Printed in Singapore BS/KYO Senior Lecturer and Honorary Consultant Ophthalmologist, University of Nottingham and University Hospital, Queen’s Medical Centre, Nottingham, UK Peter H..
Trang 1Common Eye Diseases and their Management
Trang 3A catalogue record for this book is available from the British Library
Library of Congress Control Number: 2005925513
ISBN-10: 1-85233-985-3 3rd edition e-ISBN 1-84628-033-8 Printed on acid-free paper ISBN-13: 978-1-85233-985-2
© Springer-Verlag London Limited 2006
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or trans- mitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency Enquiries concerning reproduction outside those terms should be sent to the publishers.
The use of registered names, trademarks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use.
Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book In every individual case the respective user must check its accuracy by con- sulting other pharmaceutical literature.
Printed in Singapore (BS/KYO)
Senior Lecturer and Honorary Consultant
Ophthalmologist, University of Nottingham
and University Hospital, Queen’s Medical
Centre, Nottingham, UK
Peter H Galloway, MBBS, FRCOphth Consultant Ophthalmologist, St James’ University Hospital, Leeds, UK
Andrew C Browning, BSc, FRCOphth Division of Ophthalmology and Visual Sciences, Eye, Ear, Nose and Throat Centre, University Hospital, Queen’s Medical Centre, Nottingham, UK
Artwork marked with symbol throughout the book is original to the 2nd edition (Galloway
NR, Amoaku WMK Common Eye Diseases and their Management, 2nd edition Springer-Verlag London Ltd, 1999) and is being republished in this 3rd edition.
Trang 4Preface to Third Edition
v
It is a pleasure to welcome two new authors who have contributed to the third edition
of “Common Eye Diseases”: Peter Galloway and Andrew Browning Six years have passedsince the last edition but even in this relatively short time there have been significantadvances in the diagnosis and management of eye disease and an update has becomenecessary Each author has taken a block of chapters for revision and, where needed,illustrations have been added or removed Apart from the four main authors, I amindebted to Mr Roland Ling for his invaluable work on the chapter on the retina andonce again to Professor Rubinstein for his help with the chapter on contact lenses.The original aims of the book have not been changed It remains as a textbook formedical students and those starting a career in ophthalmology, but also for those inprimary care who are likely to deal with eye problems, including nurses, optometristsand general practitioners
It has been the intention to keep explanations as simple and nontechnical as possiblewithout losing scientific accuracy; more detailed accounts should be sought in the largertextbooks An updated reference list for further reading is given at the end of the book
An internet version of this edition is being planned and, in order to keep down the retailprice, some financial help is needed For this we are grateful for the interest of Pfizer Ltd,whose policy of educational support has allowed this edition to go forward at its presentlow price
Acknowledgements
Although it is now many years since the first edition appeared, I still owe a great debt to
my former secretary, Mrs A Padgett, for her original help in preparing the basis for thesefurther editions No amount of word processing can replace this painstaking work Inthis new edition, I have kept Geoffrey Lyth’s original cartoons, which will perhaps lightenthe heaviness of the text for those with an artistic bent The two new authors have revised
a number of chapters and their fresh input to an ageing textbook has been essential andmuch appreciated
Finally, I would like to acknowledge the help and encouragement from Melissa Morton
of Springer-Verlag, who has kept the ball bouncing back into my court with greatefficiency and thereby played an important part in ensuring the birth of this new edition
Trang 5Preface to Second Edition
Like the first edition, this textbook is intended primarily for medical students, but it isalso aimed at all those involved in the primary care of eye disease, including generalpractitioners, nurses and optometrists The need for the primary care practitioner to bewell informed about common eye conditions is even more important today than whenthe first edition was produced A recent survey from North London has shown that 30%
of a sample of the population aged 65 and over are visually impaired in both eyes and alarge proportion of those with treatable eye conditions were not in touch with eye serv-ices It is clear that better strategies for managing problems of eyesight need to be set
up One obvious strategy is the improved education of those conducting primary careand it is hoped that this book will contribute to this For this second edition, I am grate-ful for the help of my coauthor Winfried Amoaku, whose personal experience in teach-ing medical students here in Nottingham has been invaluable His expertise in themanagement of macular disease, now a major cause of sensory deprivation in the elderly,
