Ophthalmology Secrets in Color

OPHTHALMOLOGY IN COLOR

OPHTHALMOLOGY IN COLOR Third Edition

James F. Vander, MD

Attending Surgeon, Retina Service Wills Eye Institute Clinical Professor of Ophthalmology Thomas Jefferson University Philadelphia, Pennsylvania

Janice A. Gault, MD, FACS

Associate Surgeon, Cataract and Primary Eye Care Service Wills Eye Institute Assistant Clinical Professor of Ophthalmology Thomas Jefferson University Philadelphia, Pennsylvania Eye Physicians PC Voorhees, New Jersey

1600 John F. Kennedy Boulevard, Suite 1800 Philadelphia, PA 19103-2899

Ophthalmology Secrets in Color Third Edition

ISBN-13: 978-0-323-03469-2 ISBN-10: 0-323-03469-1

Copyright 2007, 2002 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the publisher (Mosby, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899).

NOTICE Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editor assumes any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book.

Library of Congress Cataloging-in-Publication Data Ophthalmology secrets in color / [edited by] James F. Vander, Janice A. Gault. – 3rd ed. p.; cm. – (The secrets series) Rev. ed. of: Ophthalmology secrets. Includes bibliographical references and index. ISBN 0-323-03469-1 1. Ophthalmology–Miscellanea. 2. Eye–Diseases–Miscellanea. I. Vander, James F., 1960- II. Gault, Janice A. III. Ophthalmology secrets. IV. Series. [DNLM: 1. Eye Diseases–Examination Questions. WW 18.2 O612 2007] RE48.O666 2007 617.70 0076–dc22 2006046682 Senior Acquisitions Editor: James Merritt Developmental Editor: Stan Ward Project Manager: Mary Stermel Marketing Manager: Alyson Sherby

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DEDICATION To Caroline Anna, William Henry, and Eliza Avery

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CONTRIBUTORS Brandon D. Ayres, MD Corneal Associates PC, Wills Eye Institute, Philadelphia, Pennsylvania

Augusto Azuara-Blanco, MD, PhD, FRCS(Ed) Consultant Ophthalmic Surgeon and Honorary Senior Lecturer, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, United Kingdom

Robert S. Bailey, Jr., MD Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Attending Surgeon, Wills Eye Institute; Attending Surgeon, Chestnut Hill Hospital, Philadelphia, Pennsylvania

Vincent F. Baldassano, Jr., MD Department of Ophthalmology, Temple University, Philadelphia, Pennsylvania

Caroline R. Baumal, MD Department of Ophthalmology, Tufts University School of Medicine; Residency Director, Division of Vitreoretinal Diseases and Surgery, New England Eye Center, Boston, Massachusetts

Edward H. Bedrossian, Jr., MD Associate Clinical Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Chief, Oculoplastic and Reconstructive Surgery Division, Temple University Hospital; Associate Surgeon, Oculoplastic Surgery Department; Founding Director, Fascia Lata Bank, Wills Eye Institute, Philadelphia, Pennsylvania

Jurij R. Bilyk, MD Oculoplastic and Orbital Surgery Service, Wills Eye Institute; Parkview Eye Care Center, Philadelphia, Pennsylvania

Jeffrey P. Blice, MD Uniformed Services Health Sciences University; National Naval Medical Center, Bethesda, Maryland

Michael J. Borne, MD Department of Ophthalmology, University of Mississippi School of Medicine, Jackson, Mississippi

Steven E. Brooks, MD Eye Consultants of Augusta, Martinez, Georgia

David G. Buerger, MD Department of Ophthalmology, University of Pittsburgh Medical Center; Pittsburgh Oculoplasty Associates, Pittsburgh, Pennsylvania

Elisabeth J. Cohen, MD Corneal Associates PC, Wills Eye Institute, Philadelphia, Pennsylvania

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xii CONTRIBUTORS Marc S. Cohen, MD Associate Surgeon, Wills Eye Institute, Philadelphia, Pennsylvania

Mary Jude Cox, MD Instructor, Glaucoma Service, Wills Eye Institute, Philadelphia, Pennsylvania; Eye Physicians PC, Voorhees, New Jersey

