To the Ophthalmologist xv Crystalline Lens. 3 Diseases and Disorders. Mechanisms of Disease and Injury 23 Optician 3 Inflammatory Process Orthoptist

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1 Contents Preface xiii The Eye 14 Acknowledgments xiii Introduction to the Course xv 14 Anterior Chamber 15 Uvea: Iris, Ciliary Body, Choroid To the Ophthalmologist xv Crystalline Lens To the Student xvi 1 Cornea and Sclera 16 Vitreous 17 Introduction to Ophthalmic Medical Assisting 1 Erich P. Horn, MD, MBA Retina 18 Visual Pathway 19 3 Diseases 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 Inflammatory Process Orthoptist Allergic Process Ischemic Process Ophthalmic Photographer 3 Metabolic Process Ophthalmic Medical Assistant 4 Congenital Process 25 What Is Certification? Anatomy and Physiology of the Eye The Eye as an Optical System 9 The Globe Eyelids and Conjunctiva 12 Lacrimal Apparatus Neoplastic Process 25 Traumatic Process 25 9 Signs, Symptoms, and Syndromes Orbit Extraocular Muscles 26 Eyelids The Adnexa Degenerative Process 25 Abnormalities of the Adnexa Kenneth B. Mitchell, MD Extraocular Muscles 24 Developmental Process Professional Development Orbit 23 Infectious Process 24 Registered Nurse 3 Ocularist Lacrimal Apparatus 28 Abnormalities of the Eye 29 Conjunctiva 29 Cornea and Sclera 30 Anterior Chamber 31 iii

2 iv CONTENTS Uveal Tract 33 Crystalline Lens 33 Vitreous 33 Retina 34 Optic Nerve 34 Visual Pathway 35 4 Systemic Diseases and Ocular Manifestations 39 Charles B. Slonim, MD, FACS Inflammatory and Autoimmune Diseases 40 Myasthenia Gravis 40 Rheumatoid Arthritis 40 Sarcoidosis 40 Sjögren Syndrome 41 Systemic Lupus Erythematosus 41 Thyroid Disorders 41 Multiple Sclerosis 41 Metabolic Disorders 42 Diabetes Mellitus 42 Vascular Diseases 42 Cerebral Vascular Accident 43 Giant Cell Arteritis 43 Migraine 43 Hypertension 43 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 5 Optics and Refractive States of the Eye 49 Lee R. Duffner, MD, FACS Principles of Optics 49 Refraction 50 Refractive Properties of Curved Lenses 51 Convergence, Divergence, and Focal Point 51 Lens Power and Focal Length 52 Refractive States of the Eye 53 Emmetropia 53 Ametropia 53 Types and Uses of Corrective Lenses 55 Spheres 56 Cylinders 57 Spherocylinders 57 Prisms 58 Components of Refraction 58 Retinoscopy 59 Refinement 61 Binocular Balancing 62 Interpretation of Prescriptions 62 Transposition of Prescriptions 63 Automated Refractors 64 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

3 CONTENTS v 6 Basics of Ophthalmic Pharmacology 75 Jay S. Wallshein, MD, MBA Delivery Systems of Drugs 76 Topical Systems 76 Injections 77 Oral Systems 77 Implants 78 Improving Compliance 78 Administration of Topical Eyedrops and Ointments 78 Purposes and Actions of Drugs 78 Diagnostic Medications 78 Therapeutic Medications 82 Miotics 82 Glaucoma Medications 82 Interpretation of a Prescription 87 First Aid for Acute Drug Reactions 88 7 Microorganisms and Infection Control 93 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 Handling and Decontaminating Contaminated Materials 104 Hygienic Practices in Potentially Infectious Situations 105 Collecting Specimens for the Identification of Microorganisms Comprehensive Medical Eye Examination 109 Damien F. Goldberg, MD Overview of the Examination 109 Visual Acuity Examination 110 Alignment and Motility Examination 110 Pupillary Examination 110 Visual Field Examination 110 Intraocular Pressure Measurement 110 External Examination 110 Biomicroscopy 110 Ophthalmoscopy 111 Frequency of Examination 111 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

