CONTENTS

Contents
Preface xiii
The Eye 14
Acknowledgments xiii
Cornea and Sclera 14
Anterior Chamber 15
Introduction to the Course xv
Uvea: Iris, Ciliary Body, Choroid 16
To the Ophthalmologist xv
Crystalline Lens 16
To the Student xvi
1
Vitreous 17
Introduction to Ophthalmic
Medical Assisting
1
Erich P. Horn, MD, MBA
Retina 18
Visual Pathway 19
3Diseases and Disorders
What Is Ophthalmology? 1
of the Eye
Who Provides Eye Care? 2
Ophthalmologist 2
Martha P. Schatz, MD
Optometrist 3
Mechanisms of Disease and Injury 23
Optician 3
Infectious Process 24
Registered Nurse 3
Inflammatory Process 24
Orthoptist 3
Allergic Process 24
Ocularist 3
Ischemic Process 24
Ophthalmic Photographer 3
Metabolic Process 24
Ophthalmic Medical Assistant 4
Congenital Process 25
What Is Certification? 4
Developmental Process 25
Professional Development 5
2Anatomy and Physiology
of the Eye
Kenneth B. Mitchell, MD
The Eye as an Optical System 9
The Globe 10
The Adnexa 10
Orbit 10
Extraocular Muscles 10
Eyelids and Conjunctiva 12
Lacrimal Apparatus 13
23
Degenerative Process 25
Neoplastic Process 25
Traumatic Process 25
9
Signs, Symptoms, and Syndromes 25
Abnormalities of the Adnexa 26
Orbit 26
Extraocular Muscles 26
Eyelids 27
Lacrimal Apparatus 28
Abnormalities of the Eye 29
Conjunctiva 29
Cornea and Sclera 30
Anterior Chamber 31
iii
iv • CONTENTS
Uveal Tract 33
5
Crystalline Lens 33
Vitreous 33
Lee R. Duffner, MD, FACS
Retina 34
Principles of Optics 49
Optic Nerve 34
Refraction 50
Visual Pathway 35
4
Systemic Diseases and
Ocular Manifestations
Optics and Refractive
States of the Eye
Refractive Properties of Curved
Lenses 51
39
Charles B. Slonim, MD, FACS
Inflammatory and Autoimmune Diseases 40
Convergence, Divergence, and Focal
Point 51
Lens Power and Focal Length 52
Refractive States of the Eye 53
Myasthenia Gravis 40
Emmetropia 53
Rheumatoid Arthritis 40
Ametropia 53
Sarcoidosis 40
Types and Uses of Corrective Lenses 55
Sjögren Syndrome 41
Spheres 56
Systemic Lupus Erythematosus 41
Cylinders 57
Thyroid Disorders 41
Spherocylinders 57
Multiple Sclerosis 41
Prisms 58
Metabolic Disorders 42
Diabetes Mellitus 42
Vascular Diseases 42
Cerebral Vascular Accident 43
Components of Refraction 58
Retinoscopy 59
Refinement 61
Binocular Balancing 62
Giant Cell Arteritis 43
Interpretation of Prescriptions 62
Migraine 43
Transposition of Prescriptions 63
Hypertension 43
Automated Refractors 64
Infectious Diseases 44
Acquired Immunodeficiency
Syndrome 44
Chlamydial Infections 44
Herpes Infections 45
Histoplasmosis 45
Syphilis 45
Toxoplasmosis 45
Neoplastic Diseases 45
Metastatic Carcinoma 46
Blood Dyscrasias 46
Cerebral Neoplasms 46
Objective Refractors 64
Subjective Refractors 64
Objective/Subjective Refractors 64
Lensometry 64
Types of Lensmeters 64
Elements of Lensometry 65
Lensometry Technique for Multifocal
Lenses 65
Lensometry Technique for Prisms 67
Placement of Optical Centers 68
Keratometry 68
49
CONTENTS 6
Handling and Decontaminating
Contaminated Materials 104
Basics of Ophthalmic
Pharmacology75
Hygienic Practices in Potentially
Infectious Situations 105
Jay S. Wallshein, MD, MBA
Delivery Systems of Drugs 76
Collecting Specimens for the Identification of
Microorganisms 105
Topical Systems 76
Injections 77
8
Oral Systems 77
Implants 78
Overview of the Examination 109
Administration of Topical Eyedrops and
Ointments 78
Visual Acuity Examination 110
Purposes and Actions of Drugs 78
Alignment and Motility
Examination 110
Diagnostic Medications 78
Pupillary Examination 110
Therapeutic Medications 82
Visual Field Examination 110