Patric De Potter, MD Professor and Chairman, Department of Ophthalmology, Cliniques Universitaires St.-Luc, Universite´ Catholique de Louvain, Brussels, Belgium

Vinay N. Desai, MD Department of Ophthalmology, Washington Hospital Center, Washington, DC

John D. Dugan, Jr., MD Associate Surgeon and Codirector Refractive Surgery Department, Wills Eye Institute, Philadelphia, Pennsylvania; Eye Physicians PC, Voorhees, New Jersey

Jay S. Duker, MD New England Eye Center, Boston, Massachusetts

Ralph C. Eagle, Jr., MD Director, Department of Pathology, Noel T. and Sara L. Simmonds Professor of Ophthalmic Pathology, Wills Eye Institute; Professor of Ophthalmology and Pathology, Thomas Jefferson University, Philadelphia, Pennsylvania

Mitchell S. Fineman, MD Assistant Surgeon, Wills Eye Institute; Assistant Professor of Ophthalmology, Thomas Jefferson University, Philadelphia, Pennsylvania

Janice A. Gault, MD, FACS Associate Surgeon, Cataract and Primary Eye Care Service, Wills Eye Institute; Assistant Clinical Professor of Ophthalmology, Thomas Jefferson University, Philadelphia, Pennsylvania; Eye Physicians PC, Voorhees, New Jersey

Roberta E. Gausas, MD Department of Ophthalmology, University of Pennsylvania Medical School; Scheie Eye Institute, Philadelphia, Pennsylvania

Kenneth B. Gum, MD Section Chief, Department of Ophthalmology, Munson Medical Center, Transverse City, Michigan

Sadeer B. Hannush, MD Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Cornea Service, Wills Eye Institute, Philadelphia, Pennsylvania

Jeffrey D. Henderer, MD Assistant Professor of Ophthalmology, Thomas Jefferson University School of Medicine; Assistant Surgeon, Wills Eye Institute Glaucoma Service, Philadelphia, Pennsylvania

Philip G. Hykin, FRCS, FRCOphth Surgeon, Medical Retina Service, Moorfields Eye Institute, London, United Kingdom

Anup Khatana, MD Cincinnati Eye Institute, Cincinnati, Ohio

CONTRIBUTORS xiii

Terry Kim, MD Associate Professor of Ophthalmology, Duke Medical Center; Director of Fellowship Programs, Duke University Eye Center, Durham, North Carolina

Stephen Y. Lee, MD Cornea Service, Wills Eye Institute; Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania

Joseph I. Maguire, MD, FACS Assistant Professor, Thomas Jefferson University Hospital; Wills Eye Institute, Philadelphia, Pennsylvania

J. Arch McNamara, MD Retinovitreous Associates, Ltd., Wyndmoor, Pennsylvania

Marlene R. Moster, MD Wills Eye Institute Glaucoma Service, Philadelphia, Pennsylvania

Leonard B. Nelson, MD Associate Professor of Ophthalmology and Pediatrics, Jefferson Medical College of Thomas Jefferson University; Codirector of Pediatric Ophthalmology, Wills Eye Institute, Philadelphia, Pennsylvania

Scott E. Olitsky, MD Children’s Mercy Hospital and Clinics, Kansas City, Missouri

Robert B. Penne, MD Associate Professor of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Codirector of Oculoplastic Surgery Department, Wills Eye Institute; Chief of Ophthalmology, Lankenau Hospital, Philadelphia, Pennsylvania

Julian D. Perry, MD Section Head, Department of Ophthalmic Plastic and Orbital Surgery, The Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio

Irving Raber, MD Clinical Assistant Professor of Ophthalmology, Scheie Eye Institute at Presbyterian Medical Center, University of Pennsylvania School of Medicine; Clinical Assistant Professor of Ophthalmology, Thomas Jefferson University School of Medicine; Clinical Associate Professor of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania

Christopher J. Rapuano, MD Corneal Associates, Wills Eye Institute, Philadelphia, Pennsylvania

Sherman W. Reeves, MD, MPH Minnesota Eye Consultants, Minneapolis, Minnesota

Robert D. Reinecke, MD Professor of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Wills Eye Institute, Philadelphia, Pennsylvania

