft/hard-exudates
proliferative (PDR), Neovascularization, NVI (rubeosis), CSME
fluorescein angiography (FA), PanRetinal-Photocoagulation (PRP)
Hypertensive Retinopathy: - 124
cooper-wire, arteriosclerosis, silver-wire, A/V-nicking
malignant hypertension, Disc-edema, Telangiectasis
retinal-hemorrhages (flame-shaped), Four-Groups
Systemic Conditions w/Fundus Manifestation: - 129
Background-diabetic Retinopathy (BDR)
Proliferative diabetic-retinopathy (PDR)
Hypertension and Arteriosclerotic Retinopathy
Branch Retinal Vein-Occlusion (BRVO)
Central Retinal Vein Occlusion (CRVO)
Branch Retinal Arterial Occlusion (BRAO)
Central Retinal Artery Occlusion (CRAO)
Histoplasmosis
Toxoplasmosis, Toxocara
Sarcoidosis
AIDS: CMV-retinopathy
Multiple-Sclerosis (MS)
Retinal Pathology: - 135
Pathological- Myopia
Retinitis-pigmentosa
Pigment-Clumping
RPE- hypertrophy & hyperplasia
Age-Related Macular-Degeneration (ARMD)
ARMD Dry-form
ARMD Wet-form
Sub-Retinal Neo-Vascularization (SRNV)
Angioid-Streaks
Cystoid Macular-edema (CME)
Clinically-significant Macular-Edema (CSME)
Central-Serous Choroidopathy
Macular-Holes
Horse-shoe Tear
Retinal-Detachment (RD)
RetinoSchisis
Lattice-degeneration
Papilledema
Papilitis
Optic Neuritis
Retro-bulbar Neuritis
Ischemic Optic-Neuropathy (ION)
Anterior Ischemic Optic Neuropathy (AION)
Secondary Optic-Atrophy
Optic-Pit
Optic-nerve head Drusen
Tilted-Disc
Choroidal-Nevus
Choroidal-Melanoma
Phosphenes
Required Knowledge: => => =>
Relative Afferent-Pupillary Defect (RAPD) - 144
Marcus-Gun Pupil - 145
Horner‟s –syndrome - 145
Adie‟s - 146
Argylrobertson - 146
Bell‟s-Palsy (VII-N.) - 147
Acquired 3rd N.-Palsy - 147
3rd Nerve-Palsy - 147
4th Nerve-Palsy - 148
6th Nerve-Palsy - 148
Synergistic-muscles - 148
Agonist - 148
Antagonist - 148
Yoke muscles - 148
Hering‟s-law - 148
Sherrington‟s-law - 148
VI, IV, III(SR,IR,MR,IO), N.-Paralysis - 149
Duane‟s-retraction - 149
MS : Paralysis of medial-gaze - 150
Medial-longitudinal-fasciculus (MLF) - 150
Mobius-syndrome - 150
Brown‟s syndrome - 150
Parinaud‟s-syndrome - 150
Bell‟s phenomenon - 150
Headaches - 151
Ocular Migraines - 151
Systolic-BP, Diastolic - 152
Orbital-“Bruits” - 152
Neurological field defects - 152
Optic-Nerve lesions
Diagram of the Cortex - 153
Figure; Deficits in the Visual Pathway - 154
Brain Tumors Field Defects - 155
Pitutary- adenoma
Center of Chiasm lesions
Lesion Posterior to Chiasm
Temporal-loop of optic-Radiation
Humphrey Visual-Field - 156
Visual field-testing - 156
Tangent-screen - 156
Amsler-Grid - 156
Photo-Stress (Macular-test) - 157
Color-Saturation test - 157
Color-vision - 157
Acquired Color-Vision Deficiencies(Kollner‟s-Rule) - 158
Anomalous Trichromasy - 158
DiChromate‟s - 158
Monochromasy - 159
Farnsworth Panel D15 - 159
Ishihara - 159
Contrast-Sensitivity - 159
Temporal Resolution w/aging - 160
Pulfrich-Phenomenon - 160
Myopic-Shift - 160
NS-Catract - 161
Hyperopic-Shift - 161
Potential Acuity-Meter(PAM) - 161
BIO - 161
Lens-Ophthalmoscopy - 161
Druzen - 162
Follicules - 162
Pterygium - 163
Pinguecula - 163
Dermatochalasis - 163
Madarosis - 163
Shirmer–I - 164
Shirmer–II - 164
Jones test –I - 165
Jones test –II - 165
Fluorescein dilution-test - 165
Rose-Bengal - 165
TBUT - 166
Methylene-Blue - 166
Cultures - 166
Hirshberg‟s –test - 167
Krimsky method - 167
CT- distinction - 167
Stereopsis - 168
Worth Four-Dot test - 168
Depth-Perception - 169
Suppression - 169
Horopter - 169
Vergence system - 169
Associated-Phoria - 169
Negative & Positive Relative Accommodation - 170
NRA - 170
PRA - 171
Amplitude of accommodation - 171
Van-Graefe Binocular-Balance - 172
Secondary Focal-point - 172
Static Retinoscopy - 173
Duochrome (biChrome) - 173
Incorrect-WD - 174
Mohindra technique - 174
NPC - 174
Morgan‟s table - 175
Smooth-vergence testing - 175
Donder‟s amplitudes of Accommodation - 176
Maddox-Rod - 177
Underaction - 177
Overaction - 177
Strabismus (Comitant & Non-comitant) - 178
ARC - 178
Amblyopia - 178
Occlusion-therapy - 178
Nystagmus, Vestibular - 179
Sacadic, Pursuit - 179
Primary XT - 179
Accommodative ET - 179
Prescribing Initially - 179
Accommodative dysfunctions - 180
Accommodative-Insufficiency
Accommodative-Excess
Accommodative-Infacility
Binocular Syndromes - 181
Convergence Insufficiency
Convergence Excess
Fusional Vergence Dysfunction
Divergence Insufficiency
Divergence Excess
Basic Eso-Phoria
Basic Exo-Phoria
Flippers - 184
Keratometer - 185
Radiuscope - 185
Power-reading - 186
Lensometer - 186
Reading-Prism - 186
Transposition - 186
Latent-hyperopia - 187
Manifest-hyperopia - 187
Absolute-hyperopia - 187
Facultative-hyperopia - 187
Night Myopia - 187
Astigmatism - 188
Irregular-Astigmatism - 188
Refractive- astigmatism - 188
Internal-Astigmatism - 188
Corneal-Astigmatism - 188
Refractive-Ametropia - 189
Axial-Ametropia - 189
Knapp‟s-law - 189
Anisometropia - 190
Slab-Off (Presbyope) - 190
Reverse Slab-Off - 191
Aniseikonia - 191
Principal-planes - 192
Secondary Focal-length, „Far-point‟ - 192
Power-Magnification factor - 193
Shape-magnification factor - 193
Spectacle Magnification - 193
Aphakic-Spectacles - 194
Aphakia - 194
High Minus-lenses - 194
Spectacle Frames - 194
Optical-Center - 195
Datum-line - 195
MRP - 195
Decentration - 195
Inset - 195
Prentice‟s rule - 196
Prismatic effect - 196
Image Jump - 197
Interpupillary-distances (PD) - 198
Bifocal-Height - 198
Progressive-height - 198
Trifocal-height - 199
Location of Seg-Top - 199
Multifocal Lens-type - 200
w/High-Rx - 200
Pantoscopic-tilt - 201
Retroscopic-tilt
Face-form tilt - 202
Vertex-distance - 203
frontal angle, splay angle, vertical angle
temple-angle - 205
NosePads - 205
Sunglass-Tints - 206
Index of Refraction (n) - 207
Chromatic-Aberration (CA) - 207
Distortion - 208
Aberration type - 208
Aspheric-design - 208
Diffraction - 208
Anti-reflective Coating - 208
UV-wavelength Absorption - 208
Visible-Light - 209
Visual-Perceptual development tests - 209
FDA (Food & Drug Administration) - 209
FTC (Federal Trade Commission) - 210
ANSI – standards - 210
Toric-Rigid lens - 211
Toric-Designs - 211
Indication for RGP‟s - 211
Rules of thumb for RGP - 212
Astigmatic Contact-Lenses - 212
Sagittal-depth - 213
Base-Curve - 213
Ideal-Pattern - 214
Rigid-Lens Specifications - 215
Hard-Lenses - 216
Flexure - 216
Soft-Contact lens-Parameters - 217
Good-Fit - 218
Contact-lens F/up - 218
Lens-Deposits - 218
LARS - 219
Care of Lenses - 219
CL-Conjunctivitis - 220
Prosthetic Soft-Lenses - 220
Therapeutic Bandage-lens - 220
Keratoconus-CL - 221
Irregular-Corneas - 221
Soft-Toric; Indication - 221
CL-Contraindication - 221
Bifocal-Contact lenses - 222
Contact-lens Rotation - 223
Bailey-Lovie - 224
Snellen-VA - 224
Visual Acuity - 225
Letter-size - 226
Low-Vision - 226
Legal-Blindness - 226
Streak Retinoscopy - 227
Dr. K. method
Refraction – 228
MPMVA
Duochrome (Mon.)
JCC
Prism dissociation
Biocular Duochrome
Near Finding: - 231
Vergences
Phorias
AC/A ratio
BCC
NRA, PRA
Sheard‟s A/A
Unilateral (Cover-Uncover) test - 235
Alternating Cover Test - 236
Alternating-CT; Neutralizing Tropia and Phoria: - 237
=> Lateral - CT
=> Vertical - CT
ORTHO-induced Phoria - 238
Rx∆ => w/loose-Prisms - 239
Thorington => Phoria Measurement - 241
Park 3-Steps Method - 243
Park‟s => 3-Steps - 245
Bio-Microscope (Slit-Lamp) - 246
ParallelePiped
Optic-Section
Topical Antibiotic Drops - 249
Vigamox, Zymar, Quixin, Iquix, Ciloxan, Ocuflox, Chibroxin
Azithromycin (AzaSite), Tobramycin, Gentamicin
Combination Antibiotic Drops (sol./ung.) - 250
Polytrim, Neosporin
Topical Antibiotic Ointments - 250
Erythromycin, Bacitracin, Tobrex,
Genoptic, Tetracycline, Sulfacetamide
Combination Antibiotic Ointments (unguent) - 250
Polysporin, Neosporin
Antibiotic-Steroid Combinations - 251
Zylet, TobraDex, Maxitrol, Blephamid
Topical NSAID’S - 251
Acular, Ocufen, Voltaren, Nevanac, Xibrom
Topical Steroids - 252
Pred Forte, Lotemax, Vexol, Maxidex, FML, Alrex
Topical Antiviral - 253
Viroptic, Vira-A, Zovirax
Systemic Antiviral - 253
Acyclovir, Famvir, Valtrex, Cytovene
Systemic Steroids /Oint. - 253
Prednisone, Kenalog, Hydrocortisone
Mydriatics & Cycloplegics - 254
Antihistamine & Decongestant Combinations - 254
Naphcon-A, Vasocon-A, Albalon-A
Antihistamine - 254
Emadine
Mast-cell Stabilizer/Anti-histamine Combo. - 255
Cromolyn Sodium, Alomide, Alamast, Alocril, Zaditor/Refresh
Alaway, Pataday, Patanol, Elestat, Optivar
Antiseptic - 255
Diagnostic & Therapeutic Agents - 256
Tensilon, Mucomyst
Systemic NSAID’S - 256
Tylenol-3, Ibuprofen, Aspirin, Indocin, Naprosyn, Feldene
Oral Antihistamine - 257
Claritin, Clarinex, Zyrtec, Allegra, Benadryl
Decongestants - 257
Naphcon, Vasocon, Visine, Clear eyes, Murine, Allerest
Oral Anti-Staph. Antibiotics - 258
Augmentin (Amoxicillin + Clavulanate), Cloxacillin, Dicloxacillin
Cephalexin (Keflex), Ceftin, Duricef, Ceclor, Bactrim
Erythromycin, Tetracycline, Doxycycline, Minocycline
Glaucoma Medications - 259
Timolol-maleate (Timoptic sol, Timoptic-XE gel), Istalol [Betimol]
Betagan, Betoptic-S / Betoptic, Betaxon
Trusopt, Azopt, Methazolamide (Neptazane), Acetazolamide (Diamox)
Alphagan-P, Xalatan, Lumigan, Travatan-Z, Cosopt
Oral Medicine in Primary Eye Care
Etiology: Staph. - 261
Etiology: staph, strep, H.influ. - 262
Etiology: seasonal allergic - 263
Etiology: vernal - 263
Etiology: herpes varicella-zoster - 263
Etiology: herpes simplex virus - 263
Etiology: Chlamydia - 264
etiology: corneal epithelial defect - 264
etiology: corneal abrasions - 264
Etiology: deficiency of anti-oxidant vitamins (A,C,E) - 265
Etiology: vitamin-A deficiency - 265
Miscellaneous - 266
Activity Recommended Colors - 269
Driving, Hunting, Skiing, Fishing, Swimming
Water Sports, Cycling, Motorcycling
Golf, Tennis, Racquetball, Baseball
Soft Contact Lenses Parameter - 272
Daily, Bi-Weekly, Monthly
CibaVision
Bausch&Lomb
CooperVision
Vistakon
Valley Contax
SynergEyes
Prescription Pad & Forms
Contact Lens Consent - 279
INFORMED REFUSAL - 280
Ophthalmologist Referral - 281
Patient Ocular Examination - 282
Patient History and Information (CL-Progress Evaluation) - 283
Spectacle & Contact Lens Rx - 284
Spectacle Rx - 285
Contact Lens Rx - 286
Medicine Rx - 287
Medical Rx - 288
Therapeutic Rx - 289
Business Card (Optometric Physician) - 290
This is a notebook of quotes and paraphrases as a clinical primary eye care guide to review. It is compiled solely
for personal use, and no financial gain is expected. Information is gathered from several reference books, texts,
study guides, journals and lecture notes. Although it is generally a rewritten coalescence of summarized notations
by a scholar, divulgence of the resources has been curtailed, since these are intended only to be a note. I shall
neither assert any acknowledgement for intellectual work nor allow any reproduction, prints or copy of any
material from its contents. All privileges belong to the innovative writers and their respective thoughts.
Dr. KayGoshtasb Kavousi
Primary Eye Care Essentials
Clinician Guide
Notebook
Click here to view the notes
Meibomianitis
O
N
LY
* Hot compresses, lid massage/scrubs bid-qid
- sever: consider lid expression in office → painful!
* sever, add: Tetracycline 250mg qid/10-30 days, Doxycycline 100mg bid/10-30 days
O
PY
,V
IE
W
(suppresses lipase activity of bacteria & reduces the amount of semi-solid fatty-acid in meibomian secretions)
* add: antibiotic/steroid combo. oint./susp. to lids tid/2-3wks
- RTC 4-wks
C
- Adverse effects of Tetracyclines PO; is diarrhea, rash, stomach upset skin photosensitivity
and must be taken on empty stomach, where as with Doxycycline it can be taken with meals
O
R
DO NOT-Rx Tetracyclines for pregnant/nursing or children ↓12 years,
IN
T
(Tetracycline, attaches to calcium in teeth & bone causing discoloration and softening)
D
- chronic
O
N
O
T
PR
* burning, irritated eyes
* eyelids margins-Red w/ milky froth
* Presence of foamy, whitish tears
- Presence of milia (white plugs)
- etiology: increased of solid fatty acid in meibomian secretions, causing congestion of the glands
1
Seborrheic Blepharitis
O
PY
,V
IE
W
O
N
LY
* Lid hygiene
* Lid scrubs, bid -PRN (ocu-clens, eye scrub, baby shampoo)
* Tetracycline 250mg qid/2-4 wks (severe/persistant): tx. anti-staph oint. qhs
R
O
T
IN
O
D
O
N
- marginal erythema
- non-infectious inflammation
- elderly
T
PR
* irritation, worse in the Morning
* Greasy eyelash mattering
* greasy sleaves at base of lashes
C
- RTC: one month, prn
2
Bacterial Blepharitis
O
PY
,V
IE
W
O
N
LY
* warm compresses & lid-scrubs bid -prn
* oint. qid (narrow-Bacitracin ung500 units/gm “staph. excellent”, applied to lid-margin
broad-Erythromycin 5mg/g, 0.5% “ilotycin, AK-mycin”[long-term; angular])
C
- follow-up: 4 weeks or PRN
R
- broad-Tetracycline 10mg/g, 1% (achromycin, aerosporin)
T
O
is NOT very effective against Staph. (dermatitis, photosencitivity, NOT-children ↓12 /preg., nursing)
D
O
N
O
T
PR
IN
- Aminoglycosides:-broad spect. “staph. effect”.
Tobramycin (tobrex) 3mg/ml “localized toxicity & allergic reaction”
Gentamicin (Gentoptic, Garamycin) “Pupillary dilation, burning”
- narrow-Sulfacetamide 10% (bleph-10 , cetamide, sodium sulamyd)
NOT-w/ mucopurulent, ↑hypersensitivity/hemophilus, strep effect
- Sulfisoxazole 4% (Gantrasin), similar to sulfacetamide
3
LY
N
O
T
O
R
C
O
PY
,V
IE
W
Combination:
Polysporin Oint. (narrow -/+) “safe” (soft-lens), broad
Polymyxin-B 10000 units/g (narrow -)
Bacitracin 500 units/g (narrow +)
- Combo: Neosporin oint. (broad/aminoglycoside)
neomycin 3.5 mg/g “↑allergic reaction”
Polymyxin-B, Bacitracin
D
O
N
O
T
PR
IN
* Symptom are same but more pronounced than seborrheic
* Dry lash collarettes, scurf, sleeves (with or without Ulceration)
- chronicity: irregular thickened lid margin (tylosis),
madarosis, trichiasis
4
Chalazion
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Hot compresses bid-qid/ 2-3 wks (as often & as long as tolerable)
* digital massage after compress
- if non-responsive, injection of 1ml of 40mg/ml Triamcinolone
(Kenalog) into the lump.
“steroid can depigment darkly pigmented skin (blacks)”
- Surgical excision
* Recurrent chaluzia may indicate Sebaceous gland Carcinoma (Refer for biopsy).
- follow up, PRN unless lesion persists past 1-month
(RTC – 1 week post Sx)
D
O
N
O
* Painless,
* localized firm lid-swelling
* inflammation of a Meibomian gland, granulomatous (lump-forming)
- variable size, rate of growth
5
External- Hordeolum, (Stye)
O
PY
,V
IE
W
O
N
LY
* Hot-compresses qid
- Don‟t express (Risk of bacterial infection spread)
* Lid-hygiene as needed (scrubs) after initial inflammation subsides
O
R
C
- Add, anti-staph Oint. bid-tid (optional, depends on severity)
“Bacitracin ung 500units/gm”
PR
IN
T
- RTC, Prn (unless not-resolving in 4-weeks)
D
O
N
O
T
* Painful-lump, Red, at the lash-line
* infection or inflammation of Moll or Zeiss gland
- often in children
- often accompanied by Blepharitis
6
Internal- Hordeolum
C
O
PY
,V
IE
W
O
N
LY
* Hot-compress qid
* Anti-Staph drops q4h. & oint. qhs
tobramycin/gentamicin 0.3% gtts; Bacitracin ung 500 units/gm
- if non-responsive, (or, if there is the risk of developing preseptal-cellulitis)
then systemic treatment is often required.
PR
IN
T
O
R
* consider adding: oral anti-staph such as tetracycline, erythromycin,
Cephalexin [cephalosporins]
D
O
N
O
T
* Painful, large localized lid-swelling w/ erythema
* lump can point toward the internal (or external surface of lid)
- usually, a staph infection of a Meibomian gland
7
N
O
O
PY
,V
IE
W
* same treatment as internal-hordeolum,
Plus an oral anti-staph antibiotic for 7-10 days
- Tetanus toxoid if needed and history of trauma
- RTC, Daily (until improvement noted)
LY
Preseptal Cellulitis
D
O
N
O
T
PR
IN
T
O
R
C
* Diffuse-red, painful upper & lower Lid
(without: proptosis, EOM, VA or Pupillary-response involvement)
“If any of these effected, it would indicate deeper orbital involvement”
* swelling and redness extending from the lid-margin to the orbital-rim,
that is quite diffuse
- often there is a history of internal-hordeola, blepharitis or trauma
- if a child, consider hemophilus or strep as etiology
- if redness/swelling pass the orbital-rim,
consider orbital-cellulitis (more serious infection)
8
Allergic dermatitis:
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* frequent Cold compresses
* Hydrocortisone 0.5% -1% apply to lids tid→qid
(not to be used in eyes, available OTC-cream, use caution in dark skin
individual since it can cause depigmentation specially w/1%)
+oral antihistamine/decongestants (for type-I only, Not effective type -IV)
- claritin-10mg“OTC”(loratadine), zyrtec 5mg,10mg (cetirizine) clarinex 5mg (desloratadine)
allegra 60mg,180mg (fexofenadine), hisminal (astenizole), seldane (terfenadine)
- benadryl (25mg diphenhydramine, 60mg pseudephedrine) 1 tab q6h.→ q4h. “OTC”
PR
IN
chlortrimeton (4mg chlorpheniramine, 60mg pseudeph.), dimetane (4mg brompheniramine)
D
O
N
O
T
+Systemic steroids, (SEVER): “immediate type-I”
- Prednisone 40-60mg qd for several days then taper
- Triamcinolone (Kenalog) 40mg for 1-injection
- Methylprednisolone 80mg for 1-injection
9
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Itchy, red, swollen eye-lids, “absence of pain on palpation”
(history of exposure to a chemical or medication)
+ onset in minutes to hours (immediate type-I)
- hives, urticaria (itching)
- patchy area of erythema that may be Moist & weeping
+ onset slower “days usually” than type-1 (delayed type -IV)
- often from drug allergies (including preservatives)
- Dry, erythematous, patches w/intradermal swelling
*folow-up: 1-week
*removal of sensitizing agent
T
+common adverse effects: reduced tear production, drowsiness (from med. used to treat)
D
O
N
O
+topical antihist. & decong. have minimal effect on allergic dermatitis
- contraindication of Antihistamines: narrow angle glaucoma, diabetics,
hypertension cardiovascular & thyroid disease.
10
Allergic Conjunctivitis
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Combination (Seasonal) “acute”
“one-month /more”
+ Alaway 0.025% bid-10ml (OTC)
Mast-cell stabilizer (Chronic)
+ Patanol 0.1% 5ml-bid & Pataday 0.2% 2.5ml qd + Alamast 0.1% bid, qid-10ml
+ Zaditor 0.025% bid-5ml (OTC)
+ Alocril 2% bid-5ml
+ Optivar 0.05% bid-6ml
+ Alomide 0.1% qid-10ml
+ Elestat 0.05% bid-5ml
+ Tilade (Nedocromill)
NSAIDS (moderate)
+ (cromolyn sodium 4%)
+ Acular-LS 0.4% qid -5ml
Crolom, Opticrom qid-10ml
+ Voltaren
Anti-histamines
Steroids (severe) “5-7 days”
+ Emadine 0.05% qid-5ml
+ Alrex 0.2% qid-5ml, 10ml (long term)
Decongestants (OTC)
+ Lotemax 0.5%
+ visine-A
+ Pred Forte 1% “qid”
+ opcon-A
* “remove the sensitizing agent”-*Cold compresses, *Artificial Tears
11
R
C
O
PY
,V
IE
W
O
N
LY
* Itching, burning
- tearing, w/watery discharge (stringy mucoid-discharge)
- mild hyperemia
* tissue swelling (chemosis)
- red, edematous eyelids
+ papilae: conjuctival, (papillary-hypertrophy)
+ history of allergies
D

O
N
O
T
PR
IN
T
O
RTC, “few-weeks”
- (superior corneal inflamation sometimes “vernal / atopic”
including limbal-infiltrates)
{Anti-histamines: Livostin 0.05% qid 5ml,10ml - “Discontinued”}
12
Vernal Kerato-Conjunctivitis (VKC)
D
O
N
O
T
O
PY
,V
IE
W
O
N
LY
Mast-cell stabilizers
+ Alomide, Alocril, Alamast
+ crolom, opticrom (cromolyn sodium)
NSAIDS (moderate)
+ Acular bid-qid
+ Voltaren bid-qid
Steroids (severe)
+ Pred Forte bid-qid
+ Lotemax, Alrex, Pred-mild
Cycloplegic(ulcer):[hydrogel-lens: low water cont.]
+ homatropine, atropine, scopolamine
Antibiotic (ulcer): Vigamox, Ciloxan
ocuflox, quixin, tobrex, polytrim
C
R
O
T
PR
IN
* cold compresses (supportive ther.)
* artificial tears & oint. PRN
Decongestants (↓hyperemia)
+ naphazaline
+ Phenylephrine
Combo. /-antihist.
+ Patanol
+ zaditor
+ optivar
- “livostin”
Oral-antihistamines
+ benadryl, 25mg-tid
Ulcers: mucomyst 10%-20% q4-6h.
13
LY
N
O
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
* superior and limbal conjunctival inflammation
* Papillae, superior tarsus-large
* severe Itching
+ raised white dots (clumps) at superior limbus
+ onset typically age 3-25y. old > males
+ bilateral, chronic
- SPK, some areas
- history of Allergies
- ulcers, superiorly, in sever cases
- thick discharges
- warmer climate > prevalence
14
Viral Conjunctivitis
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
- Lavage (rinsing)
* Artificial tears ad-lib
* add, vasoconstrictors/antihistamines if itchy
* Sever: mild steroid gtts, FML qid/1-wk (↓sign & symptoms)
- RTC, 1-2 wks
- unilateral or bi-lateral (infection)
* onset of red, WATERY eye w/little irritation or else mild burning
* follicles are present inferiorly w/enlarged preauricular lymph-node
* VA varies w/blink
- usually an upper-respiratory infection or “cold” (prior)
- etiology, an adenovirus or less frequently from bird-dropping
(Newcastle‟s) or cats (Parinaud‟s oculoglandular fever)
* Keratitis w/corneal sub-epithelial infiltrates may be present
- Adenoviral disorders are self-limiting
and treatment is palliative only (not-curring it).
15
Epidemic Kerato-Conjunctivitis (EKC)
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* very Contageous (emphasize hygiene)
- lavage PRN, or Artificial tears PRN
* mild topical steroid: Prednisolone acetate 0.125% or combo. Tobradex
(if Pt. uncomfortable, VA reduced, dense sub-epithelial infiltrates or iritis
developed), it may be beneficial to use antibiotic that are effective against
gram-positive bacteria which thought cause the spread of virus in
superficial cornea. “Tobramycin, Gentamicin /Fluoroquinolones”
- Avoid school or work while discharge & erythema present
- anti-viral drops are not effective
- RTC, 1-2 wks
* unilateral, viral (adnoviral infection)
* acute, WATERY, erythema
O
* follicular conjunctivitis w/grossly enlarged preauricular node (that little painful to touch)
D
* ↓VA due to central sub-epithelial infiltrates (SEI)
* SEI present around 1-week after onset of conjunctivitis
16
Acute Bacterial Conjunctivitis
- RTC; every 1-2 days
- lavage(rinse), prn
- warm compresses, ad-lib
O
PY
,V
IE
W
O
N
LY
broad-spectrum: qid/7-10 days
+ polytrim 10ml
+ quixin 0.5% 5ml
+ ciloxan 0.3% 2.5ml, 5ml
+ ocuflox 0.3% 5ml
+ tobramycin (tobrex) 0.3% 5ml
+ gentamicin (genoptic) 0.3% 5ml
IN
Steroids:
+ Lotemax 0.5%
+ Pred forte 1%
+ Flarex
D
O
N
O
T
PR
Combination:
+ Maxitrol susp./ung 5ml
+ TobraDex susp./ung 2.5ml, 5ml
+ Pred-G susp./ung 2.5ml, 10ml
T
O
R
C
poly-antimicrobial:
+ vigamox 0.5% 3ml, qid → qh
+ zymar 0.3% 2.5ml, 5ml, qid →qh
17
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* yellowish mucopurulent “mucous & pus” discharge (wet, sticky)
- lids are matted shut, upon waking (mattering of lashes)
- photophobia & discomfort, mild
* one eye then the other eye (may-be)
- bulbar & palpebral injection
- w/minimal follicular response
- Punctate epitheliopathy, frequently
- visual function typically, normal
- pain is not typical
- w/papillary tarsal-conj. present
* worsening over a few days
18
Hyperacute Bacterial-Conjunctivitis
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* begin emprical/broad spectrum therapy: Topical tetracycline,
Gentamycin, oflaxacin or ciprofloxacin q2h
* Systemic: keflex (cephalexin) 250-500mg qid, [or Levaquin 500mg qd*1wk ]
Penicillin-G (0.6 to 5million units injected IM)
cephtriaxone (1g injected intra-muscularly)
- Amoxicillin, ampicillin, carbenicillin and ticarcillin
are effective against Strep. & Neisseria (NOT-Staph.)
Erythromycin 500mg qid (adult-dosage)
(Penicillins have 15% hypersensitivity “any drugs ending in suffix- cillin”
and Anaphylaxis is the allergic reaction of most concern).
- internist or pediatrician consultation (may co-exist w/upper-respiratory, ear infection)
- lab: Gram-stain (morphology), cytology (cell-type: bacteria, virus, allergy)
Culture (blood & chocolate agar), sensitivity (antibiotic effectiveness)
19
O
N
O
D
--Follow up, daily
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* bilateral, rapidly progressive, red-eyes
w/mild to moderate irritation
* Copious mucopurulence w/erythemia, edema or staining
(sticky discharge, eye-lids stuck together upon wakening)
* found in children & young adults
* Mixed follicular/papillary response, often w/preauricular -lymphadenopathy
* Bulbar-Petechiae (bleeding) and tarsal-membrane /Pseudo-membrane often present
- etiology: Staph., streptococcus Pneumoniae, E-coli, hemophilus influenzae,
Pseudomonas, Nisseria-gonorrhea, serratia marcensans
20
Adult Inclusion-Conjunctivitis, (Chlamydial conjunctivitis)
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* treat Systemically: Tetracycline 250mg qid/1-month
Doxycycline 100mg bid, erythromycin 250mg qid
or single dose of Azithromycin 1gm Po (Zithromax)
* treat topically: tetracycline 1% or erythromycin 1% qid for 1-month
- lab test: Urethral Culture
Giemsa stain, to detect inclusion-bodies
or use an immunoflourescent antibody test.
- RTC, 1-3 wks
* chronic, conjunctivitis w/episodes of acute inflammation
followed by resolution with or without treatment, or else
a constant sub-acute conjunctivitis.
* mixed follicular/papillary tarsal response with an
enlarged pre-aurricular (in front of the ear) lymph node.
- history of exposure to venereal disease, may present w/urethritis
- variable presentation, where the condition has lasted for some time
21
Superior-limbic Kerato-Conjunctivitis (SLK)
T
O
R
C
O
PY
,V
IE
W
O
N
LY
- manage w/drops, lubricant first,
and discontinue contact-lenses/thimerosal if any
* Pred-forte or decadron qid/2-wks
- silver nitrate 0.5%-1.0% Painted on superior bulbar and
palpebral conjunctiva followed by lavage (repeat weekly,
“usually for 2-wks”), this treatment has potential for serious
corneal damage “so rarely used”. Also used in ophthalmic-neonatorum.
- RTC, one-week
D
O
N
O
T
PR
IN
* middle-aged women (often w/thyroid dysfunction or history
of soft-contact lens wear), “possiblity of thimerosal reaction”.
* bilateral irritation & sectorial redness w/superior bulbarconjunctivitis & superior palpebral-papillae.
* limbal infiltrates, in superior cornea or
pseudo-dendrites (looks like a herpes-dendrite).
22
LY
Filamentary Keratitis
O
PY
,V
IE
W
O
N
- artificial tears (non-preservatived)
- punctal occlusion (persistent dry-eye)
+physical removal of filaments by forceps
D
O
N
O
T
PR
IN
T
O
R
C
*mucolytic agent (dissolves filaments)
- mucomyst 2-10% (from a compounding pharmacist 5% sol.)
“smell like rotten eggs”
Sever (prolong management: wks-months)
+Prophylactic-antibiotic drops bid-tid (Not a disease)
+NSAIDS/Steroid: Palliate associated discomfort
- soft bandage contact-lens (high-water ~70%)
23
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* mucus filaments within tear-film (adhered to cornea)
* ocular discomfort (mild: foreign body sensation, sever: pain)
* Rose Bengal /lissamine green dye
+ variable: tearing & photophobia
+ ↓TBUT, filamentary Keratitis
+ unilateral/bilateral, pseudo-ptosis possible
- hypermia -particularly limbal
- SPK (punctate epithelial Keratopathy)
- more in women & elderly
+ systemic: connective tissue disorders /immune deficiencies
+ accompanies: KCS /SlK/Erosion/diabetes
24
LY
Bacterial Keratitis (Ulcer)
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
Antibiotics:
+ ciloxan 0.3% iigtts-q15 min/6h, iigtts-q30 min/1d, iigtts-q4h./till resolved
+ vigamox 0.5% 3ml q1h
Culture: blood/chocolate agar
+ zymar 0.3%
Saboraud‟s sol.(fungi)
+ ocuflox 0.3%
Scraping: cornea, conj., lid (stain)
Ointment:
+ polysporin ung 3.5g
....(after 48h. if epith. is healed!
Cycloplegia:
could ?? → lotemax 0.5%q2h.
+ scopolamine 0.25% tid
pred forte 1%q2h.
+ atropine 1% bid
- if ↑IOP → aqueous suppressent
- ii gtts → around the clock!
* cold compresses (↓inflammation)
- RTC → Daily
25
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* epithelial excavation (ulcer)
w/focal stromal infiltrate, under (edematous cornea)
* acutely painful, unilateral
* sever light-sensitivity (photophobia)
* profuse tearing
* mucopurulent discharge
* ant. chamber reaction (cell &flare)
* often history of Extended Contact-lens wear (soft)
* intensely injected eye (conjunctival & episcleral vessels deeply engorged)
- often, hypopyon (pus layer in the bottom of ant. chamber)
- VA↓ -(IOP ↓ or ↑)
+ large, dense Central ulcer (Psuedomonas w/blue green discharge)
+ small Paracentral ulcer (Staph.) minimal infiltrate
26
Marginal Keratitis (Staph. marginal infiltrates /ulcers)
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Hot-packs/compresses and lid-scrubs qid/7-10 days
* Tobramycin /Gentamicin gtts q4h, ung-hs
* Add; Prednisolone acetate (Pred-forte) or
dexamethasone phosphate (decadron) qid or combo.
(after 24 to 48 hrs if no epithelial defect on top of infiltrate),
if an epithelial defect is described, (fluorescein-staining),
then select an antibiotic alone.
- follow-up, Daily
* Marginal intra-epithelial infiltrates (whitish, at edge of cornea)
at the 8-4 o‟clock position, with or without overlying epithelial defects.
* can show signs of infections-Blepharitis and papillary-Conjunctivitis
* overlying epithelial defect (Staining), means you must clinically
assume that it is no-longer an infiltrate, but an infectious “Ulcer”.
- Symptoms, range from mild foreign body sensation to sever
irritation &light sensitivity.
27
Fungal Keratitis
R
C
O
PY
,V
IE
W
O
N
LY
* Natacyn (natamycin 5% suspen. q1h. to q2h for 3-4 days then qid for 2-3 weeks)
+ Nystatin-PO, silver sufadiazine
+ Flucytosine 1%, Amphotericin-B 0.15% or IV
+ imidazoles (miconozole 1%, clortrimazole, ketoconazole)
+ triazoles (fluconazole 0.5%, itraconazole)
- Scopolamine 0.25% tid
-- Agar Petri-dish plating /corneal Smears (fungi can takes up to weeks to identify)
- RTS, daily
D
O
N
O
T
PR
IN
T
O
* ocular trauma, w/Vegetative matter
+ feathery, branching pattern -initialy (filamentary → molds)
+ smal ulceration (s-shaped), w/ infiltrate expanding (localized → yeast)
- pain, severe initialy
- uveitis, severe (iritis)
- hypopyon
- compromised immune is prone, (AIDS, cancer, diabetics)
+ raised, dirty-gray ulcer w/ ragged leading edge
28
N
O
C
R
O
T
IN
D
O
N
O
T
PR
+ PHMB & Brolene (combo.)
- chlorhexidine digluconate 0.02%
- neomycin & clortrimazole 1%
- polymixin-B
- ketoconazole (anti-fungals)
- miconazole
+ Atropine 1% tid
+ Tylenol- III (for pain)
+ contact-lens (bandage)
O
PY
,V
IE
W
* Polyhexamethylene Biguanide 0.02% (PHMB)
* Brolene (Propamidine Isethionate 0.1%)
LY
Acanthamoeba Keratitis
29
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Ulceration, “Ring-shape, (worse toward the edges of the lesion)”
w/ infiltration (under)
* Stromal Ring-infiltration (occasional, complete or partial)
* contact w/non-sterile water (swimming“lakes, pools, hot-tubs”
home-made salin sol.), “EW-soft contact”
* can present initially as dendritic-keratitis (similar to HSV)
+ painful, very (1/2 experience mild irritation)
- unilateral, Red-eye
* Chronic course (weeks → months)
- Hospitalization (often), corneal-Graft (common)
30
Herpes Zoster Ophthalmicus
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Acyclovir (Zovirax) 800mg 5xday/5-10 days
(helps ↓post-herpetic neuralgia, especialy in initial attacks
and before skin-lesions appear), maintenance dosage 200mg/5xday
“Famciclovir 500mg tid, is a newer Acyclovir-substitute”.
* alcohol-wipes, calamine, zinc-sulfate or other astringents
to skin lesions for comfort. “Bacitracin oint. to skin lesion -bid”.
* NSAIDS (Ibuprofen 200-800mg qid) for pain
* topical gram-Positive antibiotic (Bacitracin) qid to ↓viral-spread
* ocular lubricating ointments
* Capsaicin 0.025% Cream (Zostrex), an OTC cream ↓skin-pain
- cimetidine (Tagamet) PO may help ↓skin-pain
- Pred forte q2h → qid for ant. uveitis or corneal inflammatory signs
(use caution if corneal break present)
31
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* sever pain w/vesicular lesions respecting-midline
* “Dendriform” Keratitis w/tapered ends,
rather than the terminal end-buds seen in HSV
- stromal involvement is common
- Hutchinson‟s sign (vesicle at tip of the nose), indicate ocular involvement
- older patient (in young think AIDS), or history of cancer, immunosupres
* flu-like symptom in early stage
* iritis & inflammatory glaucoma are common
+ Serotonin reuptake inhibitors (SRI‟S) such as Paxil, Prozac, Zoloff
are used as adjunct therapy for post-herpetic neuralgia
+ advance-care: Cycloplegic PRN for iritis
- Prednisone 30-60mg qd for posterior-uveitis, acute retinal necrosis
- beta-blockers for inflammatory glaucoma
- corneal transplant if scarring
+ internal medicin, dermatology consult indicated
+ RTC, 1-7 days (if ocular involvement), if Not-ocular RTC, 1-2 wks
32
Herpes Simplex Keratitis
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Trifluridine 1% (Viroptic) igtt q2h. until re-epithalization
qid/1-week there-after
* Vidarabine 1% (Vira-A) ung-qhs until no-more staining
* Bacitracin gtts (reduces, viral spread)
- Cycloplegia, if iritis
- Corneal debridement (Scraping) of loose epithelium
“Not-proven effective”
- variable; pain, redness & vision impairment
* follicular conjunctivitis, w/enlarged preauricular-node.
* corneal hyposthesia (↓sensitivity to touch),
especially in re-current attacks.
* epithelial dendrite (branching, arborizing w/end-bulbs)
“best observed w/Rose-Bengal stain
or lissamine green”.
33
Herpes Simplex Infection
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Acyclovir 400mg/7-14 days
(has little effects on the number or severity of secondary attacks)
* tx. of simplex-related vesicular Blepharitis
without corneal-involvements:
+ Cold-packs and astringents (alcohol wipes,
calamine, zinc-sulfate).
+ Zovirax 1-5% Cream tid → lids
- follow-up: every few days to monitor cornea
* Primary- HSV presents, w/Vesicle formation & sores at
muco-cutaneous borders and w/lymph adenopathy, significantly.
- primary infection occurs in children
(does-not commonly affect the eye)
- later in life, direct ocular infection seen,
(secondary manifestations)
34
Peripheral Corneal Thinning (Differential -diagnosis):
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Marginal Keratitis secondary to Staph. Hypersensitivity;
(painful, infiltrate present, inset from limbus).
+ Mooren‟s ulceration: (unilateral or bilateral,
painful corneal thinning with neovascularization).
+ Dellen: (painless, oval thinning secondary to corneal drying)
+ Furrow degeneration: (painless, peripheral corneal thinning,
adjacent to corneal arcus without vascularrization).
+ Peripheral corneal Melt, secondary to collagen vascular
disease, such as rheumatoid- arthritis and polyarteritis nodosa:
(bilateral, typically painful and progressive to perforation).
+ Pellucid marginal degeneration: (painless, inferior peripheral
corneal thinning, a variant of Keratoconus).
35
Terrien‟s Marginal Degeneration
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Supportive, (periodic episodes of red, irritated eyes)
+ Lotemax 0.5% qid
+ Prednisolone acetate 0.12% or 1%
- Poly. glasses (correcting Astig. if any)
- Soft bandage lens w/RGP pigyback
* superior nasal peripheral corneal thinning (epith.-intact)
* peripheral corneal haze that spares the limbus
* ↑astigmatism (regular or irregular)
+ little if any pain, photophobia or ant. chamber reaction
+ bilateral (mostly middle-aged males), often asymptomatic
+ hydrops (in sever cases)
^ 3-features in topography:
a.) corneal flattening at the junction of the furrow
b.) corneal steepening 90 degree from the flattened area
c.) and a relatively spherical and regular central area
36
Corneal Abrasion
O
PY
,V
IE
W
O
N
LY
- Anesthetic (topical, in office)
- Cycoloplegia
D
O
N
O
T
PR
IN
T
O
R
C
* polytrim (polymyxin-B & trimethoprim)
+ gentamicin
+ tobrex (tobramycin)
* vigamox
* zymar
+ voltran (Sever- NSAID‟S)
+ acular (Sever- NSAID‟S)
- Topical steroid (only when significant uveitis?)
- OTC, analgesics (pain)
- Bed-rest /bandage contact-lens (thin ↓water content)
- RTC, 24h. “pressure patching is no-longer significant”
37
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* acute Pain
+ photophobia
- lacrimation
- blepharospasm
- foreign-body sensation
- blurry vision
- diffuse corneal edema
- epithelial disruption
D
O
N
O
T
PR
IN
- history of contact lens-wear /or being struck in eye
- folds in Descemet‟s membrane (Sever)
- use sodium-fluorescein dye
- use cobalt blue-light for inspection
38
Lid Conditions
O
PY
,V
IE
W
O
N
LY
+ Suderiferous-Cyst (Clear lid-cyst): minor, Lancing, surgery
+ Sebaceous Cyst (non-clear lid-cyst), “can be large” : Surgery
+ Molluscum-Contagiousum (multiple/small umbilicated lid-lesion /virus):Cautery, excision
+ Verruca-vulgaris (Warts): dichloroacetic-acid (also called bichloroacetic-acid)
Cautery topically-applied to the lesions
+ senile/Actinic-Keratosis: Flat, Scaly skin-lesion, related to sun-exposure, may be pre-Cancerous
R
C
+ Kerato-acanthoma (benign skin-lesion, older-men, in sun-exposed area
w/Keratin filled crater): resolves on it‟s own, Sx.-excision
PR
IN
T
O
+ Squamous-cell Carcinoma (older Pt. look like-“benign-Kerato-acanthoma”): Sx. excision-all
+ Basal-cell Carcinoma (Nodular, Pearly-Surface w/small-Vessels and Ulcerated-Center)
D
O
N
O
T
most-common: Biopsy & surgical excision
+ Sebaceous-cell Carcinoma (Malignant, from Meibomian gland, in case of
Recurrent-Chalazia this suspected): Surgery
+ malignant-Melanoma (uncommon, metastasizing, death, from-Nevi): Sx.
39
C
O
PY
,V
IE
W
O
N
LY
+ Hemangioma (benign, Purple, vascular skin-tumor, at-birth): surgery
+ Papilloma: a descriptive term of a non-specified skin-lump/bump
+ Dermoid (smooth, Cyst-like Benign, usually at lateral-Canthus):excised if symptomatic
+ Xanthelasma (Yellowish lipid-deposits in Nasal-lids ↑↓): surgical /excision
+ Trichiasis (misdirected-lashes, often from Blepharitis):
epilation, cautery, electrolysis, cryotherapy, laser
D
O
N
O
T
PR
IN
T
O
R
+ lid-Burn: Cold-packs, antibiotics
+ lid-Laceration/-Trauma: Surgical-repair soon (unless Edema present), lubrication
+ Black-eye: Cold-packs, rule-out orbital blowout-fracture
+ lid-twitching (Myokymia): Re-assurance or oral-Antihistamines
+ Blepharospasm (involuntary Orbicularis-Contraction: Oculinum-IM(Botulism-toxin)
+ Myasthenia-Gravis: Prostigmine or Pyridostigmine, ptosis-Sx.
40
Sclera /epi-sclera
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Diffuse anterior Scleritis: significant deep-boring Pain, women > men,
Progressive threatens-vision, associated
w/rheumatoid-arthritis, herpes-Zoster, gout
+ Posterior-Scleritis: Pain, ↓VA, retinal-edema, exudative retinal/choroidal
Detachments. Tx. topical-steroids w/systemic NSAID‟s & Steroids,
immunosup. drugs, thinned-sclera supported w/Sx.-graft
+ Necrotizing-Scleritis: more-severe, w/scleral-melting, vascular-closure,
Staphyloma, 30% dead by 5-years
D
O
N
O
T
PR
IN
- Simple epi-Scleritis: localized inflamation “usually triangular”, pain,
redness, lacrimation, photophobia, tenderness;
tx. mild-steroids gtts. Benign, last 1-2 weeks
- Nodular epi-Scleritis: more protracted than simple-form,
has a nodule on episclera;
tx. topical-steroids “not as helpful as w/simple”
41
Phenylephrine 2.5%: it will blanch (constrict) conj. & epi-scleral
vessel, if redness persists, it is scleritis
LY