4 vi CONTENTS Intraocular Pressure Measurement 122 Principles of Tonometry 122 Applanation Tonometry 124 Indentation Tonometry 125 Applanation Versus Indentation Tonometry 127 Pachymetry 127 External Examination 128 Anterior Chamber Evaluation 128 Biomicroscopy 129 Gonioscopy 129 Ophthalmoscopy 130 Direct and Indirect Ophthalmoscopy 130 Additional Tests 131 Color Vision Tests 131 Tear Output Test 131 Evaluating the Corneal and Conjunctival Epithelium 132 Corneal Sensitivity Test 132 Exophthalmometry Ocular Motility 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 Adjunctive Tests and Procedures 149 Diana J. Shamis, MHSE, CO, COMT Vision Tests for Patients With Opacities 149 Visual Potential Tests 150 Contrast-Sensitivity and Glare Tests 151 Assessment of Corneal Abnormalities 152 Pachymetry 152 Corneal Topography 152 Specular Microscopy/Photography 153 Ophthalmic Photography 153 External Photography 153 Slit-Lamp Photography 153 Fundus Photography 153 Tomographic Imaging 154 Ultrasonography 155 A-Scan 155 B-Scan Principles and Techniques of Perimetry 159 Neil T. Choplin, MD Anatomic Basis of the Visual Field 160 Map of the Visual Field 161 Orientation of the Visual Field Map 163 Purposes and Types of Perimetry 163 Kinetic Perimetry 164 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 Fundamentals of Practical Opticianry 179 Helen B. Metzler, COT, CCRP, ABO Types of Corrective Lenses 179 Single-Vision Lenses 180 Multifocal Lenses 180

5 CONTENTS vii Types of Lens Materials 183 Lens Safety Standards 184 Lens Treatments, Tints, and Coatings 186 Key Measurements in Fitting Eyeglasses 186 Interpupillary Distance 187 Vertex Distance 190 Base Curve 191 Fitting, Care, and Adjustment of Eyeglasses 192 Fitting of Eyeglasses 192 Care of Eyeglasses 194 Adjustment of Eyeglasses Low Vision 199 Larry Schwab, MD Mary A. O Hara, MD, FACS, FAAP Visual Acuity and Low Vision 200 Common Causes of Low Vision 200 Increasing Awareness 201 Low Vision Care 201 Low Vision Aids 201 Low Vision Devices 203 Nonoptical Aids 203 Other Services Principles and Problems of Contact Lenses 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 PMMA and RGP Contact Lenses 210 Soft Contact Lenses 210 Extended-Wear Contact Lenses 211 Daily-Wear Contact Lenses 211 Disposable Contact Lenses 211 Planned-Replacement Contact Lenses 211 Contact Lens Designs for Special Purposes 211 Cosmetic Fashion Contact Lenses 212 Cosmetic Restorative Contact Lenses 212 Toric Contact Lenses 212 Bifocal Contact Lenses 213 Keratoconus Contact Lenses 214 Therapeutic Contact Lenses 214 Care of Contact Lenses 214 Cleaning 215 Disinfecting 215 Lubrication 216 Storage 216 Insertion and Removal of Contact Lenses 216 Soft Contact Lenses 216 Rigid Contact Lenses 216 Problems With Contact Lenses 216 Allergy 217 Solution Contact Lens Interaction 218 Overwearing Syndrome 218 Improper Contact Lens Fit 219 Giant Papillary Conjunctivitis 220 Irritation and Tearing 220 Corneal Problems 221 Inability to Insert or Remove Lenses 223 Lens Lost in the Eye 223 Contraindications for Contact Lenses Patient Interaction, Screening, and Emergencies 227 Mary A. O Hara, MD, FACS, FAAP Patient Assistant Interaction 227 Patient Greeting 227 Patient Screening 228 Triage 228 Appointment Scheduling 231 Referred Patients 231 Emergencies in the Office 231 Burns 231 Trauma 234 General Emergency Assistance 235 Hospital Admission 235