Miotics 82
Intraocular Pressure Measurement 110
Glaucoma Medications 82
External Examination 110
Interpretation of a Prescription 87
Biomicroscopy 110
First Aid for Acute Drug Reactions 88
Microorganisms and
Infection Control
Frank W. Scribbick III, MD
Types of Microorganisms 93
Bacteria 94
Viruses 95
Fungi 97
Protozoa 97
Prions 98
Transmission of Infectious Diseases 98
Airborne Droplets and Particles 98
Direct-Contact Transmission 99
Indirect-Contact Transmission 99
Common-Vehicle Transmission 99
Vector-Borne Transmission 99
Infection Control Precautions 100
Hand Washing 102
Use of Personal Protective
Equipment 102
Cleaning, Disinfection, and
Sterilization 102
Aseptic Technique: Handling Sterile
Medical Equipment 104
109
Damien F. Goldberg, MD
Improving Compliance 78
7
Comprehensive Medical
Eye Examination
Ophthalmoscopy 111
Frequency of Examination 111
93
Ophthalmic and Medical History 111
Chief Complaint and History of Present
Illness 111
Past Ocular History 113
General Medical and Social History 113
Family Ocular and Medical History 114
Allergies, Medications, and
Supplements 114
History-Taking Guidelines 114
Visual Acuity Examination 115
Distance Acuity Test 115
Pinhole Acuity Test 116
Near Acuity Test 116
Other Acuity Tests 117
Procedures Following Acuity Tests 118
Alignment and Motility Examination 119
Worth 4‑Dot Test 120
Titmus Stereopsis Test 120
Pupillary Examination 120
Visual Field Examination 121
Confrontation Field Test 122
Amsler Grid Test 122
• v
vi • CONTENTS
Intraocular Pressure Measurement 122
Assessment of Corneal Abnormalities 152
Principles of Tonometry 122
Pachymetry 152
Applanation Tonometry 124
Corneal Topography 152
Indentation Tonometry 125
Specular Microscopy/Photography 153
Ophthalmic Photography 153
Applanation Versus Indentation
Tonometry 127
External Photography 153
Pachymetry 127
Slit-Lamp Photography 153
External Examination 128
Fundus Photography 153
Anterior Chamber Evaluation 128
Tomographic Imaging 154
Biomicroscopy 129
Ultrasonography 155
Gonioscopy 129
A-Scan 155
Ophthalmoscopy 130
B-Scan 156
Direct and Indirect
Ophthalmoscopy 130
11 Principles and Techniques
Additional Tests 131
of Perimetry
Color Vision Tests 131
Neil T. Choplin, MD
Tear Output Test 131
Anatomic Basis of the Visual Field 160
Evaluating the Corneal and
Conjunctival Epithelium 132
Map of the Visual Field 161
Orientation of the Visual Field Map 163
Corneal Sensitivity Test 132
Purposes and Types of Perimetry 163
Exophthalmometry 133
9
Ocular Motility
159
Kinetic Perimetry 164
137
Mary A. O’Hara, MD, FACS, FAAP
Anatomy and Physiology 137
Nerve Control 139
Eye Movements 139
Motility Examination 140
Strabismus Tests 140
Corneal Light Tests 140
Cover Tests 141
Additional Tests 142
Summary 144
10 Adjunctive Tests and
Procedures149
Diana J. Shamis, MHSE, CO, COMT
Vision Tests for Patients With Opacities 149
Visual Potential Tests 150
Contrast-Sensitivity and Glare Tests 151
Static Perimetry 166
Miscellaneous Visual Field Tests 169
Defects Shown by Perimetry 169
Generalized Defects 169
Focal Defects 170
Hemianopic and Quadrantanopic
Defects 172
Other Defects 172
Conditions for Accurate Perimetry 172
Environment-Related Factors 172
Device-Related Factors 175
Patient-Related Factors 175
Examiner-Related Factors 176
12 Fundamentals of
Practical Opticianry
Helen B. Metzler, COT, CCRP, ABO
Types of Corrective Lenses 179
Single-Vision Lenses 180
Multifocal Lenses 180
179
CONTENTS Types of Lens Materials 183
Contact Lens Designs for Special
Purposes 211
Lens Safety Standards 184
Cosmetic Fashion Contact Lenses 212