O
PY
,V
IE
W
O
N
**Conjunctival ;
D
O
N
O
T
PR
IN
T
O
R
C
+ Conj. Foreign Bodies (observation w/ fluorescein): remove by
lavage, swab, spud and antibiotic-Oint. applied
+ Conj Laceration (observation w/fluorescein): antibiotic-Oint.
+ Conjunctival Burns: immediate Irrigation, cold-compresses,
antibiotic, atropine, Sx. later if Scarring
+ ophthalmia neonatorum (child-born w/Conjunctivitis, usually due to
“gonococcal 2-3 days onset after-birth” and
“chlamydial 5-12 days after-birth” -infection)
Gonococcal tx. w/Cephtriaxone /Kanamycin-IM
Chlamydial tx. w/Erythromycin –PO
42
Orbit
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Orbital-Cellulitis:
(Most-common cause of Proptosis in Children),
develops rapidly, needs prompt Infection treatment,
Cavernous-sinus /Cranial-nerve involvement,
“erythema/Hyperemia, deep-orbital chemosis/Edema,
proptosis, limitation on eye-movement, Pain, ↓VA”,
Tx. hot-compresses, Ampicillin or Amoxicillin,
Sinus-drainage may be necessary,
(cultures: nasal, blood, conjunctival)
D
O
N
O
+ Orbital-Pseudotumor: (diffuse Orbital inflammation),
Unilateral, rapid-onset w/pain
Tx. Systemic-Steroids
43
LY
+ Blow-out Fracture:
C
O
PY
,V
IE
W
O
N
History of Trauma, Enophthalmus (use- exophthalmometry),
diplopia, limitation movement on forced-duction
(attempt to move eye by grabbing conjunctiva w/forceps),
Sensitivity of infra-orbital Nerve
D
O
N
O
T
PR
IN
T
O
R
Tx. CT-scan or waters-view X-ray,
Wait 1-2 weeks for Resolution of Edema
to Evaluate for Surgery needs,
(Persistent-Diplopia, Enophthalmos,
large-Fracture of Orbital-Floor)
44
Lacrimal-System
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Dacryocystitis: Unilateral, Infection of lacrimal-Sac, Obstructed nasolacrimal-Duct,
(acute-onset w/pain, swelling, tenderness, tearing, discharge,
Pus can be expressed on palpation of Sac, risk of Orbital-Cellulitis),
usually caused by Staph. or beta-hemolytic Strep.
Tx. Surgery; Dacryo-Cysto-Rhinostomy (DCR),
some relief w/Systemic & topical Antibiotics,
in infants this resolves on it‟s-own
(if child ↑6 months: lacrimal-Probing done,
“younger: w/antibiotic gtts &massage of lacrimal-sac”).
+ Canaliculitis: Canulicular Inflammation, w/chronic-Conjunctivitis,
(caused by fungus “Actinomyces”).
Tx. expression of granules, Surgical removal
of granules or irrigation w/Penicillin solution.
+ Punctal-Stenosis: Obstruction may be from Conjunctival-Shrinkage,
Tx. Dilation of the Punctum.
45
Rosacea (acne-rosacea)
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Tetracycline 250mg qid/4-6wks
(erythromycin if tetracycline contraindicated)
* pred-forte qid (Prednisolone acetate) if corneal inflam. signs
* metronidazole 0.75% gel bid/3-9wks (Metro Gel) applied to the affected skin area
(including, eye-lids as well).
- Reactivations are common, so retreat accordingly
- RTC, weeks
* Rhynophyma (enlarged nose), telangiectasis (dilated superficial blood vessels)
of nose, cheeks, forehead & neck.
- middle aged (primarily of Northern European descent)
* Possibly accompanied by blepharitis, conjunctivitis,
Peripheral corneal inflammation and uveitis.
- ocular irritation (eyes just don‟t feel right), w/redness of eyelid margins,
mild bulbar-hyperemia & red-swollen nose.
- disease, is not caused by any infectious organism (standard blepharitis tx. are not-effective)
46
Dry-Eye Syndrome:
O
PY
,V
IE
W
O
N
LY
* Punctal Plugs (Sever)
- ophthalmic lubricants (Artificial-Tears)
- initialy qh. then qid, PRN
* Restasis 0.05% bid “6-months for max. efficacy” (Rx)
(an immune-modulatory agent for Inflamatory dryness)
C
+ Doxycycline 100mg bid/6-12wks (Tetracycline: Meibomian /Blepharitis “mucin/lipid -evaporative”)
D
O
N
O
T
PR
IN
T
O
R
- oral Omega-3 Fatty acid supplements (Meibomianitis)
- oral Secretagogues for advance-KCS (↑Tear-Production)
(typicaly used for Xerostomia /drymouth associated w/Sjogree /cancer)
- Salagen (Pilocarpine HCL-5mg, MGI Pharma)
- Evoxac (Cevimeline HCL-30mg, Snow Brand Pharmaceutical)
* Systemic Med. that cause ↓Lacrimal-Secretion: anti-Histamines, oral-Contraceptive,
beta-blocker, diuretics, Phenothiazine, anti-anxiety, anti-depres. atropin derevat.
47
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* dryness, burning, “gritty/ sandy” foreign-body sensation, itching
* ocular irritation or discomfort
+ more in elderly, women, w/connective-tissue disorders
(rheumatoid-arthritis, sjogren‟s syndrome, ”deficient -production”)
- exacerbated by poor air-quality/ ↓humidity or extreme-heat
- more prominent Later in the Day
- excess lacrimation or Epiphora (occasionally)
- ↓TBUT < 10 sec. (tear-meniscus at the lower-lid)
- flourescein-Staining (SPK-from inter-palpebral to lower-1/3 cornea)
* Rose-Bengal or Lissamine-green (Sever; filaments “mucus, cells, debris” staining)
- Zone-Quick test (15 sec.)
* Schirmer-Tear test Strips (5 min.)
(diminished-wetting/ tear-volume deficiency)
48
A.) Artificial Tears, Supplements:
O
PY
,V
IE
W
O
N
LY
*↑corneal-contact, without blurring-VA, more-viscous, thicker:
- Systane ultra (Alcon)
- Genteal-Gel (Novartis)
- Refresh-liquigel (Allergan)
- Thera-tears liquid-Gel (Advanced-vision Research)
T
PR
IN
T
O
R
C
* preservative-free “PF” :
- Tears-Naturale (PF)
- Hypotears (PF)
-- etc.
D
O
N
O
* preservative that break-down soon after instillation:
- GenTeal (preserved w/GenAqua or Sodium-Perborate)
- Refresh-tears (preserved w/Purite)
- Tears-Again (Cynacon/Ocusoft; preserved w/Dissipate)
49
R
C
O
PY
,V
IE
W
O
N
LY
* Restasis “RX” (Allergan: 0.05% Cyclo-Sporine ophth.-emulsion; “FDA→KCS”)
(KCS - - where Tear-Production is Suppressed due to Ocular-Inflamation)
- Clinicaly-shown, ↓Symptoms by 44%, ↑basal-tear Production by 59%
“by Schirmer” in Pt. after 6-months of therapy, Bid
(some improvement after several weeks been noticed)
- Treatment for CAUSE of DRY-EYE disease
- very Expensive, ocular-burning in 17% of Patient
D
O
N
O
T
PR
IN
T
O
* Nature‟s-Tears (Bio-logic Aqua-Technologies)
- “said-manufacture”: allows for Replenishing of the Aqueous-Component
without-disturbing the other tear-layers.
(there is lack of studies, demonstrating any superiority)
50
LY
B.) Artificial Tears, Supplements:
O
PY
,V
IE
W
O
N
* Systane (Alcon, Hydroxy-Propyl “HP”-guer), Moderate -Sever
(↑ in Viscosity after Contacting the ocular surface, due to liquid in
Bottle-PH of 7.0 and Eye-PH of ~7.4, ∆ to Gel-like)
T
O
R
C
- said manufacture: provides extended-relief of dry-eye symptoms &
generates a protective coating on the ocular surface.
D
O
N
O
T
PR
IN
- enhance improvement in TBUT and surface staining (Clinicaly, shown significant)
- diminishes foreign-body sensation &dryness (in Pt. that used the sol. over 6-wks qid)
- mild blurring for ~30 sec. after instilation
- excellent for Exposure-keratopathy, and managing minor Corneal-trauma
51
O
N
LY
* Refresh-ENDURA “OTC” (Allergan, unique-vehicle, an emulsion of
Castor-Oil & Lubricants in an aqeous sol.)
O
PY
,V
IE
W
- Preservative-Free, and packaged in single-use “disposable-viale”
D
O
N
O
T
PR
IN
T
O
R
C
- said manufacture; Endura is 1st lubricant that,
Treats all-3 layers of the tear-film
- enhance improvement in TBUT and surface staining
(Clinicaly shown, Excellent)
- diminishes Symptom of irritation &dryness
(in Pt. that used the sol. over 3-months Bid-qid)
- well tolerated (suited for Pt.w/lipid deficiency due to
meibomian gland dysfunction)
52
Dry-Eye Treatment:
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Painful, photophobic, injected eyes are: Inflamed
+ Lotemax / FML or Alrex, “Cyclosporine”
+ Lotemax 0.5% qid x 2 wks & bid x 2 wks & AT‟s
(Prior to Plugging for anti-Inflamatory Check√)- “Do-NOT Plug”
+ Lotemax 0.5% qid 1-month√ & bid x 1-month & qd x 1-2 months & AT‟s
+ Lotemax 0.5% qid 1-month√ &bid x1-month & Restasis 0.05% bid x 6-12 mon+AT‟s
+ Plugs: tear-film stagnation caused by the punctal-plugs may concentrate
pro-inflammatory cytokines in the tear-film and actually exacerbates
sign and symptoms of dry-eye in Pt. w/Scant tear-volume,
“helpful in Pt. w/moderate tear-volume” -(... AT‟s -qid must be added)
+ after anti-inflammatory resolution & having the Pt. on AT‟s only,
if acutely-symptomatic again, pulsing w/Lotemax 0.5% qid x 1-wk &
bid x 1-2wks can regain control (tapered to qd x 1-2wks), or
Restasis 0.05% bid for several months, (maintain, if onset is too short)
53
O
PY
,V
IE
W
O
N
LY
+ “Evaporative” Dry-Eye results when Meibomian-gland
(modified Sebaceous-gland) function is compromised.
D
O
N
O
T
PR
IN
T
O
R
C
- both oral Doxycycline, “generic/ Photosensitivity/ Vaginal yeast-infection”
(50mg tablet, bid x 2wks & qd x 6 months or longer) and Thera-Tears
nutrition supplementation, 4-capsules “taken in the morning, takes 3-4 months
to notice effect” (oral Omega-3 Fatty acid supplements “2000mg of flaxseed-oil
/fish-oil per day”), [Cynacon/Ocusoft: makes liquid-formulation Hydrate-Essential;
a combination of flaxseed-oil, evening primrose-oil and bilberry-extract],
“occasional GI-upset”, can Enhance Meibomian-gland function,
(in Pt. w/posterior Blepharitis /Meibomianitis).
54
LY
Dry-Eye, Therapeutic Options:
C
O
PY
,V
IE
W
O
N
* Mild -options: (2 of these may be needed Concurrently)
+ Artificial-tears alone, and/or
+ Punctal-Plugs alone, and/or
+ Omega-3 Fatty acid supplementation
D
O
N
O
T
PR
IN
T
O
R
* Moderate -options: (2-3 of these may be necessary to achieve Control)
+ AT‟s used frequently
+ Gel-formation @ bedtime
+ Punctal-Plugs
+ Omega-3 fatty acid supplementation
+ Restasis 0.05% bid trial for 3-6 months
55
O
PY
,V
IE
W
O
N
LY
* Sever -options: (intervention is highly variable among Pt.)
+ more Viscous Preservative-Free AT‟s used frequently
+ Lotemax qid x 1-wk, & bid x 1-month (*√-Inflammatory)
+ Long-term *Restasis 0.05% bid, if -Lotemax brought-relief!
D
O
N
O
T
PR
IN
T
O
R
C
+ oral Doxycycline 100 mg/d x 2-wks, & 50mg/d x 6-months
+ Omega-3 fatty acid supplem. x 3-6 months
+ Punctal-Plugs, once the above measures,
have been in-effect for a month or two
+ moisture-Shields or moisture-Goggles
56
Red-Eye work-up:
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* VA w/Rx/Ph, -Pupil, (history: precise description of the Symptoms)
+ degree of conjunctival- injection
- mild: allergy, chlamydia, mild-bacterial infection, dry-eyes
- marked -acute: viral or non-specific bacterial-infection, “acute-iritis”
+ pattern of conjunctival- injection
- global -injection: uniform; bacterial or viral-infection
- sector -injection: epi-scleritis, cornea-infiltrate, phlyctenule, SLK
> pronounced in the fornices, bacterial-infection
> pronounced para-limbally, limbal-vernal, iritis
+ discharge
- watery: viral
- mucopurulent: bacterial
- mucoid: dry-eyes, allergy, chlamydia
57
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Preauricular Lymphadenopathy
- not grossly visible: most commonly, adenoviral
less commonly, chlamydial
rarely, hyperacute-bacterial conjunctivitis
- grossly-visible: Parinaud‟s-oculoglandular Syndrom (very rare)
+ Follicles vs. Papillae: Clinically-virtually meaningless
- exception: giant-Follicles in the inferior forniceal-conj.
are highly indicative of chlamydial infection
D
O
N
O
T
PR
IN
+ examin; without & with Fluorescein-Dye (Cornea)
- R/o ulcers vs. infiltrates, abrasions, herpes, siedel‟s-sign, TBUT
+ evert-lid, (R/o FB /Papila)
+ IOP√ (Not in-Pathologic eye /Cornea), angle√, ant. cham. Cell-flare, quick-Ophthalm.
58
Uveitis
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Prednisolone Acetate gtts 1% qh (sever) to qid (very-mild)
+ Homatropine 5% bid, to “ATROPINE 1% tid” (depend on severity)
(if inflam. cells limited to ant. chamber & ant. vitreous)
“Systemic-Steroids are sometimes used if Non-responsive Topically”
- Posterior-Vitreous cells, imply the need for Systemic tx.
(is based on etiology of inflammation “infection Vs inflame. Vs neoplas.”)
- F/up: 1-7 days (depends on severity)
D
O
N
O
T
PR
IN
T
* deep ache that worsen w/illumination, peri-limbal injection, miosis,
↓IOP, ant. chamber cell & flare, Keratic-Precipitates (cell deposits)
-on the corneal-endothelium
* Posterior-uveitis: (tx. w/Systemic-steroids), minimal or no discomfort,
Posterior-vitreous cells (behind iris in vitreous-cavity), distorted-Vision,
disc &macular edema, retinal exudates, vascular sheathing
59
N
O
C
PR
IN
T
O
R
+ Fuch‟s Hetero-Chromic iridocyclitis
“differing Iris-Colors of two-eyes”
mild Iritis &variable IOP
(NO-tx. for uveitis, monitor for POAG)
O
PY
,V
IE
W
+ Phacolytic (lens-protein) Glaucoma
“associated w/hypermature Cataract”
(tx. removal of lens &capsule “lensectomy”)
LY
Uveitic- Syndroms:
D
O
N
O
T
+ Posner Schlossman syndrome
“known as glaucomatocyclitic-crisis”
mild-uveitis w/episodes of uni-lateral high-IOP
(often IOP-45 or higher, tx. ↑IOP, “NO-uveitis tx.”
60
Laboratory Testing in Uveitis:
O
PY
,V
IE
W
O
N
LY
* systemic-testing in Uveitis-Patients should be considered in:
- Bilateral cases, Multiple-episodes, Children
- Granulomatous,“Chronicity”(presence of Iris-Nodules & large mutton-fat Keratic-Precipitates)
O
R
C
+ Complete Blood Count (CBC, is an indicator of general-health)
+ Erythrocyte-Sedimentation Rate (ESR↑, is an indicator of Systemic-Inflammation)
+ Chest X-Ray (used to check for; Sarcoid & Tuberculosis)
D
O
N
O
T
PR
IN
T
+ test for Syphilis (FTA-ABS, MHA-TP, VDRL)
- middle aged blacks: w/Pan-Uveitis “Mutton-Fat” Keratic-Precipitates;
indicate SARCOID, testing to consider:
+ Chest X-Ray (hilar-lymphadenopathy “Lungs”)
+ blood-serum Angiotensin Coverting Enzyme (ACE) “elevated”
+ serum-Lysozyme “elevated”
+ Kviem-test, Gallium-scan
61
O
N
LY
- Young adult Males: w/Recurrent, Chronic or Bilateral
Uveitis & HLA-B27 Positive, if has :
a) burning w/urination /pain in legs, indicates Reiter‟s-disease
(urinalysis & rheumatoid-factor are both Negative)
b) stiff lower-back, indicates Ankylosing-Spondylitis
O
PY
,V
IE
W
(which shows degenerative changes in Sacroilliac-joint “x-ray lower-spine”)
R
C
c) joint pain & lower-gastrointestinal pain, or diarrhea
indicates Ulcerative-Colitis or Crohn‟s-disease
(lower-gastrointestinal Studies-Needed)
D
O
N
O
T
PR
IN
T
O
- Child: w/mild to moderate ant.-Uveitis, Band-Keratopathy & Arthritis
indicates Juvenile-Rheumatoid-Arthritis (JRA)
“Anti-Nuclear Antibody (ANA), Serum rheumatoid-factor (-)”
- Pt. w/Cough, along w/Uveitis, may indicate, Tuberculosis (TB)
+ Chest X-Ray
+ Sputum Culture (grows acid-fast bacilli “Myco-bacterium”)
+ Purified Protein Derivative “+” (PPD, Mantoux) skin-test
62
Corneal Conditions ;
Map-Dot-Fingerprint Dystrophy, (EBMD):
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Also known as Epithelial Basement Membrane Dystrophy; gets its name from the unusual appearance of, large
slightly gray outlines, with may be clusters of opaque dots underneath or close to the map-like patches, less
frequently, the irregular basement membrane will form concentric lines in the central cornea that resemble small
fingerprints; [best seen w/retroillumination or a broad slit-lamp beam angled from the side]. Basement membranes
serve as the foundation on which the epithelial cells, which absorb nutrients from tears, anchor and organize
themselves. When the basement membrane develops abnormality, the epithelial cells cannot properly adhere to it.
This in turn, causes recurrent epithelial erosions, in which the epithelium's rises slightly, exposing a small gap
between the outermost layer and the rest of the cornea. Epithelial erosions can be a chronic problem, and may alter
the cornea's normal curvature, causing periodic blurred vision, also moderate to severe pain that lasting several
days. Generally, pain will be worse on awakening in the morning, and other symptoms include sensitivity to light,
excessive tearing and foreign body sensation. Most common, it occurs in both eyes and usually affects adults ages
40-70, although can develop earlier. Typically, EBMD will flare up occasionally for a few years and then go away
on its own, with no lasting loss of vision. Prescribe lubricating eye drops and ointments (Muro-128 gtts & ung
“Sodium-chloride 5%”), control the pain, and patch the eye, w/tx. these erosions usually heal within 3-days,
although periodic pain may occur for several weeks. Other treatments includes; therapeutic soft contact lenses,
anterior corneal punctures to allow better adherence of cells, corneal scraping to remove eroded areas and allow
regeneration of epithelial tissue, also use of the excimer laser to remove surface irregularities.
63
Fuchs' Dystrophy:
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Is a slow progressing disease that affects both eyes equally (all-dystrophies), is more common in
women, and affects vision in adults age 50-60, (although can see early-sign in 30-40 years old Pt.).
Fuchs' dystrophy occurs when endothelial cells gradually deteriorate without any apparent reason.
As more endothelial cells are lost over the years, the endothelium becomes less efficient at
pumping water out of the stroma. This causes the cornea to swell and distort vision. Eventually,
the epithelium also takes on water, resulting in pain and severe visual impairment. Epithelial
swelling damages vision by changing the cornea's normal curvature, and causing a sight-impairing
haze to appear in the tissue. Epithelial swelling will also produce tiny blisters on the corneal
surface. When these blisters burst, they are extremely painful. At first, a person with Fuchs'
dystrophy will awaken with blurred vision that will gradually clear during the day. This occurs
because the cornea is thicker in the morning; it retains fluids during sleep that evaporate in the
tear film while we are awake. As the disease worsens, this swelling will remain constant and
reduce vision throughout the day. Try to reduce the swelling with ointments, drops (Muro-128
gtts & ung). Also, may instruct the patient to use a hair dryer, held at arm's length, directed across
the face, to dry out the epithelial blisters (can be done 2-3 times a day). Corneal transplant has a
good short term success rate, but long term survival proven to be a problem.
64
Lattice Dystrophy:
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Is an accumulation of amyloid deposits or abnormal protein fibers throughout the middle and
anterior of stroma. Slit lamp observation shows these deposits in the stroma as, clear comma
shaped overlapping dots, and branching filaments. Over time, the lattice lines will grow opaque
and involve more of the stroma, and gradually converge, giving the cornea a cloudiness that may
also reduce vision. In some cases these protein fibers can accumulate under the epithelium and
cause epithelial erosion (known as recurrent epithelial erosion). This results in temporary vision
problem (due to curvature alteration) and severe pain (due to nerve ending exposures) even with
blinking. Prescribe ointments and drops (Muro-128 gtts & ung), reduce the friction on the eroded
cornea, and sometimes eye patch, to immobilize the eyelids. These erosions usually heal within
3-days, although occasional pain may occur for the next 6-8 weeks. Although lattice dystrophy
can occur at any time in life, but usually arises in children age 2-7, and by age 40, scarring under
epithelium results in haze on the cornea that can greatly obscure vision. Recurrence of the disease
can arise in the donor corneal transplant in as little as 3-years, (in 50% of transplant Pt. between
2 to 26 years after Sx.), and may require a 2nd transplant. Excimer laser has shown good response
in patients, (removes surface irregularities).
65
Keratoconus:
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
It is more prevalent in teenagers and adults in their 20‟s. Keratoconus arises when the middle of
the cornea thins and gradually bulges outward, forming a rounded cone shape. This curvature
change produces, moderate to severe astigmatism (distortion) and blurriness. It may also cause
swelling and scarring of the tissue. It is about 7% inherited and Down-syndrome could be one of
the systemic factors. Usually affects both eyes, and specially fitted contact lenses (RGP) are the
vision correction of the choice. In most-cases, the cornea will stabilize after a few years without
ever causing severe vision problems. But in about 10-20% of patients, corneal transplant is
needed due to scar, and this operation is successful in 90% of patients, with 80% of them having
20/40 or better vision after the Sx.
D
O
N
O
T
PR
+ Bullous Keratopathy (epithelial-Edema, due to poor Endothelium-function,
Bullae “epithelial-cysts” are painful on rupturing, history of Cat.-Sx):
tx. bandage soft-contact, Transplant (Penetrating-Keratoplasty).
+ Band-Keratopathy (Calcium dep. in Inter-Palpebral; metabolic-disord.
uveitis in childhood “JRA”): Tx. of Epithelium w/Irrigation by
EDTA /excimer-laser (PTK).
66
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Phylyctenule (allergic-Reaction producing a Conj. or Cornea Nodule
that spontaneously-heals, due to Staph. /TB): tx. topical- Steroids.
+ Corneal-Burns: tx. copious Irrigation of chemical, Cycloplegia,
topical antibiotic-Oint., Pain-med Po, √-IOP↑,
refer to hospital/ER, (? Steroid gtts. -↓scarring).
+ Sjogren‟s-disease (Keratitis-Sica, xerostomia “dry-mouth”, arthritis):
Tx. treat as for Dry-Eye syndrome.
+ Corneal-Abrasion (sever-pain, lacrimation, blepharospasm),
use topical anesthesia & fluorescein in office, look under upper-lid:
tx. antibiotic-Oint., cycloplegia, RTC-1 day (pressure-patch NOT-nec. anymore)
+ Corneal Foreign-bodies (exam w/topical anesthetic & fluorescein):
removal by spud /alger-brush “rust-ring”, cyclopentolate 1%,
Gentamicin etc., “pressure-patching”, RTC-1 day
+ Dry-Eye syndrome (etiology: age, drugs, sjogren‟s, lupus, etc.),
results in chronic, low-grade ocular-irritation. tx. Artificial-tears, ocuserts,
Punctal-occlusion, moist-chambers, “soft-contact”
67

Mucin deficiency:

Lag Ophth:
KCS(Viral), Dry-eye Syndrom
LY
Exposure, Dry-eye
2/3
O
PY
,V
IE
W
O
N
Kerato-conjunctivitis

Bacteria:

-
Viral-infection
Allergy
Bacteria-staph(kerato-conj)