is also evident in these chapters
The format of the book has not changed but some of the chapters have been expanded.For example, there is now a section dealing with the eye complications of acquiredimmune deficiency syndrome (AIDS) This problem barely existed at the time of the firstedition Cataract surgery has changed a great deal in this short time and is becomingone of the commonest major surgical procedures to be performed in a hospital Themanagement of glaucoma has also changed with the introduction of a range of new med-ications Our aim has been to keep the original problem-oriented layout and to keep it
as a book to read rather than a book to look at There are a number of good atlases oneye disease and some of these are mentioned in the section at the end on further reading.Although the title of the book is “Common Eye Diseases”, some less common conditionsare mentioned and it is hoped that the reader will gain some overall impression of theincidence of different eye diseases
vii
Trang 6Preface to Third Edition v
Preface to Second Edition vii
Section I Introducing the Eye 1
1. The Scope of Ophthalmology 3
2. Basic Anatomy and Physiology of the Eye 7
3. Examination of the Eye 17
Section II Primary Eye Care Problems 27
4. Long Sight, Short Sight 29
5. Common Diseases of the Eyelids 33
6. Common Diseases of the Conjunctiva and Cornea 45
7. The Red Eye 61
8. Failing Vision 67
9. Headache 71
10. Contact Lenses 77
Section III Problems of the Eye Surgeon 79
11. Cataract 81
Trang 7x Contents
12. Glaucoma 91
13. Retinal Detachment 103
14. Squint 111
15. Tumours of the Eye and Adnexae 121
16. Ocular Trauma 129
Section IV Problems of the Medical Ophthalmologist 135
17. Testing Visual Acuity 137
18. The Inflamed Eye 141
19. The Ageing Eye 149
20. The Child’s Eye 157
21. Systemic Disease and the Eye 165
22. Neuro-ophthalmology 179
23. Genetics and the Eye 189
24. Drugs and the Eye 195
Section V Visual Handicap 201
25. Blindness 203
Further Reading 207
Index 209
Trang 8Section I
Introducing the Eye
Trang 9Although the eye and its surrounding structures
would seem to provide an ideal anatomical and
functional basis for specialisation,
ophthalmol-ogy can no longer regard itself as a specialty on
its own but more the heading for a group of
sub-specialties There are those who know all about
the pigment epithelium of the retina and yet
bow to those who have a special knowledge of
the bipolar cells in the retina Over the past 100
years the science has advanced at an
unbeliev-able rate and with the increase in our knowledge
has come the development of treatments and
cures, which have had a great impact on our
everyday lives
The importance of the eye and its function is
sometimes underrated, but a consideration of
the part played by vision in our consciousness
makes us soon realise its value If we think of
dreams, memories, photographs and almost
anything in our daily existence, it is difficult to
express them without visual references After a
little careful consideration of the meaning of
blindness, it is easy to sense the rational and
irrational fears that our patients present to us in
the clinic Nevertheless, in a modern European
community the effects of blindness are not so
apparent as in former years, and blind people
tapping their way about the street or begging
for food are less in evidence to remind us of the
deprivation that they suffer This is due to the
effective application of preventive medicine and
the efficacy of modern surgical techniques
However, in the western world we have a new
and increasing problem related to the increasing
number of elderly people in the population Theproblem is that of sensory deprivation owing todegenerative disease Degenerative changes inthe eye are now a major cause of blindness andalthough support services are being developedthere is still no effective cure
The broad and detailed scientific interest inthe eye and vision is witnessed by the largenumber of journals, conferences and meetingsthat now exist, possibly more than in any otherspecialty There are several hundred ophthal-mological journals all contributing to thescientific literature on the subject and many arenow accessible through the internet or on CD-ROM As an organ of clinical specialisation,the eye does have a special advantage; it can
be seen Using the slit-lamp microscope it ispossible to examine living nerves, includingnervous system tissues and blood vessels, in amanner that is not possible in other parts of thebody without endoscopy or biopsy So much are the component parts of the eye on display
to the clinician that when a patient presents
to a casualty department with symptoms, theexplanation of the symptoms should be madeevident by careful examination Compare thiswith the vague aches and pains that present