Lens Treatments, Tints, and
Coatings 186
Key Measurements in Fitting Eyeglasses 186
Interpupillary Distance 187
Cosmetic Restorative Contact
Lenses 212
Toric Contact Lenses 212
Bifocal Contact Lenses 213
Vertex Distance 190
Keratoconus Contact Lenses 214
Base Curve 191
Therapeutic Contact Lenses 214
Fitting, Care, and Adjustment of
Eyeglasses 192
Care of Contact Lenses 214
Fitting of Eyeglasses 192
Cleaning 215
Care of Eyeglasses 194
Disinfecting 215
Adjustment of Eyeglasses 194
Lubrication 216
13 Low Vision
Storage 216
199
Larry Schwab, MD
Mary A. O’Hara, MD, FACS, FAAP
Problems With Contact Lenses 216
Allergy 217
Common Causes of Low Vision 200
Solution–Contact Lens Interaction 218
Increasing Awareness 201
Overwearing Syndrome 218
Low Vision Care 201
Improper Contact Lens Fit 219
Low Vision Aids 201
Giant Papillary Conjunctivitis 220
Low Vision Devices 203
Irritation and Tearing 220
Nonoptical Aids 203
Corneal Problems 221
Other Services 204
of Contact Lenses
Soft Contact Lenses 216
Rigid Contact Lenses 216
Visual Acuity and Low Vision 200
14 Principles and Problems
Insertion and Removal of Contact Lenses 216
Inability to Insert or Remove Lenses 223
207
Peter C. Donshik, MD, FACS
Basic Principles 208
Characteristics of Contact Lenses 208
Contact Lenses Versus Eyeglasses for
Vision Correction 208
Contact Lens Specification Versus Eyeglass
Prescription 209
Types and Materials of Contact Lenses 209
Lens “Lost” in the Eye 223
Contraindications for Contact Lenses 223
15 Patient Interaction,
Screening, and
Emergencies227
Mary A. O’Hara, MD, FACS, FAAP
Patient–Assistant Interaction 227
Patient Greeting 227
Patient Screening 228
PMMA and RGP Contact Lenses 210
Triage 228
Soft Contact Lenses 210
Appointment Scheduling 231
Extended-Wear Contact Lenses 211
Referred Patients 231
Daily-Wear Contact Lenses 211
Emergencies in the Office 231
Disposable Contact Lenses 211
Burns 231
Planned-Replacement Contact
Lenses 211
Trauma 234
General Emergency Assistance 235
Hospital Admission 235
• vii
viii • CONTENTS
Blade Handles and Blades (Scalpels) 259
16 Patients With Special
Concerns241
Donna M. Applegate, COT
Other Surgical Supplies 260
Patients and Their Families 242
Common Minor Surgical Procedures 261
Health Insurance Portability and
Accountability Act 242
General Considerations 261
Postsurgical Medications, Dressings, and
Patches 261
Office Waiting Periods 242
Disruptive Patients 243
First Surgical Experience 261
Visually Impaired or Blind Patients 243
Surgical Assisting Skills 266
Patient Greeting and History‑Taking
Guidelines 243
Aseptic Technique and Minor
Surgery 266
Offering Assistance 244
Preparing the Instrument Tray 268
Visual Acuity Assessment 245
Assisting During Surgery 269
Infants and Young Children 245
Disposition of Instruments and
Materials 270
Patient Greeting 245
Patient Positioning 245
Visual Acuity and Ability Testing 246
Elderly Patients 248
David A. Goldman MD
Visual Acuity Testing 249
History of Refractive Surgery 274
Patients Who May Be Suffering from
Abuse 249
Indications and Contraindications for
Refractive Surgical Procedures 274
Patients With Physical Disabilities 249
Evaluating Refractive Surgical Patients 274
Patients With Diabetes 250
Refraction in Myopia 274
Special Help for Patients With
Diabetes 251
Mitchell J. Goff, MD
Patient Preparation Before Surgery 255
Informed Consent 255
Preoperative Assessment 256
Patient Assistance 256
Administration of Anesthetics 256
18 Refractive Surgery
Concepts and Procedures 273
Age-Related Vision Changes 248
in the Office
Cannulas 259
