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Library of Congress Cataloging‐in‐Publication Data
Name: Leitman, Mark W., 1946– author.
Title: Manual for eye examination and diagnosis / Mark W. Leitman.
Description: Tenth edition. | Hoboken : Wiley‐Blackwell, 2020. | Includes index.
Identifiers: LCCN 2020021835 (print) | LCCN 2020021836 (ebook) | ISBN 9781119628583 (hardback) | ISBN 9781119630623 (adobe pdf) | ISBN 9781119630579 (epub)
Subjects: MESH: Eye Diseases–diagnosis | Diagnostic Techniques, Ophthalmological | Handbook
Classification: LCC RE75 (print) | LCC RE75 (ebook) | NLM WW 39 | DDC 617.7/15–dc23
LC record available at https://lccn.loc.gov/2020021835 LC ebook record available at https://lccn.loc.gov/2020021836
Cover Design: Wiley
Cover Images: (front cover) courtesy of Carl Zeiss Meditect, Inc., (back cover) JirehDesign.com and courtesy of Stuart Green
Preface
The first edition of this book was started when I was a medical student at N.Y. Medical College 48 years ago during the allotted 2‐week rotation in the eye clinic. It was published during my first year of eye residency at Albert Einstein Medical School with assistance and encouragement from my chairman, Dr Paul Henkind. At that time, all introductory books were 500 pages or more and could not be read quickly enough to understand what was going on. With this in mind, each word of this manual is shorter and more concise. On completing it, students should understand the refraction and hundreds of the most commonly encountered eye diseases, which are discussed with respect to anatomy, instrumentation, differential diagnosis, and treatment. It is highlighted with over 600 of the best images and illustrations I have collected in the past 45 years.
The book is meant to be read in its entirety in several hours and to impart to you a foundation on which to grow and enjoy this beautiful and ever‐changing specialty. The popularity of previous editions has resulted in translations into Spanish, Japanese, Indonesian, Italian, Russian, Greek, Polish, Chinese, and Portuguese as well an Indian reprint.
My special appreciation goes to Johnson & Johnson, which provided a generous grant to distribute the 7th edition to 40,000 students. I donated 60,000 copies of the 8th and 9th edition and 55,700 copies of the 10th edition to medical students. Now on with the work. Many images were generously provided by Pfizer, Wills Eye Hospital, the University of Iowa, Montefiore Hospital, and many colleagues. Elliot Davidoff, who sat next to me in medical school, and who is now assistant professor at the Ohio State University, surprised me with many unsolicited contributions, as did Lance Lyons, Glaucoma Fellow at the Mayo Clinic.
This edition has been updated with 40 new images. I hope you enjoy reading it half as much as I enjoyed writing it. I have received no monetary funding from, and I have no association with, any company whose products are mentioned in this book.
I added images of diabetic retinopathy to both the front and back covers of this latest edition so that it can be shown to patients. It will remind them of why they are making so much effort in controlling blood sugar.
I would appreciate any recommendations and images that would improve the next edition. You may email me at mark. [email protected].
Mark W. Leitman
Introduction to the eye team and their instruments
The eye exam depends on many sophisticated and costly instruments, together with highly trained professionals to operate them.
Ophthalmologist—The ophthalmologist attends 4 years of college, 4 years of medical (MD) or osteopathic (DO) school, and 3 years of specialty eye residency training. They may remain general ophthalmologists, but now, more often than not, spend an additional 1–2 years subspecializing in corneal and external disease, vitreoretinal disease, cataracts, glaucoma, neuro‐ophthalmology, oculoplastic surgery, pathology, pediatric (strabismus), or uveitis.
Optometrist (OD)—The optometrist completes 4 years of college and 4 years of optometry school. They perform similar tasks to the ophthalmologist, with subspecialty fellowships similar to ophthalmology, but with stress on medical, rather than surgical skills.
Opticians (ABO, American Board of Opticians)—Opticians grind the lenses and put them in frames (laboratory optician) or fit them on the patient (dispensing optician). Their training and certification is highly variable from state to state, but often includes 2 years at a community college.
Ocularists (BCO, BRDO, FASO)—Ocularists are few in number and often learn their craft by apprenticeship. They have to pass tests for certification. Their job is to fit the rarely needed sclera shell after removal of an eye (Figs 423–426).
Ophthalmic technicians—Ophthalmic technicians have varying degrees of licensure. With medical supervision, they may take medical histories; measure eye pressure; do refractions and visual field testing; take visual activities; teach contact lens fitting; and often assist in the following diagnostic tests.
Instruments
Routine diagnostic testing is done with a slit lamp (Fig. 237) for the anterior segment and the handheld ophthalmoscope (Fig. 466) for the retina exam. Office‐based optical coherence tomography (OCT) (Fig. 339) uses a light scanning device to measure the layers of the eye, and optical coherence tomography angiography (OCT A) physically defines the retinal and choroidal blood vessels. These light sources reflect a beam off ocular structures at up to 100,000 scans/s and require a clear, transparent media. A red blood cell has a diameter of 7 microns and OCT scans resolve down to 2–5 microns. Fluorescein angiography shows sequential blood flow and possible leakage of retinal blood vessels (Fig. 470). Ultrasound is an alternative to OCT for measuring structures through an opaque media (Fig. 560). A specular microscope (Figs 265 and 266) analyses the number and characteristics of the inner layer of the cornea called the endothelium. Corneal tomography (Fig. 73) measures the thickness and diopter power of the cornea. Treatments include lasers of different wave lengths. Argon lasers (see back cover) are preferred in the treatment of retinal disorders, and Nd:YAG lasers are used to open secondary cataracts (Figs 451 and 452) that occur after cataract extractions and to perform peripheral iridotomy for narrow‐angle glaucoma (Fig. 365). SLT Nd:YAG lasers (Fig. 345) are used to treat open‐angle glaucoma. Excimer lasers (Figs 60–62) change the shape of the cornea in the procedure called LASIK surgery. Femtosecond lasers help in certain parts of cataract surgery (Fig. 447) and SMILE refractive surgery (Fig. 77). Finally, the phacoemulsifier (Fig. 438) liquifies a 10‐mm cataract so that it can be removed through a sutureless, 3‐mm incision.
Fig 1 A seed introduced into the eye of an 8‐year‐old boy through a penetrating corneal wound became imbedded in the iris. Many months later, the seed became visible when it began germinating.
Courtesy of Solomon Abel, MD, FRCS, DOMS, and Arch. Ophthalmol., Sept. 1979, Vol. 97, p. 1651. Copyright 1979, American Medical Association.