-
Ectropion (Exp.-keratitis)
* Allergic-kerato-conj(Vernal)
- Superior-staining
N
O
T
PR
IN
T
O
R
C
1/3 Staph.-auros
D
O
typical of Bacteria
Med.-abuse (Chronic)
- Inter-Palp. as Band (mid-inferior)
* typical of Dry-eye
68
Cycloplegics & Mydriatics
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Atropine, (mydriasis 8-10 days, cycloplegia 10-18 days)
- dx: high hyperopia in children ↓5 years (1% tid/3-days Before exam)
- tx: cycloplegia in very sever ant.-uveitis (bid-tid sol. for sever iritis)
used to break posterior-synachiae
- Contraindications: Down‟s syndrome, lightly pigmented pt.
- Adverse effects: flush, fever, delirium (CNS-toxicity)
+ Homatropine, (mydriasis 12-24 hrs, cyclopl. up to 2-days, max @ 1-2 hrs.)
- dx: dilation & cycloplegia for fundus eval. or refraction (5% sol. 1-2gtts 5min. apart)
- tx: cycloplegia in moderate acute iritis (5% sol. Bid) the most comonly used
+ Scopolamine, (cycloplegia 5-7 days, max @ 1-hr.) Atropine-like CNS-toxicity
- dx: cycloplegia exam (0.25% 1-2gtts 15-20 min. apart)
- tx: anterior-uveitis (0.25% sol. tid)
- used in Atropine-sensitive pt. requiring full cycloplegia
69
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Cyclopentolate, (max Cycloplegia @ 20-45min, last 8-24 hrs.)
- dx. cyclopl.-refraction in child ↑5 years (0.5-1.0% 2gtts 10min. apart)
- tx. cycloplegia in mild-iritis (& corneal-Abration)
- Adverse: CNS-toxicity, especialy w/2%
+ Tropicamide (for routin pupil dilation only)
++ Phenylephrine, (max 20 min, duration 2-hrs)
- dx. pupil dilation /epi-scleritis diagnosis 2.5% (2.5-10%)
- tx. breaking posterior-synechiae (10%)
- Adverse effect: ↑BP&Pulse, caution in pt. w/cardiovascular dis.
especialy w/10% concentration
++ Hydroxyamphetamine 1% (Paradrine), max 40 min.
- indication: routin pupil dilation (↑safety in narrow-angles)
Diagnosis of Horner‟s-Pupil
++Cocaine 10% (max 20min, duration 2-hrs
- Diagnosis of Horner‟s-Pupil
(strong topical anesthesia)
70
Topical Antibiotic Drops
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Fluoroquinolones: (for moderate to severe ocular infections)
+ Ciprofloxacin 0.3% (ciloxan), “Penetrates non-intact epithelium better”
+ Ofloxacin 0.3% (ocuflox), “Penetrate the intact-cornea better”
- broad spect. including “Pseudomonas”
- Adverse: white corneal-precipitates in “ciloxan” (used in corneal-ulcers)
+ Norfloxacin 0.3% (chibroxin), “Adverse: minor surface-toxicities”
- broad spectrum, including “Hemophilus-influenza” (common cause of
bacterial-conjunctivitis in children 2-6y.) and “Pseudomonas”
D
O
N
O
T
PR
IN
* Combination Antibiotic drops (gtts)
+ Polytrim (Polymyxin-B, Trimethoprim) solution “only”
- broad spectrum, Bacteriocidal, effective in conjunctivitis
- safe in children & covers nearly every species
- Systemically, Trimethoprim is used to Tx. acute Urinary-tract infection (sulfonamides mechanism, like)
71
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Combination (gtts)
+ Neomycin, Polymyxin-B, Gramacidin (Neosporin, Neocidin)
- see Neosporin oint. (antibiotic-combo.), Gramacidin is substituted for “Bacitracin” to form solution.
- Gramicidin is less effective gram+ than Bacitracin, therefore sol. is less effective than oint. against staph.
Individual Agents:
+ Tobramycin 0.3% (Aminoglycoside/see oint.), slightly ↑gram- effect, preferred
for “Pseudomonas” in contact-lens Pt.
+ Gentamicin 0.3% (Aminoglycoside, see ointment discution)
+ Tetracycline 1% (see-oint.) effective against “Chlamydia”
+ Chloramphenicol 5% (see –Adverse Oint.) effective for Hemoph.-influ. in
bacterial conjunctivitis commonly in kids 2-6y. old
Sulfonamides: (for very-mild bacterial-conjunctivitis withought-mucopurulent)
+ sulfacetamide 30, 15, 10% (see ointment discution)
+ sulfisoxazole 4% (Gantrasin)
- combination: w/decongestant (vasosulf), w/steroids (Blephamide, vasocidin)
- limited usefulness, specialy w/10% Allergic reaction in Pt.
72
Topical Antibiotic Ointments
O
R
C
O
PY
,V
IE
W
O
N
LY
Individual agents:
+ Bacitracin, ung 500 units/g
- narrow spectrum, Bacteriocidal, excellent against Staph. & gram+
- safe, effective, often Rx for Blepharitis oint.
+ Erythromycin 0.5% 5mg/g (Ilotycin, AK-mycin)
- broad spectrum, Bacteriocidal, moderate staph. effectiveness
- safe, for lomg-term oint. usage in Blepharitis, effective in Angular”
D
O
N
O
T
PR
IN
T
+ Tetracycline 1% 10mg/g (Achromycin, Aerosporin)
- broad spect. bacteriostatic/cidal, moderate staph. effectiveness
- contraindicated in pregnant/nursing and children under 8-12 years
dermatitis & photosensitivity (same as Erythromycin ineffective in Pseudomonas)
+ chloramphenicol 1% ung 10mg/g (Chloroptic), “Do NOT Rx”
- broad spect. Bacteriocidal /aplastic-Anemia, Bone-marrow depression Adverse
73
C
O
PY
,V
IE
W
O
N
LY
* Aminoglycosides:
+ Tobramycin (Tobrex) 3mg/ml
+ Gentamicin (Gentoptic, Garamycin)
- broad spect. bacteriocidal, excellent Staph. effect & Angular bleph.
- Tobramycin: Ok in children, reported localized toxicity & allergic
- Gentamicin: burning sensation and pupillary dilation noted
D
O
N
O
T
PR
IN
T
O
R
* Sulfonamides:
+ Sulfacetamide 10% (Bleph-10, cetamide, sodium-sulamyd)
- narrow spect. bacteriostatic, w/excellent Strep. & Hemophilas (only)
- hypersensitivity (10% Allergic), loses effect in presense of
muco-purulent discharge.
74
Combination Antibiotic Ointments
LY
* Neosporin ointment, contains:
+ Polymyxin-B 10,000 units/g, (safe)
O
N
- narrow spectrum, bacteriocidal, effective against gram- including pseudomonas
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
+ Bacitracin 500 units/g
- narrow spectrum, bacteriocidal, effective against gram+ & gonococci
+ Neomycin 3.5mg/g
- broad-spectrum, bacteriocidal (Aminoglycoside)
w/moderate effectiveness against staph. 10% of
population are hypersensitive (Allergic) reaction
* Polysporin ointment contains:
+ Polymyxin-B
+ Bacitracin
- covers both gram+ and gram- species
- an excellent & safe choice
- often indicated for soft contact-lens wear cases
75
Antibiotic-Steroid Combination
Most-useful combo. (for marginal infiltrates & cat. post-surg.)
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Pred-G, suspension (prednisolone-acetate & Gentamicin)
+ Tobra-Dex, solution (dexamethasone sulfate & Tobramycin)
Other Combinations: (chance of sulfa or neomycin Allergy)
+ Dexamethasone & Neomycin and Polymyxin-B combo.
(Maxitrol, Dexacidin, Dexasporin, AK-trol susp. or oint
+ Dexamethasone and Neomycin combo.
(Neodecadron ung & sol.)
+ sulfacetamide-Prednisolone combo.
(Blephamide, cetapred, Metamyd, Vasocidin susp./oint.)
“used for blepharitis, conjunctivitis”
D
O
- products w/ Hydro-Cortisone are rarely prescribed anymore by eye-doctor
- Remember that, cortico-sporin and ophtho-cort both contain chloramphenicol
and thus, serious side-effects (aplastic-anemia, bone marrow depres.)
76
Steroid Pharmacology
O
N
LY
* Topical: topical steroid must be tapered to avoid rebound inflammation
acetate are suspension & must be shaken /Phosphate &alcohols: sol.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
+ Prednisolone Acetate 0.125% (Pred-mild, Econopred)
+ Prednisolone Acetate 1% (PredForte, Econopred-plus, A-K Tate)
+ Prednisolone sodium Phosphate 1% (Inflamase Forte), 0.12% (inflamase)
- PredForte, used in ant. uveitis (iritis) / Adverse: ↑IOP, PSC, Glaucoma
++ Dexamethasone phosphate 0.05% ung (Decadron, AK-Dex)
+ Dexamethasone Phosphate 0.1% sol. (Decadron, AK-Dex)
+ Dexamethasone suspension 0.1% susp. (Maxidex)
- Powerful steroid that has less corneal-penetration than PredForte but an alternative in ant. Uveitis.
+ +Fluoromethalone Suspension and Ointment 0.1% (FML)
+ Fluoromethalone suspension 0.25% (FML-Forte)
+ Fluoromethalone Acetate 0.1% (Flarex, Eflone)
- Flarex w/less chance of ↑IOP is supposedly comparable to PredForte in iritis
77
O
PY
,V
IE
W
O
N
LY
+ LotePrednol 0.5% (Lotemax), 0.2% (Alrex)
- Alrex is marketed for tx. in Allergic-conj. while Lotemax compared to PredForte
+ Rimexolone 1% (Vexol), early claims are that it‟s efficacy is comparable to PredForte
- indicated for tx. of post-operative inflammation & anterior uveitis
+ Medryson 1.0% (HMS), for minimal, superficial ant. seg. inflammation
- least side effects, but also least effective in ant. uveitis
R
C
* Topical Steroid: Absolute contraindication: Bacterial Corneal-Ulcer/HSV-dendritic Keratitis
Relative contra: Diabetic, immunocomp./HSV, Zoster attack, any epith. defe.
-↑IOP secondary to Steroid or inflamation: tx. w/beta-blocker etc. (NOT miotic like-pilo.)
N
O
T
PR
IN
T
O
- Posterior synechiae (adhesion between iris & lens): Phenyleph. 10% & Atropin 1% q15 min. for 1-2 hrs.
- Peripheral ant. synechiae:compression Gonioscopy to break, tx.w/steroid in uveitis, posterior seg. inflam.
* Systemic Steroids indication: Giant Cell Arteritis, type-4 hypersensitivity, sever ant. Uveitis
+ Prednisone(Oral) 5mg is min. anti-inflamatory dose, 100-120mg qd for Temp. Artheritis/acute-inflam. dise.
+ Triamcinolone(Kenalog)40mg,inject. for Chalazion/CME,subtenon tx.posterior uveal, retinal, scler.inflam.
D
O
+ Methylprednisone (depomedrol) 80mg (oral, injectable, topical)
+ Hydrocortisone (Topical, oral, injectable)
0.5-1% Cream, tx. dermatitis (1% depigment-skin in darkly Pt.)
78
NSAID‟S (Non-Steroidal Anti-Inflammatory Agents);
O
PY
,V
IE
W
O
N
LY
* Topical-NSAID‟S (for Pain from corneal-Abrasions or post, Lasik/PRK surgery)
+ Ketorolae 0.5% (Acular) qid “for ocular itching in “Allergic-conjunctivitis”
+ Flurbiprofen 0.03% (Ocufen) for Pain/inflam. in Trauma, to control intra-oper. miosis in sx.
+ Diclofenac 1.0% (voltaren), ↓inflam. in post-Cat. & in Lasik/PRK, ↓Pain
(Alcon-removed, voltaren due to ↓corneal healing, erosions & Keratitis report)
T
PR
IN
T
O
R
C
* NSAID‟S inhibit the synthesis of Prostaglandins (chemical mediators of inflammation)
and therefore reduce platelet aggregation (inhibits blood-clotting, caution in Pt. taking
blood-thinners), Aslo therapeutic benefits of analgesia (↓Pain), anti-Pyretic (↓fever)
N
O
+ Ibuprofen (Motrin, Advil), 800mg qid /Inflam, 200-400mg qid /Pain-fever
O
(has NO-effect on blood-coagulation, thus not used to prevent myocardial infarction)
D
+ Naproxen (Naprosyn), 375mg Bid/inflam. (same as Ibuprofen, but $↑)
79
LY
+ Acetaminophen (Tylenol) 325-500mg qid/ “only” Pain & fever
(has NO anti-inflammatory properties)
R
C
O
PY
,V
IE
W
O
N
+ Aspirin (Acetylsalacylic-acid), 1gm qid/inflam, 600mg qid/pain, fever
- prevention of myocardial infarction (lower-dose)
-- after, Retinal Vein-Occlusion (lower-dose)
(adverse: GI-upset, Reye‟s syndrome “avoid in children can be fatal”
Renal damage w/long-term use, tinnitus “ringing in ears”)
N
O
T
PR
IN
T
O
+ Indomethacin (Indocin) “only anti-inflam.” (the most potent NSAID‟S)
- ankylosing spondylitis and gout (especially indicated in)
-- topical, Indocin 1% qid/CME (must be specially compounded)
D
O
+ Phenylbutazone (highly-toxic), used short-term tx. Scleritis (acute)
+ Piroxicam (feldene) qd
80
NARCOTICS:
O
N
LY
Used, to ↓Sever-Pain in Sx, trauma, bacterial corneal-Ulcer, zoster, etc.
(adverse: dependency, constipation, hyperglycemia, vomiting, ↓respiration, rash)
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
* Acetaminophen/Narcotic Combination:
+ Codeine (30mg) and acetaminophen (300mg) “Tylenol- 3” prn
(up to 12-tab qd-common Rx. for sever Ocular-Pain)
- Hydro-codone and Acetaminophen (Vicodin)
- Darvon & Acetamino. (Davocet)
- Percodan & Acetamino. (Percocet)
* Morphine; codeine, hydrocodone, Oxycodone (Percodan), Meperidine (Demoral),
Pentazocine (Tabvin), D-Propoxyphone (Darvon)
D
O
NON-narcotic, Pain-control Medi. (NOT a controld substance):
* TRAMADOL (Ultram) 50mg, 100mg (caution in Pt. taking anti-convulsive &MAO inhib.)
81
Antiseptic Pharmacology; [should rarely be prescribed]
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Mercuric-oxide, 1.0% oint.
used for tx. of minor lid irritation in pediculosis and demedecidosis
(risk of mercury-poisoning with this compound)
+ Zinc-sulfate, 0.217% sol.
used for minor irritation in tx. of “Moraxella” Angular-blepharitis, conjunctivitis
+ Boric-acid, 5% and 10% ung - Used for tx. of mildly inflamed irritated eyes
+ Silver-Nitrate 0.5% to 10%
“occasionaly used as prophylaxis of ophthalmia-neonatorum
and chemical cautery tx. of SLK”
- fatal if swallowed
- minimal germicidal value
- incompatable w/topical sulfonamide tx.
since a precipitate is formed when used together.
82
Therapeutic & Diagnostic Agents:
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Sodium fluorescein 2% reveals corneal-epith. defects; (Sodi. Fluor. 25,10,5% inje. IV for retinal-FA)
- TBUT: less than 10 sec. implies insufficient tear film
- Seidel test: bright-green “river” (aqueous leak in Perforation / Sx-wound
- Jones Test: presence of dye in nasal-mucous after insti. in eye (open-lacrimal)
+ Rose-Bengal 1% stain devitalized (sick) cell; (KCS, SLK, HSV)
+ Edrophonium (Tensilon) 2mg IV followed by 8mg 45sec. later if no-response
- dx. Myasthenia-Gravis (Raises the Lid temporarily in “Ptosis”, MG-induced)
+ Acetylcysteine 2%, 5% sol. (Mucomyst) is mucolytic “breaks-up mucous”
- indication: GPC, Filamentous-Keratitis, Vernal Kerato-Conjunctivitis
PR
IN
+ EDTA 0.37% chelates (binds & removes “Calcium” from Bowman-memb.) tx. Band-Keratopathy
O
N
O
T
+ Aminocaproic-Acid: (anti-fibrinolytic) tx. Hyphemas (admin. Systemically)
+ Vancomycin (anti-biotic of choice) tx. Endophthalmitis
+ sodium-hyaluronate (Healon) viscoelastic, used to maintain ant. chamb in Sx; -also used for
D
“dry-eyes” occasionally (if not removed completely during Sx, IOP will stay high for couple of days)
+ ethox-zolomide (Cardrase, Ethamide); tx. Glaucoma (diuritic)
83
Topical Anti-Histamine & Decongestant
O
PY
,V
IE
W
O
N
LY
AntiHistamine:
+ Emedastine 0.05% qid (Emadine), “used in the tx. of Allergic-Conjunctivitis”
+ [Livocabastine 0.05% qid (livostin)]
DeCongestants:
+ Naphazoline 0.1% (Naphcon, Vasocon)
+ Tetrahydrozoline, oxymetazoline and phenylephrine
(clear-eyes, allerest, visine, murine)
R
C
“caution in Pt. w/narrow-angles /Adverse: mydriasis, rebound hyperemia, hypersensitivity”
O
N
O
T
PR
IN
T
O
- certain OTC decongestants been combined w/various
other products to ↓discomfort, such as; Antipyrine (an Anesthetic)
or Zinc-Sulfate: zincfrin, prefrin, vasoclear-A and visine-AC
* Decongestants & Antihistamine Combinations: OTC
D
+ Antazoline 0.5% & Naphazoline 0.05%, (Vasocon-A, Albalon-A)
+ Pheniramine 0.3% & Naphazoline 0.025% , (Naphcon-A)
84
Oral Anti-Staph. Antibiotics:
C
O
PY
,V
IE
W
O
N
LY
Penicillins:
+ Cloxacillin 250 mg/q6h. (effective against Staph.)
+ Dicloxacillin 125-250mg/q6h (same features as Cloxacillin)
+ Amoxicillin & Clavulanate (Augmentin) 250-500mg PO
- note: (most Penicillins are NOT effective against Staph.)
D
O
N
O
T
PR
IN
T
O
R
Cephalosporins:
+ Cephalexin (Keflex) 250-500mg qid
+ cefaclor (ceclor) 250 mg q8h
+ cefuroxamine (ceftin) 250-500mg bid
+ cefadroxil (Duricef) 500mg bid, PO
- Broad spect. (except Psuedomonas) and bacteriocidal
- use caution in Pt. w/Penicillin allergy, due to cross-sensitivity
85
O
PY
,V
IE
W
O
N
LY
Others:
+ Trimethoprim & sulfamethoxazole (BACTRIM), PO
- “Bactrim” is often substituted in Pt. w/Penicillin-Allergy
- (Trimethoprim is one of the components in the ocular-drop “polytrim”)
D
O
N
O
T
PR
IN
T
O
R
C
Substitutes:
+ Erythromycin 500mg, qid -PO (when Tetracycline is contraindicated,
Erythromycin is often good substitude)
- Adverse: nausea, vomiting, diarrhea and hepatitis
+ Tetracycline 250mg qid -PO (Taken on Empty-stomach)
- sunburn easily, Hepato &Gastro-toxicity, dizziness &ringing in the ears“tinnitis”
- tooth & bone impairment (therefore, contraindicated in Pregnant/nursing, child.
+ Doxycycline 50mg-100mg, bid (can-be taken with Food)
- same antibacterial-spect. & side-effects as “Tetracycline”
+ Minocycline 100mg, bid
- is like “Doxycycline” but has ↑risk of dizziness, tinnitis & pseudo-tumor cerebri.
86
Glaucoma Drugs
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Latanoprost 0.005% sol. (Xalatan) qhs “prostaglandin-analogue” IOP↓ 25-35%
- ↑Iris-Pigment., 2nd line-therapy, NOT-additive to Pilo, addit. to beta-blockers,
Monotherapy, ↑uveo-scleral Outflow
+ Brinzolamide (Azopt 1% susp.) bid “carbonic anhydrase inhibitor” IOP↓ 19%
+ Brimonidine 0.2% sol. (Alphagan) bid ”alpha-adrenergic” IOP↓ 15-20%
- about the same effect on IOP as beta-blockers, but safer
- adverse: dry eye, FB, blurred-vision, hyperemia, caution in Pt. taking beta-blocker,
MAOI, CNS-depression, fatigue, dry mouth
+ Apraclonidine 0.5% (Iopidine) bid ”alpha-adrenergic” POAG, Spikes
- 1.0% Concen. used in temp. ↓IOP prior to filtration Sx. or Prevention IOP↑ in Laser tx.
- effects only last few-weeks, ↑allergic-conj. ↑heart-rate, useful in short term
* Combination:
+ Cosopt (Dorzolamide “Trusopt” 2% & timolol maleate 0.5%) bid
+ Xalcom (Xalatan & timolol maleate)
87
O
N
LY
+ Carbachol 3% tid (Occasionally used if Pilo. 4% therapy Fails)
- same kind of ocular side-effect as Pilo. but more intense, also GI distress
C
O
PY
,V
IE
W
+ Physostigmine 0.25% sol. & ung, 0.5% sol. qid (Eserine) “anticholinestrase”
- formation of Iris-Cysts & ant. Sub-Capsular catract, both causing ↓VA
- must be discontinued before Anesthesia/caution in Pt. exposed to insecticides
T
PR
IN
T
O
R
+ Echothiophate0.03%,0.125% (Phospholine-Iodide)“refrigirate”tx. Accomodative Esotropia
- formation of Iris-cysts & ant. sub-capsular catract in prolong-use
- miotic contraindication:Pt <40 y.old, neovascular glaucoma, phakic-eyes, catra. Pt.
D
O
N
O
+ Isoflurophate 0.025% ung (Floropryl) bid, very long-duration “1-month”
+ Pilo. & Epinephrine (P1E1, etc) bid-qid, combination rarely used
88
Primary Open-Angle Glaucoma
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Setting target-pressures: “↓20” - 18 → early, 16 → Moderate, 12 → Sever (mmHg)
(if IOP is 28, then you need 28% Decline “about 8-lowering” thus target IOP 20mmHg)
* Beta-Blocker: appropriate Initial-treatment; usual-dose is, Bid (↓Secretion)
+Non-Selective (beta, 1&2) beta-blocker (affects lung & cardiovascular system)
- Timolol-maleate:0.25%,0.5%(Timoptic-sol./bid,Timoptic-XEgel/qAm),Istalol0.5%sol./qAm;IOP↓17-28%
- Timolol-hemihydrate: 0.25%, 0.5% sol./bid (Betimol)
- Levobunolol: 0.25%, 0.5% sol./bid (Betagan)
- Carteolol 1% sol./bid (Ocupress), Metipranolol 0.3% sol./bid (Opti-Pranolol)
Adverse effects: broncho-constriction, bradycardia, CNS, hypotension
(metipranolol reported iritis), mental depression
Contraindicated: Pt. w/pulmonary disease & heart failure
+Selective (beta-1) beta-blocker (much less effect on lungs)
- Betaxolol: 0.25% susp./bid (Betoptic-S), 0.5% sol./bid (Betoptic)
- Levobetaxolol: 0.5% sol./bid (Betaxon)
(better choice for Pt. w/history of Pulmonary-disease)
89
O
PY
,V
IE
W
O
N
LY
*Adding more drops when pressure is not low enough:
+add, Carbonic Anhydrase Inhibitor gtts (↓aqueous secretion)
- Dorzolamide 2% (Trusopt) bid-tid (sting upon instilation)
- Brinzolamide 1% (Azopt) bid (less sting upon instilation)
Caution in Pt. w/Sulfa-allergies, poor efficacy in blacks, less adverse than systemic
PR
IN
T
O
R
C
+add, Pilocarpine, (↑outflow/ciliary spasm, induced myopia, headache, RD
- Pilocarpine 0.25, 0.5, 1, 2, 3, 4, 5, 6, 8, 10% sol. (Pilocar) qid
- Pilocarpine 4% gel (Pilopine-hs) equivalent to Pilocar 1% qid
- Ocusert (P-20 equivalent to Pilo. 1%, P-40 equ. Pilo. 2%) q1week sustained release
D
O
N
O
T
+add, sympathomimetic “↑outflow” (NOT Rx. anymore), “NOT-add to beta-blocker”
- Epinephrine 0.5-2% (Epifrin, Glaucon) bid “most Rx. 1% sol.” IOP↓15-28%
-- Dipivefrine 0.1% (Propine)bid “pro-drug of epinephrine, turn into epin. in aqueous”
Adrenochrome deposits in cornea & conj. CME (macula swelling in aphakes & Pseudophakes)
90
Acute narrow-angle Glaucoma
O
PY
,V
IE
W
O
N
LY
a) Systemic (or IV /not-nauseated Pt.) Osmotic-agent: oral “Syrups” mixed w/fruit-juice
- Isosorbide 45% (Ismotic) “Ok, in diabetic”
-- Glycerin 50% (Osmoglyn) “Contraindicated in Diabetic”
-- IV Mannitol 1-2 gm/kg (Contraindicated in Diabetics)
b) CAI: Acetazolamide (Diamox) 250-500mg Po/IV
C
(two 250mg pills absorbed more rapidly than one 500mg sequel sustained release)
D
O
N
O
T
PR
IN
T
O
R
c) Beta-blocker, gtts q10 min. for 2-doses (ie, Timolol 0.5%)
d) Apraclonidine 1% (Iopidine) q10 min. for 2-doses
e) √IOP / Gonioscopy, every-30 min.
f) when IOP↓40mmHg, then add: Pilo. 2% q15min. till trabec. seen by Gonio.
g) add: Prednisolone-acetate 1% q2h.→ qid, ↓Uveitis & chance of Synechiae forma.
h) Laser-Iridectomy (Iridotomy) /surgical irridectomy, is the definitive Cure
k) f/up iridectomy-tx. in one-week. (from A→ K should be done in exact-order)
91
O
N
LY
* “Newer -Glaucoma Med.”
D
O
N
O
T
PR
IN
T
O
PY
,V
IE
W
+ Brimatoprost 0.03% sol. (Lumigan) qd
“caution in uveitis”
+ Travoprost 0.004% (Travotan) qd
“Am/Pm” ↓IOP 7-8 mmHg
+ unoprostone 0.15% sol. (Rescula), bid
IOP ↓12-20%
+ LatanaProst 0.005% sol. (Xalatan) qhs
“Monotherapy, Additive”
↑Pigments in iris
& eyelid / lashes
C
O
R
+ Ophthalgan, is a topical “Glycerin” sol.
(applied to↓Corneal-“edema”which may
prevent Angle-visualization by Gonio.)
+ Gonioscopy Confirms; Presence of
Closed-angle
- HYPEROPIA
- deep boring pain (severe)
- mid-dilated pupil
- Steamy Cornea (edema)
- IOP-elevated (very-high)
- haloes (around-lights)
- nausea (vomiting)
- VA↓(sudden)
- IRITIS
* Prostaglandins:enhances uveo-scleral Outflow
92
Primary Open-Angle Glaucoma, tx.
O
R
C
O
PY
,V
IE
W
O
N
LY
* add more (Oral) med. if IOP is still not controlled:
+ Add, oral Carbonic Anhydrase Inhibitor, PO
- Methazolamide (Neptazane) 25 or 50mg bid-tid (less side-effect)
- Acetazolamide (Diamox) 125, 250mg qid, 500mg sequels Bid (Peaks; 2-4h.)
- Dichlorphenamide (Daranide) 25-50mg qd to tid
adverse: Caution in Pt. w/sulfa-allergy, kidney-stone, renal-calculi & COPD, fatigue,
pregnancy, diuresis, GI-upset, CNS, hemato/dermato/pulmonary cond.
T
PR
IN
T
+ Laser or Surgical procedures, (After topical/medical therapy Fails)
- Argon Laser Trabeculo-plasty (ALT/ LTP)
D
O
N
O
- Filtering Sx: Trabeculectomy (5-Fu & Mitomycin-C used during Sx. to ↑success)
- Ciliary Body: Cryothermy or Diathermy
-Thermo-Sclerectomy, homium laser
- implant filtration (Molteno, etc.)
93
Secondary open-angle Glaucomas
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Pigmentary Glaucoma:
dx.: low myopia, young-male
- Pigment dispersion syndrome, w/corneal endothelial Pigment
(Kruckenberg -Spindle), Iris-transillumination defects
(loss of iris Pigment), Posteriorly bowed peripheral iris & trabec.
pigment seen on Gonioscopy, [Pigment have been rubbed off the
Posterior iris surface by the lens Zonules]
tx,: miotic (low-dose Pilo.), aqueous suppressant (timolol), laser-iridectomy
(avoid; sympathomimetics, since they“dilate”& exacerbate Pigm. Disper.)
* Pseudo-exfoliative Glaucoma:
dx.: older-blacks or Nort.-European females/ “Angle-Pigment”
- flaky grey-white dusting on the iris & ant. lens-capsule
tx.: same as, POAG /ALT
 Angle-Recession: ant. Chamber Angle-configuration can Change in some
pt. to produce Glaucoma, many years after-Trauma.
94
Systemic Anti-Viral
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Acyclovir (Zovirax) 200, 400, 800 mg tablets /5xday
(very safe, used in kids)
+ Famcyclovir (Famvir) tid, “treat Zoster”
+ Valacyclovir (Valtrex) a pro-drug of Acyclovir
+ Foscarnet (Foscavir) IV, 60mg/kg q8h. x21days,
90mg/kg-day maintenance can be co-administered
w/AZT (zidovudine) “Adverse: renal impairment, very toxic”
+ Ganciclovir (Cytovene) IV, 10-15mg/kg-day
indicated during Acute-phase of
CMV (cytomegalovirus) retinitis
found in AIDS, 200mg q-wk maintenance
- Contraindicated in Pt. taking AZT therapy for HIV
- Adverse: bone marrow depression, very toxic
95
Grave‟s Ophthalmopathy
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
* Ocular lubrication PRN (artificial tears, ung @ bed-time)
- treat orbital inflammation &congestion (lid-swelling, injection, myositis and proptosis)
+ Prednisone 30-50mg qd/4-6 months
+ Acetazolamide (Diamox) 1gm qd to ↓fluid in orbital & pre-orbital spaces
- Retrobulbar or subconjunctival injection of Methylprednisolone(depomedrol) 80mg
- may require orbital-decompression
- internist consult to tx. thyroid-gland
+ medicines: methimazole (tapazole), PTU, + surgical ablation, + radiation
- RTC, 3-6 mos. (depends on severity)
* proptosis (diagnosed by exophthalmometry)
* diplopia, lids-lag, lid-retraction
* EOM restrictions & palsies, tremor
- Lab tests (thyroid panel): TSH level, T4 level & T3 uptake are abnormal
- CT & ultra-sound demonstrate enlarged, inflamed
EOM‟s in advanced cases, deep-orbital congestion
96
Ocular Side Effects of Systemic Medicines:
O
PY
,V
IE
W
O
N
LY
+ Hydroxy-Chloroquine (Plaquenil): used in Rheumatoid-Arthritis treatment:
bull‟s eye maculopathy, optic atrophy, ant. &post. Subcapsular-cataract,
retinal-edema, vasoconstriction, vortex-keratopathy, ptosis, EOM-paralysis & nyst.
T
O
R
C
+ NSAIDS: vortex-keratopathy, Macular-pigment dusting w/Indomethacin
+ Corticosteroids: ↑IOP, PSC, exophthalmos, diplopia, mydriasis, myopia, ptosis,
corneal-edema, conjunctival-hemorrhage, retinal edema, toxic-amblyopia,
papilledema secondary to Pseudotumor, dyschromatopsia.
D
O
N
O
T
PR
IN
+ Digitalis (Digoxin): Dyschromatopsia “ yellow-vision” constricted-VF,
↓IOP, scotoma, diplopia, retrobulbar-neuritis, mydriases.
+ Oral-Contraceptives: reduced-lacrimation, lens-induced myopia, ↓IOP,
corneal-edema, retinal Vascular-Occlusion, optic-neuritis, EOM-Paralysis,
color-vision defects, papilledema secondary to orbital Pseudotumor.
97
LY
+ Beta-Blockers & Diuretics: ↓IOP
+ Anti-histamines: ↓tear-secretion, pupillary-dilation
IN
PR
Hypo-vitaminosis => A: night-blindness, tunnel-vision, dry-skin,
keratomalacia. / C: sub-Conj. hemorrhage, if severe retinal-hemorrhage.
/ B2: photophobia, optic-neuritis. / D: osteomalacia.
Hyper-vitaminosis => A: ↑intra-Cranial pressure, Diplopia. / B: ↓VA, CME.
/ D: zonular-Catract, conj-Calcium dep., band-keratopathy, renal-damage.
O
D

N
O
T

T
O
R
C
O
PY
,V
IE
W
O
N
+ Phenothiazines (chlorpromazine, thorazine):
lens-deposits, ↓lacrimation, ↓accommodation & miosis,
discolored conj. & sclera, descemet‟s &endoth. Pigm. deposits.
+ Lithium-Carbonate:
cycloplegia, ↓lacrimation, transient-Scotoma
98
Systemic Medicines:
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Epinephrine (Adrenalin, Primatin-mist): is a short acting adrenergic
for treating-Asthma & Anaphylaxis and is used in injectables to increase
vascular absorption, ↑heart-rate and ↑blood-pressure.
+ Theophyline (Theo-dur): is a broncho-dilator used in chronic treatment
of Asthma and other Pulmonary diseases.
+ Albuterol (Proventil, Ventolin), Terbutaline (Brethaire),
Metoproterenol (Alupent): are beta-agonist used to treat-Asthma.
+ Verapanil (Calan), Diltiazem (Cardizem), Nifedipine (Procardia):
are calcium-chanel blockers, used to treat-hypertension.
+ Catopril (Capoten), Enalapril (Vasotec), Isinopril (Zestril):
are angiotensin-converting-enzyme (ACE) inhibitors, treat ↑BP
+ Propranolol (Inderal), Nadolol (Corgard): non-sel. Beta-block. tx. hypertension
+ Metopralol (Lopressor), Atenolol (Tenormin): cardio-sel. Beta-blocker, tx. ↑BP
99
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
+ Hydrochlorothiazide & Furosemide (Lasix): are diuretics, tx.↑BP
+ Cholestyramine (Questran), Colestipol (Colestid), Lovestatin (Mevacor)
and Niacin are used to treat- ↑Cholesterol.
+ Metoclopamide (Reglan), Ergotamine (Cafergot): tx. -Migraine.
+ Carbamazepine (Tegretol), Phenytoin (Dilantin), Valproate (Depakote),
Ethoxsuximide (Zarontin): are anti-Seizure med.
+ Diazepam (Valium), Chlordiazepoxide (Librium), Alprazolam (Xanax),
Buspirone (Buspar): are anti-Anxiety mediciens.
+ Imipramine (Tofranil), Amitriptyline (Elavil): are tricyclic anti-Depress.
+ Fluoxetine (Prozac): is anti-Depressant med.
+ Phenelzine (Nardil), Tranylcypromine (Parnate): are MAO inhibitors,
used to treat-Depression, (DO-NOT use Phenylephrine -gtts in these Pt.).
100
O
PY
,V
IE
W
O
N
LY
Hypertension Medications;
Advance Hypertension: fundus-hemorrhages, exudates, papill-edema,
arterio-venous Crossing, tortuousity.
+ Classes of Med. used in Tx. hypertension:
- Diuretics: * Furosemide (Lasix), * hydrochlor-thiazide (hydro-diuril)
- Beta-Blockers: * Propranolol (Inderal), * Metoprolol (Lopressor), * Atenolol (Tenormin)
(just like Timolol: bradycardia “↓heart-rate”, constricts-bronchi “difficulty breathing”)
T
O
N
O
D
Hyper-Cholesterolima Med.
- Zocor (Sim-vastatin)
- Lipitor (Ator-vastatin)
- Pravachol (Pra-vastatin)
- Lescol (Flu-vastatin)
- Mevacor (Lo-vastatin)
PR
IN
T
O
R
C
- Angiotensin-Converting-Enzyme Inhibitors: * Lisinopril (Zestril, Prinivil),
* Catopril (Capoten),* Enalapril (Vasotec)
- Calcium-channel Blockers: * Diltiazem (Cardizem), * Nifedipine (Procardia)
- Alpha-adrenergic Blockers:* Prazosin (Minipress)
101
(good light-reaction)
in both-eyes
anisocoria: dark > light
(poor light-reaction)
in one-eye
anisocoria: light > dark
“Slit-Lamp”
iris sphin.
sector-palsy of
completely
iris sphincter
immobile
iris transillum.
O
PY
,V
IE
W
O
N
LY
“Flash-Photos”
no dilation-lag
dilation-lag of
smaller pupil
impared
pupil margin-torn
light reaction
pilocarpine 0.1%
(cholinergic hyper-sensitivity test)
C
Cocaine 2-10%
O
T
IN
both dilate
PR
Herner‟s Syndrome
O
O
N
1%
Hydroxyamphetamine
no dilation
D
pre-ganglionic
or central
pilocarpine 1%
(anti-cholinergic blockade test)
constrict
Adie‟s
Tonic-pupil
T
Simple Anisocoria
dilation
no-constriction
R
smaller pupil
fails to dilate
post-ganglionic
constrict
no-constriction
3rd N.-Palsy
Atropinic
mydriasis
iris damage
102
Diagnostic Pupil -Testing
O
PY
,V
IE
W
O
N
LY
Horner‟s (Constricted) use, Cocaine 10%, Then Paradrine 1% (to dilate)
Adie‟s (Dilated) use, mild-Pilocarpine 0.1% or 0.125% (to constrict)
D
O
N
O
T
PR
IN
T
O
R
C
+ Aide‟s or Tonic-Pupil, (Prognosis-excellent):
- young women, ↓ joint-reflexes, benign-condition
- mydriasis in light
- sluggish response
- vermiform movement (moves like a worm) of the iris pupillary margin
Procedure:
-- pilocarpine 0.125% to affected eye
- if, no-constriction, then this is a “simple anisocoria”
or “Pharmacological dilation”
- if, constriction, then Pt. has Aide‟s
103
+ Horner‟s Pupil:
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
- elderly, smokers (lung-cancer), history of trauma in young
- miosis in dark
- ptosis & anhydrosis (lack of sweating, which can result in ↑skin temp.)
on the side of the affected pupil
Procedure:
-- Cocaine 10% 2gtts 5 min. apart to affected eye
- if, dilation occurs, this is “physiological anisocoria”
- if no-dilation, wait 24hours, then use Paradrine 1%
-- Hydroxyamphetamine 1% (Paradrine) 2gtts 5 min. apart
- if dilation occurs; pre-ganglionic (1st or 2nd order) neuron-lesion
(work-up: MRI of lung “cancer”, internal medicin-consult)
- if NO-dilation; Post-ganglionic (3rd order) neuron lesion
(work-up: rule-out Orbital-disease, possibly trauma-induced)
104
Heart –Disease
LY
Heart-attack or myocardial infarction “MI” is loss of heart-tissue
due to lack of blood flow and death of the tissue.
Congestive heart-failure: heart fails to pump blood normally
which results in congestion in the lungs or systemic circulation
(especially legs and feet “gravity”),causes cough or swollen feet &ankle.
Cardiac arrhythimias: abnormal rhythm of heart, beating too fast,
slow or irregularly (can be from previous heart-attack), “can cause
heart failure”, med. used: pacemaker implantation, beta-blockers,
calcium channel blockers, amiodarone (cardarone), [brown “whorl
like pattern” cornea epithelial-depositis in few-weeks, can become
dense causing glare or ↓VA].
A stroke is a permanent Ischemic -Attack, and pt. is left w/some
permanent neurological disability, (MRI-scan confirm the brain-damaged).
O
PY
,V
IE
W
O
D

N
O
T
PR
IN
T
O
R

C

O
N

105
Transient Ischemic-Attack (TIA); is a sudden onset neurological defect (like
loss of vision) that is temporary. Pt. is at risk for stroke, (carotid-arteries, is
usual site for production of plaques that occlude blood-vessels in the brain),
“non-invasive Doppler-ultrasound gives flow-rate as well as picture of any
plaque in the vessels”. Tx. End-arterectomy Sx.
Med. used: aspirin, coumadin, ticlid

Temporal Arteritis (TA): Giant cell arteritis is the most common cause of
A-AION and is a disease of late middle-aged and elderly person, almost 3-times
more common in women (Caucasians), is an inflammation of the arteries, that
can result in optic-neuritis (inflammation of the optic-nerve) “sudden loss of
vision /visual-field defect”, transient visual loss (amaurosis fugax), symptoms
(20% No-symptom) includes: “jaw claudication, neck pain, anorexia”, weight
loss, scalp tenderness, headache, malaise, myalgia, anemia. w/↑ESR or
elevated CRP (C-reactive protein) measurements; Biopsy, FA;
"catastrophic vision loss is-preventable" w/timely tx. Steroids -Po
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

106
Vascular -Disease
Pulse: the normal pulse is “between 50 and 100 beats per minute”,
↑ or ↓ measures may be an indication of some “cardiac-disorder.”

BP over “140/90” is usually considered “high”, (↑↓BP, cardio-vascular problem).

Carotid-artery ausculation: hearing of “bruits” (unusual sounds)
when listening to pt. neck w/stethoscope (where you can hear the
carotid artery) is indication of ↓ in flow through the artery, which can
indicate significant arterio-sclerosis, suggesting that the pt. is at risk for
a TIA or stroke as well as temporal-arteritis.
Heart-failure symptoms: chest-pain [angina: narrowing of heart vessels,
causes ↓oxygen “should rest”/dilated by: Nitroglycerine tablet “placed under
tongue” (Nitrostat…)], difficulty breathing (dyspnea), weakness, fatigue
(especially w/effort), fainting (syncope), palpitation (awareness of heart-beat,
usually irregular or rapid), nocturia (excessive urination at night:
could be diabetes!), anorexia, peripheral edema.
O
T
IN
PR
T
O
N
O
D

R
C
O
PY
,V
IE
W
O
N
LY

107
A loss of vision that associated w/headache may clue “tumor”, if alone “stroke”.





Any swelling of the “ankles” or “feet” can suggest heart-failure.
Timolol-gtts for glaucoma can ↓heart rate.
Blockage of a brain-vessel, is a “stroke” (cerebro-vascular accident “CVA”).
Blockage of heart-vessel results in“heart-attack”(myocardial-infarction“MI”).
Hypercholesterolemia (↑blood-cholestrol) the major risk factor for CVA & MI
[med.: Gemfibrozil (lopid), Lovastatin(mevacor)]
Atherosclerosis (no-tx. exist), refers to thickening and hardening
of arteries by atherosclerotic “plaques” (due to hypertension,
↑blood-cholesterol, smoking, genetic, age), [can have broken-piece].
Blood-thiner (used after “stroke” due to “vascular-occlusion” to ↓chance
of heart-attack or additional stroke): aspirin (↓blood-clothing), warfarin
(coumadin), ticlopidine (ticlid).
CABG “Cabbage” coronary-artery bypass graft (treatment for “heart-attack”)
N
O
O
PY
,V
IE
W
C
PR
D

O
N
O
T

IN
T
O
R

LY

108
A.) Diabetes
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Insulin: glucose is a sugar-metabolized by cell to create the energy
necessary for biological-processes. Insulin is a hormone produced
by the islet-cells in the pancreas, it promotes the transport of glucose
from the blood across the cell-membrane into muscle and fat cells
where it is converted-into glycogen (a form of glucose that can be
stored in the liver), insulin also ↑both the rate of synthesis of proteins
from amino-acids and the cellular-uptake of amino-acids certain ions
and fats. Consequently, insulin ↓blood-glucose-concentrations.
*Glucagon is a hormone that is also produced in the pancreas but acts
to ↑blood-glucose level by promoting the metabolism of glycogen in the
liver into glucose.
D

109
Long-term complication of diabetes, due to effect of excess
glucose on the blood & blood-vessels, changes clotting-factors
in the blood, and resulting in ↑blood-clots.
Furthermore glucose in excess have vascular-endothelium effects,
resulting in weak, leaky-capillaries which lead to less blood-perfusion
to tissues.

Diabetic-nephropathy, results from the thickening of the capillary
basement-membrane in the glomerulus of the kidney resulting in
a poor-filtration.
The result is abnormal-excretion of larger macro-molecules such as
proteins. As the disease progresses, frank renal-failure and hypertension
occurs requiring kidney-transplantation.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

110
B.) Diabetes
O
PY
,V
IE
W
O
N
LY
Symptoms: excess blood-glucose (over 300 mg/dl) is excreted in the
urine (glycosuria), which osmotically draws water leading to excessive
urination (polyuria), thus diabetic Pt. drink excessive amounts of water
(polydypsia) in order to replace that which is excreted in the urine.
PR
IN
T
O
R
C
Weight-loss occurs initially, because of water, glycogen and fat storage
depletion and subsequently to decreased muscle-mass when proteins
begin to be diverted into glucose-formation.
O
N
O
T
The ↑osmolarity of extra-cellular fluid, draws-out fluid from
crystalline-lens & retina, leading to symptom of blurred-vision.
D

111
O
N
O
T
Most concern in diabetic-neuropathy is “Ophthalmoplegia”, which
generally resolve “spontaneously” within 6-9 weeks, (critical period
for diabetic “retino-pathy” is between 10-20 years of the disease).
D

PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
*Transient partial or complete numbness in the extremities (parasthesias)
is an occasional early complaint, (neuro-toxic effect of excess-glucose),
fat begins to be broken down to provide new sources of glucose,
a consequence of this fat-metabolism is the formation of ketone-bodies,
which are acidic-in-PH, ketone bodies can accumulate in the extra-cellular
fluids in excessive-amounts leading to a condition called keto-acidosis,
the cause of diabetic-coma and occasionally death.
Keto-acidosis can also result in sweet-smelling breath, as the body tries to
eliminate the condition through expiration.
112
C.) Diabetes
LY
N
O
O
PY
,V
IE
W
C
O
D

N
O
T
PR
IN
T

R

Fluctuating-VA and frequent urination (polyuria) are symptoms of diabetic pt.
fasting ↑blood-glucose concentration (hyper-glycemia)can damage blood-vessels,
poor-circulation, tissue and organ damage (normal blood-glucose concentration
is 80-120 mg/deci-liter “deci-liter is 100 ml”).
Two measurement of over 140 mg/dl, or single 12-hours fasting blood-glucose
concentration of over 200 mg/dl is diagnostic confirmation of diabetes.
If Pt. has suspicious symptoms, but glucose-level <140 mg/dl then
glucose-tolerance test performed, after an over-night fasting, a 75grams
of glucose dissolved in 300ml of water is administered orally;
blood-glucose exceeding 200mg/dl at a time between 0 and 2hours after
drinking, and again at 2hours after drinking, is confirmatory for diabetes.
Infection in the feet, due to poor-circulation leading to ischemia and
↓resistance to infection.
O


113
A certain form of hemoglobin (Hb) in the blood, termed “A1C”
binds to blood-glucose, (normal 4-6% Hb-A1C, “glycosylated”,
hemoglobin has half-life of eight-weeks), which it‟s ↑% presents
in the blood “at any episodes over 8 wks” reflects, fluctuating
blood glucose-levels.

Diets, without-excessive calories are important for maintaining
blood-glucose level and preventing obesity.
Exercise ↑effectiveness of insulin “making this an important part
of diabetes-care”, while “avoidance” of sucrose (table-sugar) is
mainstay of the diabetic-diet;
The “use” of fructose (the sugar found in “fruits”) is important for
hypo-glycemic patients.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

114
D.) Diabetes
O
PY
,V
IE
W
O
N
LY
NIDDM, type-II: Pathophysiology processes of this diabetes-mellitus has
adult onset, and milder forms of hyper-glycemic conditions (90% of cases).
Ample amount of insulin is produced by the pancreas, but the insulin is
ineffective at transporting glucose across muscle and fat cell membranes.
O
N
O
T
PR
IN
T
O
R
C
There are two sub-types: “non-obese” form occurs when the insulin that is
produced is defective in promoting glucose transport across cell-membranes.
In the most common form of diabetes, the “obese” form of NIDDM, the
insulin produced is normal in both amount and its effectivity.
The disease lie at the level of the insulin-receptors on the outside-surface
of muscle and fat cells that do not-respond properly to the effect of insulin,
(cause unknown, speculation that over-eating leads to desensitizing “perhapsreversible” of target-cell insulin-receptors). Glucose-build in the blood-stream
causing to further ↑insulin being-produced.
D

115
IDDM, type-I: damage (possibly from prior infection by a virus or an exogenous-toxin)
to the insulin-producing cells of the pancreas causes an insufficient amount
of insulin to be produced, consistently there is not sufficient ability to move
the glucose across cell membrane into muscle and fat cells, and blood-glucose
levels increases, (10% of all cases, usually diagnosed in children, certain genetic

Oral hypoglycemic drugs (category of sulfonyl-ureas), are first-line choice
for NIDDM patients, they act by ↑activity of insulin-producing cells in the
pancreas, (most effective in non-obese NIDDM, but used in all types).
**first-generation: -chlorpromadine (diabenese) 100 - 250 mg qd,
-tolbutamide (orinase) 500mg bid, -tolazamide (tolinase)100-500 mg qd-bid
**second-generation; more-powerful, and commonly prescribed NIDDM):
-Glipizide(glucotrol)5-15mg qd, -Glyburide(diabeta, micronase)2.5-10mg qd
*Insulin (concentration of 100 units/ml “u100” are dispensed in 10ml vials) sub-cutaneous
injection, for IDDM “and NIDDM who poorly controlled by oral-medicines”.
O
PY
,V
IE
W
O
N
LY

D
O
N
O
T
PR
IN
T
O
R
C
makers “HLA-antigens” occur more frequently, degree of heredity is unclear).
116
Diabetic Retinopathy
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
The retinovascular consequences of diabetes essentially consist of microvascular
leakage and capillary-nonperfusion. Microvascular leakage fallows the impairment
of the structural integrity of retinal capillaries heralded by the development of
microaneurysms. Microaneurysms may either become thrombosed or may leak
serum components into the surroundings retina, “microaneurysms may leak-fluid
and can sometimes be at the center of a ring of exudates”. Retinal-edema, lipidexudates and dot-blot intraretinal hemorrhages are the result of such break-down
of the blood-retinal barrier. Capillary nonperfusion, on the other hand, results
in the formation of arteriovenous-shunts known as intra-retinal micro-vascular
-abnormalities (IRMA) - [Unlike extraretinal neovascularization, IRMA do
not-leak on fluorescein angiography (FA)]. Elaboration of vascular-endothelial
growth-factor (VEGF) form hypoxic-retina in areas of capillary-nonperfusion
results in the development of extraretinal-neovascularization. These new-vessels
extend from the retina-into the vitreous.
D

117
Extraretinal-neovascularization is associated with vitreous-hemorrhage and
production of fibrovascular-traction. These new-vessels may arise from the optic
disc (NVD) or elsewhere in the retinal-periphery (NVE). Such neo-vascularization
and its associated fibrous-component may spontaneously involute, or be complicated
by vitreous-hemorrhage or traction retinal-detachment. Neovascularization may be
easily seen on fluorescein-angiogram by the profuse-leakage of dye from these new
vessels, since they lack the tight-endothelial junctions of the retinal-vasculature.
Impaired axoplasmic-flow in areas of retinal-hypoxia result in cotton-wool spots.
Until the late-stages of its development, diabetic-retinopathy remain largely
asymptomatic. For this reason uniform-classification and careful screening of
diabetics is required in order to identify those patient who would benefit from
timely-treatment.

Diabetic-retinopathy is Classified into two main-groups: Nonproliferative and
Proliferative, based on the presence of neovascularization. Macular-edema may
be associated with either-group. Areas suspicious for neovascularization may
be confirmed by their marked leakage of fluorescein-dye by angiography.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
-
118
Nonproliferative diabetic retinopathy (NPDR) can be further divided into
mild-NPDR, moderate-NPDR, and severe-NPDR in an effort to predict which
eyes are at higher risk of developing-proliferative retinopathy. Mild-NPDR
describes eyes with scattered-hemorrhages and microaneurysms. Moderate-NPDR
contains hemorrhages and microaneurysms and mild-degrees of soft-exudates,
venous-beading and IRMA. Severe-NPDR is defined by the presence of
venous-beading in two or more-quadrants, IRMA in one or more-quadrant or
microaneurysm and dot-hemorrhages in all 4-quadrants.
Proliferative diabetic retinopathy(PDR)can be divided into Non-High-riskPDR
and High-RiskPDR in order to identify those eyes at greater risk of severe visual
loss, and therefore most likely to benefit from panretinalPhotocoagulation(PRP),
PRP may be successful by ablating areas of ischemic-retina, reducing the
production of growth-factors responsible for neovascularization.
C
R
O
T
IN
PR
T
O
N
O
*High-risk PDR is defined by the presence of three or more of the following
characteristics {which requires PRP without-Delay}: Any-new-vessels, new vessels
on-or-within one-disc-diameter of the optic-nerve head (NVD), Severe-new-vessels
[as defined by one-third-disc-area neovascularization at the optic-nerve or one-half
disc-area neovascularization elsewhere (NVE)], and pre-retinal or vitreous hemorrhage.
D
-
O
PY
,V
IE
W
O
N
LY
-
119
Clinically-significant macular-edema (CSME) is defined by the presence
of retinal-thickening within 500microns of the foveal-center, hard-exudates
within 500microns of the foveal-center associated with retinal-thickening,
or retinal-thickening of one-disc-area-or-grater located partially-within
one-disc-diameter of the foveal-center.
*The presence of diabetic macular-edema, is a clinical determination made
by the Stereoscopic-observation of retinal-thickening by contact lens-fundus
examination or stereoPhotography.

All eyes with PDR should undergo detailed examination of the Iris and angle
for signs of growth of new-vessels (NVI, rubeosis) in order to avert the
devastating development of neovascular-glaucoma in severely ischemic eyes
or those with extensive retinal-detachment.
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

D
O
*The importance of these distinction is that 52% of severe NPDR, versus
27% and 5% of moderate and mild NPDR respectively, progress to
proliferative diabetic retinopathy (PDR), within 1-year.
120
The Early Treatment Diabetic Retinopathy Study ( ETDRS) evaluated the
benefit of early panretinal-photocoagulation (PRP) in patients with mild to
severe-NPDR. While early-PRP compared with-deferral of treatment; it was
associated with a small-reduction in the rates of severe visual-loss to the 5/200
level or-worse over 5-years, (the incidence of such-loss was-decreased in-both
the treatment and deferral-groups 2.6% and 3.7% respectively).
The Diabetic Retinopathy Study (DRS) evaluated the benefits of panretinalphotocoagulation in eyes-with PDR; treated-eyes with high-risk-PDR
were half-as-likely to-sustain severe visual-loss, to the 5/200 level or-worse
at 4-years.
PhotoCoagulation; reduces only 2-years rate of sever vision-loss (NEI).
IN
PR
N
O
T
The ETDRS evaluated-the-benefit of focal-or-grid laser-photocoagulation for the
treatment of macular-edema. At 3-years treated-eyes with CSME were half-as-likely
to-sustain moderate-visual-loss (doubling of the visual-angle) as-untreated-eyes
(12% versus 24%). In eyes-with CSME and foveal-thickening, treatment-tripled the
chance of moderate-visual-gain compared with untreated-eyes (17% versus 5%).
O

D

T
O
R
C

O
PY
,V
IE
W
O
N
LY

121
Panretinal-Photocoagulation was found to worsen diabetic Macular-edema;
more over, focal-laser treatment benefit-is-delayed until after the placement
of panretinal-photocoagulation, as such, efforts should-be-made to treat
diabetic macular-edema before the institution of panretinal-photocoagulation,
if at all possible.
Fluorescein-Angiography; is useful in identifying-sites of focal-leakage from
microaneurysms, as well as diffuse-areas of leakage and cystoids-macular-edema.
Areas of diffuse-leakage may benefit from treatment with a grid-pattern of laser
in these areas. Extensive-diffuse-edema and cystoids-macula-edema are
less-likely to-respond to-treatment.
Despite-treatment with panretinal-photocoagulation, a small-portion of eyes
still-progress to non-clearing vitreous-hemorrhage or traction-retinal-detach.
Vitreous-surgery may be indicated when these complications-occur.
O
PY
,V
IE
W
O
T
O
O
N
The Diabetes Control and Complication Trail (DCCT) showed that intensive-therapy
with tight-control of blood-sugars, as compared with conventional-therapy in patients
with Type-I, IDDM delayed the onset and slowed-the-progression of diabetic
retinopathy, nephropathy and neuropathy.
D

T
PR
IN

R
C

O
N
LY

122
The Diabetic Retinopathy Vitrectomy Study (DRVS) examined the timing-and-benefit
of vitrectomy in eyes with advanced-proliferative diabetic-retinopathy. *At 2-years
early-vitrectomy for vitreous-hemorrhage compared with deferral, was associated with a
three-fold-increased likelihood of achieving 20/40 or better visual-acuity(36% versus 12%).
This benefit was only-present in Type-I diabetics; and no-difference in the ability to
prevent severe visual-loss was observed for Type-II diabetics (28% versus 26%).
*Four-years results of early-vitrectomy for eyes with severe-PDR characterized by
extensive-neovascularization with fibrovascular-proliferation, showed an improved
likelihood of achieving 20/40 or better visual-acuity compared with the deferral-group
(44% versus 28%), but-again no-benefit in the prevention of severe visual-loss was observed.