Carolyn S. Repke, MD Philadelphia Eye Associates, Philadelphia, Pennsylvania

Douglas J. Rhee, MD Assistant Professor, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts

xiv CONTRIBUTORS Lorena Riveroll, MD Department of Ophthalmology, Cornea Service, Asociacio´n Para Evitar la Ceguera en Mexico, Mexico City, Mexico

Peter J. Savino, MD Professor of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director, Neuro-ophthalmology Service, Wills Eye Institute, Philadelphia, Pennsylvania

Barry Schanzer, MD Department of Ophthalmology, Jefferson Medical Center, Philadelphia, Pennsylvania

Bruce M. Schnall, MD Associate Surgeon, Pediatric Ophthalmology, Wills Eye Institute, Philadelphia, Pennsylvania; Clinical Assistant Professor, Department of Surgery, Robert Wood Johnson Medical School, Piscataway, New Jersey

Carol L. Shields, MD Attending Surgeon, Ocular Oncology Service, Wills Eye Institute; Professor of Ophthalmology, Jefferson Medical School of Thomas Jefferson University, Philadelphia, Pennsylvania

Jerry A. Shields, MD Director, Oncology Service, Wills Eye Institute; Professor of Ophthalmology, Jefferson Medical School of Thomas Jefferson University, Philadelphia, Pennsylvania

Sobha Sivaprasad, FRCS Moorfields Eye Institute, London, United Kingdom

Nancy G. Swartz, MS, MD Associate Surgeon, Wills Eye Institute, Philadelphia, Pennsylvania

George L. Spaeth, MD Attending Surgeon, Glaucoma Service, Wills Eye Institute; Professor of Ophthalmology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania

Janine G. Tabas, MD Cataract and Primary Eye Care Service, Wills Eye Institute, Philadelphia, Pennsylvania

Madhura Tamhankar, MD Department of Ophthalmology, University of Pennsylvania Medical School; Scheie Eye Institute, Philadelphia, Pennsylvania

William Tasman, MD Ophthalmologist-in-Chief, Wills Eye Institute; Professor and Chairman, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania

Richard Tipperman, MD Cataract and Primary Eye Care Service, Wills Eye Institute, Philadelphia, Pennsylvania

Sydney Tyson, MD, MPH Attending Surgeon, Cataract and Primary Care Eye Care Service, Wills Eye Institute, Philadelphia, Pennsylvania

James F. Vander, MD Attending Surgeon, Retina Service, Wills Eye Institute; Clinical Professor of Ophthalmology, Thomas Jefferson University, Philadelphia, Pennsylvania

CONTRIBUTORS xv

Tamara R. Vrabec, MD Associate Eye Surgeon, Wills Eye Institute; Associate Professor, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania; Lehigh Eye Specialists PC, Allentown, Pennsylvania

Richard P. Wilson, MD Professor of Ophthalmology, Thomas Jefferson University School of Medicine; Attending Surgeon and Codirector, Wills Eye Institute Glaucoma Service, Philadelphia, Pennsylvania

Vernon K. W. Wong, MD Assistant Clinical Professor, Division of Ophthalmology, Department of Surgery, University of Hawaii School of Medicine, Honolulu, Hawaii

PREFACE Much of the information in this book can be found in a number of other ophthalmology textbooks. The table of contents is similar to that of many other books already in print. So why bother to write a new ophthalmology text? The value of the book is in the unique manner in which the material is presented, continuing the tradition the Secrets SeriesW has established in numerous other specialties. The question-and-answer ‘‘Socratic method’’ format reflects the process by which a large portion of clinical medical education actually takes place. Our purpose is not to displace the comprehensive textbooks of ophthalmology from the shelves of clinicians and students. Instead, we hope that we have filled a useful spot beside them. We greatly appreciate the efforts of the talented contributors who have shared their wisdom and experiences to help fill this void. We have received much positive feedback on the first two editions of this book. This third edition includes many more color figures as well as the helpful study aids of the Top 100 Secrets and Key Points. We have enjoyed updating Ophthalmology Secrets, and we hope that clinicians and students will enjoy this book and find it valuable. James F. Vander, MD Janice A. Gault, MD, FACS

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TOP 100 SECRETS These secrets are100 of the top board alerts.They summarize the concepts, principles, and most salient details of ophthalmology.