6 viii CONTENTS 16 Patients With Special Concerns 241 Donna M. Applegate, COT All Patients Considered 241 Patients and Their Families 242 Health Insurance Portability and Accountability Act 242 Office Waiting Periods 242 Disruptive Patients 243 Visually Impaired or Blind Patients 243 Patient Greeting and History Taking Guidelines 243 Offering Assistance 244 Visual Acuity Assessment 245 Infants and Young Children 245 Patient Greeting 245 Patient Positioning 245 Visual Acuity and Ability Testing 246 Elderly Patients 248 Age-Related Vision Changes 248 Visual Acuity Testing 249 Patients Who May Be Suffering from Abuse 249 Patients With Physical Disabilities 249 Patients With Diabetes 250 Special Help for Patients With Diabetes Minor Surgical Assisting in the Office 255 Mitchell J. Goff, MD Patient Preparation Before Surgery 255 Informed Consent 255 Preoperative Assessment 256 Patient Assistance 256 Administration of Anesthetics 256 Surgical Materials and Instruments 257 Sutures and Suture Needles 257 Forceps 258 Scissors 258 Needle Holders 259 Clamps and Curettes 259 Blade Handles and Blades (Scalpels) 259 Lacrimal Instruments 259 Cannulas 259 Syringes and Needles 260 Other Surgical Supplies 260 Common Minor Surgical Procedures 261 General Considerations 261 Postsurgical Medications, Dressings, and Patches 261 First Surgical Experience 261 Surgical Assisting Skills 266 Aseptic Technique and Minor Surgery 266 Preparing the Instrument Tray 268 Assisting During Surgery 269 Disposition of Instruments and Materials Refractive Surgery Concepts and Procedures 273 David A. Goldman MD History of Refractive Surgery 274 Indications and Contraindications for Refractive Surgical Procedures 274 Evaluating Refractive Surgical Patients 274 Refraction in Myopia 274 Refraction in Hyperopia 275 Refraction in Astigmatism 275 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 Laser In Situ Keratomileusis 276 Photorefractive Keratectomy 277 Laser Subepithelial Keratomileusis 277 EPI-LASIK 277 Astigmatic Keratotomy 277

7 CONTENTS ix Conductive Keratoplasty and Laser Thermokeratoplasty 278 Intrastromal Corneal Ring Segments 278 Phakic Intraocular Lenses 279 In Review 281 Coding for Ophthalmology Office Visits 294 Eye Codes 294 Ophthalmic Coding Specialist 295 In Review Understanding Practice Management 283 Sue J. Vicchrilli, COT, OCS Morgan L. Taylor III, CPA, COE Emanuel Newmark, MD, FACS The Ophthalmic Practice and You 283 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 Compliance 290 Coding 291 Coding Systems 291 The Benefits of Proper Coding 292 Documentation 293 About ICD Code Linking and Medical Necessity Medical Ethics, Legal Issues, and Regulatory Issues 297 William H. Ehlers, MD History 297 Code of Ethics of the Academy 298 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 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 Major Causes of Reversible and Irreversible Blindness 309 VISION 2020: The Right to Sight 309 Strategies for Improving Utilization of Eye Care 310 Local Delivery of Health Education Information 310 Screening Programs 310 Surgical Programs 311

8 x CONTENTS Community Eye Care Programs and the Team Approach 312 Keratometer Local Resources Available to Assist Visually Impaired Patients 312 Slit Lamp 320 Projector Care of Ophthalmic Lenses and Instruments Applanation Tonometer 323 Indentation Tonometer 323 Tono-Pen 315 Indirect Ophthalmoscope Perimeters Standard Guidelines for Care of Lenses 316 Lenses That Contact the Eye 316 Care of Instruments 318 Standard Care Guidelines 318 Retinoscope Potential Acuity Meter Lenses That Do Not Contact the Eye 324 Direct Ophthalmoscope 324 Lindreth G. DuBois, MEd, MMSc, CO, COMT Care of Lenses 320 Lasers Answers to Chapter Self Assessment Tests Appendix A: Glossary Phoropter 319 Appendix B: Resources Lensmeter 319 Index