Current-indication for vitreoretinal-surgery for complications of diabetic-retinopathy
Include: macular-tractional-retinal-detachment, non-clearing-vitreous-hemorrhage,
combined tractional/rhegmatogenous-retinal-detachments, severe-progressive
fibrovascular-proliferation, neovascular-glaucoma-with-vitreous-hemorrhage,
dense-pre-macular-hemorrhages, continuous-macular-edema-with-a-thickened
posterior-hyaloid and anterior-hyaloidal-fibrovascular-proliferation.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

123
Hypertensive Retinopathy
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
A normal arteriolar-wall is transparent, so that what is actually seen is the
column of blood within the vessel. A thin, central light-reflection in the center
of the blood-column appears as a yellow-refractile-line about one-fifth the
width of the column. As the wall of the arterioles become infiltrated with lipids
and cholesterol, the vessels become sclerotic; as this process continues, the
vessel-wall gradually-loses its transparency and becomes-visible, the blood
column-appears wider than normal,and the thin-light-reflection becomes-broader.
The grayish-yellow fat-products in the vessel-wall blend-with the red of the
blood-column to produce a typical “cooper-wire” appearance; this indicates
moderate-arterioSclerosis. As sclerosis-proceeds, the blood-column vessel-wall
light-reflection resembles“silver-wire”,which indicates severe-arterioSclerosis;
at times, which occlusion of an arteriolar-branch may occur.
*Red-free light (a white-light with a green-filter) allows-detail of hemorrhages,
focal-irregularity of blood-vessels, and nerve-fibers to be seen more clearly.
D

124
Chronic-hypertension; usually does not-produce any visual-symptom or
dysfunction. Ophthalmoscopy shows generalized and focal arterial-narrowing
through-autoregulation, in-response to elevated perfusion-pressure. Narrowing
is best-appreciated in-relative arterial-to-vein diameters,the so-called A/V-ratio.
A normal-value is approximately 2/3. Over-time, arterial-walls lose their luster,
assuming first a copper-color, and finally a silver-wire appearance.
Depression of underlying-veins at crossing-sites by thickening arterial-walls
typically occurs, referred to as A/V-nicking.

Acute, severe (malignant) hypertension; produces visual-symptoms. Affected
patients may complain of transient-obscuration of diminished central-visions.
Systemic complaints may include headache, nausea and vomiting, alterations
in mental-status, and convulsions. The retinal-venules may become dilated
and tortuous in acutely or severely-elevated blood-pressure. Ophthalmoscopy
findings include prominent cotton-wool spots, nerve-fiber layer hemorrhages,
and lipid-exudation in the posterior-pole. Both-eyes are involved, typically
symmetrically.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

125
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Disc-edema, may be present. Rarely, hypertensive-choroidopathy with
Secondary exudative-retinal-detachments can occur. Focal areas of choroidal
and chorio-capillaris infarction with secondary fibrinoid-necrosis of the retinal
pigment epithelium (RPE) may occur.This RPE-necrosis and pigment-clumping
represents the so-called Elsching‟s-spots. Fluorescein angiographic(FA) findings
in acute, severe-hypertensive retinopathy include capillary-nonperfusion,
microaneurysm-formation, telangiectasis, and retinovascular-leakage.
*FA-findings of hypertensive-choroidopathy will characteristically show early,
multiple-punctate areas of hyper-fluorescence, which leak-later in the study.
PR
IN
*Histopathologic examination shows thickening and fibroblastic infiltration
O
N
O
T
of the intima. Fibrinoid-necrosis of pre-capillary arterioles occurs. Swollen
nerve-fibers with accumulation of organelles (cytoid-bodies) are noted in the
area corresponding to cotton-wool spots as a result of ischemic interruption
of axoplasmic-flow.
D

126
Patients with Hypertensive-Retinopathy are Classified into Four-Groups:
Group-I; minimal-narrowing of the retinal-arteries (mild-arteriolar attenuation).
Group-II; narrowing of the retinal-arteries in conjunction-with regions of focal
constriction and arterio-venous nicking. Group-III; abnormalities-seen in groups
I and II as well as retinal-hemorrhages (flame-shaped), hard-exudation, and
cotton-wool spots. Group-IV (i.e. malignant-hypertension); abnormalities
encountered in group I through III, as well as swelling of the optic-nerve
O
PY
,V
IE
W
O
N
LY

O
N
O
T
PR
IN
T
The changes seen in group I and II are typically chronic, and those encountered
in groups III and IV are seen with more acute-rise in blood-pressure.In an adult,
a Diastolic blood-pressure of greater than or-equal to 110 mmHg is usually
necessary to-induce the fundus-changes seen in group-III, and a Systolic
pressure of greater or-equal to 130 mmHg usually correlates with changes
in group-IV, [systolic/diastolic].
D
-
O
R
C
head (disc).
127
Treatment consists of gradual-normalization of blood-pressure. With adequate
systemic-treatment, the fundus-changes seen in group III and IV resolve-over a
period of weeks to months. If visual-acuity is affected in the short-term, some
improvement may be expected with-resolution of the fundus-changes such as the
Serous retinal-detachments.However, visual-recovery may be limited by retinal
pigment-epithelial disruption in the macula or optic-nerve damage. Patients
with acute, severe-hypertension mandate emergent-medical evaluation and
often require-hospitalization. Local ocular-treatment has not been beneficial.

Hypertension; may also be associated with central-retinal vein-occlusion,
branch retinal-occlusion, retinal-macroaneurysms, and ischemicoptic-neuropathy.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

128
Systemic Conditions w/Fundus Manifestation ;
Background-diabetic Retinopathy (BDR): diabetes history, dilated-veins
microaneurisms, small flame-hemes, dot & blot-hemes, exudates, may or
may not have macular-edema.
Tx. laser-treatment for clinically significant macular-edema, “control of diabetes”.

Proliferative-diabeticRetinopathy(PDR):neovascularization,Vitreous-hem,traction-RD
O
PY
,V
IE
W
O
N
LY

R
Background diabetic-retinopathy, BDR (non-proliferative): dilated-veins
microaneurysms, dot & blot-hemorrhages, cotton-wool spots(“soft-exudates”)
retinal-edema, hard-exudates (serum-lipoproteins)
Pre-Proliferative retinopathy (sever stage of background) w/retinalhemorrhages and macular-edema
Proliferative diabetic-retinopathy (PDR): neovascularization (NVD/NVE)
vitreous-hemorrhage, (RD), [30% of retinal abnormality in diabetic found at
T
O
D
+
N
O
+
PR
IN
T
O

C
Tx. argon-laser panretinal-photocoagulation (PRP), Vitero-retinal Sx.
prephery, so dilate w/BIO]: FA, Panretinal-Photocoagulation(PRP),asprin has no-effect
129
Hypertension and Arteriosclerotic Retinopathy: retinal artery reflection
becomes wider, arterio-sclerosis (copper-wire or silver-wire appearance),
cotton-wool spots, hemorrhages, exudates, disc-edema.
LY


O
PY
,V
IE
W
O
N
Tx. retinal fluorescein angiogram (FA) indicated, laser-treatment may be needed.
Hypertensive-retinopathy: ↑BP damages to the Heart, Brain, and Kidneys,
Pt. w/group-IV has a life expectancy of 10.5-months, group-III has bout 27.6-months
Grade-1: barely detectable arterial-narrowing &constriction w/brightened cooper/silver wire reflex
-
Grade-2: obvious arterial-narrowing w/focal-irregularities, AV-Crossing &
pronounced-Attenuation (Pt. with continually increased high blood pressure)
Grade-3: Same as grade-II and retinal-Hemorrhages (flame-shaped, near-disc),
exudates & cotton-wool spots (malignant), BRVO
Grade-4: same as grade-III, and Papilledema, macular-Star (the shiny hard-exudates
PR
O
is collection of macrophages filled w/lippid-material in OPL of retina), w/sever
nervous-system & renal disturbances.
D
-
N
O
T
-
IN
T
O
R
C
-
130
R
T
O
N
O
D

PR
IN
T
O

C
O
PY
,V
IE
W
O
N

Branch Retinal Vein-Occlusion (BRVO): is isolated area of retinal
hemorrhage secondary to venous-occlusion.
Tx. may resolve on it‟s own, may need laser photocoagulation.
Central Retinal Vein Occlusion (CRVO):
Elderly hypertension, diabetes, dilated tortuous retinal-veins,
Macular &retinal edema w/massive-hemorrhages in retina,
attenuated-arteries, secondary Neovascular-glaucoma may develop.
Tx. argan-laser Panretinal-photocoagulation (PRP) to ↓chance of
neovascular-Glaucoma, prognosis for Vision is poor.
Branch Retinal Arterial Occlusion (BRAO):
only a Sector of the retina affected.
Tx. as w/CRAO
Central Retinal Artery Occlusion (CRAO):
usually due to Emboli from Carotid-artery, retinal-pallor (turns white),
macula has “Cherry-red spot”, total-retinal swelling.
Tx. breathing-into a bag to ↑CO2 level (↑blood flow by dilation of vessels),
massage-globe, Acetazolamide-IV, paracentesis to ↓IOP
LY

131
Histoplasmosis “fungal”, (Endemic, primarily Ohio-Mississippi river-valley):
“No- uveitis /vitritis”, Histo spots - scattered Punched-out chorioretinal round lesions
in fundus, Peri-papillary atrophy, Choroidal-nevoascu.-membrane (CNVM) - usually in
the Macular-area, Inflammation of Choroid, can lead to subretinal-neovascular.(SRNV),
“Positive histoplasmosis Skin-test”. Tx. Laser “SRNV”, No- effective antifungal.
Histoplasmosis (tx.w/Argon laser Photocoagulation): more seen in 20-50y. old men
(Midwest), Macular-involve., bilaterality, CircumPapillary Choroidal- atrophy/Scarring,
Peripheral-atrophic histo-Spots, exudative disciform-maculopathy/Scarring,
“asymptomatic” till↓VA and metamorphopsia, Punched-out lesions surrounded
w/pigment in mid-periphery, Histo-Spot in Macula-area.
O
T
O
Toxoplasmosis gondii “protozoan”,(Cat is the host, “pregnant can transmit to fetus”):
Punched-out retinal-Lesions, Choroidal and Retinal Inflammation w/floaters,
photophobia or ↓VA, “can recur at borders of lesions”. Tx. Uveitis treated
w/Cycloplegia & Steroids. Pyri-methamine (Daraprim), Sulfa-diazine w/trimethoprim,
Clindamycin and newer drug atovaquone. Photocoagulation, Crytherapy, vitrectomy.
Toxocara canis “roundworm”, (transmitted by Dog, “usually in children”, Elisa-test):
white-pupil, granulomas (elevations) on the retina, or Chronic Endophthalmitis,
redness, ↓VA. Tx. Prednisone -Po/Injection.
D

O
N
O
T
PR
IN

R
C
O
PY
,V
IE
W

N
LY

132
Toxoplasmosis: commonly-Congenital (if-immunocompromised; reactivation),
“Active → granulomatous -Uveitis, focal white-fuzzy Retinitis Overlying-w/Vitritis”,
eventually the inflammation subsides to leave a oval or round pigmented chorioretinal
atrophic scar of variable size, Scar of the Macula can cause severe VA reduction
(20/200 to 20/400 or worse), frequent in White-teenage girls, Chorioretinitis
w/sometimes papilitis and papilledema, exudate.

Sarcoidosis: Uveitis, decreased or hazy vision, pain, photophobia, lacrimation,
O
PY
,V
IE
W
O
N
LY
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O
N
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conjunctival injection, cells and flare, granulomatous iritis with large "mutton fat"
keratic precipitates scattered over the back surface of the corneal endothelium, vitritis
with white exudative debris in the region of the ora serrata (snowball or snowbank
retinopathy) with retinal vasculitis (candle wax drippings) and phlebitis (venous
sheathing). Nodules of the iris stroma (Busacca nodules), nodules of the pupillary border
(Koeppe nodules), conjunctival granulomas, band keratopathy, posterior synechiae,
cataract formation, secondary glaucoma, retinal hemorrhage, retinal neovascularization,
cystoid macular edema, venous occlusion, optic disc swelling, optic nerve infiltration,
optic neuropathy, proptosis and extra ocular muscle palsy. 20-60y.old black female,
Tx. Cortico-Steroid systemic & topical.
133
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O
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IN
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AIDS: CMV-retinopathy => Kaposi-Sarcoma;
Cottonwool-spot, hemorrhage, ischemic macular-edema, papiledema, N-palsies
AIDS (weight-loss, swollen lymph-nodes, encephalopathy, diarrhea, fever):
conjunctival blood-vessel Abnormalities, hemorrhages, cotton-wool spots,
Cytomegalo-virus (CMV) Infection of retina (hemorrhagic necrosis of retina
w/arteriolar-occlusions), optic Disc-edema, herpes-simplex retinitis
(manifested as arteriolar-occlusion & w/encephalitis), toxoplasma
chorio-retinitis (manifests as vitritis), Zoster “if in young, think Aids”.
Tx. AZT (zidovudine) for the infection itself, “new protease-inhibitor therapies”
Acyclovir for herpes, Ganciclovir for CMV.
Multiple-Sclerosis (MS): chronic-Demyelinating disorder of CNS, age 15-55y.
multiple focal-demyelinating lesion caused by Degeneration of Myelin-sheaths
of Nerve-fiber w/Sparing of the Axon (VEP+).Sympto:Vision-Fluctuation, acute
Unilateral loss of Vision w/tendency for Recovery (due to Retrobulbar /optic-neuritis),
Color-vision loss (R&G), Muscle-Weakness, Parasthesia, sensory & urinary
disturbances, Diplopia (EOM-involve.) due to Intera-Nuclear Ophthalmoplegia,
(lesion is in MLF),typically Paralysis of One or Both Medial-Rectus muscle (MR).
134
Retinal Pathology ;
Pathological- Myopia: posterior-elongation of eyeball due to
progressive thinning of the sclera, presence of staphyloma,
choroidal-atrophy lacquer-cracks create-space for neovasc.-net.
(5% have fuch‟s-spots, neo-nets w/overlying RPE-hyper-plasia,
seen in 4-6th decade, often in macular-area), predisposed to RD,
white without-pressure, lattice, atrophic-holes, cobblestone,
retinal-break and detachments, OAG.
Retinitis-pigmentosa (dystrophy): common symptom is night-blindness,
signs: attenuation of the retinal-vessels, RPE∆, clumping of pigment
clustering around retinal-vessels in the mid-periphery of the fundus, waxy
pallor of the optic-disc, and annular-scotomas, (low-vision-aids, only tx.).
Pigment-Clumping: increased pigment < 1DD in size. Benign,
proliferation of RPE-cell. Clumps may have small retinal-break
around equator, (secondary to vitreal-traction).
R
O
O
N
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135
RPE- hypertrophy & hyperplasia => Congenital: ↑of melanin
in epithelial-cells, flat-round lesion w/distinct-margins (may have
hypo-pigmented surround-ring) several-DD in size, unilateral in
85% of Pt. => Acquired: irregularly-shaped, no-hypopigmented
ring-surrounding, Hyperplasia, [both are due to loss of
photo-receptors, so VF-defect may be seen].
Age-Related Macular-Degeneration (ARMD):
associated w/age; DRY-means drusen & RPE-atrophy,
WET-means Subretinal-neovascularization
Tx. Dry: monitor, Wet: FA & Laser-Photocoagulation
ARMD Dry-form: geographic RPE atrophy, area of “depigmentation,
granular-clumping of RPE & RPE-hyperplasia”, RPE-cell undergoes
complete-degeneration resulting in photoreceptor-loss and degeneration
of rest of the retina. Color-vision (Blue-yellow) is affected, loss of VA
variable, rarely-progresses to legal-blindness. As drusen-calcifies & RPE
disappears risk of conversion to wet-form is almost non-existent.
Seen in 15% of Pt. over 80-yrs old.
O
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IN
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O
N
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136
Dry-ARMD: soft-drusen (Non-exudative), RPE pigment-mottling
and geographic-atrophy (causing photoreceptor-damage).
Tx. Amsler-grid watch, (strong-Add, low-vision).
*Wet-ARMD: drusen, exudation, Metamorphopsia (due to
Serous-detachment of macular-area, from sub-RPE exudation-of choroidal
neovascular membrane “CNM”), sub-retinal hemorrhage or lipid-exudates
may also be present (resolution of hemorrhage, leaves a “white” disciformscar and severe vision-loss). Tx. FA, Photocoagulation.
ARMD Wet-form: 10% of pt. w/macular-drusen develop exudative
maculopathy in about 5-years. Four-types: exudative-degeneration,
C
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O
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choroidal-neovascularization, hemorrhagic-degen. and disciform-degener.
O
N
O
T
PR
IN
(choroidal occurs as a result of RPE/Bruch‟s barrier-disruption,
new-vessels grow in response to hypoxic-stimulus, which may leak,
hemorrhage or form a disciform-scar), “distorted color & ↓VA”,
prognosis is poor if left untreated (do FA & Photocoag.), “soft-drusen,
hard-exudates, metamorphopsia”. (75% treatable early, 20% after
8-wks, only 15% after 4-months), the other-eye will highly be affected.
D
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137
Sub-Retinal Neo-Vascularization(SRNV): due to ARMD, Angioid-Streaks, histoplasmo.

Angioid-Streaks: represent-Breaks on Thickened &calcified Bruch‟s-memb.
Circum-papillary appearance of irregular-Spokes, gray-Red, Mottled-fundus,
may-develop Macular-degeneration –“Dry” or -Neovascular “Wet”.
Cystoid Macular-edema(CME):↓VA, post-Cat. Sx“2-6 wks is peak incidence”
retinal vascular-Leakage (Vein-occlusion , Diabetes) or inflammation from
macular-irritation (epi-retinal Membrane, vitreous-traction, primary
macular-inflammatory disease). Fluid-fills in separate intra-retinal Cyst or
blisters-surrounding Fovea. Peri-foveal Hyper-flourescence on FA is diagnosis
Tx. NSAID‟s (Voltaren-gtt.), Steroids (injectable, gtts) -Po
CME: Secondary to post Cat.-Sx, vascular- Occlusive-disease, Pars-planitis,
Pigmentary-degeneration, YAG-Capsulotomy.
Loss of Foveal-reflex, (FA, shows Petalliform-pattern),
frequently Recovers-Spontaneously, “Grid-Photocoagulation”.
N
O
O
T
O
Clinically-significant Macular-Edema: Hard-exudate within 500 micron(μ) [optic nerve
head is about 1.5mm or 1500μ in diameter “thus 500μ is 1/3 of a disc diameter”]of Fovea
w/macular-edema, caused by Diabetes. Tx. Focal or Grid -Laser (depending on FA)
D
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N
O
T
PR
IN
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138
Central-Serous Choroidopathy: Young Pt. associated-w/Stress, Recurrences,
Spontaneous-Recovery 1-6 months later.Trans.-episodes of central-Vision loss,
elevated-Macular area (Edema) causes loss of Foveal-reflex (long-Standing ones
show yellow-Exudates), Metamorphopsia, ↑PhotoStress-Recovery, loss-VA.


Macular-holes: unknown cause, elderly, VA 20/200 - 400, Sx.
Macular-Holes: Circular to Oval-depression in avascular-macula.
*Lamellar-holes => results from Rupture of Macular-Cyst,
reddish-color, Partial-thickness Excavation w/Metamorphopsia &
Slight-↓VA, often w/Epiretinal-membrane.
*Through & through-hole => .25-.3 DD, reddish area w/Gray edemaSurround, Yellow-deposit @base, Severely-↓VA and Central-Scotoma.

Horse-shoe Tear: Tear is Red in color, “Flap is white(degen.)”, result of
Vitreo.-Traction to Thin-Retinal-tissue. Pulls-detached Retina-posteriorly
w/Anterior-margin of Tear staying-Flat. Apex of the Tear-points to the
Posterior-Pole. Commonly @Posterior-border of Vit.-base, 30% rhegmet.-RD.
D
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139
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
Retinal-Detachment (RD): fluid between Retina &RPE, usually from a retinal
Tear, w/field-loss & Gray appearing Retina w/folds, retina movement on eyemovement. Tears alone treated w/laser-photocoagulation /Cryo. to Seal the tear.
RetinoSchisis: Separation of Sensory-retina at OPL&INL,(large Systic-Cavity
in Sensory-retina Filled w/hyaluronic-acid from Neuronal-deg.)Infra-temporal
70%, seen in Pt.>40y.-bilaterally. look-Red, can-lead to RD, sympt:Floaters &
Flashes (due to Vit.-Traction); Photocoag. &Crytheropy, If-RD Scleral-Buckle.
Lattice-degeneration: all-have White w/o-pressure ring-Surround,
82% have alteration in RPE,100% have Liquefied-Vit. &Strong VitreoRetinal
Adhesion. 50% Bilateral, usually anterior to the Equator, 3% RD-develop,
LY

O
N
O
T
Papilledema: normal-VA, bilateral, blurred disc-margins, enlarged
blind-spot, no-venous pulsation (even if pressure put on globe),
no-pain on eye-movement, disc-elevation > 2D, transitory-obscuration
of vision for about “5-10 sec.” (usually resolves itself if underlying
condition is treated /i.e. Benign intra-Cranial-hypertension).
D
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PR
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T
Circumferentially-oriented, a Degen.-process of Retinal-Thinning & Vit.-Abnormality.
140
Papilledema: due to ↑intra-Cranial Pressure (because of Trauma,
Malignant-hypertension, Tumor), swollen-nerve on ophthalmoscopy,
peri-papillary Edema, cotton-wool spot, Hemorrhages, Enlarged blinds-spot
Tx. MRI /CT-scan

Papilitis (optic-neuritis): venous-pulsation possible, pain on
eye-movement, swelling of disc w/elevation < 2D, (APD +), ↓VA,
red-desaturation, blurred hyperemic-disc, hemorrhages. Rule-out
temporal arteritis (ESR↑), [differentiate from => hysterics visual-loss
(stereo-intact), ischemic optic-neuropathy, disc-drusen, papill-edema],
suspect optic-neuritis if Pt. >40y. old, optic-atrophy present w/short-history,
VF-defects respect the vertical-meridian.
Optic Neuritis: No-Ophthalmoscopy Signs, Normal-disc, Color Vision impairment,
PR
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IN
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D
O
N
O
RAPD + , Central or ceco-central Scotoma, associated w/Multiple- Sclerosis; can be
temporary or permanent, Markedly ↓VA, inflammation of Optic-nerve, painful
eye-movement. Tx. Steroids -Po (often shorten the course)
Retro-bulbar Neuritis: ↓VA, pain on eye-movement, inflammation behind-orbit,
25-40% of these Pt. develop Multiple-Sclerosis (MS), can-become papillitis.

141
Ischemic Optic-Neuropathy (ION): infarct of pre-laminar anterior
optic-nerve due to blockage of 2-main PCA, supplying optic-nerve and
choroids. (Two common causes are Giant-cell Arteritis “TA” and
non-arteritic “ArterioSclerosis”), abrupt ↓VA, pallor and swelling of
optic nerve-head, No-pain w/transient Monocular vision-loss (2-5 Min.),
[“APD +” in eye w/severe ischemic-Papillitis or CRA-Occlusion];
symptom: HA/temporal pain-tenderness of temp-artery, neck-pain, fatigue

AION (Anterior Ischemic Optic Neuropathy): swollen-disc, Giant-Cell / TA,
associated w/Arterio-Sclerosis or Temporal-Arteritis(elderly, pain on chewing
or over temporal-Artery, malaise, fever, aches, wheight-loss, ↑ESR), Acute ↓VA
or Altitudinal visual Field-loss.

Secondary Optic-Atrophy: “Pt. must have visual-Field defect or ↓VA”,
follows (after) Papillitis & chronic-Papilledema, yellow-cup (seen),
(also, w/Glaucoma).
Peripheral-Retina: lies Between the Equator(vortex-Veins) & Ora-Serrata
D
O
N
O
T
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IN
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142
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O
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C
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O
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,V
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O
N

Optic-Pit: a congenital defect of the optic-nerve, w/scotoma &Macular-edema.
Optic-nerve head Drusen: blurred disc-Margin, large “blobs” on-disc,
No-optic-Cup, CRA-branches in front of disc, (Hereditary).
Tilted-Disc (small): 80% Bilateral, myopic-astigmatism w/oblique-axis,
“VF: supero-temporal defect,” (non-progressive), Congenital.
Choroidal-Nevus: Gray-color (Disappear w/red-free Filter-“Green-Ophthal.”)
[you-view them through the RPE]
Choroidal-Melanoma (Malignant): most-frequent Intraocular-Tumor (fatality),
mottled (due to drusen &degen. of RPE) may be flat &diffuse or very-elevated,
Slow-growing, Greenish-gray to brownish w/Orange-stipples on surface.
Nevus: Colored-fundus or skin lesion w/solid coloration, might be a pre-Malign.
Phosphenes: Flashes of light in Vertical-direction seen in the Periphery
of the eye, these Streaks are followed by dark-spots before the eyes, this
phenomenon is result of Vitreous-Detachment (PVD); as it shrinks and
traction on the retina produce phosphenes (a subjective visual sensation
of luminous-spot in the external visual-Field, arising from mechanical or
electrical stimulation of the eyeball), for such Pt a DFE and search of RD is in order.
LY
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143
Required Knowledge ; => => =>
LY
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N
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
The smooth muscle of the pupil (iris) is innervated by the sympathetic(dilator)
and parasympathetic system (constrictor). “{Efferent-lesions, w/Anisocoria}”
Relative Afferent-Pupillary Defect (RAPD): an objective sign of
asymmetrical-lesion of the afferent visual system, (retina, optic-nerve,
chiasm or tract carrying the pupillary light-fibres), “transfering of the
light from the good-eye to the bad-eye will result in less-stimulation of
the E-W nucleus from that eye and a comparative dilation of both-pupil
and vice-versa. This is seen in practice as an alternating constriction
and dilation of each-pupil as the light is swung from eye to eye
(i.e. shine-light OS “Afferent-defect OD” and you will see-constriction
of both-eyes, swing-light to OD and you will see-dilation of both-eyes).
[optic disc-pallor is the only clinical sign], “{No-anisocoria in Afferent-lesion}”
Marcus-Gunn (RAPD): can provide evidence of impaired-function of
“retina or optic-nerve”; can roughly-quantify “w/neutral-density filters”
in-front of “Normal-eye” to “balance” the visual-loss.
O
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144
Marcus-Gunn Pupil(swinging-flashlight test): have Pt. look at your nose,
shine-light in one-eye &then rapidly “swing” it to the other-eye and shine
it at the same angle. “Dilation of Either-eye upon-shining the light is
“Abnormal” and noted as a “positive-finding” (Marcus-Gunn Pupil),
[a negative-finding can be recorded as PERRLA: =>
Pupils Equal, Round, Reactive to Light and Accommodation]

Horner‟s -syndrome: the affected-eye shows anisocoria greater in
darkness (doesn‟t-dilate “it looks-constricted”). Using 4-10% cocaine in
both-eyes, the normal-pupil dilates and eyelids-retract as re-uptake of
nor-epinephrin at the synapse is blocked by the cocaine.The“constricted”
diseased-eye has no nor-epinephrine release to-be-blocked and the pupil
size therefore does not alter, (Hetero-chromia is a feature of congenital
Horner‟s, the affected-iris being light-in-color); then failure to dilate to
1% hydroxyamphetamine demonstrates a post-ganglionic lesion (this is
a good-sign), since pre-ganglionic lesion may accompany pancoasttumor of the lung. [sympathetic-paresis]
D
O
N
O
T
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145
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
Abnormal-Parasympathetic: Anisocoria-greater in the light (doesn‟t constrict
“it looks-dilated”), [Adies-pupils, Argylrobertson, 3rd nerve-palsy].
Adie‟s-pupil: “lesion of the ciliary-ganglion” (mostly females 20-40 y.
old, w/prevalence of 2/1000), pupil is dilated w/absent of poor-tonic lightreaction and tonic-slow (vermicular) pupillary near-reflex. “deep-tendonreflexes can be lost / if with hypo-reflexia it‟s called Adie‟s-syndrome”,
sectorial-iris atrophy due to de-nervation of sphinecter, (hyper-sensitivity of
the pupil “constriction” to 0.1% pilocarpine “due to deprived of Ach” is the-diagnosis
“normal-pupil will-not respond”), Tinted-lenses to hide-unequal pupil-size
T
O
R
C
“unequal bifocal-add or reading-glass” [Adies is a benign-condition].
Argylrobertson: the lesion is located in the region of E-W nucleus, pupil are
irregular and asymmetrical in size w/poor light-reflex (both direct & consensual)
and brisk (good) near-reflex. They are the hallmark of neurosyphilis,
(however, similar-pupil occasionally seen in diabetes).
Pharmacological-blockade or “Atropinic” (Anticholinergic-mydriasis):
O
D

N
O
T
PR
IN

0.5 or 1% pilocarpine “will-not” constrict the pupil (since the receptor sites are “occupied”
by anticholinergic-drugs); “this will distinguish the condition-from 3rd N.-Palsy”.
146
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O
N
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
Bell‟s-Palsy (VII-N.): Palpebral-Fissure remains Open (Lids will not-Close)
the lower-lid sags & Punctum-falls away w/epiphoria,
affect all-muscles of facial-expression.
Onset is acute, and 80% of Pt. Recover w/few-weeks to months.
3rd N.-Palsy (interruption of the pre-ganglionic innervation of sphincter),
most common cause of “sudden-palsy” in an adult w/dilated & fixed
pupil and HA is an “aneurysm” at the junction of the ipsilateral
“internal-carotid” artery and the “posterior-communicating” arteries
(most common-cause is diabetes-mellitus). [use 0.125% pilo first to
distinguish-from Adie‟s], moderate-concentration of pilo. “0.5 or 1%”
will result in prompt “constriction” (diagnosis of 3rd N.-palsy).
Acquired 3rd N.-Palsy => involve partial/complete EOM: IR, SR, MR, IO
and “if w/intra-ocular muscles involvement” (if-both: complete-progressive
- external-ophthalmoplegia → then, fixed-dilated pupil w/paralysis of
accommodation, w/eye down & out; etiology: MLF & brain-stem lesion
inflammatory-vascular disease, MS, trauma).
3rd Nerve-Palsy: Eye points down & out (XT & Hypo)in affected-pupil; Neurological.
O
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147
4th Nerve-Palsy: superior-oblique (SO)-Paresis, “non-comitant”,
(#1 cause of vertical-deviation), diplopia and vertical-deviation
worse w/down-gaze @ near, Pt. presents w/head-tilted to the opposite-shoulder,
*“Bielschowsky‟s -sign: hyper-deviation increases markedly-towards
the side of the paretic-SO w/Madox-Rod”. (etiology: trauma is #1 cause,
also lesions, infarcts, aneurysms, diabetes, hypertension)
6th Nerve-Palsy: LR-Paresis, Eso-tropia in primary-position, which
increases on attempted lateral-gaze, head-turn towards the side of
the paretic-muscle; (trauma / non-comitant).
C
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Synergistic-muscles, gives the same-action in a given-eye.
Agonist: are muscles that moving the eye in desired-direction of gaze (same-eye).
Antagonist: muscles in the same-eye that having the opposite-action.
Yoke muscles: those muscle of the two-eyes which simultaneously
contract to turn the eyes-equally the same-direction.
Hering‟s-law; of equal-innervation in all-voluntary eye-movement, there is
equal-innervation to the yoke-muscles of the two-eyes.
Sherrington‟s-law; of reciprocal-innervation: whenever agonist-muscles are
innervated, antagonist-muscles are innervationally-inhibited.
N
O
D
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O
T
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148
VI, IV, III(SR,IR,MR,IO), N.-Paralysis => SR: paretic-eye in primary-position
is hypo-tropic, w/absent of “Bell‟s-phenomenon”. / IR: paretic-eye in primaryposition is hyper-tropic (& incyclotropia). / MR: paretic-eye in primary-position
is Exo-tropic (must be differentiated from inter-nuclear-ophthalmoplegia).
/ LR (VI): paretic-eye in primary-position is Eso-tropic, w/head-tilted towards
the involved-side, (it must be differentiated from Duane‟s-retraction syndrome
& from nystagmus-blocking syndrome which causes congenital eso-tropia, and
from “Mobius-syndrome”). / IO: greatest-deviation seen upon-elevation in the
adducted-position. Overaction of the unopposed-SO causes incyclo-tropia.
(the forced-duction test is necessary to differentiate this from Brown‟s-syndr.)
/ SO (IV): the Overaction of IO will produce “hyper-tropia” in the primaryposition, w/head-tilt toward noninvolved-side, the palsies are bilateral in 20%
of traumatic-damage,(most-common).

Duane‟s-retraction syndr: absence of abduction of one-eye in lateral-gaze
(looks-like, but isn‟t LR-paresis; VI-n.) head-turn to the affected-side.
D
O
N
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149
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O
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O
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N
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
MS: Paralysis of (medial-gaze) both “or one” MR-muscle “MLF”,
[w/possibility of LR also-affected.]
Medial-longitudinal-fasciculus (MLF) lesion => internuclearophthalmoplegia: looks-like MR-paresis (convergence is intact),
if bilateral, think multiple-sclerosis (MS)
Mobius-syndrome: bilateral-paralysis of lateral-gaze (LR), eso-tropia
is common. Resemble bilateral sixth-nerve palsy (lack of lateral-gaze),
and appearance of bilateral facial-palsy “7th N.”
Brown‟s-syndr: the superior-oblique (SO) tendon-sheath is fibrosed,
(inability to elevate the adducted-eye above mid-horizontal),
mimics inferior-oblique paresis.
Parinaud‟s-syndrome: paralysis of upward & downward gaze
(etiology: tumors of pineal-gland most-commonly)
Bell‟s phenomenon: is the normal upward and outward rotation
of the eyes on bilateral-closure of the eyelids.
Levator M.→ raise the eye-lid, /muller‟s-muscle → maintain the tonus of the
elevated-upper lid, (orbicularis oculi → closure of eyelids).
150
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can have a variety of visual-symptom. Typically they will see a small, enlarging blind-spot
(scotoma) in their central-vision with bright, flickering lights (scintillations) or a shimmering
zig-zag line (metamorphopsia) inside the blind-spot. The blind-spot usually enlarges and may
move-across their field of vision. This entire migraine phenomenon may end in only a few minutes,
but usually lasts as long as about 20-30 minutes.
Generally, ocular-migraines are considered harmless. Usually they are painless, cause no
permanent visual or brain damage and do not require treatment.
The vision symptoms accompanying painless ocular migraines are not related directly to the eyes.
Instead, these visual symptoms occur as a result of the migraine “activity” in the visual cortex of
the brain in the back of the skull.
O

N





O

Ocular-Headache: dull, frontal, non-throbbing, caused by uncorrected
refractive-error, presbyope, phorias, and poor-lighting, asso. w/eyes-used
Migraine-HA:gradual build-up, intense, throbbing, vascular(dilation&constr.), unilateral,
intensified by light-noise-movement associated w/nausea, blurred, photophobia
Cluster-HA (migranous-neuralgia): unilateral, sever-pain, daily for few-wks
Depression-Headache: worse in the morning
Sinus-HA: occurs over affected sinus, w/sinus-infection
Tension-HA: constant, daily, generalized around neck &back of head
Post-Traumatic HA: constant, dull-ache, dis-equilibrium may occur
Ocular Migraines: Ophthalmic (eye) migraines are quite common. People with ocular migraines
D

151
LY
N
O
-
Systolic-BP: normal < 140, borderline 140-160 mmHg, HTN > 160 mmHg.
*Diastolic: normal < 85, High-normal 85-90, mild-HTN 90-105,
moderate-HTN 105-115, severe-HTN >115, (Normal-oral Temperature: 98ºF, 36.7ºC)
Formula ∆ (Fahrenheit / Celsius): Tc = (5/9) (Tf - 32), Tf = (9/5) (Tc + 32)
O
PY
,V
IE
W

Orbital-“Bruits”: Carotid “Cavernous-Sinus Fistula” (80% results from
Trauma to the Head), signs: pulsating-Exophthalmos & very loud-bruit,
(use the bell-portion of your Stethoscope and hold the bell-over the Pt.-Eye,

TIA / Stroke: temp./perm. Loss of Vision, from Occlusion of blood-Vessel in the Brain

Neurologically significant field defects are most often central scotomas (due to optic
nerve lesions), bitemporal field defects (due to chiasmal disease), or homonymous
visual field defects (due to retrochiasmal damage to the optic tracts, the radiations, or
the occipital cortex). In almost all locations, the effects produced are most profound
within the central 30' of the visual field.
C

D
O
N
O
T
PR
IN
T
O
R
if you hear a laud “train-sound or bruit” you may have a Cavernous-Sinus Fistula on your hand).
152
153
O
D
N
T
O
T
IN
PR
R
O
O
PY
,V
IE
W
C
O
LY
N
Figure: Deficits in the visual field produced by lesions at various points in the visual pathway. The level of a
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
lesion can be determined by the specific deficit in the visual field. In the diagram of the cortex the numbers along the
visual pathway indicate the sites of lesions. The deficits that result from lesions at each site are shown in the visual field
maps on the right as black areas. Deficits in the visual field of the left eye represent what an individual would not see
with the right eye closed rather than deficits of the left visual hemifield.
1. A lesion of the right optic nerve causes a total loss of vision in the right eye.
2. A lesion of the optic chiasm causes a loss of vision in the temporal halfes of both visual fields (bitemporal
hemianopsia). Because the chiasm carries crossing fibers from both eyes, this is the only lesion in the visual system that
causes a nonhomonymous deficit in vision, (ie. a deficit in two different parts of the visual field resulting from a single lesion).
3. A lesion of the optic tract causes a complete loss of vision in the opposite half of the visual field (contralateral
hemianopsia). In this case, because the lesion is on the right side, vision loss occurs on the left side.
4. After leaving the lateral geniculate nucleus the fibers representing both retinas mix in the optic radiation. A lesion of
the optic radiation fibers that curve into the temporal lobe (Meyer's loop) causes a loss of vision in the upper quadrant
of the opposite half of the visual field of both eyes (upper contralateral quadrantic anopsia).
5, 6. Partial lesions of the visual cortex lead to partial field deficits on the opposite side. A lesion in the upper bank of
the calcarine sulcus (5) causes a partial deficit in the inferior quadrant of the visual field on the opposite side. A lesion
in the lower bank of the calcarine sulcus (6) causes a partial deficit in the superior quadrant of the visual field on the
opposite side. A more extensive lesion of the visual cortex, including parts of both banks of the calcarine cortex, would
cause a more extensive loss of vision in the contralateral hemifield. The central area of the visual field is unaffected by
cortical lesions (5 and 6), probably because the representation of the foveal region of the retina is so extensive that a
single lesion is unlikely to destroy the entire representation. The representation of the periphery of the visual field is
smaller and hence more easily destroyed by a single lesion.
154
Isolated lesions anterior to the chiasm within the optic nerve produce visual field defects
in one eye only. Optic nerve dysfunction typically produces a central scotoma, with
accompanying reduction in visual acuity. Common causes of unilateral optic neuropathy
include optic neuritis, optic nerve glioma, and meningioma.
Lesions in the optic chiasm produce visual field defects that affect both eyes, but in a
dissimilar fashion. The most common example is a bitemporal hemianopia caused by
pituitary adenoma. Another common visual field defect due to disease near the chiasm
is loss of central field in one eye and a temporal visual field defect in the other eye.

