iii

Contents

Preface xiiiAcknowledgments xiii

Introduction to the Course xvTo the Ophthalmologist xvTo the Student xvi

1 IntroduCtIon to ophthalmIC medICal assIstIng 1

erich p. horn, md, mBaWhat Is Ophthalmology? 1Who Provides Eye Care? 2

Ophthalmologist 2Optometrist 3Optician 3Registered Nurse 3Orthoptist 3Ocularist 3Ophthalmic Photographer 3Ophthalmic Medical Assistant 4

What Is Certification? 4Professional Development 5

2 anatomy and physIology of the eye 9

Kenneth B. mitchell, mdThe Eye as an Optical System 9The Globe 10The Adnexa 10

Orbit 10Extraocular Muscles 10Eyelids and Conjunctiva 12Lacrimal Apparatus 13

The Eye 14Cornea and Sclera 14Anterior Chamber 15Uvea: Iris, Ciliary Body, Choroid 16Crystalline Lens 16Vitreous 17Retina 18Visual Pathway 19

3 dIseases and dIsorders of the eye 23

martha p. schatz, mdMechanisms of Disease and Injury 23

Infectious Process 24Inflammatory Process 24Allergic Process 24Ischemic Process 24Metabolic Process 24Congenital Process 25Developmental Process 25Degenerative Process 25Neoplastic Process 25Traumatic Process 25Signs, Symptoms, and Syndromes 25

Abnormalities of the Adnexa 26Orbit 26

Extraocular Muscles 26Eyelids 27

Lacrimal Apparatus 28Abnormalities of the Eye 29

Conjunctiva 29Cornea and Sclera 30Anterior Chamber 31

iv • CONTENTS

Uveal Tract 33Crystalline Lens 33Vitreous 33Retina 34Optic Nerve 34Visual Pathway 35

4 SySTEMIC DISEASES AnD OCuLAR MAnIFESTATIOnS 39

Charles B. Slonim, MD, FACSInflammatory and Autoimmune Diseases 40

Myasthenia Gravis 40Rheumatoid Arthritis 40Sarcoidosis 40Sjögren Syndrome 41Systemic Lupus Erythematosus 41Thyroid Disorders 41Multiple Sclerosis 41

Metabolic Disorders 42Diabetes Mellitus 42

Vascular Diseases 42Cerebral Vascular Accident 43Giant Cell Arteritis 43Migraine 43Hypertension 43

Infectious Diseases 44Acquired Immunodeficiency Syndrome 44Chlamydial Infections 44Herpes Infections 45Histoplasmosis 45Syphilis 45Toxoplasmosis 45

Neoplastic Diseases 45Metastatic Carcinoma 46Blood Dyscrasias 46Cerebral Neoplasms 46

5 OPTICS AnD REFRACTIvE STATES OF THE EyE 49

Lee R. Duffner, MD, FACSPrinciples of Optics 49

Refraction 50Refractive Properties of Curved Lenses 51Convergence, Divergence, and Focal Point 51Lens Power and Focal Length 52

Refractive States of the Eye 53Emmetropia 53Ametropia 53

Types and Uses of Corrective Lenses 55Spheres 56Cylinders 57Spherocylinders 57Prisms 58

Components of Refraction 58Retinoscopy 59Refinement 61Binocular Balancing 62

Interpretation of Prescriptions 62Transposition of Prescriptions 63Automated Refractors 64

Objective Refractors 64Subjective Refractors 64Objective/Subjective Refractors 64

Lensometry 64Types of Lensmeters 64Elements of Lensometry 65Lensometry Technique for Multifocal Lenses 65Lensometry Technique for Prisms 67Placement of Optical Centers 68

Keratometry 68

CONTENTS • v

6 BASICS OF OPHTHALMIC PHARMACOLOGy 75

Jay S. Wallshein, MD, MBADelivery Systems of Drugs 76

Topical Systems 76Injections 77Oral Systems 77Implants 78

Improving Compliance 78Administration of Topical Eyedrops and Ointments 78Purposes and Actions of Drugs 78

