Lecture Notes Ophthalmology, 12th Edition

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Ophthalmology
Lecture Notes
Twelfth Edition

Bruce James
MA, DM, FRCS (Ed), FRCOphth
Consultant Ophthalmologist
Department of Ophthalmology
Stoke Mandeville Hospital
Buckinghamshire
and School of Medicine, St. George’s University, Grenada, West Indies

Anthony Bron
BSc, FRCOphth, FARVO, FMedSci
Professor Emeritus
Nuffield Laboratory of Ophthalmology
University of Oxford, Oxford

Professor of Experimental Ophthalmology,

Vision and Eye Research Unit,
Anglia Ruskin University, Cambridge

Manoj V. Parulekar
MS, FRCS (Ed), FRCOphth
Consultant Ophthalmologist
Birmingham Children’s Hospital
and Oxford University Hospitals NHS Trust
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This edition first published 2017  2017 by Bruce James, Anthony Bron and Manoj V Parulekar

Previous editions 1960, 1965, 1968, 1971, 1974, 1980, 1986, 1997, 2003, 2007, 2011
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Library of Congress Cataloging-in-Publication Data

Names: James, Bruce, 1957- author. | Bron, Anthony J., author. | Parulekar,
Manoj V., author.
Title: Lecture notes. Ophthalmology / Bruce James, Anthony Bron, Manoj V.
Parulekar.
Other titles: Ophthalmology
Description: 12th edition. | Chichester, West Sussex ; Hoboken, NJ : John
Wiley & Sons, Inc., 2017. | Includes bibliographical references and index.
Identifiers: LCCN 2016026509 (print) | LCCN 2016027367 (ebook) | ISBN
9781119095903 (pbk.) | ISBN 9781119095927 (pdf) | ISBN 9781119095941 (epub)
Subjects: | MESH: Eye Diseases | Handbooks | Problems and Exercises
Classification: LCC RE50 (print) | LCC RE50 (ebook) | NLM WW 39 | DDC
617.7–dc23
LC record available at https://lccn.loc.gov/2016026509
A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not
be available in electronic books.
Set in 8.5/11pt UtopiaStd-Regular by Thomson Digital, Noida, India

1 2017
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Contents
Preface to twelfth edition, vii
Preface to first edition, ix
Acknowledgements, xi
Abbreviations, xiii
About the companion website, xv

1 Anatomy, 1
2 History, symptoms and examination, 19
3 Clinical optics, 44
4 The orbit, 50
5 The eyelids, 56
6 The lacrimal system, 63
7 Conjunctiva, cornea and sclera, 69
8 The lens and cataract, 84
9 Uveitis, 92
10 Glaucoma, 102
11 Retina and choroid, 116
12 Retinal vascular disease, 133
13 The pupil and its responses, 145
14 Disorders of the visual pathway, 150
15 Eye movements and their disorders, 161
16 Trauma, 175
17 Tropical ophthalmology: eye diseases in the developing world, 184
18 Eye diseases in children, 195
19 Services for the visually handicapped, 205
20 Clinical cases, 208