Lesions affecting the visual pathways behind the chiasm produce homonymous
hemianopia or homonymous defects that are less than a complete hemianopia.
Because the fibers serving the corresponding portions of the two retinas lie increasingly
closer together as the fibers pass back toward the occipital cortex, there is greater
correspondence of the field defects in the two eyes as the lesions occur more posteriorly.
Central visual acuity is not affected in homonymous hemianopia unless both
hemispheres are involved. Stroke is the most common cause of a homonymous
hemianopia. Middle cerebral artery occlusion tends to cause a complete hemianopia
with other neurologic signs, whereas posterior cerebral artery occlusion causes isolated,
congruous (identical) hemianopic scotomas.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

155
Humphrey Visual-Field: 30-2 macula-test \ 81 full-field (screening)
24-2 neurological-test \ 10-2 peripheral-test
- Mean deviation: MD →if <-3: general depression
- Pattern standard deviation: PSD→if >2: focal defect
- Standard fluctuation: SF→if >2: not-reliable
- Corrected pattern standard deviation: CPSD→if >2: focal defect
* fixation-losses, false-pos. errors & false-neg. errors: must-be <10% for test to be valid.
Visual field-testing: automated-static (non-moving) perimeter“Humphrey”for
Glaucoma-test => standard 30-2 (w/follow-up 24-2) every 6-months.
(Glaucoma-VF: usually respect the horizontal-meridian, due to nerve-fiber
O
R
C

O
PY
,V
IE
W
O
N
LY

PR
IN
Tangent-screen: up to 90% of all VF-defect in the central 30-degrees
T
may be picked-up by this method of Kinetic-perimetry (supra-threshold-stimulus).
N
O
Amsler-Grid (qualitative): analyze the earliest maculopathies and their
progression (scotoma @ central 10-degrees of vision) useful for dry-ARMD
watch of metamorphopsia (when it changes to wet-ARMD form).
Amsler-Grid: chart@ 30cm, can detect edge of Bjerrum-Scotoma. [ARMD]
D
O

T
bundle-defect & papilo-macular fiber are resistant to chronic-pressure until late in the disease)


156

Macular Photo-Stress test: Pt. look at a flash-light @ 2cm from the eye
for 10 sec. normal-time is 55 sec. for visual-recovery of one-line >VA
recovery taking 90-180 seconds indicates macular-dysfunction.
Photo-Stress test(Macular-test): in-disease of “optic-nerve” no-delay is expected,
LY

O
N
(since photosensitive-pigment regeneration is un-altered) 60sec cut-off point for macular-disease.
O
PY
,V
IE
W
Color-Saturation test: have Pt. look at top of mydriatic-bottle (Red),
first-with one-eye and then with the-other, and he is asked if there is
a difference in-the-two “colors” of the “cap” if there is an “optic-nerve”
conduction-defect, the Pt. will report that the “cap” seems to be “faded”
or “desaturated” for the “defective-eye”.
R
C

ARMD →B/Y defect, Retrobulbar-neuritis →R/G defect, Amblyopia →normal CV
Color-vision: CV, particularly Red-perception, may be disturbed in early
Macular-disease, commonly used tests are the polychromatic-plates of Ishihara
[Protans &Deutans are red-green deficient(the only-discrimination by Ishihara)
and are found in 4% of all-males and 0.4% of all-females, Tritans &“tetratans”
are very-rare and blue-yellow deficient]. (in Pt. taking “Chloroquine
for RPE-Atrophy in Bull‟s-eye Maculopathy” if-CV+ order-FA)
D
O
N
O
T
PR
IN
T
O


157
Acquired Color-Vision Deficiencies(Kollner‟s-Rule):disease of the Retina
& changes of the Ocular-Media are associated with “Blue-Yellow” defects,
while disease of the Optic-Nerve & Visual-Pathways are associated with
“Red-Green” deficiencies, [exception: most Hereditary Color-defect are
Red-Green].
Anomalous Trichromasy: have 3-class of Cone, but one-is-abnormal,
require 3-primary to match another-wavelength but the proportion are
different from-normals; Protanomalous “abnormal Red/erythrolabe”,
Deuteranomalous “abnormal Green/chlorolabe”, Tritanomalous
“abnormal Blue/cyanolabe”.
Dichromasy: have only 2-classes of Cones, uses 2-primaries to match
another-wavelength; Protanope “lack-Red-Cones”,
Deuteranope “lack-Green-Cones”, Tritanope “lack-Blue-Cones”.
DiChromate‟s =>Protanopes: missing Red-cone (erythrolabe),Confuses-Red
w/any-color,and B-G w/white.Deuteranopes: missing Green-cone(chlorolabe)
Confuses-Green w/white. Tritanopes: missing Blue-cone (pigment cyanolabe)
Confuse-Yellow w/white.
O
PY
,V
IE
W
O
T
O
N
O
D

T
PR
IN

R
C

O
N
LY

158
LY
N
O



Monochromasy: one-primary to match all-wavelengths, truly-ColorBlind,
uses-Intensity to distinguish one-color-from-another; Rod-monochromat
“aka complete or normal-monochromat”, /Cone-monochromat “aka
incomplete monochromat”, have Rod-plus one-Cone type “Red or Green”.
X-chrome: Red-lens used by Rod-monochromates, “cut-off @ 580 nm”.
Half-life of Rods = 5 minutes; where Half-life of Cones = 1.5 minutes
in general-population 8% males and 0.5% females are color-defective,
O
PY
,V
IE
W

(deuteranomalous 5% incidence,Tritanope 0.002%, monochromat < 0.003%, the rest 1%).
Farnsworth Panel D-15: detects R/G and Y/B anomalies, “Tritan”.
Ishihara: figure made-up of “dots” that vary from the background in
“hue” as well as “brightness”, (screens Red/Green anomalies only).

Contrast => defined as the relative-difference between the intensities of the
target and it‟s surround. (limitation of high-spacial frequencies: → blur and
disease of fovea. limitation of middle spacial-frequencies:→ neuronal-patho.)
Contrast-Sensitivity => Cataract: ↓high-spatial-frequency, MS: ↓medi. S.F.,
Amblyopia: ↓all S.F.

D
O
N
O
T
PR
IN
T
O
R
C


159


LY
N

O

Contrast Sensitivity w/aging: decreased spatial-contrast sensitivity to-all
frequencies, (low, intermediate, high).
Temporal Resolution w/aging:Critical Flicker Fusion (CFF)declines w/age,
(will-perceive pulsating-light as being constantly-on).
Subj.-Refraction: Older-Pt. require more-time due to “↓blur-Sensitivity”
from small-pupil or media /retina changes; (however, Prolong/excess Exposure
“to a VA - Line” will result in Diminish Response, so be-careful.
O
PY
,V
IE
W

Depth of Field: range of an Object that can be moved w/o it‟s ↓image-quality noticeably.
Depth of Focus: range of the Image-plane that can be moved w/o↓in image-quality.
Pulfrich-Phenomenon: apparent-motion in depth of a moving-object,
viewed w/neutral-density filter before one-eye. Eye w/filter in-front of it
sees a lag in target-location w/respect to that seen by the other eye.

Catract: w/Pinhole will not-improve. Anterior ∆: affect Near VA 20/40/↑,
PSC: affect Far VA 20/200/↑(direct Ophth. difficult /blurred Fundus),
Nuclear Sclerosis: affect Near VA 20/25 & Far VA.
Myopic-Shift: seen due to NS or Diabetes(Transient), Spasm of Accom. and ↑IOP
D
O
N
O
T
PR
IN
T
O
R
C


160


Blue &Violet Sensitivity↓ due to Lens-yellowing(high-frequency wavelength absorbed)


Potential Acuity-Meter(PAM):projects a standard Snellen-acuity/Chart onto the Pt.retina
C
O
PY
,V
IE
W
O
N
LY

NS-Catract: causes Myopic-shift in refractive-errors & also of Bluediscrimination, as Color-perception changes lead to blue-color defect,
as yellowing-lens filter Short-wavelength.
Hyperopic-Shift: seen due to Cortical-cataract,
Intra-ocular Masses (or Macular-elevation due to edema, etc.),
Uncorrect. High-hyperope in Children can lead to Accommoda.-EsoTropia,
hyperopic Pt. have greater chance of Angle-closure glaucoma (due to ∠1,2).
IN
PR
T
O
N
O

BIO: image is Inverted (upside-down) & Reversed, field of view “10x of direct-oph.”
but image-size is 3x, (smaller).
Lens-Ophthalmoscopy: direct-oph. “set @+4D at 20cm” from the Pt., Lens
Opacity appear “Black” against reddish-orange Reflex; (nuclear-Cat. appear as
“lens w/i a lens”): if “upgaze” &the Opacity “move-Up” it is in the “Anterior”
of the Lens or Cornea, if “move-Down” it is in the “Posterior of lens or Vitreous”.
D

T
O
R
BIO-magnification: Power of the Eye divided by Power of the Condensing-lens,
(i.e. 60D/20D = 3x).
161
O
PY
,V
IE
W
C
R
O
T
IN
PR
T
O
N
O






D




O
N


druzen: at the apex of Bruch‟s-membrane, under-RPE (by-product of RPE)
yellowish /white, small “appears-farther”.
Exudate: in OPL (outer plex. layer) yellow & brighter “appears-closer”.
concretion: whitish-dots, kind of flat on palpebral-conjunctiva (elderly)
are deposite of ca+ response to allergy.
follicules: indicate-viral (accumulation of dead-WBC)
large-papila → allergy-origin / small-papila → bacteria-origin
pterygium: is a triangular band of fibro-vascular tissue, w/apex on cornea
pinguecula: elevation on conj. they are formed by elastic-degeneration of
collagen within the substantia-propia.
flares: protein from ciliary-body / ∙ dyscoria: pupil is not-round
diabetic: venous is engorged
/
∙ affirent def. → MG (+APD)
hypertention: artery is thinner /
∙ efferent → Aniscoria
dot & blot hemorrhage: @ middle-layer of retina
pre-retinal hemorrhage: bowl-shaped, floating on-top of retina
LY

Cotton-wool: superficial, hides blood-vessels (@ nerve-fiber layer “flame-hemorrhage”)
162



Pterygium: degeneration of cornea-epith. & bowman‟s (replacement of the tissue
w/elastic tissue & hyaline), related to UV-exposure. Tx. -Sx.
Pinguecula: elastic tissue and hyaline on conj, due to UV-exposure.
Concretions:Conj.-Cyst w/yellow particles in the cul-de-sac if Symptomatic; Excision&Antibiotic
LY

Dermatochalasis: age-related upper-lid Laxity & drooping. Tx. w/Sx.
Blepharochalasis: Skin-folds in lids, form because of loss of elasticity due to
Chronic Swelling in young. Tx. w/Sx.

Ectropion/Entropion:Outward-drooping/Inward-turning of Lid and Lashes, Ageing.



Distichiasis: Congenital Extra-Row of Lashes Posterior to normal-lashes in meibomian-Orifices.
O
PY
,V
IE
W
O
N

R
C
Tx. w/Lubricant, Sx.

Ectopia-lentis:lens dislocation due to poor-zonule structure, usually Marfan-syndrome.
T
IN
PR
T
O
N
O
Streak- Retinoscopy : Sleeve is in Down-position (w/Plane-mirror
“used Clinically”). [when you tilt the retinoscope light-downward, it moves
the retinal-image down as well, but the apparent light-source goes-up].
D

O

Madarosis: Loss of Lashes, usually due to blepharitis.
Poliosis: De-pigmentation of the Lashes, usually due to blepharitis.
Vitiligo: Localized-loss of Skin-pigment.
163
Shirmer-I: reflex & basal tear, No-anesthetic
Shirmer-II: Basal-tear only, Anesthetic-used (produ.: 0.5-1.25 ml/day)

[Whatman No. 41filter-paper-strips 5 mm-wide x 30mm-length, known
as “Schirmer-tear test filter-strip”], in Schirmer-I, no-anesthetic used.
It tests-Basal (maintained by accessory-conj. lacrimal-gland of krause &
wilfring) and reflex tear-secretion (product of the main lacrimal-gland).
5mm from the end-folded strip is placed @ lateral 1/3 of lower-palpebral
conj. for 5minutes, while Pt keep the eyes-open w/upward looks (w/dimroom-light & blinks-ok). Normal is 10-30 mm wet. <5 mm on repeated
testing indicate hypo-secretion of Basic-tearing w/15% chance of error.
[by rubbing a dry-cotton tipped-applicator on un-anesthetized nasal-mucosa,
the wetting-filter is measured after 2min (not 5min), <15 mm wetting
indicate-failure of Reflex-Secretion]. Schirmer-test II:
- In Basal-Secretion test, the same-procedure ( Schirmer-I) repeated
w/anesthetic (the Reflex-tearing is eliminated).“most commonly-used test”
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY


164
T
O
N
O
D

PR
IN
T
O
R
C

O
PY
,V
IE
W
O
N

Jones-test → I: fluorescein is instilled into the conj-sac and if the
excretion is normal, the dye can be recovered from the nose with a
cotton-swab within 5min.
Jones-test → II: if after jones-I, no staining is present in the nose, the cul-de-sac
is irrigated with saline. If the cotton-swab from the nose is wet after irrigation,
there is partial-obstruction of the system, If there is no-wetting even after
irrigation, there is complete-obstruction of the naso-lacrimal passage.
Fluorescein dilution-test: instill a tiny-drop on the superior-bulbar conj.
look at the tear-film w/cobalt-filter in the slit-lamp @ 5min. intervals.
In normal it becomes very-difficult to see any-fluorescein at 10 or 15 min.
If there is still a lot of fluorescence after 15 min. this indicates an
“aqueous” production deficiency, (middle-layer of tear-film).
Rose-Bengal staining: used for detection of Damaged-epithelial cells,
(mucus & debris) in KCS. Eye-anesthetized and saline-wetted Rose-Bengal
strip is instilled in each conj-sac, a positive-test will show triangular-staining
of the nasal & temporal Bulbar-conjunctiva in the inter-palpebral area and
possible Punctate-staining of cornea, specially in the lower two-thirds.
LY

165
LY
N
O
Stains: Gram, Giemsa, Hansel and Wright-stains
Cultures (taken prior to use of topical-antibiotics): by moistening
the sterile “applicator-tip” w/saline and wiping the “lid-margin” or
conj. “cul-de-sac”. The culture is then inoculated onto an “agar”
or “media-plate”, (Bacteria: blood-agar & chocolate-agar).
Scraping (w/anesthetic and after cultures-taken): A sterilized
“spatula” is used to scrape the involved-surface and then spared
onto a“glass-slide”for microscopic-examination,(Gram-stain:+ or organism. Giemsa-stain: effective @ showing-presence of viruses)
O
N
O
D

T
PR
IN
T


O
PY
,V
IE
W

C

R

TBUT: No-anesthesia, w/fluorescein-strip & no-blink (no-holding lids by
fingers) appearance of black-Spots <10 sec. (normal is >20 sec.) indicate
tear-film instability (due to mucin “by goblet-cells” and aqueous tear
deficiency or meibomian-gland-↑secretion).
TBUT: test assess the “Mucin” layer of the tear, (the Closest to Cornea).
Rose-Bengal: test measures abnormalities in the Oily-layer “Top” (instil in Palp.-Conj).
Methylene-Blue stain → corneal-Nerve; Rose-Bengal stain → Mucus-strand (KCS)
O

166

Hirshberg‟s -test: fixation-light @ 33cm, and the deviation of corneal lightreflex from-center of pupil in the not-fixating (turned) eye is estimated.
1mm of decentration corresponds to 14 prism-diopter “7-degree” of deviation.
N
O
O
PY
,V
IE
W
C
IN
PR
T

T
O

Krimsky method: dissimilar-position of corneal-reflex (Hirshberg), in the
pupils of each-eye are indicative of strabismus, which measured by placing
successively-increasing prism-power Before the Deviating-eye until the
reflection is similarly positioned in both-eyes (BO∆ used for esotropia “ET”,
BI∆ for exotropia“XT”), this is a direct-reading of the estimated Squint-angle.
Krimsky: Prism are placed in-Front of the Deviating-eye Until the Reflex are
Aligned; (Hirschberg: Asymmetrical binocular-Reflex, indicate a Squint).
Cover-Test: Unilateral -CT detect-Presence of Squint; Alternate -CT
measures-Amount of Squint, [both ET & XT have Suppression-Scotomas].
R

LY
(ie. 2mm inward deviation of light-reflex, corresponds roughly to 28∆ D“XT”exo-tropia)
Cover-Uncover test, detect Tropia and does indicate its direction, but does not-determine the magnitude.
-
During Unilateral-CT, if movement is noted, a Tropia is present. If no-movement was seen,
then Alternating-CT is performed.
During Alternate-CT, if movement is noted, then Pt. has a Phoria. Alternate, measures Magnitude
of Phoria and Tropia, also confirms direction of the deviation.
D
O
N
O
-
-
167
Stereopsis: tested-grossly by having pt.- touches end of his finger to the tip of
examiners-finger coming-in horizontally end to end, past-pointing may indicate
lack of depth-perception.

Worth Four-Dot test:@ near-33cm(macular/central-fusion)& distance-6m(peripheral).
O
PY
,V
IE
W
O
N
LY

D
O
N
O
T
PR
IN
T
O
R
C
Pt. views: two-green, one-red, one-white. (normally white-seen by both-eyes,
greens through-green-filter, red through-red-filter) pt that fusing: reports
four-light, w/white seen as mixture of red & green. If pt suppressing the eye
w/red-filter, will see only-green, and if pt suppressing the eye w/green-filter,
will see only-red. [NRC will be identified in strabismic pt if they report that
they see five-lights (three-green & two-red), “if the position of the lights
corresponds to the angle of deviation”]. The dots-seen by the fixating-eye
will be clear, where as those seen by the deviating-eye will be blurred.
(ARC is present if pt report 4-dots seen while displaying a manifesteddeviation or if they have a micro-strabismus). “pt w/eso-tropia of 10D
or greater will not-fuse the distance-worth-4dots”.
168
C
Horopter: the locus-of-point in-space which fall-on corresponding retinal
Points of both-eyes for a fixed-convergence “position of maximum- sensitivity
to stereoscopic-depths”, (object-that does not-lie in-Panum‟s area,
will be seen-double).
Vergence system -(tonic, accommodative, fusional, proximal);
align visual-axes to maintain bi-foveal fixation, (at various distances).
T
O
Blur-Stimulate“Accommodation”,where Disparity Stimulate“Fusional-Convergence”
D


N
O

PR
IN
T
O
R

O
PY
,V
IE
W
O
N

Depth-Perception: worth-4dot “Subj.-measure of Suppression”, (test of 1st
and 2nd degree fusion). Randot stereo-test (test 3rd degree fusion“Stereopsis”).
Amblyoscope: 1st through 3rd degree.
Suppression: an anomaly of binocular-vision, where all or part of the visualfield of one-eye is not-consistently perceived, due to cortical-inhibition from
the non-suppressed eye, it occurs in the absence of binocular-fixation, to-avoid
diplopia and confusion.
LY

Associated-Phoria; is the Amount of Prism required to Reduce the
Fixation-Disparity to Zero.
169
w/Cycloplegia: near-testing, binocular-balances, muscles-balancing are Not-Valid.

NRA / PRA, Negative & Positive Relative Accommodation; Plus to blur
st
(NRA) is done 1 , since it is a Relaxing-test, (Presbyope done w/Add).
“note this change in power, as the NRA result relative to the tentative-add”

as Plus-lenses are added during the NRA-test, a reduction in the stimulus
to-accommodation occurs which in turn relaxes accommodative-convergence.
To-avoid Diplopia,Positive Fusional Vergence is required.As-long as positive
fusional-vergence is available, accommodation and accommodativeconvergence can be relaxed but-when the “Limit” of “PFV” is reached,
no-further accommodation is relaxed, and Blur is reported.
thus, NRA is a Test of “Positive Fusional-Vergence” an NRA of < +2.00D
may indicate PFV is severely-Limited, or Pt. was “Over-Plused”
in subjective refraction.
Since +2.5D of accommodation is stimulated at 40cm, the NRA should
not-exceed +2.5D, if Greater, Then Subj.-refraction is “Over-Minused”.
-
T
D
O
N
O
-
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

170
PRA: reduce the Sphere-binocularly until the Pt. reports Blur.
“note this change in power, as the PRA result relative to the tentative-add”
as Minus-lenses are added (plus-reduced) the stimulus to accommodation
increases. Accommodative convergence also occurs and To-avoid Diplopia
“Negative-Fusional-Vergence” must be used. Therefore, the minus-lens
to-blur test is considered a Test of the “Limit of NFV”. A finding of Less-than
normal (-2.50) for PRA, may indicate “Low-amplitude of Accommodation”
or Limited-NFV.

A person can-use ½ of their accommodation comfortably. [@40cm:1/.4=+2.5D]
Amplitude of accommodation, is the Difference expressed in-Diopters
between the “Farthest-point & Nearest-point” of Accommodation.
(a person w/5D of Accom. or greater, not-required bifocal at distance of 40cm [2.5D]
“pt. is comfortable when no-more than ½ of amplitude of accommoda. used”)
If, for a stimulus to-accommodation of 2.5D, & the accommodative response
is-only 1.5D, the difference (1.0D) is known as the Lag-of-accommodation.

R
O
T
O
D

N
O
T
PR
IN

C
O
PY
,V
IE
W
O
N
LY

If Pt accepts > +2.5D in NRA, he is “over-minused” /if < -2.5D in PRA, he has “low AOA”.
171
Adjusted-tentative Add, using NRA, PRA method, “Balances the Range”.
Add +(PRA + NRA) =Adjusted Add [+2.00 +(-1.25 + 0.75)]= +1.75 Add: +2.00
2
2
PRA:-1.25

Use JCC w/minus-axis @ 90 “before-both-eyes” and fogging-lens of
+1.00 Over the “expected-need” Add in place, (Pt. initially-sees Vertical-lines
clear, ↓plus till Pt. report Horizontal-lines are Clear).
Van-Graefe Binocular-Balance: To balance the Accommodative Stimuli to the
two-eyes. This comparison test achieves its goal only if the Monocular- Acuity
are Equal. If VA-differ by more-than one-line do-Not use this procedure.
[“w/ 3BD, 3BU” add +0.75DS to fog-OU. ↑+0.25 to-the Clear-eye image till
“equally-Blurred”, then remove prism and ↓-0.25 Sphere-OU, till the addition
of minus no-longer increases the VA].
Correction; for both Myope and Hyperope: the objective is to place the
Secondary-Focal-point of the Lens and the Far-point of the-Eye, Together.
The Secondary Focal-point of the Correcting-Lens must Coincide with the
Far-point of the Eye.
NRA:+0.75
O
N
O

D

T
PR
IN
T
O
R
C

O
PY
,V
IE
W
O
N
LY


172
O
PY
,V
IE
W
N
O
T
PR
IN
T
O
R
C
Cornea than the Long wave-length (red). This chromatic-interval provides a way to
identify the spherical-end point.
[done-after completion of monocular sphero-cylindrical refraction, w/very dim-room,
done-Monocularly if Pt. has equal-VA in both-eyes,or done Binocularly in conjunction
w/Prism-dissociation in Pt. w/Un-equal VA in two-eyes. “add „-‟sphere if Pt. report Red
is Sharper and if-letter on Green are Sharper add „+‟sphere”.The accepted endpoint is
the least-minus which makes the letters on the Green-background slightly-Sharper.
“in Binocular, Pt. attention is directed at top or bottom image one-at-a-time and
corrected for the Color, it is balanced when-simultaneously both-images (top & bottom)
corresponds to the same-change in the Color”].
O

D
-
O
N
-
Static Retinoscopy: Pt. fixates @ Distance so accommodation & vergence
Relaxed. The principle is to make the Far-Point (FP) of the Eye (Pt. retina)
Conjugate to the Retinoscope, this is the Neutral-point.
If FP is Closer-than the working-distance (Myope-Real “in-Front of the Eye”)
“Against-motion”, requires Minus (Concave) lenses to Neutralize the reflex.
If FP is Farther-than working-distance (Hyperope-Virtual “Behind the Retina”)
“With-motion”, requires Plus (Convex) lenses. [Emmetrope FP is @ infinity]
Duochrome (biChrome): Short wavelength-light (blue -green) focuses closer to the
LY

173

C
O
R
NPC: see double: Diplopia
N
O
T
PR
IN
T
eye break but not seeing double: Suppression (OD-out)
didn‟t lose fixation: TTN
O ortho
- break > 5cm is considered abnormal O no-Horizontal dev.
- recovery within 7.5 cm is expected
O no-Vertical deviation
• EOM: SAFE Smoth
T – tropia, P – phoria
Accurate
X – exo, E – eso
Full
cc : w/correction
Extensión
sc : without correction
CF, EOM, pupil
O

PERRLA, MG “–”
Randot: 40 Arc/sec @ 16"
Ishihara: 14/14 OD, OS
D

O
PY
,V
IE
W
O
N

Incorrect-WD: working-distance Closer-than-Calculated, causes Over-Plusing.
Accommodating-Control: if Pt. Looks-at-Light during-Retinoscopy, this will
Produce-accommodation, which causes “Over-Minusing”.
Mohindra technique: for young-Children,(one-eye is Patched,room-completely
darkened).Pt-looks @ retinoscope-light @ 40cm, and Dr. neutralizes the reflex
w/lens-Bars. Distance Rx = neutralize lenses -1.25D “for working-distance”.
NPC: the moment one-eye begin to deviate outward, the limit of convergence
has been-reached; an NPC >5-10cm is considered abnormal and may result in
excessive-tiring of the eyes on closed-works such as reading, etc.
LY

174
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
XP
dist. lateral Phoria: 1exo +/- 2 Accommodative facility: 20/30

Morgan‟s table of Expected: near lateral phoria: 3exo +/- 3 +/- 2.00 D flippers w/Rock card
Binocular
AC/A ratio:
4/1 +/- 2 Monocular
7 cpm
5 cpm (children)

*Smooth-vergence testing: *Step-vergence testing;
11-12 cpm
8 cpm (adults)
→ Base-Out (distance)
=> ^
S.D.
BO (distance)
BO (near)
9
+/- 7 break: 11
+/- 8 break:
23
+/- 4 blur:
+/- 8 break:
19
+/- 2 recovery: 7
+/- 6 recovery: 16
+/- 4 recovery: 10
BI (distance)
BI (near)
→ Base- In (distance)
+/- 3 break:
7
+/- 5 break:
12
+/- 3 break:
7
+/- 2 recovery: 4
+/- 4 recovery: 7
+/- 2 recovery: 4
• BO (near)
(Children 7-12 years) ^
=> Base-Out (near)
+/- 9 break:
19
+/- 5 blur:
17
+/- 7 recovery: 14
NPC “accommodative target”
+/- 6 break:
21
• BI (near)
break: 2.5 cm +/- 2.5
+/- 7 recovery: 11
+/- 6 break:
13
recovery: 4.5 cm +/- 3.0
=> Base-In (near)
+/- 5 recovery: 10
NRA: + 2.00 +/- 0.50
+/- 4 blur:13,+/- 4 break: 21
PRA: - 2.50 +/- 1.00
+/- 5 recovery: 13
(Adults) ^
175
Age determined Adds: think of a 40 years old as needing a + 1.00 D add,
and add + 0.25 for every 4 years after ….
40 → +1.00
48 → +1.50
56 → +2.00
64 → +2.50
“Vergence”
44 → +1.25
52 → +1.75
60 → +2.25
BO (dist): 9/19/10
Donder‟s amplitudes of Accommodation:
BI (dist): x/7/4
Norm = 18.5 – 0.33 (patient‟s age)
BO (near): 17/21/11
Min. = 15.0 – 0.25 (pt. age)
BI (near): 13/21/13
10 → 14 D
Age: Amp.
15 → 12 D
30 → 7.0 D
45 → 3.5 D
60 → 1.0 D
20 → 10 D
35 → 5.5 D
50 → 2.5 D
65 → 0.5 D
25 → 8.5 D
40 → 4.5 D
55 → 1.75 D
70 → 0.25 D
75 → 0.0 D
Prism deviates the Light towards it‟s Base, so prism in Glasses causes the
Image to deviate towards the Apex of the Prism.
image
O
PY
,V
IE
W
O
N
O
D

T
PR
IN
T
O
R
C

O
N
LY

Light
176

Maddox-Rod: (Horizontal/Vertical shape on eye, pt. sees a line opposite direction of the groove)
*[Corrective-prism has it‟s Base in the direction of the Line] **{Vergence; BD: Supra, BU: Infra}
- OD: w/vertical shape, pt. see; red-Line Bellow the white-light ... Hyper-OD (hypo-OS)
LY
use: BD in OD “w/MR” or, (BU-OS the Uncovered eye) “NVP c Red-MR …∆ R hyper”
O
PY
,V
IE
W
C
O
T
PR
EOM, =>
fields-of
actions :
1º 2 º
N
OD
OS
SR, IO IO, SR
Ω
IR, SO SO, IR
IN
T
O
R
i.e. if RLR is Paretic, then it requires abnormally high-innervation
sent to the LMR, making it Spastic.
1º
2º
O
*
Underaction- are due to trauma, faulty-muscle-insertions and ligament
abnormalities, innervational-deficiencies (III, IV, VI) or infectious-disease.
Overaction- can be explained in terms of Hering‟s-law of
equal-innervations to two-yoked muscles.
D

O
N
- OD: w/Horizontal shape, pt. see; red-Line to the left of white-light.
... Exo (phoria)=> use: Base In on the Right (“Both”) eye. *[Eye-position is where the Light is]
SO / SR : incyclo
IO / IR : excyclo
MR: Add
LR: Abd
IR: depression
SR: elevation
IO:
excyclo
SO: incyclo
-
3º
-
excyclo add
incyclo
add
elevation abd
depression abd
177
Strabismus: an anomaly of Binocular-vision, where the visual-axis of one
eye fails to intersect the target of regard in the binocular visual-field, when
the target is visible to both-eyes. Strabismus is a manifest-deviation of the
Visual-axis, where as a Phoria is a Latent-deviation;
(↓VA in the Turned-eye → Amblyopia).
Strabismus (Comitant & Non-comitant) => Comitant: maintins an
equal-deviation in all-directions of gaze, for a given fixation-distance.
Non-comitant: deviation manifest a minimum-change of 5-degree in
at-least one-field of gaze.
ARC prevents-diplopia, allows for peripheral-fusion in the presence of
strabismus and offers some degree of stereopsis “up to 100sec of ARC in
micro-Strabismis”,(HARC only-useful type of ARC).[NRC: two-foveas correspond]
O
PY
,V
IE
W
C
N
O
Amblyopia: a monocular reduction in VA, which can‟t be explained by
obvious Pathology or Refractive-error, (Mon. ↓VA of at-least one-line).
Occlusion-therapy: direct-patching for number of days equal to the Pt. age,
followed by one-day of indirect-patching, (intermittent ET, patch 3-4 days).

D
O

T
PR
IN
T
O

R

O
N
LY

178
LY
N
O
PR
IN
T
O
R

O
PY
,V
IE
W




Nystagmus: can be Pendular or Jerk, and is categorized-by the
Direction-of the Fast-phase.
Sacadic (corrects Position-errors)system do-place object of interest on-fovea rapidly.
Pursuit (corrects Velocity-errors) to-maintain object of regard near-fovea.
Vestibular (Non-Optic reflex); to maintain-eyes with-respect to head-position.
Primary XT: starts Intermitant and becomes Constant.
tx.: correct-RE, given Minus-add (on bottom or top-portion of bifocal)
where appropriate (follow w/Orthoptic-training), [or Prism].
Accommodative ET => Refractive;
-High-hyperope “+4.50 D” w/normal AC/A:
tx. given full-cycloplegic
-Average-hyperopia “+2.50D” w/high AC/A > 8/1:
C

O
T
tx. full-cycloplgic for distance & given @ near Centration-point Add, “Bisect @ pupil”
O
N
Prescribing Initially an intermediate-Rx; Between the Cycloplegic and NonCyclople. is recommended, (in the F/up can ↑Rx.) in case of AccommodativeEsoTropia given the Full-Cycloplegic Rx. perhaps-using a Bifocal is the best.
D

179
Accommodative dysfunctions
=>Reading-problem, headaches, fatigue, avoidance;(w/all acc. prob.)Near-Far/ Hart-Chart
LY
Accommodative-Insufficiency (Acc. Ins.): not enough-acc., blurry @ near,
tires-easily, loses-focus, letter-jump, sleepiness when-reading after a while.
“can be either XP or„EP‟@near”,VT,(prescribe +lenses @near).↑MEM, A/A: low
(comp. to Age) PRA: low (trob. accep. -), BCC: lag, Flipper: monocularly prob. Accommodative-Excess (AE): acc. more-than necessary at near & far. can-not
relax-acc, Variable-VA, blurry at near & far(Transient), blurred when-changing
from NV to DV, ↓working-distance after-reading for a while, Fluctuating:
Retinoscopy & Subjective (w/tendency toward-myopia), pseudo-myopia, low
AR-astigmatism (not-justifiable w/K-reading),“may have EP@NV&DV”,often
secondary to TCI, “vision-therapy”, NRA: low (trob. accep+), BCC: lead,
A/A: normal w/time↓, Flip: prob+ mono & bino.
O
Accommodative-Infacility (Acc. Inf.): can-not relax or stimulate accommodation,
blurry (slow-focusing) when ∆ from-near to-far & vice-versa, sleepiness when reading
after a while. “VT”, NRA &PRA: low (Symmetrically), BCC: normal, Flip.
(w/+/- 200 D): prob. + & - mon. &bin. Symmetrically.
D

N
O
T
PR
IN
T
O
R
C

O
PY
,V
IE
W
O
N

180
Binocular Syndromes
Convergence Insufficiency (TCI): problem at Near, diplopia @ near,
↑exo @near (common to both), AC/A: low, NRA: low, w/low BO vergence,
PRA: higher, flip: bin + prob, (PFV: low),VT (to improve PFV) “BI prism”.
*False Convergence Insuf. (FCI): Insufficiency of accommodative (prob.)
“not-convergences”, ↑exo @ near (common to both), AC/A: normal,
NRA: high (low), w/better BO vergence, PRA: low, flip. mono. - prob.,
(Ok- PFV/ NFV), NPC: improve w/acc. target, “VT” (improv. Acc.).
O
PY
,V
IE
W
R
C
-
O
N
LY

Convergence Excess (CE):problem at Near,get sleepy when reading,↑eso@near,
AC/A: high, NRA: higher (accept lots of +), PRA: low, (NFV: low) w/low BI
vergence, flipper: binocularly – prob, “vt”, tx. w/plus “+” lenses @ near.

Fusional Vergence Dysfunction (FVD): normal-Phorias, low-Vergences;
↓ BI & BO, low NRA & PRA, flip. bin. + & - slow, Vision-Therapy (VT).
D
O
N
O
T
PR
IN
T
O

181
Divergence Insufficiency (DI):problem at Distance, interm. tropia,↑eso @far,
AC/A: low, (NFV: low). “VT” w/prism BO (eso-correction) @ Far.

Divergence Excess (DE): problem at Distance, intermitant tropia, diplopia,
loss of focus, headache, (PFV: low), ↑exo @ far, AC/A : high, “vt”,
tx. w/minus “-” lens glasses (over-minus @ Far).

Basic Eso (BE): problem at Both-distances, ↑eso @ far & near (equally),
AC/A: normal, PRA: low. (BI: ok). “vt”,Prism (“for High Eso only”) near
& far (BO ,esophoria Correction).

Basic Exo (BX): problem at Both-distances, ↑exo @ far “& near” (equally)
AC/A: normal, NRA: low, (BO: ok), “vt” w/Prism (“for High Exo only”) near
& far (BI ,exophoria Correction).
-
*[NRA: tests limit of PFV], + lens : ↓stim. to accom. (relaxing) → divergence, (BI)
[PRA: tests limit of NFV], - lens : ↑stim. to accom. → convergence, (BO)
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

182
Basic Eso-Phoria: tx. BO prism
(“common”, no-HA‟s, fall-asleep when-reading)

Basic Exo-Phoria: tx BI prism, VT
(“common”, headaches especially w/increased-reading)

for Excess & Insufficiency cases, difference between
near & distance Phorias should be 10 Prism-diopters.

Divergence Insufficiency “eso-Phoric”: tx. BO∆ for Distance
(rare, “intermediate”-diplopia at near)

Divergence Excess “exo-Phoria”: tx Minus-add @ distance,
VT (not as effective) (“rare”, tired-eyes, occasional double-vision
at distance, close-one-eye in bright-light)
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

183

O
N
LY

Convergence Insufficiency “exo-Phoria”: tx. BI, “reading-glasses”,
VT (best) (“common”, HA, eye-strain, tired-eyes, diplopia, avoidance
Convergence Excess “eso-Phoria”: tx Added-Plus for Near
(“rare”, HA w/prolong-reading)
Eso: treat Entire-angle of deviation, “Optics work-better.”
Exo: treat 1/3 of angle-of-deviation, “VT works-better”.

Convergence; Increases-accommodation, (BO∆ causes-convergence,
so accommodation-increases through CA/C).
Divergence; Relaxes-accommodation, (BI∆ causes-divergence,
so accommodation-decreases through CA/C).
T
IN
O
O
N
Accommodative Facility => flippers: Children +/- 2.00D @ 33cm,
10 cycles, mean = 52 sec; Infacility if greater or equal to 75 sec.
(Adults +/- 1.50D @ 40 cm & do 20 cycles, mean = 64 sec.,
Infacility if > 90 sec.)
D

T
PR

O
R
C
O
PY
,V
IE
W


184
C
IN
PR
T
O
N
O
D

T
O
R

O
PY
,V
IE
W
O
N

Keratometry: 44.12 H. “mires: clear/distorted”
WR: 0 – 30 / 150 – 180
46.62 V. 44.12 @ 180/46.62 @ 90 AR : 60 – 120
- 2.50 x 180
Oblique: 30 – 60 /120 –150
Keratometer => Prediction of Astigmatism is made Using;
Javal‟s-Rule: Total-Astigmatism (TA) = 1.25 (K∆) “ - 0.50 axis 090”
or “+ 0.50 axis 180”, where K is the Corneal-toricity.
[42.00 @ 180, 43.00 @ 090 ; thus: K = -1.00 x 180
TA = 1.25 (-1.00 x 180) + 0.50 => TA => -0.75 x 180]
Keratometer: measures Corneal Radius-of-Curvature (assumes Spherical-surface),
a Reflected-image from the Corneal-surface is focused within the Keratometer,
and it‟s-Size is measured by-use of a Coincidence-doubling device.
Radiuscope; [H2O between the lens-holder & Contact-lens “eliminate
back-surface reflections”]: measure the Radius[BC] of Contact-Lenses
(usually back-surface radius) => given two-position where the targetfocuses, one-at the lens-Surface (A), and one-at the lens‟s-Center-ofCurvature (B); So distance A→B (distance the Radiuscope is moved)
= Contact-Lens Radius [BC].
LY
*
185
LY
N
O
T
T
O
N
O
D

PR
IN

R
C

O

Contact-lens Power-reading: Power of Contact-lens is indicated
in the same-form as if ordering Glasses (back-vertex Power),
“Use Lensometer”. [Base-Curve: can be verified by Radiuscope,
(K-reading in mm “radius of back-surface”)]
Cylinder; is Grounded on the side of the Lens (Spectacle) Opposite to the
Base-curve (usually on the Back-surface).
Lensometer: the lensometer has a Standard-lens of Known Focal-length
and Power (+20.0D); against-which the focal-Lengths of Unknown-Lenses
are Compared to determine-their Power (F), “the Target is at the Primaryfocal-length of the Standard-Lens”.
Reading-Prism by-Lensometer: remember to Start w/Lens of the Highest
Power; the Mires will Appear in the Same-Direction as the Base of Prism.
Transposition: add Cyl. to Sphere (w/respect to their Sign), to get the newSphere, change the Sign of the Cyl. (i.e. - to +) w/o-changing the #, change
Axis by 90º (i.e. 90 to 180); [+5.00 - 3.00 x 090 => +2.00 + 3.00 x 180]
+5
O
PY
,V
IE
W

(+5.0 x 180 , +2.0 x 090) (+5.0 @ 090 , +2.0 @ 180)
+2
186
O
PY
,V
IE
W
hyperopia that can-not be overcome by-accommodation represent Absolute-hyperopia;
-the additional diopter of hyperopia that can-be compensated for by
accommodation is Facultative-hyperopia.
O
N
O
T
Night Myopia: in Low-illumination sharp-detail is lacking, so in many people
accommodation tends to be Suspended at an Intermediate-distance.
[Pseudo-Myopia; due to Spasm of Ciliary-muscle “usually - 0.50D to -1.00D”
// - 4.00D or more usually Axial-length // small-amounts of Myopia usually due
to a Combination of axial-length & focal-length].
D

PR
IN
T
O

C
-
R

O
N

Latent-hyperopia: is a condition in-which all-or-part of Pt. refractive
error “at distance” is compensated by accommodation.
(Symptom: severe-asthenopia, headaches, eye-pain, discomfort, fatigue)
If +3.00D (Retinoscope-Objective), but +2.00D (Subjective) refraction
found “the +2.00D represent Pt. Manifest-hyperopia”.
Absolute-hyperopia; can-not be compensated for by accommodation,
the total-hyperopia is greater-than the amplitude of accommodation.
If Pt. has +3.00D hyperopia, and has 1.00D of accommodation, the +2.00D of
LY

187
Astigmatism: for an astigmatic-eye the closest-thing to a point-image
for a point-object is the “Circle of Least Confusion”, located at the Diopteric
(Reciprocal in cm) midpoint-between the Horizontal and Vertical focal-lines.
[the 3-dimensional-shape between the two focal-lines in astigmatism is known
as the “Interval of Sturm”].
Irregular-Astigmatism:condition where the primary meridians are not 90ºapart
(usually corneal in origin and needs Rigid-contact),also applied to“one meridian
being Distorted”due to disease/trauma,(or Crystalline lens section-irregularities
in refractive-power), [the two principal-meridians of the eye are not-at
“Right-Angle” to-one-another, “Pathology such as Keratoconus”].
Refractive- astigmatism: is the Total-Astigmatism of the Eye.
Astigmat.: against-the-rule (AR)/with-the-rule(WR)//simple/compound/mixed
Internal-Astigmatism: due to meridional-variation in refracting-power of the
“posterior-surface” of the cornea to the tilting of the crystalline-lens with
respect to the optic-axis of the eye, etc.
Corneal-Astigmatism: meridional-variation in refracting-power of the
“anterior-surface” of the cornea, as measured-by “Keratometer”.

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188
Rule of thumb: if Ametropia > 4D it is Axial, if < 4D then it is Refractive,
“High-Astigmatism is generally due to Cornea, so correct w/Contact-lenses”.