Diagnostic Medications 78Therapeutic Medications 82

Miotics 82Glaucoma Medications 82

Interpretation of a Prescription 87First Aid for Acute Drug Reactions 88

7 MICROORGAnISMS AnD InFECTIOn COnTROL 93

Frank W. Scribbick III, MDTypes of Microorganisms 93

Bacteria 94Viruses 95Fungi 97Protozoa 97Prions 98

Transmission of Infectious Diseases 98Airborne Droplets and Particles 98Direct-Contact Transmission 99Indirect-Contact Transmission 99Common-Vehicle Transmission 99Vector-Borne Transmission 99

Infection Control Precautions 100Hand Washing 102Use of Personal Protective Equipment 102Cleaning, Disinfection, and Sterilization 102Aseptic Technique: Handling Sterile Medical Equipment 104

Handling and Decontaminating Contaminated Materials 104Hygienic Practices in Potentially Infectious Situations 105

Collecting Specimens for the Identification of Microorganisms 105

8 COMPREHEnSIvE MEDICAL EyE ExAMInATIOn 109

Damien F. Goldberg, MDOverview of the Examination 109

Visual Acuity Examination 110Alignment and Motility Examination 110Pupillary Examination 110Visual Field Examination 110Intraocular Pressure Measurement 110External Examination 110Biomicroscopy 110Ophthalmoscopy 111

Frequency of Examination 111Ophthalmic and Medical History 111

Chief Complaint and History of Present Illness 111Past Ocular History 113General Medical and Social History 113Family Ocular and Medical History 114Allergies, Medications, and Supplements 114History-Taking Guidelines 114

Visual Acuity Examination 115Distance Acuity Test 115Pinhole Acuity Test 116Near Acuity Test 116Other Acuity Tests 117Procedures Following Acuity Tests 118

Alignment and Motility Examination 119Worth 4-Dot Test 120Titmus Stereopsis Test 120

Pupillary Examination 120Visual Field Examination 121

Confrontation Field Test 122Amsler Grid Test 122

vi • CONTENTS

Intraocular Pressure Measurement 122Principles of Tonometry 122Applanation Tonometry 124Indentation Tonometry 125Applanation Versus Indentation Tonometry 127

Pachymetry 127External Examination 128

Anterior Chamber Evaluation 128Biomicroscopy 129Gonioscopy 129

Ophthalmoscopy 130Direct and Indirect Ophthalmoscopy 130

Additional Tests 131Color Vision Tests 131Tear Output Test 131Evaluating the Corneal and Conjunctival Epithelium 132Corneal Sensitivity Test 132Exophthalmometry 133

9 OCuLAR MOTILITy 137

Mary A. O’Hara, MD, FACS, FAAPAnatomy and Physiology 137Nerve Control 139Eye Movements 139Motility Examination 140Strabismus Tests 140

Corneal Light Tests 140Cover Tests 141Additional Tests 142

Summary 144

10 ADJunCTIvE TESTS AnD PROCEDuRES 149

Diana J. Shamis, MHSE, CO, COMTVision Tests for Patients With Opacities 149

Visual Potential Tests 150Contrast-Sensitivity and Glare Tests 151

Assessment of Corneal Abnormalities 152Pachymetry 152Corneal Topography 152Specular Microscopy/Photography 153

Ophthalmic Photography 153External Photography 153Slit-Lamp Photography 153Fundus Photography 153

Tomographic Imaging 154Ultrasonography 155

A-Scan 155B-Scan 156

11 PRInCIPLES AnD TECHnIquES OF PERIMETRy 159

neil T. Choplin, MDAnatomic Basis of the Visual Field 160Map of the Visual Field 161

Orientation of the Visual Field Map 163Purposes and Types of Perimetry 163

Kinetic Perimetry 164Static Perimetry 166Miscellaneous Visual Field Tests 169

Defects Shown by Perimetry 169Generalized Defects 169Focal Defects 170Hemianopic and Quadrantanopic Defects 172Other Defects 172

Conditions for Accurate Perimetry 172Environment-Related Factors 172Device-Related Factors 175Patient-Related Factors 175Examiner-Related Factors 176

12 FunDAMEnTALS OF PRACTICAL OPTICIAnRy 179

Helen B. Metzler, COT, CCRP, ABOTypes of Corrective Lenses 179

Single-Vision Lenses 180Multifocal Lenses 180

CONTENTS • vii

Types of Lens Materials 183Lens Safety Standards 184Lens Treatments, Tints, and Coatings 186