Useful references, 217

Appendix 1: Conversion table for representation of visual acuity, 219
Appendix 2: Drugs available for ophthalmic use, 220
Index, 223
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Preface to
twelfth edition
Welcome to the twelfth edition of Ophthalmology Lec­ astigmatism and restoring near and distance vision in
ture Notes! As in the past, our aim has been to make the some patients without the need for glasses. Vitreor­
diagnosis and management of eye disease a palatable etinal surgery employs inert gases and silicone oil to
process and once again we stress the value of a good flatten the detached retina and endoscopic probes
history and careful clinical examination of the eye. which allow manipulations in the vitreous space and
The eye is remarkably accessible. Optical and digital the dissection of microscopic membranes from the
techniques continue to develop giving increasingly retinal surface. Glaucoma surgery is developing tiny
detailed access to the structures of the eye at cellular drainage implants to reduce intraocular pressure.
level. Specular microscopy can image the corneal Despite these advances, most ophthalmic diag­
endothelial cells which regulate corneal hydration noses can still be made from a good history and
and transparency; optical coherence tomography clinical examination of the eye. This book aims to
allows the layers of the retina to be dissected and teach skills which will be useful to anyone engaged in
recently allows the retinal vasculature to be imaged medical practice. Many systemic disorders have ocu­
without the need for injection of fluorescein. Confocal lar features which are critical in diagnosis. This book
microscopy provides a three-dimensional view of the covers the ophthalmic features of systemic hyper­
optic nerve head. The shape of the cornea can be tension, diabetes, sarcoidosis, endocarditis, demyeli­
plotted digitally and, outside the globe, orbital struc­ nating disease and space-occupying lesions of the
tures and the visual pathway can be viewed by brain. It also explains how to recognize iritis, distin­
neuroimaging. guish various forms of retinopathy and understand the
Therapeutically, lasers are used to relieve acute, difference between papilloedema and papillitis.
angle closure glaucoma, to lower ocular pressure in As in the eleventh edition, each chapter provides a
chronic glaucoma, to open up an opaque lens capsule set of learning objectives and a summary of key points,
following cataract surgery and to seal retinal holes. as well as bullet lists for emphasis. You can test your
They have an established role in reshaping the cornea understanding with the questions and picture quizzes
to treat refractive errors of the eye and their role is now at the end of each chapter. In this edition, we have
extending to use in cataract surgery itself. Sight-threat­ updated all the chapters and added to the extended
ening diabetic retinopathy can be treated effectively matching questions (EMQs) and multiple choice
by retinal photocoagulation, to remove the angiogenic questions to bring this small volume up to date.
stimulus to vasoproliferation. More recently, it has Chapter 20 offers classical case histories, which will
become possible to inhibit new vessel formation in let you test your diagnostic skills. The final section of
diabetic retinopathy, macular degeneration and other the book provides a list of further reading and the
retinal vascular disorders by intravitreal injections of details of attractive websites which offer an expanded
antiangiogenic drugs. Roles for these drugs in treating view of the speciality. Try some of these out.
oedema of the retina, see for example in diabetes, are We hope that you will have as much fun reading
also becoming established. these Lecture Notes as we did putting them together.
These techniques are matched by technological
innovations in microsurgery, responsible for dramatic Bruce James
advances in cataract and vitreoretinal surgery. Optical Anthony Bron
function in cataract surgery is restored by insertion of Manoj V. Parulekar
a lens which unfolds within the eye. These are becom­
ing increasingly complex allowing for the treatment of
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Preface to
first edition
This little guide does not presume to tell the medical classify a long succession of ocular structures, all of
student all that he needs to know about ophthalmol­ which emerged as isolated brackets for yet another
ogy, for there are many larger books that do. But the sub-catalogue of small and equally isolated diseases.
medical curriculum becomes yearly more congested, Surely it is time now to try and harness these miscel­
while ophthalmology, still the ‘Cinderella’ of medi­ laneous ailments, not in terms of their diverse mor­
cine, is generally left until the last, and only too readily phology, but in simpler clinical patterns; not as the
goes by default. So it is to these harassed final-year microscopist lists them, but in the different ways that
students that the book is principally offered, in the eye diseases present. For this, after all, is how the
sincere hope that they will find it useful; for nearly all student will soon be meeting them.
eye diseases are recognized quite simply by their I am well aware of the many inadequacies and
appearance, and a guide to ophthalmology need be omissions in this form of presentation, but if the
little more than a gallery of pictures, linked by lecture belaboured student finds these lecture notes at least
notes. more readable, and therefore more memorable, than
My second excuse for publishing these lecture notes the prolix and time-honoured pattern, perhaps I will
is a desire I have always had to escape from the be justified.
traditional textbook presentation of ophthalmology
as a string of small isolated diseases, with long Patrick Trevor-Roper
unfamiliar names, and a host of eponyms. To the
nineteenth-century empiricist, it seemed proper to
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Acknowledgements
Numerous colleagues have provided valuable advice Thanks are due also to Karen Moore and the staff at
in their specialist areas, for which we are most grateful. Wiley Blackwell for their encouragement, efficiency
The authors wish to thank Tom Meagher and Ramona and patience during the production of this edition. We
Khooshabeh for providing additional pictures for the are also grateful to Shikha Pahuja and the copyediting
twelfth edition. Tom Butler provided substantial input team of Thomson Digital, for meticulous reading and
to the chapter on clinical optics. We are particularly production of the text.
grateful to Professor Allen Foster at the London School
of Hygiene and Tropical Medicine, who kindly pro­ Bruce James
vided the illustrations for the chapter on tropical Anthony Bron
ophthalmology. Richard James, Chris King and Ajay Manoj V Parulekar
Mohite worked on the questions and assessments.
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Abbreviations
AIDS acquired immunodeficiency syndrome LASEK laser-assisted subepithelial keratomileusis
AION anterior ischaemic optic neuropathy LASIK laser-assisted in situ keratomileusis
AMD age-related macular degeneration LGB lateral geniculate body
ARM age-related maculopathy MLF medial longitudinal fasciculus
CCTV closed circuit television MRA magnetic resonance angiogram
CMV cytomegalovirus MRI magnetic resonance imaging
CNS central nervous system NSAID non-steroidal anti-inflammatory drug
CRVO central retinal vein occlusion OCT optical coherence tomogram
CSF cerebrospinal fluid PAS peripheral anterior synechiae
CT computed tomography PEE punctate epithelial erosions
DCR dacryocystorhinostomy PHMB polyhexamethylene biguanide
ENT ear, nose and throat PMN polymorphonuclear leucocyte
ERG electroretinogram PPRF parapontine reticular formation
ESR erythrocyte sedimentation rate PRK photorefractive keratectomy
GCA giant cell arteritis PS posterior synechiae
GI gastrointestinal PVR proliferative vitreoretinopathy
GPC giant papillary conjunctivitis RAPD relative afferent pupil defect
HAART highly active anti-retroviral therapy RPE retinal pigment epithelium
HIV human immunodeficiency virus TB tuberculosis
HLA human leucocyte antigen TNF tumour necrosis factor
HSV herpes simplex UV ultraviolet
ICG indocyanine green angiography VA visual acuity
INR international normalized ratio VEGF vascular endothelial growth factor
IOL intraocular lens VKH Vogt–Koyanagi–Harada disease
KP keratic precipitate
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WEBFABOUT 09/15/2016 23:50:29 Page xv

About the companion

website
Don’t forget to visit the companion website for this book:
www.lecturenoteseries.com/ophthalmology

There you will find valuable material designed to enhance your learning, including:
• Interactive MCQs
• Interactive EMQs
• Figures from the book
Scan this QR code to visit the companion website.