Uncorrected -Axial : Hyperope has a Smaller retinal Image-size, where
Myope has a Larger retinal Image-size.
In Refractive-Myopia; the Power of the Eye is “Too-Strong”.
Refractive-Ametropia: with Uncorrected-refractive Ametropia, the retinal
Image-Size is “Identical” for the “Myope, Hyperope and Emmetrope”.
O
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Axial-Ametropia; w/correction at Anterior-focal-point (Spectacle) the
image-size differences are Corrected, [w/correction at the Corneal-plane
(Contact-lens) the image-size difference are Not-corrected].
O
Knapp‟s-law: Spectacle-lenses Changes retinal image-Size, and contact
lenses don‟t; (Spectacle-lenses are better for correcting Axial-ametropia,
& Contact are better for correcting Refractive-ametropia).
D
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N
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T
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IN
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(when-Corrected by “Spectacle-lenses” this Image-Size Equality is “Destroyed”).
Refractive-Ametropia;w/correction at Corneal-plane(Contact-lens),the image-size are-Equal.
O
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T
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189
LY
N
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(D) X Reading-level “from DOC” (cm) = Vertical imbalance (Prism∆), “for Presbyope”
[OD: +4.0DS, OS: +1.0DS; 3D x 0.8cm (8mm Reading-level) = 2.4∆] “disturbs Binocularity”
O
A Slab-off is a special lens that utilizes a prismatic effect in the lower half of a lens to
balance a Pt. near vision.
Add w/ >3D Anisometropia: The lens with the most-minus or least-plus should have the
D
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N
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IN
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O
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If pt. Anisometropia is due to differences in “Axial-length” for the 2-eyes,
correcting with “Spectacle-lenses” is expected to result in Minimal-retinal
image-Size differences between the two-eyes, this is known as “Knapp‟s-law”.
If pt. Anisometropia [when Difference is 1.00D or More], is due to differences in
the “Refractive-element” of the two-eyes, correcting with “Contact-lenses”
is expected to result in Minimal image-Size differences between the two-eyes.
Usually because of Anisometropia in the 90º meridian, there is an
Induced Prismatic-effect upon Down-gaze.
Anisometropia (D) x Reading-level (cm) = Vertical-imbalance ∆
Anisometropia → “the Difference between Two eyes-Rx in Vertical-meridian only”
O
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
conventional Slab-Off, and the Revers-Slab-off is done in the lens with most-plus or least-minus.
190
Regular Slab-off (BU, “inside of the blank lens”) on-one-eye and a Reverse-Slab-off
(BD, “on the front side of the lens”) on-the-other, (this should create easier acceptance
for the patient).
Aniseikonia: condition in which there is a Difference in Image-Size or
Image-Shape of the two-eyes, (clinically Significant if > 0.5 – 0.75%
Most-troublesome when-between 3 and 5%, there is some-loss in binocularity
But-fusion is still-present. If > 5% Diplopia or Suppression occurs).
Aniseikonia: usually accompanying Anisometropia,
Astigmatism (meridional /compound / overall).
Aniseikonia: Can be induced by Anisometropia or High-astigmatism,
if Refractive best given Contact-Lenses or “if used Spectacle thenneed to adjust the Design” (Can be minimized by Spectacle-Lens Design;
“Base-curve, lens-Thickness, Vertex-distance”), and if Axial then correct
w/Spectacles “no-need for adjustment in lens-design”.
O
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T
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Slab-Off or “Bicentric Grind”; is a technique (To correct for vertical imbalance,
“Presbyope”) in which the Base-Up prism is Ground on half the lens in either
the most-minus or least-plus lens.
LY
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191
when Crystalline-lens is Removed; the eye performs all its Refraction
at the Cornea, and so the “Principle-planes” of Spectacle-lens/Cornea
are “Shifted in-Front of the Cornea”, because this happens there is an
“Increase in Focal-length” which is Directly-Related to “Image-Size”.
As the lens approaches the cornea the principle-planes of the lens also
approach the cornea and the “Secondary Focal-length” gets “Shorter”.
*Magnification Increases the Further the Lens is from the Eye, for this reason,
Contact-lenses give much-Less of a magnification-Problem than do spectacle.
When Moving the Lens; Closer to the-Eye, Plus-lenses under-corrected
(become Less-plus “need to ↑Rx”) and Minus-lenses over-corrected
(become More-minus “need to ↓Rx”).
When changing Spectacle to Contact or vice-versa:
IN
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PR
*When giving Contact lens, Change phoropter Rx for: “-”Subtract / “+”Add, From your Glass Rx.
O
N
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T
+ → less
Closer
D
- → more
+ → more
Farther
(↓vertex distance => :
↑minus or ↓plus power)
- → less
{Spectacle “-”/+10.00D change to-Contact w/vertex 14mm=>100/10D=10cm (far-point,
or secondary focal-length), 10cm “+”/- 1.4cm = 8.6cm, 100/8.6cm = +11.63D /“-8.75D”}
192
Plus-lenses Limit the Field of view, where Minus-lenses Increases the Field of view.

all Plus-lenses Magnify (SM > 1), & all Minus-lenses Minify (SM < 1).

Power-Magnification factor: ↑w/ ↑Plus-power, ↓w/ ↑Minus-power,
↓w/ ↓in-Vertex distance w/Minus-lenses, ↓w/ ↓in-Vertex distance w/Plus-lenses.
O
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PY
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W
(It is better to change-Magnification; by BC or Vertex-distance ∆‟s than by thickness ∆ in “Spectacle”)
Shape-magnification factor: ↓w/ ↑index-of-refraction of lens-material,
∆‟s w/lens-thickness ∆ and, ∆‟s w/front-surface-power ∆.

Spectacle Magnification: when an Ametrope observes a Distant-object
through Corrective-Lenses, the previously-blurred retinal-image not only
comes into sharp-Focus but also undergoes a “change-in Size”.
SM (Mono.“Power & Shape”) = image-size of Corrected “A” eye
image-size of Uncorrected “A” eye
RSM (Bino.) = image-size of Corrected “Ametropic” eye
image-size of “Emmetropic” eye
D
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193
Aphakic-Spectacles: the Magnification [retinal Image-size, (difference of
Corrected “Ametrope” to Uncorrected “Emmetrope” eye)] can be 20-25%,
and the tolerance-level of Anisokonia (the Image brain-perceives from-each
eye is Not-the-same) is believed to be <5%, (the Jack-in-the-box effect
caused by the Ring-scotoma “Movement-of-field”).
Aphakia: best-corrected w/Contact-lens; (Spectacle: ↑retinal image size by 25%,
O
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aberrations, ↓field-of-view; //use: mild-shade of tint to ↓UV-transmission, Aspheric, Lenticular).
C
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IN
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O
for smaller noses. /Temples => Skull-temple: most-common
Library-temple:goes straight-back,for people who take their glasses on and off
constantly
Comfort-cable: a spring-type loop w/plastic-cover the loop
Riding-bow: like-comfort but w/plastic all-around.
O
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
High-Minus Lenses: gets-multiple Ring-effect from internal-reflections.
tx. Edge-Coating (↓Transmission), Hide-a-bevel (↓Prismatic-area).
High Minus-lenses: consider Contact-lens, //choose Small-eye-size w/Polyc.
Spectacle Frames: Bridges => Saddle-bridge: rests on the bridge of the nose
for large noses, Keyhole-bridge: rests on either-side of the nose-bridge
D
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194
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Distance from Seg-top to Seg-OC for Bifocals: Flat-top 5mm,
Round seg 11mm /Kryptok 11mm, Ultex-A 19mm, Executive 0 mm.
Optical-Center: ideally the Distance Optical-Center (OC) should be Placed 3mm
Below the Center of the Pupil,because the normal viewing-angle is about 6-degrees
Down,(for the same-reason a Pantoscopic-tilt is good); Lab automatically place the
OC “MRP”(if MRP = OC => No-Prism) on the Datum-line which is usually 2-3mm
Lower-than the-Pupil, (only needs-to-specify the level of MRP in Cases of
∆
Anisometropia, and when > 5 Induced).
Decentration: movement of the Optical-Center from the Geometric-center,
decentration is done to either move the Optical-center so that it line-up with
the eyes, to-Avoid inducing-prism, or to-induce a Desired prismatic-effect by
intentionally moving-it.
w/Strong-Add the working-Distance is Closer, and causing the eyes to
Converge-more to see the target. This high-convergence cause a normally
Inset-bifocal (2mm in OD / OS “not-to-be enough”) to Induce-BO Prism
(which requiring more unnecessary convergence). Then the Lens Needs-to
be Decentered-In to-Avoid inducing-BO∆.
^
195
Lateral-Prism in Near (dist.) portion-Add : In setting-Segment More-than
that-Indicated by-the Near-PD creates-BI∆ prism, and in setting-the-Segment
Less-than it Needed-to-be, creates-BO∆.
[Prentice‟s rule: Z∆ = d(cm)p]

The Vertical-component of “+4.00 - 1.00 x 090” from a point 10mm below the
Distance Optical-center is what∆? +4.00
4D x 1cm = 4∆ BU
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+3.00
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O
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Prismatic effect =Distance from Optical-center(MRP)in cm“dist/near”X lens-power in D“dist/near”
(what is the Prismatic-power 5mm from the Optical-center of a +3D//0.5cm x 3D = 1.5∆)
Decenteration“movement of the Optical-center from the Geometric-center” =(FramePD - Pt.PD)÷2
R
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T
^
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(5D Myope w/58mm PD,Optical-center 64mm:64–58=6mm; (0.6cm)(-5D)=3∆BI Total/2
58mm
[Rule of thumb:for-each Diopter of Add, there is 1.5mm Total-decenteration;(add 1mm
More, if dist. PD is > 68mm), i.e. +2.0D Add →3mm Total-decent.“1.5mm Each-Eye”]
-
2∆ BI OD&OS => 4∆ BI Total, // 2∆ BU OD + 2∆ BD OS = No-Vertical Prism-effect
(BI∆ or BO∆ prism Added // BU∆ and BD∆ Subtract)
D
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-
196
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[3+11+2=16mm], Total∆ = 1.6cm (“-”4.0D) + 0.2cm (“+”2.0D) => 6.4 BD + 0.4 BU = 6∆ BD
T
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R
3
dist. OC
far
add
PR
IN
11
O
N
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2
near OC
Pt. look-here
*[Segment: usually Lab will have; from DOC “a drop of 3mm to Top of the Seg.”
and “inset of 1.5mm”, if not-specified.]
D
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Image Jump∆ = (Distance “cm” From-Seg-OC to Top-of-Seg) x (F add “D”),
Flat-top: 5mm → (0.5cm x F add = jump∆)
A Segment-whose Optical-Center is at the Seg.-top would have no-jump
at the Seg.-top But would have jump @ the Reading-level.
(jump∆ = distance from Near-OC to Reading-level “cm” x Add “D”)
Image-Jump∆: - 4.0D lens with a +2.0D add, 22mmKryptok Round-segment,
what is the total Prismatic-effect, if pt looks 2mm Below the Near optical-Center?
197
InterPupillary-distances(PD)=>Near -PD: @40cm Pt.-looks@Dr. LE (OU-open)
& doctor (line-up the ruler “0” w/temporal-limbus of Pt. RE) then-measure the
reading @Nasal-limbus of Pt. LE ; // Distance -PD: (then Without-moving the
Ruler from Pt. eyes)after Near-PD, Now Pt. asked to look at-Dr. RE,and Again
doctor-reads the scale @Pt. LE Nasal-limbus.
[Expected; about 4mm difference between NPD & DPD]
Bifocals: 1st time Bifocal-Wearers, should be-Informed to Move-their
Eyes-Down through the-Lenses and Not-drop their-Head when-Reading.
when-using Stairs, look-through Distance-portion, “it takes 2-4 weeks to
Adjust to-bifocals”. for Progressive-users, they need-to Turn & move-their
Head (as-opposed to moving-eyes) to direct the visual-axis at the object of
regard, “for-Reading needs to looks-through Bottom of the-Lens”.
Bifocal-Height: is measured from the bottom of the Lens (not-eyewire), to the
lower-Limbus, (usually lab will have; a drop of 3 mm “to Top of the Seg” and
inset of 1.5 mm from DOC, if not-specified).
Progressive-height: is measured-from the bottom of the lens to the Center-of
the-Pupil, (may want to Prescribe an “Extra +0.25” due to Small add-Area).
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O
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198
N
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Trifocal-height: measured-from the bottom of the lens-to the bottom-of-the-Pupil.
Location of Seg-Top: General rule → set the Top of the Bifocal-seg at the top
of the lower-Lids (for most people this is the same-level as the lower-limbus)
or bottom of the Iris.
Taller Pt look-lower to read, therefore segs set-lower, occupation w/lots of
near-work, should have seg. fit-higher.
If segment set too-low, Pt gets stiff-neck, due to head tilted-back,
“error-made more often by fitting too-high”.
VT - Children w/bifocal; seg-top should be @ Center-of-the-Pupil,
to force the use of bifocal.
Round-Tops should set-higher than Flat-tops.
Trifocal-height => Occupational; fit closer to bottom of the pupil,
Non-Occupational; fit 1-2 mm below the pupil. Most failures-occur when
the Seg. is set too-Low.
The difference-between Bifocal seg-top & Trifocal seg-top is usually 6mm,
this corresponds to the width of Intermediate zone.
The segment is placed w/it‟s Optical-Center corresponding to Pt. near- PD.
O
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D
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199
Multifocal Lens-type: Progressive-addition → a gradual change in curvatures
(about 12 mm; lens-aberration “Astig.”-induced) is used to obtain a distance and
near lens (Infinite-range of focuses).Blended (Plastic) → the transition-between the
distance and near lens is blended (a blurred-zone, w/induced-Astig.). Fused → the
same-curvature for dist & near (no-ledge), ↑ add-power is due to ↑ index of
refraction (↑chromatic- aberration) in fused-portion.One-piece (Plastic) → segment
can be felt (has-ledge) due to change in the curvature (power-difference), index is
constant in distance and near.

w/High-Rx; chose as Small-eye size (Frame-PD that is close to Pt.-PD) as
practical (to ↓lens-Thickness), “thick-edges of high-minus lenses can be hidden
by frame w/thick-Edges (Bevel)on the frame-front”.Best colors frame are those
that matches Pt hair-color & skin-tone. Pt prefer frame that hide their refractive
error, and make their face to be noticed (not the frame) or compliments it.
D
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200
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Most of the time, all eyewear must sit on a patient with a certain amount of
angle toward the face from the lower rim. This lower rim tilt toward the cheeks
is called pantoscopic tilt, and it is needed in order for patients to rotate the eyes
from distance to reading without having difficulty, looking under the glasses and
in order to maintain vertex distance, also to decrease surface reflections.
Pantoscopic tilt refers to the frame alignment in the up and down position
of the frame. A properly adjusted frame will normally have 7-12 degrees of tilt
towards the cheek. This provides the multifocal wearer the maximum benefit
from the reading portion of the lens.
O
N
O
D
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T
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C
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
Standard Adjustment: The temples on the frame should be open and “equally
angled to the front of the frame”. Before presenting a frame to a patient, ensure
that the “temple tips” and “both corners of the front” lie in the “same plane”.
Pantoscopic-tilt, vertex-distance and face-form are critical adjustments,
to ensure patient comfort and good vision.
We rotate the lens horizontally, or on the 180 meridian, for pantoscopic tilt.
And we rotate the lens vertically, on the 90 meridian, for face form.
LY
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201
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Face form is the adjustment that matches the frame front to the wearer‟s facial
shape. A correct face form adjustment matches the curve of the frame to the
brow line. To add face form on a plastic frame, use the frame warmer until the
frame is pliable and use gentle hand pressure to obtain the correct curvature.
*To add face form on a metal frame, “bend the frame at the bridge” using
gentle hand pressure.
A “positive” face-form-tilt brings the left edge of the lens toward the observer
and takes the right edge of the lens away from the observer.
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O
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
*To obtain proper pantoscopic tilt, use angling pliers to “bend the temples
down from the frame front at the end-piece”.
A “positive” pantoscopic tilt displaces the top edge the lens “forward”, away
from the patient‟s eyebrow in the usual configuration, and the bottom of the lens
“backward” toward the cheekbone.
-Retroscopic tilt is the opposite of pantoscopic tilt. The frame is tilted away
from the cheek. Retroscopic tilt is sometimes necessary to fit frames on people
with full cheeks, but it is not a desirable adjustment.
202
Vertex distance is the distance from the front of the cornea to the back of
the lens. The frame front should be positioned as close as possible to the eye
without the lenses touching the brow, lashes or cheeks. This provides the widest
viewing areas in all parts of the lens. Proper vertex distance also helps eliminate
back surface reflections on the lenses.
*To obtain the correct vertex distance, adjust the “nose pads” on a metal frame
with nose pad pliers to bring the “frame front” closer to or farther away from the
face. When fitting a plastic frame, it is necessary to start with the proper bridge fit.
*The three important “Nose-Pad” angles are: the frontal angle, the splay angle
and the vertical angle.
View the frontal angle from the “front of the frame”. Standard alignment of the
frontal angle requires that the pads be closer together at the top than at the
bottoms. This angle relates to the “side of the nose” and the fact that a nose is
wider at the bottom than at the top. Be sure that each pad sits at the same height
and is the same distance from the eye-wire.
C
IN
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T
O
N
O
D
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O
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203
LY
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O
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View the splay angle from the “top of the frame” looking down. Standard
alignment of the splay angle requires that the front edges of the pads be closer
together than the back edges of the pads. This angle relates to the “slope” from
the “crest of the nose to the inner eye” area.
View the vertical angle from the “side of the frame”. Standard alignment of the
vertical angle requires that the bottom edges of the pads be closer to the
eye-wires than the top edges of the pads.
After the “frame-front” is adjusted, you are ready to adjust the temples. Temple
wrap refers to the portion of the temple that extends “from the frame front to the
top of the ear”. As with all adjustments, the closer the frame conforms to the
face and head structure, the better the overall fit. In most cases, a very slight
curve from front to back will help the temple to achieve a comfortable fit.
The next consideration in adjusting the temple is the temple bend. This is the
portion of the temple “from the top of the ear to the back of the ear”. A good
temple bend will follow the contour of the ear. A good over-the-ear fit will
allow gravity to work in your favor. The temple will lie close to the contours of
the ear without pressing against it.
O
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204
LY
N
O
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,V
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by“Lowering theTemple”on-the“side-that‟s too-Low”or Raising-it on-theOpposite-side
T
PR
IN
T
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C
NosePads: if the bridge is too-wide (causes frame to sit-low on
the face), then Bend guard-arm in-&-down. / if the bridge is
too-narrow (causes the frame to sit-high on the face), then
Bend guard-arm out-&-up.
[NosePads: if the “frame is too-close to the face”, “straighten-out the
guard-arm” in the longitudinal-direction, then roll-guard-arm-over
at-bend. / if “frame is too-far from the face”, “bend-guard-arm”
in the longitudinal-direction toward the frame-front and then
roll the guard-arm-over at-the-bend].
O

N

O

The final consideration for temple adjustment is the into the head adjustment
which concentrates on matching the “inside surface of the temple to the side of
the head”. This final adjustment allows the frame‟s temple to gently but firmly
hug the contours of the patient‟s skull.
If “one-lens” is “Farther-from the face”: adjust the “temple-angle” so that it is
“Greater-than 90º” on the “side-Farthest” from-the-face.
Temple: if the “Frame” is riding “too-Low on one-side” of the Pt. face, (raise-the-lens)
D
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205
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O
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PhotoChromic-lenses; need to go through as many as “Ten” light to dark Cycles
before they will darken to Potential, (usually darken by 60sec & cleared by 5min).
Sunglass-Tints => Gray: (Rayban G-15, G-31) good for Color-deficiencies
“since has fairly even-absorption across the spectrum”. /Polaroid: good for
water-sports & skiing. /Pink: for Indoor use w/bright-fluorescent light.
/Yellow: enhance-contrast by ↓blue end of spectrum, used for shooting.
Clear w/UV absorption up to 300nm.
Kalichrome: “yellow-lens”, makes blue-background darker by
“decreasing Scatter” and “increasing-Contrast”, used for skiing, shooting.
Didymium: special mineral-absorbing 550-600 nm, looks blue-under
fluorescent-light & pink in incandescent, used by glass-blowers.
Green-glass: protect from UV & near-IR. used for glass-blowing, hot-ovens, etc.
Cobalt: red & blue transmission, IR-protection, used in steel-mills.
Unisol / Therminon: a “light-blue-tint” for IR-protection.
X-ray glasses: uses a lot of led, density = 5.18, index = 1.8
Pink-I (10%): cut-out some scatter from fluorescent-light,
“it also cuts-down transmittance at the blue-end of the spectrum”.
206

Refractive-index: the higher the index, the thinner the lens-material.
The Higher the(lens-Material) NU-value of Dispersion,the Less-chromatic Aberration
CR-39 => n:1.49, NU: 58, specific-gravity: 1.32, /Polycarbonate => n: 1.586, NU: 30,
gravity: 1.2,/Crown-glass => n: 1.523, NU: 59, gravity: 2.54,/High-light glass => n: 1.7,
NU: 31, gravity : 2.99,/High-index plastic => n: 1.54 - 1.66, NU: 32-37, gravity: 1.2-1.5
PR
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Chromatic-Aberration (CA): When white-light is passed obliquely through
a reflecting-surface “/Prism”, since wave-length have different velocities in
the denser media “Red being Fastest and violet the slowest”, spread differently
and Red-focus the Farthest. The higher the refractive index the slower a
wave-propagate through a medium. Short-wavelengths as Blue “w/higher index”
are refracted-more, Bends-more and focus Closer to the Crystalline-Lens,
O
T
(seen by bend of light toward Prism-base, “image displacement toward prism-Apex”)
O
N
than do Long-wavelength as Red-light “w/lower index”, this is directly related
to Dispersion (nu-value) of the Lens-material. To minimize CA you want a
High nu-value, the lower the “nu-value” the higher the “Chromatic Aberration”.
D
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
Index of Refraction (n) : Plastic (CR 39) → 1.49, Polycarbonate → 1.586 = n,
Hi-index Plastic → 1.54 – 1.66, Crown-Glass → 1.523, High-light Glass → 1.7
LY
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207
Distortion (as pt. looks @ an object-Image): Magnification ↑ as one moves
off-axis towards periphery w/Plus-lenses, the distortion is “Positive” or
“Pin-Cushion” object-image elongate @ Corners. And magnification ↓ as
one moves off-axis toward periphery w/Minus-lenses, the distortion is
“Negative” or “Barrel” object-image shorten @ Corners.
Aberration, are of 5-distinct Type: Spherical, Oblique-astigmatism, Coma,
Curvature-of-field, Distortion.
Aspheric-design: reduces spherical-aberration, these lenses have a stable
center-portion which Flattens on the front-side, power ↓ in periphery.
Diffraction:when the pupil-size is less than 2.5mm in diameter,then diffraction
defines the blur-limit. (it is a type of “Distortion”).
O
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Anti-reflective Coating:use square-root of lens material-index to find the coating
index needed,(i.e. crown-glass n= 1.523 =>√1.523 = 1.23 closest coating-index)
N
O
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O
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“Anti-Reflective coating are Purple, they minimize yellow-light, they reflect blue & red”

UV-wavelength Absorption => cornea: 200-290 nm (UV-C), lens: 290-365nm
(UV- A,B), retina: > 365nm.
208
Visible-Light: 380-760 nm, the light of maximum intensity (wavelength of
greatest-sensitivity) that we are exposed to is 560-590 nm. Ultraviolet: ionizing
radiation and causes delayed tissue-damage, out of 200-380 nm UV range
265-280 nm are the most-effective, “in aphakes the retina is at risk”. Infrared:
produces thermal-effect, most effective are 800-1200 nm, causes immediate
solar-burns, coagulation of protein, Iris-atrophy and Corneal-opacities.

Test used by OD to determine a Child‟s level of, Visual-Perceptual development:
Test of Visual Analysis Skills (TVAS),Motor-free Visual Perception Test (MVPT)
O
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
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N
O
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FDA (Food & Drug Administration):requires“Impact-Resistance of Lenses”
and restrict utilization of new products (such as Contact-lenses),until safety
is determined, (Medical-devices: are in “Three-Classes” Ophthalmic-material are Class-II device).
D

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Visual Motor Integration (VMI).
209
LY
N
ANSI – standards => Z80: All-lenses should be capable of with-standing
the Impact-test [5/8 inch (15.9mm) steel-ball dropped from 50 inches],
=> Z80.1: sets Tolerances for Sphere, Cylinder and Axis of Finished
Prescription-lenses.
ANSI standard Z-87: able to not-Fracture from drop-ball test, using 1-inch
steel-ball dropped from 50 inch“is not-pierced by singer#25 needle dropped from 50inch”.
2.5mm Edge or 3mm minimum Center-thickness on Plus-lens, Bevel-angle and
lens-Edge are both 113 degrees. Lenses must have manufacture Logo at the
Top-center, Frame must be Stamped “Z87” on Fronts and Temples, and both
lenses and frames must-meet Z87-Standards.
IN
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O
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O

FTC (Federal Trade Commission): force the health-field industry into a
“competitive market model”, (↑competitiveness of Dr. fees and ophthalmic
goods “advertising”, also by requiring Release of Spectacle /CL-Rx, so pt.
may shop for best-price). Allows Pt. to inspect their-Files.
FTC- prescription requirements; Should-include: “complete-Rx”,
date, expiration, signature & lic.# of Dr., w/printed Pt. & Dr. Names.
O
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210
Toric-Rigid lens: (Astigmatism should-always be corrected w/Spherical
rigid lenses if possible, since they are easier to fit and less-money).
Rigid-Spherical can correct-up to 3.0D astigmatism, where
Rigid-Gas-Permeables (RGP) can-correct as much as 5.0D of Cyl.
(due-to thickness, weight and rotation, toric are-not as-successful
as-Spherical lenses. Rigid-lenses come in 3-design :
Aspheric, Spherical, Concentric).
Toric-Designs: for Pt w/ < 1D Astigmatism, a Spherical-lens is fine.
Corneal-toricity of > 3D requires a Toric-design, and low-to-medium
toricity may require a thicker or Flatter Spherical-design.
Indication for RGP‟s: Pt w/GPC, Keratoconus, Corneal-Astigmatism
(up to 3.0D w/Sphere, and up to 5.0D w/toric), and Irregular-Corneas.
O
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IN
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O
Rules of thumb for PMMA => minimal-toricity < 1.5 → ON-K,
moderate-toricity 1.5 – 3.0 → fit 1/3 Cylinder Steeper than-K,
large-toricity > 3.0 may-require Toric-BC.
D
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N
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[RGP‟s mold-corneas somewhat better-than PMMA while-allowing good-optics]
211

Rules of thumb for RGP => Corneal Cylinder: < 1.00D → ON Flat-K [BC],
LY
1.0 to 2.0D→fit 0.50D Steeper than Flat-K,>2.25D→fit1/3Cylinder Steeper than Flat-K
[44.00/45.50@090 (1.50 Corneal Cyl.), 44.0 + 0.50 = 44.50D (7.58mm “BC”)]
The Power must-be Corrected anytime you-fit Steeper or Flatter than-K.
for Steeper base-curve, the Tear-lens creates Plus-power, and an-equivalent
amount of Minus-power is needed to compensate.for Flatter BC the Tear-lens
creates Minus-power and an-equivalent amount of Plus is-added to the Rx.

Astigmatic Contact-Lenses: if < -2.00D cyl. use RGP-Spherical lens,
(w/low-residual < 0.50D in over-refraction). / if < -2.00 cyl.
(w/moderate residual-astig. 0.50 → 2.00D in over-refraction), use
front-toric RGP or Soft-toric [1.25D or 1.75D]
// if corneal-toricity > -2.00D cyl. use Soft-toric or RGP-bitoric
(w/low-moderate refractive-astigmatism).
/ if > -2.00D cyl. (w/high refractive-astigmatism “> 2.0D”), use
custom-Soft-toric or RGP-Bitoric.
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212
Sagittal-depth: the perpendicular distance between the lens-apex
and the plane of the lens-edge, [related to the Diameter and BC,
(Posterior Central-curve Radius ; “Not secondary/intermediate
or peripheral/bevel”), useful in adjusting lens-Fit].

If you-want to “let-Loose”: decrease the sag.-depth by-Increasing
the BC “Flattening”, or Decreasing the lens-Diameter.
[Flattening → loosen // by ↓dia. → loose / by ↑BC → loose]
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If you-want to “get-Tight”: increase the sag.-depth by-Decreasing
the BC “Steepening” or Increasing the lens-Diameter.
[Steepening → tighten // by ↑dia. → tight / by ↓BC → tight]
N
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„Note: if-you decrease the diameter, then make-it steeper, “by ↓BC” so as
to-keep the-same sagittal-depth, which-keeps the-same bearing-relationship‟
Base-Curve: initial BC should be slightly-flat (0.25 Flat), since a flatter-lens
will facilitate tear-exchange and help prevent limbal-compression.

Flattening or widening the Peripheral-curve Loosen the lens & Promotes tear-exchange.
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213
Given Trial-Lens, consideration: Decide whether BC should be ;
On-K, Flatter or Steeper.

Slit-lamp => Tight: blanching of conj. blood-vessels & indentation at
lens-edge, w/possibly central air-bubble & circum-corneal injection.
Loose: edge of lens may lift-off from cornea & bubbling at the edge.

Ideal-Pattern => Periphery: bright-green (good-clearance),
Center: faint-green, (minimal apical-clearance).
Intermediate: slight dark-green, (minimal-clearance).


If-Lens too-Steep: periphery-dark (touching-cornea), central deep-green (pooling).
If-Lens too-Flat: periphery bright-green (pooling), center dark (bearing /touching).



Fluorexon → Soft-contact / Hard-fitting ; [Fluorescein → Hard-only].
{40.50K: Steeper → BC 8.33mm // 38.75K: Flatter → BC 8.71 [337.5/38.75]}
[BC: 8.3 is Steeper (↑K),where BC: 8.7 is Flatter (↓K);“337.5/K(D)//337.5/BC(mm)”]
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214
Rigid-Lens Specifications => OZD: 7.0 to 8.5mm “> max-pupil diameter”.
Diameter: Ave ≈ 8.8mm, range is 7.5 – 11.0mm, “9.0 is size of palpebralaperture”, (w/RGP if-cornea < 10mm, order 8.5mm or less).
[Palpebral-aperture is 8-10mm, which is about 2mm less-than Cornea →fit
lenses so they extend-slightly under upper-lid “Palpebral-aperture + 1mm”]
The-thinner the-better as long as the lens doesn‟t Flex; minimum-Center
thickness is 0.12mm to max of 0.35mm, thin-lens fit-tighter, thicker-lens
move-more easily, thinner-lens center-well and facilitate tear-exchange,
↑delivery of oxygen and decrease corneal-edema.
Peripheral and secondary curves: specify these by-best fitting trial-lens.

C.t. < 0.1mm (ultrathin) used in minus-powers to-increase comfort and
reduce residual AR-astigmatism, since these-lenses Flex in the opposite
direction of the corneal-toricity.
Edge thickness: The optimal e.t. is ≈ 0.08mm, but up to 0.15mm acceptable,
(any-thicker starts to cause lid-discomfort).

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215
Hard-Lenses => the thinner the better oxygen, down to 0.12mm (which-lens “fixing to Flex”), a thin-lens usually fits-Tight,
where as a thicker-one fits-Loose and moves too-much;
(maximum c.t. is about 0.35 - 0.4mm /PMMA c.t. is Less-than RGP).

Flex: is when a lens “Bends” on the eye due to corneal-toricity and
thus-induces residual-Cylinder, an RGP < 0.12 ct. will do this.

Flexure: is a function of not only thickness, but also BC, diameter,
corneal-toricity, fit and lens-material. In general, Steeper (by ↓BC)
tend to increase-flexure. Also, if Gas-Perms re-prescribed to a
Pt. w/AR-astigmatism (@ 90), flexure is likely. To control this,
Increase lens Thickness by 20-30% for large-lenses and 40-60%
for smaller-lenses, can also Flatten (Loosen, by ↑BC ).

Lens-Diameter (usually): RGP → 9.00mm (Cornea, less 2mm), Soft → 13.0mm (Cornea, more 2mm)

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
Soft-Lenses => larger/thinner moves-less // smaller/thicker moves-more.
216
Soft-Contact lens-Parameters => *Diameter: cover entire cornealsurface & overlap-limbus by 1mm on each-side. Average 13.5 - 14.5mm
“range 12.0 – 16.0 mm”, fit 0.5 – 2.0 mm greater-than cornea.
*Base-curve; three-specifications for : average, flat & steep cornea
“^the-larger the-lens, the-flatter the-BC required”. *Power: use-table for
vertex-distance compensation if-power is > 4.0D.*Material: mostly-HEMA,
combined w/PVP to ↑water-carrying ability, and MMA to ↑lens-firmness.
“Generally, the-thinner the-lens the-better, but manufacture-controlled”
*Water-content: Low 25 - 35%, Medium 35 - 60%, High 60 - 85%,
“Oxygen-permeability ↑w/water-content↑”; Disadvantage of ↑H2O is
↑fluctuation of VA and no-thermal disinfection.

Vision => w/Steep-fit: (Tight “poor-movement w/good-Centration”),
→ fluctuating VA, w/clearing after-blink (Keratoconic central-distortion
in Retinoscopy); w/Flat-fit: (Loose “significant decentration”), → variableVA, initially-clear but poor after-blinking (Pt. is aware of lens,/can fall-out).
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217
Adaptation-period: dry-eye, blurring-vision during Near-work, glare or
double-images at-night/dim-illum. ↑sensitivity to light, lens-awareness
and tenderness @ lid-margins; “EW: dry & gritty-sensation in the morning,
possibly w/mucous-debris on lid or tears”, (PMMA: brief-Spectacle blur
when-changing from-Contact).
Good-Fit: good-Centration and good-Coverage (cornea), absence of
inferior edge-lift,vertical-movement w/blink at primary-gaze up to 1mm,
Axis-rotation not changing more than 5 degrees w/blink,Consistently good-VA.
O
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C
Contact-lens F/up: a change in K-reading of 0.75 - 1.00 is significant due
to edema “SCL → Vertical-Striae” (compare pre-fit K‟s & post-fit K‟s).
Neovascularization: especially seen w/SCL, if-deep can get Deposition of
Lipids in-Stroma and Scar the tissue,(discontinue lens-wear,causes regression)
Lens-Deposits: Calcium (white-spots, “replace-lens”), iron-salt
(rust-spot, caused by thermal-disinfection), proteins & lipids looks-white
(Jelly-bumps). // Microbial => Colored: black, brown, orange, pink or yellow
(w/irregular borders, fungal/yeast).
IN
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O
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218
LARS => if Marking rotate Clockwise(LA) → Axis-ordered is Greater (LA)
than the Spectacle cylinder-axis. if Markings rotate Counterclockwise(RS) →
Axis-ordered is Less (RS) than the Spectacle cylinder-axis. Lens Rotation of
25-degrees or more is Unsatisfactory, and a Steeper lens-should be Fitted.
To reduce Blink-related Rotation, choose a thinner-edge
design, Steeper (by decreasing-BC) or Larger-diameter.

LARS (√ @ Contact-Bottom, from Dr. Observation)
[Pt. Rx-axis @ 75º, bottom-dot rotates 25º to Right,
then Order New lens-Axis @ 75 - 25 = 50º].
L
R
T
Care of Lenses: “wetting Sol.”, Cleaners, Disinfection, Enzymatic
(may require Peroxide for Ew-SCL)
Peroxide disinfection, expensive but no-allergic reaction, requires
extra-neutralization step. (BAK is bad for scl‟s / EDTA,
chlorhexidine, thimerosol)
O
D

N
O
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219
CL-Conjunctivitis: acute red-eye without-pain or photophobia,
allergic → itching, excessive-tearing & mucous-secretion,
GPC → pappilary hypertrophy w/severe itching & lens-coating.

Inflammed-Pingueculae: due to rubbing by CL-edge
(try smaller diameter or ultra-thin lens).

Sport-Vision: Soft-Contact are the lenses of choice for contact-sports,
(for non-contact sports: soft or hard), for High-Altitude sports only
EW are practical.

Prosthetic Soft-Lenses: 3-types => Pattern-lenses, Iris replica-lenses,
Translucent tinted-lenses.

Therapeutic Bandage-lens => Indication: recurrent-Erosions, trichiasis,
bullous-keratopathy, dry-eyes, non-healing epithelial-defects,
corneal-perforations, protection from sutures, stromal-melts.
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220
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R
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O
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O
N

Keratoconus: Soft or Hard lens may be used, “RGP-Preferred”,
(Diameter: should be “2mm” larger than corneal-diameter,
select a “Steep-BC” initially, VA-somewhat compromised).
Irregular-Corneas: use Hard-Lenses, to make the cornea a more-regular
optical-surface via the tear-film.
Soft-Toric; Indication: ATR-astigmatism (minus-Cyl. Axis @90)
Contraindication: Irregular-astigmatism, abnormal Lid-closure.
CL-Contraindication: Diabetes, arthritis, glaucoma (Drops), thyroid,
menopause, “Allergy, pregnancy, sinusitis, psychiatric, epilepsy, BP, etc.”
Color-Vision Deficiencies: a special “Red-lens” (CL) may
be prescribed, to enhance Pt. ability to discriminate-Colors
[Red-lens in-front of “one-eye”, have a greater-effect for “deuteranopes”
green-deficiencies than for (protanopes) red-deficiencies].
X-Chrome Lens: Red “Hard-Contact” lens (Monocularly, for
R/G defective Pt.), enable the distinguish between red, green,
blues, purples, oranges and browns. This is due to the
“brightness-difference” cues for different-colors in each-eye.
LY
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221
Bifocal-Contact lenses => Alternating vision: lens move-to position
the near-portion over-the-pupil during near-gaze, (near-zone is either
Concentric - Annulus or Crescent-shaped Seg.). Distance VA is better
than near (due to difficulty in locating near-zone), require about
3mm of movement as eye goes from straight-ahead to down-gaze
(can cause ↓comfort). // Simultaneous vision:
These lenses position the distance and near zone over the pupil
continuously, (Concentric or Aspheric). In the Concentric-design,
near-vision is better than distance, the opposite is true w/Asphericdesign, (comfort is as good as regular-contact). Centration over the pupil
is critical, so need minimal lens movement, (wearers may see halos at
night & some ghost-images).

Bifocal-Contact Fitting: requires very good-centration (via, Steep-fit)
w/o compromising corneal-physiology.
Bifocal Contact-Lenses: are thicker & larger (causes less-comfort)
w/compromised Acuity, “Pt. must be very motivated for success”.

D
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222
Bifocal CL: also classified by Surface-design (Aspheric or Spherical),
Aspheric-design: can only be used w/Simultaneous-vision and
produces Multifocal rather than bifocal-vision.
Spherical-lenses: may be used w/both-designs and can be either;
non-segmented (Concentric or Annular), or segmented (Fused).
In the non-segmented lenses, the near-portion is a complete-circle,
in segmented lenses, the near-portion is a segment.
In a fused-segment bifocal, the near-seg. is constructed of plastic of
higher-index and fused to the rest of the lens,“usually poor optical-quality”.
In a mono-centric seg. bifocal there is one-piece construction by generating
different powered radii on the front-surface (in this case, there is a
“wide-field of view” and no-image jump).
O
Contact-lens Rotation: Clockwise-Add, Counter-clockwise Subtract
*LARS (from “Dr. Observation”, Not- Pt. direction)
D
*
N
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223
Bailey-Lovie: Constant-task w/Constant-Spacing between-Letters.
it Can-be-moved to Different-Distance for “Low-Vision” Pt, and the Score is
easily-Calculated, (log-MAR scale is on the right-border); “changing distances:
for-each 4/5th interval closer-to-the-chart, you add 0.1 to-the-score”.
(i.e. at 16ft you are at 4/5th of standard 20 feet distance, so if pt. score 0.6
you add 0.1 to get 0.7 corrected-Score)
“20/20 is log MAR 0.0, 20/200 is 1.0, 20/16 is -0.1”

Snellen-VA: a Letter-chart w/letters of Over-All Size“5 x MAR”.The “Method
of-Limits” is where the Pt.-goes to the Threshold of their-Ability to Correctly
Identify the Letters, (Record the Line at which Pt. Misses-half the Letters).
“Disadvantage : the Test is Not-Constant from Line-to-Line; Since
Different-Lines, have Different-Spacing, and Different-Numbers of Letters”.