Syringes and Needles 260
All Patients Considered 241
17 Minor Surgical Assisting
Lacrimal Instruments 259
Refraction in Hyperopia 275
Refraction in Astigmatism 275
255
Near Refraction in Presbyopic
Patients 275
Cycloplegic Refraction 275
Wavefront Analysis 275
Pupil Size Measurements 276
Ultrasound Pachymetry and
Keratometry 276
Videokeratography 276
Refractive Surgical Procedures 276
Surgical Materials and Instruments 257
Laser In Situ Keratomileusis 276
Sutures and Suture Needles 257
Photorefractive Keratectomy 277
Forceps 258
Laser Subepithelial Keratomileusis 277
Scissors 258
EPI-LASIK 277
Needle Holders 259
Astigmatic Keratotomy 277
Clamps and Curettes 259
CONTENTS Conductive Keratoplasty and Laser
Thermokeratoplasty 278
Coding for Ophthalmology Office
Visits 294
Intrastromal Corneal Ring Segments 278
Eye Codes 294
Phakic Intraocular Lenses 279
Ophthalmic Coding Specialist 295
In Review 281
19Understanding Practice
Management283
In Review 295
20 Medical Ethics, Legal
Issues, and Regulatory
Issues297
Sue J. Vicchrilli, COT, OCS
Morgan L. Taylor III, CPA, COE
Emanuel Newmark, MD, FACS
William H. Ehlers, MD
The Ophthalmic Practice and You 283
Code of Ethics of the Academy 298
For Whom Do You Work? 284
You Are Part of a Team 284
Why Management Matters 284
Management and the Patient 284
Management and Your Doctor 285
The Office Manager’s Role 286
The Chain of Command 286
Management of Communications 286
Management by the Numbers 286
Management Through Policies and
Procedures 286
Commitments and Responsibilities 287
Is It All About Attitude? 287
Understanding Your Commitment 287
Optimizing Your Work Time 287
Understanding Expectations 288
Additional Duties 288
Understanding Patient Prescriptions 288
Coordinating Patient Flow 288
Answering the Phone 289
Working With Patient Charts 289
Scheduling 289
Scribing 290
History 297
Ethics for Assistants 298
Ethical Behavior 298
Providing Technical Services 299
Competence of Technicians 299
Communication With Patients 299
Informed Consent and Ophthalmic
Assistants 300
Ethics and Pharmaceutical Company
Representatives 301
Professional Conduct 301
Appearance 301
Respect and Sensitivity 302
Supplementary Topics 302
21 Community Health
Eye Care
307
Karl C. Golnik, MD
D. Hunter Cherwek, MD
Heather Machin, RN
Definitions of Vision Impairment and
Blindness 308
Governmental Definitions of Visual
Impairment and Blindness 308
Compliance 290
Major Causes of Reversible and
Irreversible Blindness 309
Coding 291
VISION 2020: The Right to Sight 309
Coding Systems 291
The Benefits of Proper Coding 292
Documentation 293
About ICD‑10 293
Code Linking and Medical Necessity 293
Strategies for Improving Utilization of Eye
Care 310
Local Delivery of Health Education
Information 310
Screening Programs 310
Surgical Programs 311
• ix
x • CONTENTS
Community Eye Care Programs and the Team
Approach 312
Keratometer 320
Local Resources Available to Assist Visually
Impaired Patients 312
Projector 321
22 Care of Ophthalmic
Lenses and Instruments
315
Care of Lenses 315
Standard Guidelines for Care of
Lenses 316
Lenses That Do Not Contact the Eye 316
Care of Instruments 318
Standard Care Guidelines 318
Applanation Tonometer 323
Indentation Tonometer 323
Lindreth G. DuBois, MEd, MMSc, CO,
COMT
Lenses That Contact the Eye 316
Slit Lamp 320
Tono-Pen 324
Direct Ophthalmoscope 324
Indirect Ophthalmoscope 324
Potential Acuity Meter 325
Perimeters 325
Lasers 325
23 Answers to Chapter
Self‑Assessment Tests
Retinoscope 319
Appendix A: Glossary 343
Phoropter 319
Appendix B: Resources 365
Lensmeter 319
Index 373
329