to the gastroenterologist or the neurologist,symptoms that might ultimately resolve with-out any cause being found for them The student or newly qualified doctor must bewarned that if the patient presents with eyesymptoms and no abnormality can be foundafter examination, then he or she must look
1
The Scope of Ophthalmology
3
Trang 104 Common Eye Diseases and their Management
again, because it is likely that something has
been missed
Most of the work of the ophthalmologist is
necessarily centred on the globe of the eye
it-self, and there are a number of conditions that
are limited to this region without there being
any apparent involvement of the rest of the
body Ophthalmology is usually classified as
a surgical specialty but it provides a bridge
between surgery and medicine Most of the
surgery is performed under the microscope and
here the application of engineering principles in
the design of finer and finer instruments has
played an important part There is overlap with
the fields of the plastic surgeons and the
neuro-surgeons On the medical side, the
ophthal-mologist has links with the physicians and
particularly the diabetic specialists and
cardiologists, not to mention paediatricians
and dermatologists
Historical Background
In 1847, the English mathematician and
inven-tor Charles Babbage showed a distinguished
ophthalmologist his device for examining the
inside of the eye, but unfortunately this was
never exploited and it was not until 1851 that
Hermann von Helmholtz published his classic
description of his instrument, the
ophthalmo-scope He developed the idea from his
knowl-edge of optics and the fact that he had
previously demonstrated the “red reflex” to
medical students with a not dissimilar
instru-ment In principle, he had, for the purposes of
his demonstration, looked through a hole in a
small mirror, which reflected light from a lamp
into the subject’s eye This produced the red
reflex in the pupil well known to photographers
and night drivers and no doubt this fascinated
medical students at that time Von Helmholtz
worked out that a similar device could be used
to inspect the inside of the eye According to
correspondence of the time, it took him about a
week to learn the technique of examining in
detail the structures within the eye and he wrote
a letter to his father telling him that he had made
a discovery that was “of the utmost importance
to ophthalmology” Soon after this, a mass of
descriptive information on the optic fundus
appeared in the scientific literature and modern
clinical ophthalmology was born The changes
in the eye associated with systemic diseasessuch as hypertension and anaemia becamerecognised Several blinding conditions limited
to the eye itself, such as glaucoma and maculadegeneration, were also described at this time.But we must not belittle the developmentsthat had occurred before the invention of theophthalmoscope In the eighteenth century, con-siderable advances had been made in the tech-nique and instrumentation of cataract surgery,and the science of optics was being developed
to enable the better correction of refractiveerrors in the eye If we go back to the seven-teenth century, the existing ophthalmologicalservices were definitely limited, as is revealed inthe writings of the famous diarist, SamuelPepys Although we have no record of his eyecondition other than his own, he did consult anoculist at the time and unfortunately receivedlittle comfort or effective treatment His failingeyesight brought his diary to an abrupt end inspite of the use of “special glasses” and themedicaments, which caused him great pain.Although records of eye surgical techniques
go back as far as 3000 years, modern eye surgerywas largely developed thanks to the introduc-tion of cocaine and then of general anaesthesia
at the end of the nineteenth century The use ofeserine eye drops to reduce the intraocular pres-sure in glaucoma was introduced at the sametime, this being the forerunner of a number ofdifferent medical treatments that are now avail-able Cataract surgery saw great advances at the beginning of the twentieth century, with the introduction of the intracapsular cataractextraction In the 1920s, successful attemptswere being made to replace the detached retina,which had previously been an irreversible cause
of blindness Such early surgical techniqueshave now been developed to produce some ofthe most dramatic means of restoring sight As
a spin-off from the last war came a ary idea of “spare-part” surgery in the eye Theobservation that crashed fighter pilots were able
revolution-to revolution-tolerate small pieces of perspex in their eyesled to the use of acrylic intraocular implants, thelens of the eye being replaced by an artificialone Such spare-part surgery has now becomecommonplace, as will be seen in Chapter 11 Theoperating microscope was introduced in the1960s, and with it came the development of finesuture materials and the use of instruments toosmall for manipulation with the naked eye This