The Contrast of Printed-Snellen letter is 90%, Projected-charts are 40-50%,
(Contrast just-needs to be 20-30%, VA-is-independent of contrast at
High-luminance).
D
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224
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O

Chart; should be at-least 6m-away, because any-distance short-of-Infinity will
lead to Over-Plusing the patient, (at 20 Feet the Pt. is Over-Plused by 1/6 m
or 0.17D), “it is recommended that at-least 12-20 foot-Candles be Projected
onto the Screen” Also, below 30% Contrast, VA drops-off quite-steeply.
Visual Acuity: a normal visual-system can identify an“Entire”letter-subtending
an angle of 5 minutes of Arc, and any-components of the letter-subtending
1 minute of Arc, at a distance of 20 feet, (Snellen –VA 20/20), “Pinhole, if
VA< 20/30”. (if pt. reads @ 10 feet 10/20 recorded)
VA; is recorded as the Angular-size of the Gap for the given Optotype
“Letter”, (Gap-size is the Minimum Angle of Resolution “MAR”).
The Letter-Size is that distance at which the Letter-subtends 5-minutes
of-Arc, w/detail of 1-minute-of-arc, (Snellen “in feet”). Use the fraction
“Target-Distance/Letter-size” (TD/LS), the Inverse of this fraction is MAR
[LS/TD(in feet)] → (i.e. Snellen 20/40 => MAR = 40/20 = 2 min. of arc).
D

5’
1’
20/20 Letter @ 6m
225
Letter-size: to calculate how-tall a given Snellen-letter should be at a known test-distance;
i.e. How tall should a 20/200 letter be at 6m => Gap-size(MAR)= 200/20 =10 min. of Arc
and since a Standard Snellen-letter is 5-gaps tall, then this letter will Subtend an
Angular-size of 5 x 10 = 50 min. of Arc. Given the Angle & Distan. to the letter,
the Height of the Letter is “h = d x tanAngle”
which is h= 6m x tan(50/60)degree =0.087m
or an 87mm tall-Letter.
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
20/200
h
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IN
Legal-Blindness: visual Acuity Correctable by glass or contact-lenses to 20/200
or worse (/less) in better-eye (/both-eyes),OR visual-field in better-eye (/both-eyes)
of less-than 10-degree Centrally, constitutes legal-blindness, in the united-states.
D
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50’
______________
6m
Low-Vision: VA 20/60 or 20/70 Considered Low-Vision,{Not legally-blind}
[Feinbloom-Chart: 14in x 12in Booklet, “Numbers” easy to read, range of
size is substantial, goes to small-steps, psychologically good].
226
Streak Retinoscopy => [Dr. K. - Method]
First neutralize w/with-the-rule the “least-plus” meridian then Change your Retinoscope
Light-axis 90º and again neutralize w/with-the-rule the “most-plus” meridian (with +/- lenses);
after that, Switch the axis-back from your current-light-direction to the previous-light-direction
(the least-plus meridian) in the Phoropter-Axis, and then Place the dioptric-Difference
between the two-meridian into the Minus-Cylinder, without changing anything in the
Sphere (Except: Reducing -1.50D at the end for Working-distance, Binocularly from the Sphere).
*{1st Nut. the Less-plus Meri. w/WR then Switch the Ret.-Light & Nut. the 2nd Meri. w/WR
→ Change the Axis to the First-meri. & Put the diptric-Diff. of the 2-Meri. in the Cyl.}
**[Note: you don‟t need to be concern with Phoropter-Axis while doing your Neutralization with
your-retinoscope,Only change the Retinoscopy-Light direction 90ºand neutralize the 2nd “most-plus”
meridian again, with +/- lenses “by ↑+ or ↓-” (after you have done the 1st “least-plus” meridian);
“till that point don‟t need to touch the Phoropter-Axis”, at this point you are Done with the Retinoscope,
and all you need is, to Adjust the Phoropter accordingly, by putting the Axis in the cylinder the Same
Direction as your 1st neutralized “Least-Plus”meridian(the Opposite-direction of the Last retinoscope-Light,
the 2nd “most-plus”meridian),then put the diopter-differences of the two-meridian in the minus-cylinder,
without changing anything in the sphere,Except taking -1.5Doff the sphere-binocularly for working-distance]
For every -0.50 Increase in the Cylinder, then Increase the Sphere by +0.25D, during the Subj. Refr.
and, For every -0.50 Decrease in the Cylinder, then Decrease the Sphere by -0.25D,“Monocularly”.
Using Welch-Allyn Retinoscope, always Keep the (Wide-light) Sleeve/neck & Button Down.
2
3
C
D
O
N
O
T
PR
IN
T
O
R
-
O
PY
,V
IE
W
O
N
LY
1.
227
Refraction- VA (sc, cc, Ph.):
O
N
LY
Retinoscopy : R-eye, L-eye (Proj. w/R-G @ 20/400)
VA: OD, OS, (Cover the other eye) [repeat step 3-7 for Each-Eye]
MPMVA (Full-illumination: FOG to 20/40 (by adding about +0.75 → +1.5 to
the sphere, then go down few-clicks till Pt sees 20/40 Clearly & read it), then go
down one-line per-click and have Pt read 20/30, 20/25 and 20/20 line, then stop &
O
PY
,V
IE
W
1.
2.
3.
add one more click, to see if Pt sees smaller & darker or more clear, if clear leave it, if not go back.
Duochrome (Monocularly): 20/25 line w/Red-Green (room Completely Dark)
5.
Ask Pt which is more clear, if Green add “+” sphere one click at a time“Mono.”
till Pt. sees Clear-equally in both-Colors.
Red (you move toward Red)
JCC (VA 20/30 line“two above best VA”): Axis
Axis of cylinder (where your arrow is)
C
4.
N
O
T
PR
IN
T
O
R
[also,(if signific.sphere chang.)done after JCC, “w/Equal-VA” (end-point,Green slightly Sharper)]
O
P (p will be @ the axis) Dots parallel to axis of the patient.
D
Power
If (Pt. prefers) Red in top of axis add “–”Cyl., if white take away Cyl. (↓cyl.).
228
Add ½ of the cylinder to sphere; (if you ↑cylinder “or decrease” by – 0.50,
then ↑sphere “or decrease” by 0.25).
sph. - 1.00, cyl. -1.50
sph. -1.00, cyl. -1.50
“↑ - cyl. ↓ - sph”
∆cyl. -2.00
∆cyl. -1.00
“↑ - cyl. ↑ + sph”
∆sph - 0.75
sph∆-1.25
[this procedure used, in minus cylinder form]
7.
Duochrome: Mono.(done Again; if significant sphere changes during JCC) w/Equal–VA OU,
O
PY
,V
IE
W
[“Binocularly” if Un-equal VA: done in conjunction w/Prism-dissociation;
(while pt. attention is directed at top or bottom image, one at the time)]
Prism dissociation: [Van-Graefe Binocular-Balance (To Balance the Accommodative
Stimuli to the two-eyes), done Only w/Equal VA in both-eyes]; VA line 20/30
C
8.
O
N
LY
6.
D
9.
O
N
O
T
PR
IN
T
O
R
(line 20/25 blurred by adding +0.50 → +0.75 to both eyes,
3
but able to distinguish 20/30 line “used”)
00
3BD∆(OD), 3BU∆(OS), ask which, is clear,
add +0.25 @ a time to Clear-base,
3
till Pt. report that both-line eqally-Blurred.
Biocular MPMVA: Remove Prism, “Pt. will be Blurred 20/30 - 20/40”
Decrease -0.25 @ a time Binocularly, till Pt. sees 20/20 1st time.
229
O
PY
,V
IE
W
O
N
LY
10. Biocular Duochrome – if Un-equal VA only “done w/Prism-dissociatio”:
line 20/25 w/Red-Green (Dark-room)
ask Pt. which is more Clear, if Red add “–” sphere Binocularly
one click @ a time, till Pt. sees Clear-equally in Both-colors,
“it is Balanced when-simultaneously both-images (top & bottom)
corresponds to the same-changes in the Color”.
*[Binocularly; done w/Prism-dissociation and only if Un-equal VA in two-eyes]
R
C
11. Add -0.25 to Both-eyes at the End, then ask Pt for Clarity;
“if No ↑clarity, then go-Back to the original Rx”.
D
O
N
O
T
PR
IN
T
O
12. At the end of Binocular MPMVA: (Optional)
Ask the Pt. When 20/20 is Completely-blurred,
“expected by +0.75 to happen” as you add +0.25 @ a time Binocularly.
i.e. If you needed +1.00 to see completely blurred, it means you are
0.25 over-minused, so Take-Out -0.25D from your original Rx.
(*whatever you added to get completely 20/20 blurred, take out only -0.75
from that and leave the rest in you final Rx. “no-verification needed”)
230
Vergences: One line-above best VA
a.) Horizontal
° BI
°
° BO °
Far &
Near
N
1.
blurre point 8∆
break point 10∆
recovery 5∆
BI 8/10/5
BO 8/10/5
O
New- Rx, in Phoropter:
O
R
C
O
PY
,V
IE
W

LY
Near Finding;
OD
O
D
O
N
b.) Vertical
OS
T
BU
PR
IN
T
move both prisms @ same time,
“Add both together”
0
no
prism
break-point: 3∆, recovery: 2∆ (3/2)
OD: BD 3/2, BU 3/2
Far &
Supra
Infra
Near
BD
231
0
2.
Phorias: One single-word above best VA-line
a.) Vertical-Phoria:
Far &
Near
(moving toward zero)
Head-light on the Car
DVP: 3∆ Left hyper
0
LY
0
12 6
O
N
12
0
O
PY
,V
IE
W
(if-was 3BU on OS then; 3∆ right hyper-phoria)
3
3BD (image up)
b.) Horizontal (Lateral)
C
0 5
Button on the Shirt
O
R
6
0
IN
T
DLP: 5∆ exo (5∆ XP)
OD
OS
O
N
O
T
AC/A ratio: (Near Phoria, “Horizontal-only”)
3
° 5 6
first do Near-horizontal,
0
∆
then Add -/+1.00D
NLP: 5 exo
to the Sphere-part of Rx,
and-do Phoria-again:
w/ -1.00 => NLP: 3∆eso ; AC/A: 8/1
D
3.
PR
5BI (image out)
232
BCC (dim-light):
Add plus “+” to Sphere-part of Rx,
Binocularly @ near, till Pt sees Equally Clear
LY
P Red
O
PY
,V
IE
W
O
N
Red P
(Red-dot Verticaly, w/minus-axis @ 90º)
N
O
T
PR
IN
T
O
R
C
*Horizontal seem darker (lag of accommodation) “i.e. BCC = +1.00”
-if vertical seem darker: lead or vertical-preference?
*When vertical darker, then you change “P” to Horizontal-position;
if still vertical darker, then it‟s “vertical-preference”, or
if changed to horizontal been darker, it is “lead of accommodation”.
O
*When you add above +0.75 to see Clear, then leave it there to do A/A, NRA, PRA
[Presbyope: Before NRA/PRA; Binocularly Add plus to Sphere till
Pt. reports Clear “chart @ near” (tentative Near-Rx)]
D
4.
233
NRA, PRA @ Near (one-line above best VA)
Binocularly, “over-tentative Add, if any”
Not-Sustained; [NRA “+” done 1st]
NRA: add Plus “+” to Sphere-part of Rx till sees Blurred.
PRA: add Minus “–” to Sphere-part of Rx till sees Blurred.
ex. (NRA/PRA: +2.25/-2.50 “w/Add +1.25”)
6.
Sheard‟s A/A (Amp. of accommodation)
one-line above best VA, @ Near
Monocularly (one-eye @ a time)
Add Minus “–” to Sphere-part of Rx, till Pt. sees
Sustained Blurred; (ex.“if OD blurred w/-2.0D” then)
OD => -(2.00) + (2.50 @near) = 4.50D A/A
Amp. OD: 4.5D
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
5.
234
Unilateral (Cover-Uncover) test =>
O
N
LY
*To Detect the presence of a manifest deviation (Tropia) in the alignment of
the eyes, (done @ both distances w/corrected best VA-letter).
C
O
PY
,V
IE
W
*The occluder is used to cover-one-eye. This-eye is then uncovered 1-2sec. later,
(enough time to break fusion). Doctor monitors the movement (if any) of the
non-covered-eye. [Do not monitor movement of the covered-eye at any time]
D
O
N
O
T
PR
IN
T
O
R
- If movement is detected Inward, upon covering the contralateral eye, then an
ExoTropia is present.
- If movement is detected Outward, upon covering the other-eye, then an
EsoTropia is present.
*Additional-testing is necessary if movement is detected, to determine if
Tropia is Constant or Alternating and Always-present or Intermittent.
If No-movement of either-eye is noted upon the Unilateral (Cover/Uncover) test,
then no-tropia is present, and continue to do the alternating-CT.
235
Alternating Cover Test =>
O
PY
,V
IE
W
O
N
LY
*To Detect the presence of a latent deviation (Phoria) in the alignment of the
eyes, (done @ both distances w/corrected best VA-letter).
PR
IN
T
O
R
C
*The occluder is used to cover-one-eye, this-eye is then un-covered 1-2sec.
later And the opposite-eye-is-covered. This action is Repeated to cover the
eyes in an alternating fashion, (covering one-eye, followed-by covering the
opposite-eye). Doctor monitors the movement of the un-covered-eye.
[Do not monitor movement of the covered-eye at any time]
D
O
N
O
T
- If movement is detected Inward, upon covering the contralateral eye, then an
ExoPhoria is present.
- If movement is detected Outward, upon covering the other-eye, then an
EsoPhoria is present.
236
Alternating-CT; neutralize Tropia and Phoria: =>
*Lateral cover-test w/Prism:
R
O
*Vertical cover-test w/ Prism:
C
O
PY
,V
IE
W
O
N
LY
- Place compensating prism in-front of either-eye (or, Deviated-eye), use BO∆ for Eso
Tropia or Phoria correction and BI∆ for Exo Tropia or Phoria correction.
-Using Alternate-CT, increase prism-amount until no-movement of the eye is noted,
then increase some more prism till opposite-movement of the initial direction is “just”detected. Then-Reduce prism amount until same-movement as initial-direction is “just”detected.
-Neutralizing prism is amount half-way between “just”-detected opposite-movements,
[Bracket Technique].
D
O
N
O
T
PR
IN
T
-Place compensating prism in-front of Either-eye, use BD/BU prism on OD/OS to
compensate for right/left Hyper/Hypo (use BU/BD prism on OD/OS to compensate for
right/left Hypo/Hyper).
-Using Alternate-CT, increase prism-amount until no-vertical-movement of the eye is
noted, then increase some more prism till opposite-movement of the initial direction is
“just”-detected. Then-Reduce prism amount until same-movement as initial-direction is
“just”-detected.
-Neutralizing prism is amount half-way between “just”-detected opposite-movement.
237

ORTHO-induced Phoria(when you See No-movement in Alternating-CT“no-phoria”):
You cover the Right-eye with the prism Base-In for 2-3sec. then move to cover the
O
N
LY
left-eye, while you Observe the movement of the Right-eye as you Increase the
Prism-diopter. Once you see movement you record it, & then you do-the-Same
with prism Base-Out, in the Same-eye, till you see movement again.(ex. 1BI, 4BO)
If you see Movement: In Cases of Exo/Eso Phoria/Tropia, you use Base In/Out
C

O
PY
,V
IE
W
4 – 1 = 1.5 BO => 1.5∆ EP (apex @ deviation;“therefore BO represent Eso-phoria”)
2
*prism Apex at the direction of the Deviation in the eye
Tropia; Sometimes move & some other-times doesn‟t move: Intermittent, that move All-the-time: Constant
O
-
N
O
T
PR
IN
T
O
R
respectively, &↑it till you See No-movement, &↑more till you see Opposite-movement.
Last Move. + First Opposite mov. = BI => XP /XT-right/left
2
BO => EP /ET (both w/Alternating-CT)
Good-eye is Covered, & you Observe the Bad eye that is Not-covered for Movement, w/Unilateral-CT
-
Neutralize w/Alternate-CT; and w/Prism before Tropic-eye, (Phoria use Prism, Either-eye)
D
-
238
Rx∆ => w/loose-Prisms:
O
PY
,V
IE
W
O
N
LY
Maddox-Rod, in Front of Deviated-eye (Vertical-groove),
Transillum. @ arm-length “opposite-eye”,
-if Pt. w/MR on deviated-eye Sees the Line Above the light
use Base-UP prism in-Front of the Maddox- Rod
or if-sees the line-below the light, use BD prism in-front of MR
PR
IN
T
O
R
C
*Rx “Full” in Vertical-prism;
given ½ Rx to the Deviated-eye,
of the Same Base-direction as the “Line”
and ½ Rx of Opposite-Base, in Opposite-eye.
O
N
O
T
*(i.e. deviated-Right eye w/MR sees the Line-Below the light →BD∆ -OD)
*[Fresnel∆, for temporary-Deviation only]
D

*Fresnel prism: put BD∆ on the eye w/least-minus(most-plus),“↓VA by ½ to 1-line”
239
Maddox-Rod, in Front of Deviated-eye (Horizontal-groove),
Transillum. @ arm-length “opposite-eye”,
“Pt. Sees Vertical Red-Line”
-If Pt Sees, the Red-Line to the R/L of the Light, then Use
prism-Base in the Direction of the -Line in-Front of the
Deviated-eye w/MR till the Line is on-light.
O
PY
,V
IE
W
O
N
LY

(i.e. Deviated Right-eye w/MR, sees the Line to the left of light,
T
O
R
C
then, Use BI∆ in-front of the OD w/MR till the Line is on-light)
D
O
N
O
T
PR
IN
*Rx about Half of the prism-Found;
given to Both-eyes, the Same-Base in Horizontal
(i.e. if found 6∆ -BO give only-total of 3∆ BO;
w/1.5∆ BO -OD and 1.5∆ BO –OS

[Connect the Dot (light) and the Line (MR) then you See your respective Prism“Shape”, Apex & Base-direction]
240
N
O
C
O
PY
,V
IE
W
Maddox-Rod (grooves-horizontaly)
“Pt. Sees Vertical Red-Line”
in front of the Right-eye;
pen-light through the central-aperture
of the “Thorington Near-card”
LY
Thorington => Phoria Measurement
N
O
T
PR
IN
T
O
R
*if the Line is to the left of the spotlight
(crossed-images) the patient has an exo-phoria (XP)
If the Line is to the right of spotlight
(uncrossed-images) the patient has an eso-phoria (EP)
D
O
*[treat: exo: BI∆, eso: BO∆]
“Base of prism, in direction of Line”
241
LY
N
O
O
PY
,V
IE
W
*Maddox-Rod, OD (grooves-vertically);
“Pt. Sees horizontal Red-line”
if the Line is above the spotlight,
the patient has a right-hypophoria
or Left-hyper-phoria.
IN
T
O
R
C
The size of the deviation is determined by
asking the patient, which-number on the
vertical-series of letters on Thorington-card,
line-passes through.
O
N
O
T
PR
*[Treat: hyper: BD∆, hypo: BU∆]
„Apex of prism, in direction of light‟
D
“apex @ deviation -(pupil-position)”
242
Park 3-Steps Method:
LY
N
O
O
PY
,V
IE
W
Etiology of “acquired” 4th N.–Palsy (SO) is most commonly closed-head trauma,
vascular causes (diabetes, hypertension), intracranial-tumor and aneurysms most
be rouled-out.
IN
T
O

(the disparity will increase-markedly if the head is forced to be tilted toward
the shoulder on the side of the paretic -SO “Bielschowsky‟s-sign”).
[for “SO” dev↑ w/tilt to the Same-side as paretic-muscle]
[for IO dev↑ w/tilt to the Opposite-side (the field of it‟s action)]
C

Pt w/SO(4th N.)-Palsy“most common”usually presents to Dr. office w/head-tilted to the
opposite-shoulder “in Compensatory-movement against the torsion of the affected eye”
R

D
O
N
O
T
PR
a) Determine the hyper-tropic eye, (using alternate cover-test).
b) Determine whether the vertical deviation ↑ to the right or the left gaze.
c) Determine whether the vertical deviation ↑on tilting the head toward the
right or left shoulder.
243
1.
Using alternate-cover test: find -R./L hypertropia, [paretic could be =>
2.
3.
R./L -hyper ↑ w/R./L -gaze [implicating now only RIR, LIO ; (LIR, RIO)]
R./L -hyper ↑ w/R./L -tilting of the head => paretic muscle: LIO ; (RIO)
SR IO Ω IO SR
IR SO ^ SO IR
Hyper-eye in
/ hyper-greater / hyper-greater / paretic-muscle
primary-position /
on gaze
/ on head-tilt /
is:
R
R
R
LIO
R
R
L
RIR
R
L
R
RSO
R
L
L
LSR
L
R
R
RSR
L
R
L
LSO
L
L
R
LIR
L
L
L
RIO
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
RSO/LSR, RIR/“LIO” ; (LSO/RSR, LIR/“RIO”)]
244
Park‟s 3-Steps: =>
LY
N
C
O
PY
,V
IE
W
2.
The Hyper-eye “bottom 2 muscles”.
R or L: SO, IR
“Direction of Action” of the Hyper 2M in the Other-eye, (4M-Total).
L
R
SR, IO Ω IO, SR
RSO, LSR – RIR, LIO
LSO, RSR – LIR, RIO
IR, SO ^ SO, IR
O
1.
PR
IN
Superiors-M. ↑-hyper w/head Same-side Tilt (SO, SR)
Inferiors-M. ↑ -hyper w/head Opposite-side Tilt (IO, IR)
O
*If RIR were paretic, the deviation would ↑ in head tilt to the left.
*A weak RSO or LSR results in a R-hyper “tropia” ↑ in the L-gaze,
“the field of action of these two-muscles”
D


N
O
T
3.
T
O
R
(Pick the 2M w/Oblique gaze-direction)
245
Bio-Microscope (Slit-Lamp)
LY
N
O
O
PY
,V
IE
W
C
R
O
T
IN
PR
T
O
N

O

Diffused: eyelid, eyelashes, conjunctiva(bulbar, palpebral),iris,cornea (over-view)
∠ : depends … √ (30°-45°), mag: 5-8x, int: low
Conical-beam: ant.chamber ∠ : 30°-45°, mag: 20-25x, int: low, ill: small-circle
(the space between cornea & iris light) “focus on cornea then scan across all iris,
ParallelePiped:
/not a fixed focus spot.”
- Conjunctive → ∠ : 30°-45°, mag: 8-10x, int: med
- Cornea & Iris → ∠ : 30°-45°, mag: 16x, int: med
(focus on cornea then move across the iris)
* Retro-Illumination: ∠ : θ, mag: 16x, int: high “shagreen”
posterior lens, cornea (focus on iris)
* Specular-reflection: ∠ 60°-90°, mag: ~ 8 → ~ 32, int: med-high
“cornea-Endoth” (it‟s found by moving the arm & the slit-lamp)
“mag. High, focus at each power on cornea”
(light over reflection) “only one-eye sees”
D

246
Optic-Section:
- Cornea → ∠ : 30°-45°, mag: 16x, int: med (for exact location of opacity)
“to separate 3-layers” focus on cornea then move the ∠ for clarity of layers.
- Ant. chamber: ∠ 30°-45°, mag: 20x, int: high
- Lens: ∠ ~ 30°→10°, mag: 16x, int: med “focus on iris, to see ant. then move
(from ant → post. capsul “/cortex”) -in with closing ∠ to focus-post.”
* iridio-corneal Angle: ∠ ~ 60°, mag: 16x, int: med-high
(shadow between the, cornea-focus & iris-light)
* “focus on cornea at the edge of limbus”
if shadow > ½ of light: ∠ 4
> ¼ but not much: ∠ 2+
“
”
= ½ - ¼ of light: ∠ 3
Slit ∠ : light barely-visible
“
”
¼ of light:
∠ 2
Closed ∠ : no-interval between
“
“
< ¼ of light:
∠ 1
Reflection off iris-illum: ParellelPiped, ∠: 45°, mag: 16, int: med.
(to see corneal posterior/edema) “focus on iris” ∆-depth
Sclerotic-scatter: pen-light @ limbus (reflection off iris)
(to look for corneal edema “hallow-seen” / → slit-lamp@ limbus “Optic-Section”)

O
N
D
O

T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY

247

O
PY
,V
IE
W
C
O
N
D
O

T
PR
IN
T

R

O

O
N

Surface Optical-quality (especially of the “tear-film”): optic-Section,
Parallelo-piped and Specular-reflection, can all be used.
Diffuse-illumin.: survey of scars, boundaries of infiltration, edema
and neovascularization.
Optic-section: allows determination of the Depth of Opacities, (apparent-depth
is around 2/3 of it‟s real-depth).
Retro-illumination: Opacities “appear-dark” (scar, pigment, neovascular),
edema & keratic-precipitates “appear-lighter”: (since they scatter-light).
Specular-reflection: the only-way endothelium can be seen;
can see “guttata”, tears in endo-surface, “vertical-striae”,
elevations and depressions in the anterior-surface of the cornea appear
as “dark-defect” against a background of brilliantly-light cornea.
Sclerotic-scatter: opacity will appear “whiter”, (central-corneal
clouding is best seen in dark-room w/naked-eye)
Tangential-illum.: shows Corneal-nerves, Fleischer‟s-ring, Hudson stahli-line
LY