Key Measurements in Fitting Eyeglasses 186Interpupillary Distance 187Vertex Distance 190Base Curve 191

Fitting, Care, and Adjustment of Eyeglasses 192

Fitting of Eyeglasses 192Care of Eyeglasses 194Adjustment of Eyeglasses 194

13 LOW vISIOn 199

Larry Schwab, MD Mary A. O’Hara, MD, FACS, FAAPVisual Acuity and Low Vision 200Common Causes of Low Vision 200Increasing Awareness 201

Low Vision Care 201Low Vision Aids 201

Low Vision Devices 203Nonoptical Aids 203

Other Services 204

14 PRInCIPLES AnD PROBLEMS OF COnTACT LEnSES 207

Peter C. Donshik, MD, FACSBasic Principles 208

Characteristics of Contact Lenses 208Contact Lenses Versus Eyeglasses for Vision Correction 208Contact Lens Specification Versus Eyeglass Prescription 209

Types and Materials of Contact Lenses 209PMMA and RGP Contact Lenses 210Soft Contact Lenses 210Extended-Wear Contact Lenses 211Daily-Wear Contact Lenses 211Disposable Contact Lenses 211Planned-Replacement Contact Lenses 211

Contact Lens Designs for Special Purposes 211

Cosmetic Fashion Contact Lenses 212Cosmetic Restorative Contact Lenses 212Toric Contact Lenses 212Bifocal Contact Lenses 213Keratoconus Contact Lenses 214Therapeutic Contact Lenses 214

Care of Contact Lenses 214Cleaning 215Disinfecting 215Lubrication 216Storage 216

Insertion and Removal of Contact Lenses 216Soft Contact Lenses 216Rigid Contact Lenses 216

Problems With Contact Lenses 216Allergy 217Solution–Contact Lens Interaction 218Overwearing Syndrome 218Improper Contact Lens Fit 219Giant Papillary Conjunctivitis 220Irritation and Tearing 220Corneal Problems 221Inability to Insert or Remove Lenses 223Lens “Lost” in the Eye 223

Contraindications for Contact Lenses 223

15 PATIEnT InTERACTIOn, SCREEnInG, AnD EMERGEnCIES 227

Mary A. O’Hara, MD, FACS, FAAPPatient–Assistant Interaction 227

Patient Greeting 227Patient Screening 228Triage 228Appointment Scheduling 231Referred Patients 231

Emergencies in the Office 231Burns 231Trauma 234General Emergency Assistance 235Hospital Admission 235

viii • CONTENTS

16 PATIEnTS WITH SPECIAL COnCERnS 241

Donna M. Applegate, COTAll Patients Considered 241

Patients and Their Families 242Health Insurance Portability and Accountability Act 242Office Waiting Periods 242

Disruptive Patients 243Visually Impaired or Blind Patients 243

Patient Greeting and History-Taking Guidelines 243Offering Assistance 244Visual Acuity Assessment 245

Infants and Young Children 245Patient Greeting 245Patient Positioning 245Visual Acuity and Ability Testing 246

Elderly Patients 248Age-Related Vision Changes 248Visual Acuity Testing 249

Patients Who May Be Suffering from Abuse 249Patients With Physical Disabilities 249Patients With Diabetes 250

Special Help for Patients With Diabetes 251

17 MInOR SuRGICAL ASSISTInG In THE OFFICE 255

Mitchell J. Goff, MDPatient Preparation Before Surgery 255

Informed Consent 255Preoperative Assessment 256Patient Assistance 256

Administration of Anesthetics 256Surgical Materials and Instruments 257

Sutures and Suture Needles 257Forceps 258Scissors 258Needle Holders 259Clamps and Curettes 259

Blade Handles and Blades (Scalpels) 259Lacrimal Instruments 259Cannulas 259Syringes and Needles 260Other Surgical Supplies 260

Common Minor Surgical Procedures 261General Considerations 261

Postsurgical Medications, Dressings, and Patches 261First Surgical Experience 261Surgical Assisting Skills 266