248
Topical Antibiotic Drops
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Moxifloxacin 0.5% sol. (Vigamox) 3 ml.
Gatifloxacin 0.3% sol. (Zymar) 2.5 ml., 5 ml.
Levofloxacin 0.5% sol. (Quixin) 5 ml.
Levofloxacin 1.5% sol. (Iquix) 5 ml.
Ciprofloxacin 0.3% sol. ung. (Ciloxan) “generic” 2.5 ml., 5 ml., 10 ml., /3.5 g.
Ofloxacin 0.3% sol. (Ocuflox) “generic” 5 ml., 10 ml.
Norfloxacin 0.3% (Chibroxin)
Azithromycin 1% sol. (AzaSite) 2.5 ml.
Tobramycin 0.3% sol. ung. (Tobrex) “generic” 5 ml./3.5 g.
Gentamicin 0.3% sol. ung. (Genoptic) “generic” 1 ml., 5 ml.
Tetracycline 1%
“Sulfacetamide 30, 15, 10%”
“Sulfisoxazole 4% (Gantrasin)”
249
LY
Combination Antibiotic Drops (sol./ung.)
Polytrim sol. (polymyxin B & trimethoprim) 10 ml.
Neosporin, Neocidin sol. ung.(polymyximB &neomycin +gramicidin) 10ml/3.5g.
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
Topical Antibiotic Ointments
Erythromycin 0.5% ung. (Ilotycin, AK-Mycin) “generic” 3.5 g.
Bacitracin ung. 500 units/gm (AK-Tracin) “generic” 3.5 g., 3.75 g.
Tobramycin 0.3% ung. sol. (Tobrex) “generic” 5 ml./3.5 g.
Gentamicin 0.3% ung. sol. (Genoptic) “generic” 5 ml.
Tetracycline 1% (Achromycin, Aerosporin) 10 mg./g.
Sulfacetamide 10% (Bleph-10, Cetamide, Sodum sulamyd)
Sulfisoxazole 4% (Gantrasin)
D
O
N
O
Combination Antibiotic Ointments (unguent)
Polysporin oint. (polymyxin B & bacitracin) 3.5 g.
Neosporin oint. sol.(polymyxinB 10,000units/g. &neomycin 3.5 mg./g.+ bacitracin 500units/g.)
2 ml, 10ml/3.5g
250
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Antibiotic-Steroid Combinations
Zylet susp. (loteprednol 0.5% + tobramycin 0.3%) 5 ml., 10 ml.
TobraDex susp/ung (tobramycin 0.3%& dexamethasone sulfate 0.1%)2.5ml,5ml/3.5g
Maxitrol, Dexacidin “susp.”, Dexasporin, AK-Trol susp./ung.
(polymyxinB 10000 u/ml +neomycin 0.35% +dexamethasone 0.1%)5 ml/3.5g
Pred-G susp./ung. (prednisolone acetate 1% &gentamicin 0.3%) 2.5 ml., 10 ml./3.5g.
Poly-Pred susp. (polymyxin B 10,000 u/ml+ prednisolone acetate 1% & neomycin 0.35%) 5 ml., 10 ml.
Cortisporin susp. (hydrocortisone 1% + polymyxinB 10000 u/ml + neomycin 0.35%) 7.5 ml.
FML-S susp. (fluorometholone 0.1% + sodium sulfacetamide 10%) 5 ml., 10 ml.
Blephamid susp./ung, Metimyd, Cetapred susp. or oint.
(sodium sulfacetamide 10% + prednisolone acetate 0.2%) 2.5 ml., 5 ml., 10ml., /3.5g
NeoDecadron sol. (neomycin 0.35% + dexamethasone 0.1%) 5 ml.
Vasocidin sol. (prednisolone sodium phosphate 0.05% +sodium sulfacetamide 10%) 5ml., 10 ml.
Topical NSAID‟S
Ketorolac tromethamine 0.5% (Acular), [0.4% Acular LS ] 3ml., 5ml., 10ml.
Flurbiprofen 0.03% (Ocufen) 2.5ml.
Diclofenac sodium 0.1% (Voltaren) 2.5ml., 5ml.
251
Nepafenac 0.1% (Nevanac) 3 ml.
Bromfenac 0.09% (Xibrom) 5 ml.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Topical Steroids
Prednisolone acetate1% susp.(Pred Forte“generic”,econopred plus)1 ml.,5 ml.,10 ml.,15 ml.
Loteprednol etabonate 0.5% susp. (Lotemax) 2.5 ml., 5 ml., 10 ml., 15 ml.
Rimexolone 1% susp. (Vexol) 5 ml., 10 ml.
Fluoromethalone acetate 0.1% susp. (“Flarex”, eflone) “2.5 ml., 5 ml., 10 ml.”
Dexamthasone suspension 0.1% susp. (Maxidex)
Fluoromethalone alcohol susp. & oint. 0.1% (FML, FML s.o.p) “generic” 1ml,5ml,10ml,15ml,/3.5g
Loteprednol etabonate 0.2% (Alrex) 5 ml., 10 ml.
“Medrysone 1.0 % (HMS)”
Prednisolone acetate 0.125% susp. (Pred Mild, “generic”) 5 ml., 10 ml.
Prednisolone sodium phosphate 1% sol.(Inflamase Forte),“0.12% Inflamase” 5ml,10ml,15ml
Fluoromethalone susp. 0.25% (FML Forte)
Dexamethasone phosphate 0.1% sol. (Decadron)
Dexamethasone phosphate 0.05% ung. (Decadron, AK-Dex)
252
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Topical Antiviral
Trifluridine 1% gtt. (Viroptic)
Vidarabine 3% ung. (Vira-A)
Acyclovir 3%, 5% ung. (Zovirax)
Idoxuridine 0.1% sol. & 0.5% oint. (Herplex, Stoxil)
Cidofovir gtt.
Systemic Antiviral
Acyclovir (Zovirax) “generic” 200, 400, 800 mg. tablets
Famciclovir (Famvir) 250, 500 mg.
Valacyclovir (Valtrex) 500, 1000 mg.
Ganciclovir (Cytovene)
Foscarnet (Foscavir)
Systemic Steroids /Oint.
Prednisone
Methylprednisone (Depomedrol)
Triamcinolone (Kenalog or Aristocort) [0.025%, 0.5%, 0.1% cream]
Hydrocortisone 0.5 - 1.0% (Cortizone 5, Demarest, Cortaid) “cream OTC”
253
LY
N
O
O
R
C
O
PY
,V
IE
W
Mydriatics & Cycloplegics
Tropicamide 0.5%, 1%
Phenylephrine 2.5%, 10% (Neo-Synephrine, Mydfrin)
Cyclopentolate 0.5%, 1% (Cyclogel)
Homatropine 5%
Atropine 1%
Scopolamine 0.25%
Hydroxyamphetamine 1% (Paradrine)
Cocaine 10%
N
O
T
PR
IN
T
Antihistamine & Decongestant Combinations
Naphcon-A (pheniramine 0.3% & naphazoline 0.025%)
Vasocon-A , Albalon-A (antazoline 0.5% & naphazoline 0.05%)
D
O
Antihistamine
Emedastine difumarate 0.05% (Emadine) 5 ml. “acute” qid
{Levocabastine (Livostin) 0.05% sol.} “Discontinued”
254
T
O
N
D
O
Antiseptic
Mercuric Oxide 1.0% oint.
Zinc Sulfate 0.217% sol.
Boric Acid 5% , 10% ung.
Silver Nitrate 0.5% to 1.0%
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Mast-cell Stabilizer /Anti-histamine Combo.
Cromolyn Sodium 4% (Opticrom, Crolom) 10 ml. “chronic” qid
Lodoxomide tromethamine 0.1% (Alomide) 10 ml. “chronic” qid
Pemirolast potassium 0.1% (Alamast) 10 ml. “chronic” qid/bid
Nedocromil sodium 2% (Alocril) 5 ml. “chronic” bid
Ketotifen Fumarate 0.025% (Zaditor/Refresh) 5 ml. “combo/acute” bid - OTC
Ketotifen Fumarate 0.025% (Alaway) 10 ml. “combo/acute” bid - OTC
Olopatadine Hydrochloride 0.2% (Pataday) 2.5 ml. “combo/acute” qd
Olopatadine Hydrochloride 0.1%, (Patanol) 5 ml. “combo./acute” bid
Epinastine HCL 0.05% sol. (Elestat) 5 ml. “combo/acute” bid
Azelastine HCL 0.05% sol. (Optivar) 6 ml. “combo/acute” bid
255
LY
N
O
O
PY
,V
IE
W
C
R
D
O
N
O
T
PR
IN
T
O
Diagnostic & Therapeutic Agents
Sodium Fluorescein 2%
Rose Bengal 1%
Edrophonium (Tensilon)
Acetylcysteine 2 & 5 % sol. (Mucomyst)
Sodium Hyaluronate (Healon)
Ethoxzolamide (Cardrase, Ethamide)
Amino Caproic Acid
EDTA 0.37%
Systemic NSAID‟S
Acetaminophen + Codeine (Tylenol 3)
Ibuprofen (Motrin, Advil)
Aspirin (Acetylsalacylic acid)
Indomethacin (Indocin)
Naproxen (Naprosyn)
Piroxicam (Feldene)
Phenylbutazone
256
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Oral Antihistamine
Claritin 10 mg. (Loratadine) OTC “Alavert / Tavist ND / Dimetapp ND”
Clarinex 5 mg. (Desloratadine)
Zyrtec 5 mg., 10 mg. (Cetirizine)
Allegra 60 mg., 180 mg. (Fexofenadine)
“Hisminal (Astenizole)”
“Seldane (Terfenadine)”
Benadryl 25 mg. (Diphenhydramine) “OTC”
Chlor-Trimeton 8 mg. (Chlorpheniramine) “OTC”
“Dimetane”
D
O
N
O
T
Decongestants
Naphazoline 0.1% (Naphcon, Vasocon)
Tetrahydrozoline, Oxymetazoline & Phenylephrine (Visine, Clear eyes, Murine, Allerest)
257
LY
N
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
Oral Anti-Staph. Antibiotics
--Penicillins:
Augmentin (Amoxicillin + Clavulanate) 250 - 500 mg.
Cloxacillin 250 mg.
Dicloxacillin 125 - 250 mg.
--Cephalosporins:
Cephalexin (Keflex) 250 - 500 mg.
Cefuroxamine (Ceftin) 250 - 500 mg.
Cefadroxil (Duricef) 500 mg.
Cefaclor (Ceclor) 250 mg.
--Others:
Bactrim (trimethoprime + sulfamethoxazole)
Erythromycin 500 mg.
Tetracycline 250 mg.
Doxycycline 50 mg. / 100 mg.
“Minocycline 100 mg.”
258
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Glaucoma Medications
Timolol-maleate: 0.25%, 0.5%(Timoptic sol.-bid/qd “generic”, Timoptic-XE gel.-Am “generic”)2.5,5,10,15ml,
-Istalol 0.5% sol.-Am; [Timolol-hemihydrates: 0.25%, 0.5% sol.-bid (Betimol)] // 5ml, 10ml, 15ml.
Levobunolol hydrochloride: 0.25%, 0.5% sol.-bid (Betagan) “generic” 2 ml., 5 ml., 10 ml., 15 ml.
Carteolol 1.0% sol.-bid (Ocupress)
Metipranolol 0.3% sol.-bid (Optipranolol)
Betaxolol hydrochloride: 0.25% susp.-bid (Betoptic-S), 0.5% sol.-bid (Betoptic)
[Levobetaxolol 0.5% sol.-bid (Betaxon)] // 2.5ml, 5 ml, 10 ml, 15 ml.
Dorzolamide 2% sol. (Trusopt) 5 ml., 10 ml.
Brinzolamide 1% susp. (Azopt) 5 ml., 10ml., 15 ml.
Methazolamide (Neptazane) 25, 50 mg. tablets
Acetazolamide (Diamox) 125, 250 mg. tablets & 500 mg. Sequels
Dichlorphenamide (Daranide) 25, 50 mg.
Ophthalgan (topical Glycerin sol.)
Glycerol 50% (Osmoglyn) PO
Isosorbide 45% (Ismotic) PO
Mannitol 1-2 gm./kg IV
259
Carbachol (Miostat) 0.01% “1.5%, 2.25%, 3%” sol.
Pilocarpine hydrochloride (Isopto Carpine) 1, 2, 4% sol. & 4% gel (Pilopine HS)
Epinephrine 0.5 - 2% (Epifrin, Glaucon)
N
O
O
PY
,V
IE
W
Physostigmine 0.25% sol & ung. , 0.5% sol (Eserine)
Echothiophate 0.03%, 0.125% (Phospholine Iodide)
Isoflurophate 0.025% ung. (Floropryl)
LY
Dipivefrin 0.1% (Propine)
Demecarium Bromide (Humorsol) 0.125%, 0.25% sol.
PR
IN
T
O
R
C
Brimonidine 0.15%, 0.1% {(Alphagan-P)} [“generic” 0.2%] 5 ml., 10ml., 15 ml.
Latanoprost 0.005% sol. (Xalatan) 2.5 ml.
Brimatoprost 0.03% sol. (Lumigan) 2.5 ml., 5 ml., 7.5 ml.
Travoprost 0.004% (Travatan, Travatan Z) 2.5 ml., 5 ml.
O
T
{Unoprostone 0.15% sol. (Rescula) 5 ml.}
D
O
N
Apraclonidine 0.5% (Iopidine) 5 ml., 10 ml. [1% unit-dose]
Cosopt: (Trusopt 2% + Timolol maleate 0.5%) 5 ml., 10 ml.
Combigan (Alphagan 0.2% + Timolol maleate 0.5%) 5ml., 10ml.
{Xalacom: (Xalatan 0.005% + Timolol maleate 0.5%)//Extravan: (Travotan 0.004% + Timolol 0.5%)}
260
*Oral Medicine in Primary Eye Care:
Meibomianitis/Blepharitis/Rosacea/Phlyctenular Kerato-Conjunctivitis => Etiology: Staph.
O
PY
,V
IE
W
O
N
LY
--Doxycycline: 50-100 mg. bid x 1-2 months or longer “category D”
--Tetracycline: 250-500 mg. qid x 4-6 weeks or longer “category D”
(Meibomianitis: tetracycline 250 mg. qid/2 months then bid/6 mts. and qd x 3-6 mts more
Doxycycline 100 mg. bid x 2-6mts then 50-100mg. daily x 2-6 months and 50mg. qd maintain,
Acne Rosacea: Tetracycline 250 mg. qid x 1-2 mts then bid x 1-2 mts.)
“tetracycline taken 1-hour before or 2-hours after meals, where doxycycline can be taken with meals.
R
C
Avoid sun-burn and in children under 8-12 years old and pregnant/nursing women due to
effect on tooth and bones malformation”.
D
O
N
O
T
PR
IN
T
O
(drug interactions: penicillins, anticoagulants, oral contraceptives, lithium carbonate,
methoxy flurane, ferrous sulfate, antacids)
Internal Hordeolum, [w/ staph. etiology “gram +”]
--Dicloxacillin [penicillin] 250 mg qid x 7-10 days “generic” (category-B)
--Cephalexin (Keflex) [cephalosporins] 250-500 mg qid x 7-10 days “generic, B”
--Ciprofloxacin (Cipro) [fluoroquinolone] 500 mg bid x 7-10 days “category-C”
--Azithromycin(Zithromax)500 mg. day-1, then 250 mg qd x 2-5 days“macrolides-B”
261
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Preseptal Cellulites, (lid-trauma “for prophylaxis”)
Etiology: staph, strep, H.influ. etc.
--Cephalexin (Keflex) 250-500 mg po q6h x 7-10 days “1st generation / cell-wall”
--Dicloxacillin 250 mg po q6h x 7-10 days
--Cefaclor(Ceclor)[cephalosporins]250-500 mg tid x 7-10 days “category-B /2nd gen.”
--Cefadroxil (Duricef) [cephalosporins] 1-2 g./d “qd/bid” /children 30 mg/kg/d bid
oral susp. 125, 250, 500 mg/5ml x 7-10 days (generic-B)
--Augmentin (Amoxicillin &Clavulunate) 250mg po q8h to 500mg q12h x 7-10 days “children H.influ.”
--Ciprofloxacin (Cipro) 500 mg po bid x 7-10 days
--Azithromycin (Zithromax) 500 mg po day-1 then 250 mg qd x 2-5 days
Acute Dacryocystitis, [etiolog: staph. strep. H.influ.]
--Dicloxacillin 250 mg. qid x 7-10 days (cross-sensitivity between cillin. & cephalo.)
--Augmentin (Amoxicillin&Clavulunate)250mg bid to 500mg bid x7-10days children: 20-40mg/kg/d, bid
--Cephalexin (Keflex) 250-500 mg qid x 7-10 days “gram +”
--Ciprofloxacin (Cipro) 500 mg bid x 7-10 days
--Azithromycin (Zithromax) 500 mg day-1 then 250 mg x 2-5 days
262
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Conjunctivitis, [etiology: seasonal allergic]
--Loratadine (Claritin) 10 mg po qd “category - B”
--Cetirazine (Zyrtec) 5-10 mg po qd “category - B”
--Fexofenadine (Allegra) 60 mg po bid “category - C”
--Chlorpheniramine (Chlor-Trimeton) 2, 4, 6, 8, 12 mg q 4-12 h. “C /OTC”
--Diphenhydramine (Benadryl) 25-50 mg q 4-6 h. “ B /OTC, sedation”
Conjunctivitis, [etiology: vernal]
--Aspirin 325-650 mg tid (caution in teenager w/ Reye‟s syndrome, influenza, chicken pox /D)
**Cortico-steroids: Scleritis, vitritis, retinitis, hyphema, neuritis, optic neuropathy
Periocular Dermatitis (shingles) / keratitis / conjunctivitis
Etiology: herpes varicella-zoster (chicken pox) virus
--Acyclovir (Zovirax) 600-800 mg 5 x day / 7-10 days “best within 72h.of onset / C”
--Valacyclovir (Valtrex) 1000 mg tid x 7 days “category - B”
--Famciclovir (Famvir) 500 mg tid x 7 days “category - B”
Keratitis / Conjunctivitis / Periocular Dermatitis
Etiology: herpes simplex virus
--Acyclovir (Zovirax) 400 mg bid /12 months “category - C”
263
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Adult Inclusion Conjunctivitis, [etiology: Chlamydia]
--Azithromycin (Zithromax) 1g. po qd “single dose may do the job!”
--Doxycycline 100 mg bid x 3 weeks
--Tetracycline 500 mg tid x 3 wks
--Erythromycin 500 mg qid x 3 wks “macrolides-B”
--Ofloxacin (Floxin) [fluoroquinolones“gram + & -“]300mg bid x 7days“category-C”
Keratitis, [etiology: corneal epithelial defect, general eye-pain]
--Acetaminophen 325 mg q 4-6 h. “OTC”
--Ibuprofen (Advil, Motrin) 200 mg q 4-6 h. “C /OTC”
--Naproxen (Aleve, Naprosyn) 220 mg bid “B /OTC”
--Ketoprofen (Orudis) 12.5 mg q 6-8 h. “B /OTC”
--Rofecoxib (Vioxx)50 mg qd x 5 days /12.5, 25 mg/5ml oral. susp.“Not pregnant /C”
--Ketorolac (Toradol) 10 mg q 4-6 h. x 5 days “category - C”
--Tramadol (Ultram) 50-100 mg q 4-6 h. “maxDose 300-400 /24h. /C”
Keratitis, [etiology: corneal abrasions, some refractive surgeries “PRK/RK”]
--Tylenol 300mg w/Codeine 30mg(Tylenol 3)1-2 tablets q4-6h.“schedule III controlled substance /C”
--Tylenol 500/750mg w/hydrocodone 5/7.5mg (VicodinES, Lortab) 1-2 tablets q4-6h.“control /C”
264
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Glaucoma, [etiology: open angle]
--Acetazolamide (Diamox) 125-500 mg po q 6-12 h. “renal stone /C”
--Methazolamide (Neptazane) 25-50 mg po bid - tid “sulfa sensitivity /C”
Acute Glaucoma, [etiology: closed angle, per-yag PI]
--Diamox 500 mg in office (Not-Sequel /depression, hypokalemia)
--Isosorbide 45% (Ismotic) 1.5-2 g./kg PO (OK in Diabetic)
--Glycerin (Osmoglyn) 1-1.5 g./kg PO (Not Diabetic)
Optic-Neuritis, [etiology: TB-dry toxicity, isoniazid]
--Pyridoxine (B6) 50 mg qd “category - A”
Macular Degeneration
Etiology: deficiency of anti-oxidant vitamins (A,C,E) zinc, cooper, selenium
--Ocuvite, Ocuvite preser vision, Icaps Plus
T
(provides qd: 500 mg vit.C, 400iu vit.E, 15mg Beta-carotene, 80mg Zinc-oxide, 2mg Cupric-oxide)
D
O
N
O
[dark-green leafy vegetables has abundance of Lutein]
Dry Eye / Keratitis, [etiology: vitamin-A deficiency]
--Vitamin-A 50,000 units qd “fat-soluble / toxicity: dry-mucous, eye irritation /C”
265
N
O
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
Propamadin Isenthionate (Brolene)
Natamycin 5% susp. (Natacyn)
Nystatin (Mycostatin)
Ketoconazole (Nizoral)
Miconazole
Amphotericin-B (Fungizone)
Clindamycin & Trisulfapyrimidine
Pyrimethamine & Sulfadiazine
Zidovudine (AZT)
Vancomycin “antibiotic”
Clarithromycin (Biaxin), “macrolides /gram +”
Penicillins: Ampicillin, Carbenicillin, Ticarcillin
Levofloxacin (Levaquin) “Fluoroquinolones”
Cimetidine (Tagamet) po
Botulism Toxin (Oculinum) IM
LY
Miscellaneous
266
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Metronidazole 0.75% gel (MetroGel)
Capsaicin 0.025% cream (Zostrix) “OTC”
Cefazolin (Ancef)
Vasoclear-A, Visine-AC, Zincfrin, Prefrin
Lacri-Lube, Vaseline
Alcohol wipes, Calamine
Eye scrub, Ocu clens
Kwell shampoo, RID
Sodium Chloride 5% oint./sol. “2%” (Muro-128 or Adsorbonac)
Systane-ultra, Soothe-xp // Restasis 0.05% (Cyclosporine)
Omega-3 essential Fatty acid Supplementation (derived from fish/flaxseed-oil)
Tears Again Hydrate (Rx) bid
Thera Tears Nutrition Supplementation (OTC) qd
Icaps (vitamin A, C, E, B2, Lutein & zeaxanthin)
Ocuvite Extra (vitamin A, C, E, B2, B3, Niacin, Riboflavin)
I-Sence (vitamin A, C, E, B2)
PreserVision (AREDS formula Eye Vitamins), bid
267
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Betadine 5% (Iodine/Povidone) sterile ophthalmic pep Solution
Dapiprazole (Rev-Eyes)
Fluorescein-benoxinate (Fluress)
Paremyd (hydroxyamphetamine - tropicamide)
Proparacaine 0.5%
Hydroxychloroquine (Plaquenil)
Topiramate (Topamax)
Tamoxifen [Nolvadex]
Tolterodine Tartrate [Detrol-LA]
Rifamicin 300 mg.
Flurbiprofen Sodium 0.03%
Theophylline (theo-dur)
Pyrimethamine (DaraPrim)
“Tramadol (ultram) 50, 100mg qid”
Lortab, Vicodin
[Punctal Gauge Device]
[Dichloroacetic-Acid / Derma–Caute-All “Kit”]
268
Activity Recommended Colors
Gray or Brown
Polarized
• In general use Gray or Brown as dark as needed for driving comfort.
• Polarized lenses are a must.
Hunting
Yellow, Orange, Red
Contrast Browns
Polarized
• Most hunters require multiple lens choices.
• Yellow, Amber, Orange and Red or light lenses work great in
low light conditions.
• Contrast Browns or darker lenses work better in bright conditions.
• Suggest frames with inter-changeable lenses or multiple pairs.
Skiing
Yellow, Orange and Brown
Polarized
Fishing
Brown, Amber and Gray
Polarized
• Brown, Amber or Brown-yellow lenses are excellent choices.
• Yellow or Orange and Contrast Brown (high VLT)
for low light conditions.
D
O
N
O
T
PR
IN
T
O
R
C
O
PY
,V
IE
W
O
N
LY
Driving
• Polarized is important depending on the type of fishing,
both Gray and Brown work well, as does Contrast Brown.
• For flats, lake and streem Brown is recommended,
for open water or deep sea Gray is recommended.
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• AR and flash mirrors are good to diminish the reflection of water.
• For competitive swimming use clear lenses, flash mirrors, back AR.
Water Sports Brown or Gray
All Polarized
• Polarized lenses reduce blue light, and light scatter off water.
• Choose Gray family colors for general water activities.
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Cycling
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Swimming Clear, Light Blue, Light Yellow
Most Browns
Some Greens
C
Gray or Brown Photochromics
• Bright sunlight- high contrast Brown and Greens also,
polarized in Brown or Contrast tint Brown, enhance contrast.
• Low light- Yellow, Red or Orange.
• Photochromic lenses are increasing in popularity due to UV and
the variable density feature.
• Back surface AR.
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IN
T
O
R
Polarized
T
Motorcycling Most Browns
N
O
Some Gray and Green Lenses
D
O
Photochromics
Polarized
• Contrast Brown, since contrast enhancement is key at high speed,
plus backside AR can improve safety.
• Polarized is good for road vision but some instrument clusters
are LCDs, and polarized lenses could cause problems.
• Photochromic is increasing in popularity in large frames or
in wraps, where a UV absorbing face-shield is not used.
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Golf
Green and Brown
Tennis
Yellow and Orange, Clear
Polarized
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• The ball needs to be highlighted against the sky and the grass.
• The background and the specifics of driving vs. putting have varied
and opposite color requirements.
• Brown is preferred and density can be tuned to personal preference,
polarized with back surface AR is a plus.
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R
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• General purpose- Yellow tinted lens will pick up the yellow ball
better.
• Outdoors, yellow will be too bright and allow-in too much light,
use Orange or Brown.
• Primary indoors- Yellow or Orange heightens ball visibility.
• Clear with AR is also a good choice.
O
N
O
Gray or Green
Polarized
D
Baseball
T
PR
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Racquetball Yellow and Orange, Clear
• Green or Gray is the better choice to highlight the ball against
the sky or grass.
• Mirrors can help enhance contrast.
• Back surface AR blocks reflection at critical times.
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Soft Contact Lenses
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CibaVision: Focus Daily Aqua Comfort-Plus (daily $......) 8.7/14.0 -10.0 to +6.0 “0.50 steps above -6.50”
Bausch&Lomb: SofLens Daily-Disposable (daily/Aspheric $38 ,90pk)8.6/14.2 -9.0 to +6.50 .5steps above -6.0
CooperVision: ClearSight 1-day (daily $14.50,30pk) 8.7/14.2 -10.0 to +6.0 “.5 steps above -6.0&+5.0”
CooperVision: Proclear 1-day (daily $40.0,90pk) 8.7/14.2 -0.25 to -10.0 “.5 steps above -6.0”
Vistakon: 1-day Acuvue (daily $19.50,30pk) 8.5,9.0/14.2 -12.0 to +6.0 “0.50 steps above -6.50”
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O
N
O
T
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O
R
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CooperVision: Avaira (2wks/Aspheric $19.0 ,6pk) 8.5/14.2 -6.0 to -0.25 “Aquaform technology”
Vistakon: Acuvue Oasys w/hydroclear+ (2wks $20.25) 8.4/14.0 -12.0 to +8.0 “.5 steps above +6.0”
CibaVision: Air-Optix Aqua (2wks to monthly $......) 8.6/14.2 -10.0 to +6.0 “0.50 steps above -8.0”
CibaVision: O2Optix (2wks $15.75) 8.6/14.2 -10.0 to +6.0 “0.50 steps above -8.50”Custom-avail.
CooperVision:Biomedics55 Premier(2wks/Aspheric $14.50)8.6,8.8+,8.9-/14.2 -10.0 to +6.0“.5 steps above -6.5”
Vistakon: Acuvue2 (2wks $13.50) 8.3,8.7/14.0 -12.0 to +8.0 “0.50 steps above +6.50”
Bausch&Lomb: SofLens38 (2wks/ultra-thin $12.75 ,6pk) 8.4,8.7,9.0/14.0 -9.0 to +4.0 (.5 steps above -6.50)
CooperVision: Biomedics-XC (2wks $15.0) 8.5/14.2 -10.0 to +6.0 “0.50 steps above -6.0”
CooperVision: Biomedics38 (2wks $15.50) 8.6/14.0 -0.25 to -10.0 “0.50 steps above -6.0”
CooperVision:Vertex-Sphere (2wks $14.50) 8.3,8.6,8.9,8.8/14.2 -10.0 to +8.0 “.5 steps above -8.50”
CibaVision:Precision-UV(2wks $15.0)14.4: 8.4/-10.0 to +8.0, 8.7/-16.0 to +10.0 “.5 steps above -6&+5”
Vistakon: Acuvue Advance (2wks $16.50) 8.3,8.7/14.0 -12.0 to +8.0 “0.50 steps above +6.50”
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CibaVision: Air-Optix Night&Day (Monthly $......) 8.4,8.6/13.8 -9.0 to +6.0 “0.5 steps above -8.0”
CooperVision: Biofinity (Monthly/Aspheric, $27.50) 8.6/14.0 -10.0 to -0.25 “0.5 steps above -6.0”
CooperVision: Proclear-Sphere (Monthly $25.0) 8.6,8.2-/14.2 -10.0 to +10.0 “.5 steps above +6.0”
Bausch&Lomb:PureVision(Monthly$28.0)8.6,8.3/14.0 -12.0 to +6.0 “.5 steps after -6.0/8.3: -0.25 to -6.0”
CooperVision:Frequency55 Aspheric(Monthly $16.50)8.4,8.7/14.4 -10.0 to +8.0 “.5 steps above -8.0”
CooperVision: Frequency38 (Monthly $15.50) 8.6/14.0 -8.0 to +8.0
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Cooper Vision: ClearSight 1-Day Toric (daily $25 ,30pk) 8.7/14.5 -7.00 to Plano “.5 steps above -6.0”
Cyl. -0.75,-1.25 “axis:180,90,160,20”
CibaVision: Focus Dailies Toric (daily $18.50,30pk) 8.6/14.2 -8.0 to +4.0 “.5 steps above -6.0”
Cylinder: -0.75,-1.50/Axis: 90&180
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N
O
T
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Vistakon: Acuvue Oasys for Astigmatism (2wks $......) 8.6/14.5 -9.0 to +6.0 “0.5 steps above -6.50”
Cyl. -0.75, -1.25, -1.75, -2.25 axis: 10deg. steps (no-Oblique/↑check-Axis)
CooperVision: Biomedics Toric (2wks $20.0) 8.7/14.5 -9.0 to +6.0 Cyl: -0.75,-1.25,-1.75,-2.25 axis10deg.
Bausch&Lomb: SofLens Toric (2wks $19.50) 8.5/14.5 -9.0 to +6.0 0.50 steps above -6.50
Cyl: -0.75,-1.25,-1.75,-2.25,-2.75 axis: 10deg. steps
CooperVision: Vertex Toric (2wks $20.0) 8.6/14.4 -8.0 to +6.0 0.50 steps above -6.50
Cyl. -0.75,-1.25,-1.75,-2.25 axis: 10deg. steps
CooperVision: Vertex Toric-XR (2wks $40.0) 8.6/14.4 -8.0 to +6.0 “.5 steps above -6.50”
Cyl: -2.75,-3.25,-3.75 axis: 5deg. steps
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Vistakon: Acuvue Advance for Astigmatism (2wks $24.0) 8.6/14.5 -9.0 to +6.0 .5 steps above -6.50
Cyl. -0.75,-1.25,-1.75,-2.25 axis: 10deg. steps
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CibaVision: FreshLook Toric (2wks $36.0) Median/14.5 Plano to -4.0 “Handling Tint”
Cyl. -0.75,-1.25,-1.75 axis:10deg.steps (+20deg. @ 90&180)
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O
N
O
T
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IN
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O
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IE
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O
CibaVision: Air-Optix for Astigmatism (Monthly/Dw, aspheric, $42.0) 8.7/14.5 -6.0 to Plano
Cyl: -0.75, -1.25 axis: 10deg. steps
CooperVision: Proclear Toric (Monthly/Dry Eyes $32.0) 8.4,8.8/14.4 -8.0 to +6.0 0.50 steps above -6.50
Cyl. -0.75,-1.25,-1.75,-2.25 axis: 10deg. steps (PC-Technology)
Cooper Vision: Proclear Toric-XR (Monthly $65.0) 8.4,8.8/14.4 -10.0 to +10.0 “.5 steps above +6.50”
Cyl. -2.75 to -5.75 in .5 steps, axis: 5deg. steps
Bausch&Lomb: PureVision Toric (Monthly/Ew $30.0) 8.7/14.0 -9.0 to +6.0 “.5 steps above -6.50”
Cyl. -0.75,-1.25,-1.75,-2.25 axis: 10deg. steps
CooperVision: Frequency55 Toric (Monthly $38.0) 8.4,8.7/14.4 -8.0 to +6.0 .5 steps above -6.50
Cyl. -0.75,-1.25,-1.75,-2.25 axis: 10deg. Steps
CooperVision:Frequency55 Toric-XR (Monthly $62.0) 8.4,8.7/14.4 -8.0 to +6.0 .5 steps above -6.5“&cylinders”
Cyl. -2.75 to -5.75 axis: 5deg. steps
Cooper Vision: Preference Toric (Quarterly/Dw $77.0,4pk) 8.4,8.7/14.4 -8.0 to +6.0“.5 steps after -6.50”
Cyl. -0.75,-1.25,-1.75,-2.25 axis: 5deg. steps (avail. in XR & Sphere )
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CibaVision: FreshLook One-Day Color (daily $10.50,10pk) 8.6/13.8 -0.50 to -6.0
Colors: Blue,Green,Pure-Hazel,Grey
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CibaVision: FreshLook ColorBlends (2wks $29.50) Median/14.5 -8.0 to +6.0
Colors: Blue,Brown,Gray,Green,Honey,Amythest,Pure-Hazel,True-Sapphire,Turquoise
CibaVision: FreshLook Colors (2wks $29.50) Median/14.5 -8.0 to +6.0 Blue,Green,Hazel,Violet
Vistakon: Acuvue-2 Colours Opaque (2wks $24.0) 8.3/14.0 -9.0 to +6.0 0.50 steps above -6.50
Colors: Chestnut-Brown,Sapphire-Blue,Hazel-Green,Jade-Green,Pearl-Grey,Warm-Honey,Deep-Blue
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CibaVision: Focus 1-2weeks Softcolors (2wks “Enhancer” $29.0) 8.4,8.8/14.0 -6.0 to +4.0
Colors: Aqua,Evergreen,Royal-Blue
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CibaVision: FreshLook ColorBlends Toric (2wks $45.0) Median(8.6)/14.5 -4.0 to Plano
Cyl: -0.75,-1.25,-1.75 axis:10deg.steps(+20deg90&180) Colors: Blue,Green,Honey,Gray
D
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CibaVision: DuraSoft-3 OptiFit ColorBlends Toric (Yearly/Ew “Opaque” $95.0) -8.0 to +4.0
Steep,Flat,Median/14.5 Cyl: -0.75 to -5.75 in .5 steps axis: 5deg. steps
Colors: Blue,Green,Gray,Brown,Honey,Turquoise,Amythest
CibaVision:DuraSoft-3 Complements Colors(Yearly/Ew“Enhancing”$67.0)-20.0 to +20.0 .5 steps above +10
9.0/14.5 (above: -8.25&+6.25 BC:8.3/8.6 -8.0 to +6.0) Colors-Complements: Brown,Blue,Green,Blue-Violet,Shadw-Gray
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CibaVision: Focus Dailies-Progressive (daily/tint $18.50,30pk) 8.6/13.8 -6.0 to +5.0 Progressive Add to +3.00
all Ciba-Progressive Add calculation:Vertexed Spherical Equivalent + ½ Add = Single Power
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B&L: Bausch&Lomb SofLens Multi-Focal (2wks $31.25) 8.5,8.8/14.5 -10.0 to +6.0 Tint: Light-Blue
Low-add (up to +1.50), High-add (+1.75 to +2.50)
Vistakon: Acuvue Oasys for Presbyopia (2wks $...) 8.4/14.3 Plano to -9.0 Low: +0.75/+1.25 Mid: +1.50/+1.75
CibaVision: Focus Progressive (2wks or monthly $30.0) 8.6,8.9/14.0 -7.0 to +6.0 Progressive Add to +3.00
CooperVision: Biomedics-EP (2wks/PC-technology,$20.0) 8.7/14.4 -8.0 to +6.0 “.5 steps above -6.0” Add:+1.0
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CooperVision: Proclear Multifocal (Monthly/Tint $38.0) 8.7/14.4 -6.0 to +4.0 Add: +1.0 to +2.50 in.5steps (D&N)
CooperVision:Proclear Multifocal-XR (Monthly $70.0) 8.7/14.4 -20.0 to +20.0 Add: +1.0 to +4.0 in .5 steps (D&N)
Bausch&Lomb: PureVision Multifocal (Monthly/Ew $34.0) 8.6/14.0 -10.0 to +6.0 (.5 steps above -6.50)
Add: Low (up to +1.50) / High (+1.75 to +2.50)
CooperVision: Frequency-55 Multifocal (Monthly $38.0) 8.7/14.4 -6.0 to +4.0 Add: +1.0 to +2.50 in.5steps (D&N)
O
N
O
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CooperVision:Proclear Multifocal-Toric(Monthly/tint$90.0)8.4,8.8/14.4 -20.0 to +20.0 “.5 steps above +6.0” (D&N)
Cyl. -0.75 to -5.75 in .5 steps axis: 5deg. steps Add: +1.0 to +4.0 in .5 steps (Dry-Eye)
D
CibaVision: CibaSoft Progressive Toric (Yearly/D $99.0) 8.6/14.5 -9.0 to +9.0
Cyl. -0.75 to -2.75 in .25 steps Axis: 5deg. steps Progressive Add to +3.00
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CooperVision:Cooper-Prosthetic(Yearly/Dw $180.0)8.4,8.7,8.9/14.5 -20.0 to +20.0 “.5 steps above +10.0”
9 Colors, w/Open or Closed Pupil & Black or Clear Backing
CibaVision: DuraSoft-3 “Prosthetic” (Yearly/Ew $200/$300-400Tria$60) 8.3,8.6,9.0/13.8,14.5
Spheres: -20.0 to +20.0 / -8.0 to +4.0 : Cyl. -0.75 to 5.75 (Clear or Dark Pupil)
“Colors: Opaque, Enhancement, Complements, ColorBlends & Total-Occluder”
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CooperVision: Hydrasoft Aphakic (Yearly/Quarterly:Dw, $59.0/$92.0,4pk) “also, available in Toric”
8.3,8.6/14.2 8.6,8.9,9.2/15.0 +10.50 to +20.0 in 0.50 steps
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CooperVision:Permalens Therapeutic(Yearly/Ew $104.0)Plano 8.3,8.0,7.7/13.5 8.6/14.2 9.0/15.0
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Valley Contax: Flexlens Post Refractive-Surgery Lens (Quarterly/Dw/tint $85,$150 3pk after) DK18.8/16
Dia: 8.0 to 16.0 in .1 steps, BC: 5.0 to 11.0 in .1 steps, Power: -50.0 to +50.0 in 0.25 steps
D
O
N
O
T
Valley Contax: Flexlens Tri-Curve Keratoconus Lens (Quarterly/Dw/tint $85warranted ,$150 3pk) DK18.8/16
Dia:10.0 to 16.0 in 0.5 steps, BC: 6.0 to 9.9 in 0.3 steps, -30.0 to +30.0 in .5 steps
ValleyContax (ParagonVision Sciences): Paragon HDS-100 (DK100, $32-45) Blue,Green
Valley Contax (Bausch&Lomb):Boston-XO (Y/D$32-45) Colors(UV)blue,ice-blue,green,violet,yellow,Red
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Valley Contax: I-Kone (Boston-XO/DK100, $55-80) Dia:9.6, BC:up to 2D change 44K to 70K
Valley Contax: PS -Lens (1/2year/Dw, HDS-100/hema) 14.5/7.6 to 9.0 in .2 steps -6.0 to +20.0
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Valley Contax (Bausch&Lomb): Boston ES (fluorosilicone acrylate) DK 31/18
Colors (UV): blue,green,gray,brown $28-45
Valley Contax (ParagonVision Sciences): FluoroPerm 30/60 (fluorosilicone acrylate) DK 30/60
Colors (UV) gray,brown,blue,green,clear $28-42
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T
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CibaVision: SoftPerm (Yearly/Dw $98.0, Clear) DK 12 /HEMA T-Butylstyrene Silicone acrylate
Dia:14.3 BC: 6.5 to 8.1 in .1 steps -16.0 to +6.0 “41K to 51K” (Center- RGP/ Soft -Peripheral)
SynergEyes, Inc: SynergEyes – KC “PS-Lens, Multifocal” (1/2Year/Dw $225+ ,2pk) hybrid /DK100 /tint
14.5/5.7 to 7.1 in .2 steps, -20.00 to Plano “in .5 steps” (Rigid-center/Soft-skirt) Custom+
SynergEyes: SynergEyes A-Lens (1/2Year/Dw $168+ ,2pk)14.5/7.1 to 8.0 in .1 step
-20.0 to +20.0 “.5step above +8.5”
D
O
N
Flat K greater than or equal to 45.25D → Steeper Fit, (BC 9.0mm)
Flat K between 42.25D to 45.00D → Ave Fit, (BC 9.2mm)
Flat K less than or equal to 42.00D → Flatter Fit, (BC 9.5mm)
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Date: ____ / ____ / ____
Contact Lens Consent
Name: ___________________________________
Previous Contact Lens Wearer: Yes____ No____
Instructions:
Age: ____
Wash hands thoroughly.
Clean, Rinse and Disinfect with: __________________.
First week wearing schedule; for new wearers and those who have not worn lenses in more than a month:
Begin 4 hours the first day. Add 2 hours to each day there after, (Increments of 2hrs/day).
Your trial lenses are inspected and dispensed to you free of cuts, nicks, discoloration and microorganisms.
We do not assume responsibility for your lenses once they leave the office, if causes damage to your eyes.
Please follow these simple procedures to ensure successful contact lens wear:
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1) Always wash hands with oil/perfume free soap prior to handling lenses.
2) Never wear a torn, discolored, scratched, chipped or infected lens.
3) Disinfect your lenses daily by cleaning, rubbing, rinsing and then storing with fresh solution.
4) When disinfecting your contact lenses, remember to put fresh solution in CL case.
5) Rinse your contact lens case with saline solution, and let it air dry during the day.
6) Contact lens cases should be replaced at least every month, and after any infected lenses.
7) Use only prescribed solutions, mixing brands or types may discolor your lenses and result in problems.
8) Never wear lenses longer than prescribed time, which has been suggested by contact lens manufacturer.
9) Do not exceed the wearing time or replacement schedule that we have recommended for your lenses.
10) If your lenses cause redness, pain or blurred vision, discontinue wear immediately and see your doctor.
11) If you have severe allergies, a cold, sinus problems, or are sick, remove your contact lenses.
12) Improper use and inadequate care of contact lenses can cause eye irritation, infection, scar and disease.
Special Note: No sleeping, no swimming, no showering and no bathing with your contact lenses on.
Contact Lens Policy
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Prescription release and expiration date: Your contact prescription is valid up to 1 year from the date of
the EXAM. The expiration date is determined by the State law and our doctor and will be based on the
health of your eyes, as well as your compliance with necessary follow-up care and lens use. After this time
you cannot replace/purchase your contact lenses until you have a new exam or an updated prescription
from another doctor. There is no valid prescription for contact lenses until you have completed the entire
fitting process.
Follow-up visits: After you get your contacts from us (even if you have worn them before), you must
come back to our doctor to receive the follow-up exam(s). The importance of this is to make sure your
contacts are fitting and interacting with your eyes properly. Remember that a contact lens is a medical
devise and problems can occur that may not be felt. Our follow-up exams are designed as prevention of
complications and to ensure good fit, comfort, and good vision. The cost of all regularly scheduled
follow-up exams is included in your fitting. Failure to comply with these scheduled appointments such as
not showing up, failing to call to reschedule, or a time lapse greater than the prescribed replacement of
the trial contact lenses between follow-up will result in additional office visit fees or invalidation of the
prescription.
Disposable or frequent replacements: These lenses come in a specific Daily, Bi-weekly or Monthly
replacement plans depending on the brand and the manufacturer’s recommendation. The brand is specific
to the contact prescription, as is with any contact lens. You may not change brands without having been fit
for that specific brand of contact lens.
Spectacles: You must have a pair of spectacles with a usable prescription for times that you are not
wearing the contact lenses. This can be an out of date prescription as long as it corrects your vision to
20/40 or better in each eye.
By signing below; I agree to the conditions of the above stated office policy. I acknowledge that my failure
to comply with this policy and/or proper recommended use and follow-up care of my CL, will result in my
prescription being invalid.
I have read all the enclosed material and have been instructed and educated on insertion, removal, and care
of my contact lenses and I understand it completely. I acknowledge that I have chosen to assume the risk of
injury or infection that may result from wearing my contact lenses, by failing to properly care for my
lenses or failing to follow my doctor’s instructions regarding my contact lens wearing-time and
replacement-schedule.
Patient Signature: _______________________________ My next follow-up visit is: ________________
INFORMED REFUSAL — DILATION
A dilated fundus exam is the use of eye drops to temporarily enlarge the pupil to allow for better viewing of the
inside of the eye. Without dilation only 45% of the retina can be seen. Dilating the pupils may cause blurred vision,
especially up close, and an increased sensitivity to light which may last up to 4 hours. Driving is usually not
impaired but may require extra attention. A dilated exam is recommended on the initial examination. Every two
years for those over 40, or whenever the doctor cannot properly evaluate your eyes without dilation. It is especially
important for patients with a history of diabetes, high blood pressure, flashes of light or floaters, high spectacle
prescriptions, glaucoma or a family history of eye disease.
____/____/____
(DATE)
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I, __________________________________ have been informed on this date by my optometrist of the need for a
dilated examination of my eyes. It has been explained to me and I understand that a condition with the potential for
partial or total loss of vision may exist and without dilation it may go undetected. Being advised of the above, I
hereby decline to have my eyes dilated.
_____________________________________
(PATIENT SIGNATURE)
INFORMED REFUSAL — TONOMETRY “GLAUCOMA TEST”
____/____/____
(DATE)
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I, ___________________________________ have been informed on this date by my optometrist of the need for an
eye pressure test to screen for glaucoma. I have been informed and understand that if I have glaucoma and a pressure
test is not performed, the disease may be undetected with the potential for a partial or total loss of vision. I have also
been informed of the various means by which my eye pressure may be tested. Being advised of the above, I hereby
decline an eye pressure test.
_____________________________________
(PATIENT SIGNATURE)
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INFORMED REFUSAL — VISUAL FIELD TESTING / SCREENING
Visual field testing is an important tool that measures, detects and monitors retinal function. This test can help in the
early detection of many disorders including, but not limited to, glaucoma, retinal detachment and brain tumors.
During this test you will be instructed to press a buzzer when you become aware of a small light within your
peripheral field. Once the results are printed out by the computer your doctor can easily detect blind spots or other
abnormalities in your visual field. Your optometrist strongly recommends this test, particularly for those patients
who have any of the following: headaches, flashes of light or floaters, reduced vision without apparent reason, heart
or circulatory problems, or those who take certain medications including plaquenil, and especially for glaucoma
suspect patients.
Date:
I, ___________________________________ have been informed on this date by my optometrist of the need for a
visual field test, have read the above and understand the importance of the findings and the information regarding the
visual field testing. Being advised and explained in detail of the seriousness, I hereby decline the visual field test.
Patient / Guardian Signature:
Primary Eye Care Clinic
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Date: ____ / ____ / ____
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Ophthalmologist Referral
Ref. Patient:
Tel (716) 763 - 3937 Fax (716) 763 - 3937
318 E. Fairmount Avenue, Lakewood NY 14750
To Doctor:
DOB:
Add +
Fax No.
Spectacle Rx
Pt. Phone No.
OD:
OS:
Phone No.
I had the pleasure of seeing this patient for:
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Consultation for:
The findings of today’s exam are as follows:
My recommendations are:
MD appointment: ____/____/____ at _____
Thank you kindly for your assistance in the care of this patient. Please let me know of our findings,
and call if you need any additional information.
Sincerely,
KayGoshtasb Kavousi, OD
Patient Ocular Examination
Current Rx
OD _________________________
OS
ENTRANCE TESTS
Pinhole VA:
OD 20/ ____
OS 20/
PY
,V
IE
W
WNL
OS
OD
R
O
LATE
BD
BI
BO
/
/
/
/
supra
Infra
/
/
Cyl
NEAR
LATE
Vergences VERT
TPA - Rx’d
Axis
Prism
Base
Perimetry
Amsler Grid
WNL
WNL
20/
20/
/
/
/
/
supra
Infra
/
/
Mono.
Bino.
BI
BO
Duochrome:
BD
Internal (Ophthalmoscopy)
BU
DFE - Refused by Pt. ____
DO BIO & 2OD
Biomicroscope: w/ 9OD
WNL WNL
WNL WNL
WNL WNL
WNL WNL
___ ___
Vitreous
Media
A/V ratio
Post. Pole
Macula /Fov.
Disc Margins
C/D ratio
OD OS
WNL WNL
VA
Periph. Ret.
WNL WNL
WNL WNL
ADD
_______________________________ O.D. Lic #______
Sphere
Confrontation WNL
ADD + ________
20/ ___ ___ Progressive
20/
Bifocal—FT28
NCT
@________ am
TBUT ____ Sec
OD
pm
or OD _____
KER
OS
Shirmer ____ mm AT OS
mmHg
EOMs:
NPC _____ cm
PD ___ /___ mm Field
Screen
Hirshberg’s:_____mm BP
/
O
C
Motility
DIST
SUBJ
BVA
REFRACTION
20/
20/
DIST
Vergences VERT
BU
BCC: Lag of Accommodation + ______ D AC / A ratio: /1 NRA+_______D
Lead or Vertical Preference
Acc. Amp(-)_____D PRA -_______D
EXO
ESO
PHOROMETRY
BI
BO
Hyper
Hypo
T
N
LY
O
WNL
20/
20/
NEAR LATE
Phoria VERT
BD
BU
IN
Hyper
Hypo
PR
WNL WNL
T
WNL WNL
O
Tears
WNL WNL
N
Lids /lashes
WNL WNL
O
Cornea
WNL WNL
Signed:
OS
OD
Rx:
DPA: OU @ _______ Am / Pm
Tropic. 0.5% , 1%
Phenyl. 2.5%
Cyclopent. 0.5% , 1%
Proparacain 0.5%
Fluress
Rev-Eyes
__________________OD
OS____________________
_____________________
_______________________
_____________________
_______________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________
_____________________
________________OD
OS__________________
___________________
_____________________
___________________
_____________________
___________________
_____________________
___________________
_____________________
___________________
_____________________
D
OD 20 / ___
OS 20 / ___
OU 20 /
Near / Far
Name:_______________________________________________ Age: _____ Sex: ____ Date: ____________
Eye Medications / Drops: _______________________________ How often do you discard your contact lenses? _______________
Do you sleep in your contact lenses? _______________________
________________________________________ Your
Present contact Lens Age:____________________________
Chief Complaint ________________________________________ Your contact Lens Name:_________________________________
Solution you Use:_______________________________________
______________________________________________ Your
Comfort with this lens Brand:_________________________
History ______________________________________________
Sphere
Cylinder
Axis
BC Dia
PEH: ________________________________________________
PMH: _______________________________________________ Right: ___________________________ ____ ____
___________________________ ____ ____
FEH: ________________________________________________ Left:
20/
FMH: _______________________________
Movement: _____________________ CL—VA
20/
(—APD)
Unaided OD 20 /___ Unaided:
DIST
OS 20 /___
Near
VA
OU 20 /
VA
Pupils
Cover
Test
PERRL
Pal Conj
WNL WNL
EXO
ESO
Color vision (Ishihara) Stereo fusion
OD WNL
(Randot)
OS WNL
BI
BO
Retinoscopy OD
or
AutoRefract. OS
Near OD
Subj OS
DIST
LATE
Phoria VERT
BD
BU
External (Biomicroscopy)
ANGLE Grade (VH - Est.)
OD
1
2
3
4
OS
1
2
3
4
Bulb Conj
WNL WNL
OD OS
Ant Cham
WNL WNL
Lens
Iris
Assessment:
________________________________________________________
___________________________________________________
__________________________________________________
__________________________________________________
Plan: _____________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
_______________________________________________
___________________________________________________
__________________________________________________
Next Appointment (F/Up): ____________________________
Patient History and Information
Contact Lens Fitting
Progress Evaluation:
Name: ________________________________________________ Date of Birth: _________________
Date: _______________ Dist: VA
MWT:_______________
Comfort:_____________
Rewetting:___________
Solution:_____________
Movement
Center
O-Ref.
Address: ___________________________________________________________________________
OD 20/
City / State / Zip: _____________________________________________________________________
20/
Home Phone: ____________________________________Work Phone: ________________________
OS
Schedule Rep.
Daily________
Bi-Weekly ___
Monthly_____
Slit - Lamp
Cell Phone: ______________________________________Occupation: _________________________
Daily-Wear only
OD
OS
Reason for today’s Exam:______________________________________________________________
EW ____
Date of last Eye Exam: ______________________ Date of last Medical Exam: ___________________
N
LY
WT today: ___________
Near
Who is your Family Doctor? __________________ Your previous Eye Doctor: ___________________
___ Patient is trained in I&R and educated in lens-care, wear-time & sch. replacement.
O
Medications you are Currently Taking? ___________________________________________________
Current Medical Condition: ____________________________________________________________
Remarks: ______________________________________________________________
Contact Lens
Trial
Sphere
Cyl.
Axis
BC
Dia
PY
,V
IE
W
Rx:
Do you or any family member, suffer from any of the following conditions?
Family Self
Family Self
Lens Name - OU
Diabetes or Hypoglycemia
High Blood-Pressure
Glaucoma (high eye-pressure)
R
By:
L
Retinal Disease /Detachment
Macula Degeneration
Blindness or Prosthetic-Eye
Movement
Rx:
O
T
IN
Daily-Wear only
OS
Cyl.
Axis
BC
Dia
R
O
CL — Trial
Lens Change
Sphere
Slit - Lamp
OD
EW ____
PR
Solution:_____________
Schedule Rep.
Daily________
Bi-Weekly ___
Monthly_____
Lens Name - OU
N
Rewetting:___________
O-Ref.
R
WT today: ___________ OD 20/
MWT:_______________
OS 20/
Comfort:_____________
Center
By:
D
L
Recommendation
Pt. Comments:
Frequent Headaches
Migraines
Allergies
Pregnant
Use Contraceptives
High Cholesterol
Thyroid Problems (H/L)
Heart Problems
Vascular Disease
Rheumatoid Arthritis
Respiratory Problems
Asthma
Chronic Cough
Smoking
Seizures
Stroke
Cancer
HIV or AIDS
Psychiatric
Depression
Any Plaquenil Medication
Any Steroid Medicines
Previous Head Injury
Previous Eye Injury/Trauma
Previous Eye Disease/Infection
Previous Eye Surgery
Previous Lazy Eye
Refractive or Cataract Surgery
Any Medication Allergy?
Other__________________
Check any of the following that apply to you:
Eye Pain /Soreness
Eyes frequently Red
Bothered by Light
Mucous Discharge
Sudden flashes/sparks in vision
Sudden loss of vision
Distorted vision /halos
Eye Dryness
Sandy /Gritty Sensation
Foreign body Sensation
Excess Tearing/watering
Eye Itching
Eyes Burning
Experience Glare
Blurred vision
Tired Eyes/fatigue
Squinting
Rub Eyes frequently
Excessive Blinking
Double vision
Other__________________
Check all the following that apply to your activities:
Rx:
Contact Lens
Final Rx
C
Near
T
Dist: VA
O
Date: _______________
O
Do you have any of these conditions?
Sphere
Cyl.
Axis
BC
Dia
Lens Name - OU
OD
OS
Computer use
Near fine detailed work
Extended reading
Require wide range of vision
Operation of heavy/light machinery
Handling of hazardous materials
Skiing /snowboarding
Fishing /boating
Trouble with night driving
Interested in Contact Lens?
Other ________________
Contact Sports
Tennis /racquetball
Running /walking
Gardening
Golf
By:
Patient Signature: _______________________________________________________________________________
Dr. KayGoshtasb Kavousi
Optometrist
Primary Eye Care Clinic
318 E. Fairmount Ave. • Lakewood, NY 14750 • Phone: (716) 763 - 3937
Name:
Date:
Address:
N
LY
Age:
Spectacle Exp. Date:
/
/
O
Contact Lens Expires: ______________
Cylinder
Axis
OD
Base
ADD
O
OS
R
Progressive Lenses
Bifocal FT 28
Scratch Resistant Coating
UV Protection
□
□
□
□
Anti-Reflective Coating/Tint
Transitions / Photochromic
Polarized
Rx Sunglasses
CL Rx
Sphere
Axis
BC
Dia
Lens Name
O
N
OS
Cylinder
T
OD
PR
IN
T
O
□
□
□
□
Distance only
Near only
Computer
Polycarbonate
C
Recommendation:
□
□
□
□
Prism
PY
,V
IE
W
Sphere
SRx
D
O
Remarks:_________________________________________________________________
Lens Care System: ____ Opti-Free Replenish ____ ReNu-Multiplus Other: _____________
____ Monthly ____ Daily
Wear Schedule: ____ Daily-Wear only Other: ____ CL Manufacturer: __________________
Replacement Schedule:
____ Bi-Weekly
Lic. # 7112 _____________________________ O.D.
One to two years spectacle, and one year contact lens, follow-up visit recommended.
N
LY
Dr. KayGoshtasb Kavousi
O
Optometrist
Primary Eye Care Clinic
PY
,V
IE
W
318 E. Fairmount Ave. • Lakewood, NY 14750 • Phone: (716) 763 - 3937
Name:
Address:
Date:
Cylinder
Axis
Prism
O
Sphere
C
OD
ADD
___ /___
VA 20
PR
IN
PD
T
O
R
OS
T
Remarks: __________________________________
O
Lic. # 7112 _____________________________ O.D.
O
N
Expiration Date: ____ /____ /____
D
One to two years follow–up visit recommended, unless otherwise noted.
Age:
Recommendation
Distance only
Near only
Computer
Polycarbonate
Progressive Lenses
Bifocal FT 28
UV Protection
Rx Sunglasses
Polarized
Transitions / Photochromic
Anti– Reflective Coating/Tint
Scratch– Resistance Coating
N
LY
Dr. KayGoshtasb Kavousi
Optometrist
O
Primary Eye Care Clinic
PY
,V
IE
W
318 E. Fairmount Ave. • Lakewood, NY 14750 • Phone: (716) 763 - 3937
Name:
Address:
Date:
Age:
Sphere
Cylinder
Axis
C
CL Rx
O
Exp. Date:
Dia
/____
Lens Name
O
R
OD
BC
/
IN
T
OS
PR
Remarks:_________________________________________________________________
Lens Care System: ____ Opti-Free Replenish ____ ReNu-Multiplus Other: _____________
____ Bi-Weekly
____ Monthly ____ Daily
Wear Schedule: ____ Daily-Wear only Other: ____ CL Manufacturer: __________________
N
O
T
Replacement Schedule:
D
O
Lic. # 7112 _____________________________ O.D.
One year follow-up visit required, unless otherwise noted.
N
LY
Dr. KayGoshtasb Kavousi
Optometric Physician
O
Primary Eye Care Clinic
PY
,V
IE
W
318 E. Fairmount Ave. • Lakewood, NY 14750 • Phone: (716) 763 - 3937
Name: __________________________________________________ Date: __________
Address: ____________________________________________________ Age: _______
IN
T
O
R
C
O
□ Zylet 2.5ml, 5ml, 10ml
□ Lotemax 0.5% 2.5ml, 5ml, 10ml
□ Pred Forte 1% 1ml, 5ml
□ Alrex 0.2% 5ml, 10m
□ FML 0.1% 1ml, 5ml
□ Flarex 0.1% 2.5ml, 5ml
□ Maxitrol 5ml, 3.5g
□ Blephamide 2.5ml, 5ml, 3.5g
□ Xibrom 0.09% 2.5ml, 5ml
□ Restasis 0.05%
□ Pataday Oph. Sol 0.2% 2.5ml
□ Patanol 0.1% 5ml
□ Timoptic XE 0.25%, 0.5%
□ Istalol 5ml
□ Betoptic S 0.25%
□ Xalatan 0.005% 2.5ml
□ Lumigan 0.03% 5ml
□ Travatan Z 0.004% 5ml
□ Alphagan P 0.15% 5ml
□ Cosopt 5ml
□ Azopt 1% 5ml
□ Trusopt 2% 5ml
□ Viroptic 1% Sol.
□ Vira-A 3% Oint.
O
T
PR
□ Vigamox 0.5% 3ml
□ Ciloxan 0.3% 2.5ml, 5ml
□ Zymar 0.3% 2.5ml, 5ml
□ Gentamycin 0.3% 5ml
□ Tobramycin 0.3% 5ml 3.5g
□ Bacitracin 500 units/gm 3.5g
□ Erythromycin 0.5% 3.5g
□ Polytrim 10ml
□ Polysporin 3.5g
□ Neosporin 10ml 3.5g
□ TobraDex 2.5ml, 5ml
□ TobraDex Oint. 3.5g
D
O
N
Dispense as written
Label by name and concentration
□ No Substitution Allowed
□ Generic Substitutions Allowed
Lic# 7112____________________________________O.D.
N
LY
Dr. KayGoshtasb Kavousi, OD
O
General Optometrist
Primary Eye Care Clinic
PY
,V
IE
W
318 E. Fairmount Ave. • Lakewood, NY 14750 • Phone: (716) 763 - 3937
Name:
Date:
□ Zylet 2.5ml, 5ml, 10ml
□ Lotemax 0.5% 2.5 ml, 5ml, 10ml
□ Alrex 0.2% 5ml, 10ml
□ FML 0.1% 1ml, 5ml
□ Pataday Oph. Sol 0.2% 2.5ml
□ Restasis 0.05%
C
T
PR
IN
T
O
R
□ Vigamox 0.5% 3ml
□ Ciloxan 0.3% 2.5ml, 5ml
□ Tobramycin 0.3% 5ml, 3.5g
□ Bacitracin 500 units/gm 3.5g
□ Polytrim 10ml
□ Polysporin 3.5g
Age:
O
Address:
D
O
N
O
Dispense as written
Label by Name and Concentration
□ No Substitution Allowed
□ Generic Substitutions Allowed
Lic.# 7112 ___________________________________O.D.
PY
,V
IE
W
O
Primary Eye Care Clinic
Board Certified Ocular Therapeutic
N
LY
Dr. KayGoshtasb Kavousi
TPA, Optometrist
318 E. Fairmount Ave. • Lakewood, NY 14750 • Phone: (716) 763 - 3937
Name:
Date:
Age:
O
T
PR
IN
T
O
R
C
O
Address:
D
O
N
Label by Name and Concentration
□ No Substitution Allowed
□ Generic Substitutions Allowed
Lic. # 7112 _____________________________ O.D.
N
LY
O
PY
,V
IE
W
Dr. KayGoshtasb Kavousi
O
R
C
O
OPTOMETRIC PHYSICIAN
Primary Eye Care
Treatment of Ocular Disease
318 E. Fairmount Ave
D
O
N
O
T
PR
IN
T
LAKEWOOD, NY 14750
General Eye Clinic
PH. (716) 763-3937