Aseptic Technique and Minor Surgery 266Preparing the Instrument Tray 268Assisting During Surgery 269Disposition of Instruments and Materials 270

18 REFRACTIvE SuRGERy COnCEPTS AnD PROCEDuRES 273

David A. Goldman MDHistory of Refractive Surgery 274Indications and Contraindications for Refractive Surgical Procedures 274Evaluating Refractive Surgical Patients 274

Refraction in Myopia 274Refraction in Hyperopia 275Refraction in Astigmatism 275Near Refraction in Presbyopic Patients 275Cycloplegic Refraction 275Wavefront Analysis 275Pupil Size Measurements 276Ultrasound Pachymetry and Keratometry 276Videokeratography 276

Refractive Surgical Procedures 276Laser In Situ Keratomileusis 276Photorefractive Keratectomy 277Laser Subepithelial Keratomileusis 277EPI-LASIK 277Astigmatic Keratotomy 277

CONTENTS • ix

Conductive Keratoplasty and Laser Thermokeratoplasty 278Intrastromal Corneal Ring Segments 278Phakic Intraocular Lenses 279

In Review 281

19 unDERSTAnDInG PRACTICE MAnAGEMEnT 283

Sue J. vicchrilli, COT, OCS Morgan L. Taylor III, CPA, COE Emanuel newmark, MD, FACSThe Ophthalmic Practice and You 283

For Whom Do You Work? 284You Are Part of a Team 284

Why Management Matters 284Management and the Patient 284Management and Your Doctor 285The Office Manager’s Role 286The Chain of Command 286Management of Communications 286Management by the Numbers 286Management Through Policies and Procedures 286

Commitments and Responsibilities 287Is It All About Attitude? 287Understanding Your Commitment 287Optimizing Your Work Time 287Understanding Expectations 288

Additional Duties 288Understanding Patient Prescriptions 288Coordinating Patient Flow 288Answering the Phone 289Working With Patient Charts 289Scheduling 289Scribing 290

Compliance 290Coding 291

Coding Systems 291The Benefits of Proper Coding 292Documentation 293About ICD-10 293Code Linking and Medical Necessity 293

Coding for Ophthalmology Office Visits 294Eye Codes 294Ophthalmic Coding Specialist 295

In Review 295

20 MEDICAL ETHICS, LEGAL ISSuES, AnD REGuLATORy ISSuES 297

William H. Ehlers, MDHistory 297Code of Ethics of the Academy 298Ethics for Assistants 298

Ethical Behavior 298Providing Technical Services 299Competence of Technicians 299Communication With Patients 299Informed Consent and Ophthalmic Assistants 300

Ethics and Pharmaceutical Company Representatives 301Professional Conduct 301

Appearance 301Respect and Sensitivity 302

Supplementary Topics 302

21 COMMunITy HEALTH EyE CARE 307

Karl C. Golnik, MD D. Hunter Cherwek, MD Heather Machin, RnDefinitions of Vision Impairment and Blindness 308

Governmental Definitions of Visual Impairment and Blindness 308Major Causes of Reversible and Irreversible Blindness 309VISION 2020: The Right to Sight 309

Strategies for Improving Utilization of Eye Care 310Local Delivery of Health Education Information 310

Screening Programs 310Surgical Programs 311

x • CONTENTS

Community Eye Care Programs and the Team Approach 312Local Resources Available to Assist Visually Impaired Patients 312

22 CARE OF OPHTHALMIC LEnSES AnD InSTRuMEnTS 315

Lindreth G. DuBois, MEd, MMSc, CO, COMTCare of Lenses 315

Standard Guidelines for Care of Lenses 316Lenses That Do Not Contact the Eye 316Lenses That Contact the Eye 316

Care of Instruments 318Standard Care Guidelines 318Retinoscope 319Phoropter 319Lensmeter 319

Keratometer 320Slit Lamp 320Projector 321Applanation Tonometer 323Indentation Tonometer 323Tono-Pen 324Direct Ophthalmoscope 324Indirect Ophthalmoscope 324Potential Acuity Meter 325Perimeters 325Lasers 325

23 AnSWERS TO CHAPTER SELF‑ASSESSMEnT TESTS 329

Appendix A: Glossary 343

Appendix B: Resources 365

Index 373