1. Corneal opacification in a neonate has a differential diagnosis of STUMPED: sclerocornea, trauma, ulcers, metabolic disorder, Peter’s anomaly, endothelial dystrophy, and dermoid. 2. A break in Bruch’s membrane is necessary for a choroidal neovascular membrane to form. 3. Posterior fractures most commonly occur in the posteromedial orbital floor. 4. Eyelid trauma that reveals orbital fat has, by definition, violated the orbital septum. 5. The goal of refractive correction is to place the circle of least confusion on the retina. 6. To find the spherical equivalent of an astigmatic correction, add half the cylinder to the sphere. 7. Recheck the axial lengths if the A-scan measures less than 22 mm or more than 25 mm, or if there is more than a 0.3 mm difference between the two eyes. For each 1 mm in error, the calculation is off by 2.5 diopters (D). Recheck keratometry readings if the average K power is 47 D, or if there is a difference of more than 1 D between eyes. For every 0.25 D error, the calculation is in error of 0.25 D. 8. According to Kollner’s rule, retinal diseases cause acquired blue-yellow color vision defects, whereas optic nerve diseases affect red-green discrimination. 9. Ultrasound findings of low-to-medium internal reflectivity and collar-button shape can confirm diagnosis of a choroidal melanoma and differentiate it from other choroidal lesions. 10. A junctional scotoma is a unilateral central scotoma associated with a contralateral superotemporal field defect and is caused by compression of the contralateral optic nerve near the chiasm. 11. False-negative errors cause a visual field to appear worse than it actually is. False-positive errors cause a visual field to look better than it actually is. 12. Lesions anterior to the optic chiasm cause unequal visual acuity, a relative afferent papillary defect, and color abnormalities. The optic disc may also have asymmetric cupping and pallor. 13. Always check the pressure in the contralateral eye in a patient with ocular trauma. Asymmetrically low intraocular pressure may be an important clue to a potential ruptured globe. 14. A drop of 2.5% neosynephrine is a simple test to distinguish between episcleritis (these vessels will blanch) and scleritis (these vessels do not)—two entities with very different prognoses and evaluations. Because 50% of patients with scleritis have systemic disease, referral to an internist is necessary for further evaluation.

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2 TOP 100 SECRETS 15. A patient with a corneal abrasion from a dirty source (contact lens use, tree branch) is at risk for a corneal ulcer and should not be patched while healing. 16. Immediately irrigate any patient with a chemical ocular injury from an alkali or acid, even before checking visual acuity. 17. Recurrent subconjunctival hemorrhages should be evaluated to rule out uncontrolled hypertension or blood dyscrasias. 18. A corneal ulcer is infectious until proven otherwise. You are never wrong to culture an ulcer, and any ulcer not responding to therapy should be recultured. 19. Systemic treatment is necessary for gonococcal, chlamydial, and herpetic neonatal conjunctivitis due to the potential for serious disseminated disease. The mother and her sexual partners must be evaluated for other sexually transmitted diseases. 20. Treatments that are effective for prophylaxis of gonococcal and chlamydial neonatal conjunctivitis include 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline. Silver nitrate is rarely used, however, due to its potential for causing chemical conjunctivitis. 21. Topical steroids may promote herpetic keratitis if viral shedding is coincident with administration. 22. Steroid-induced increases in intraocular pressure occur in about 6% of patients on topical dexamethasone. This risk is higher in patients with known glaucoma or a family history of glaucoma. 23. Ask about gastric bypass procedures in patients who have recent severe dry eye with no discernible cause. Vitamin A deficiency may be the reason. 24. Treat patients for dry eye if they are symptomatic even if their exam is normal. Rose bengal stain will show signs of dry eye earlier than fluorescein stain. 25. If a patient presents with symptoms consistent with recurrent corneal erosion syndrome but no findings of the same, look for an underlying dystrophy, specifically epithelial basement membrane dystrophy. 26. If a patient with a corneal dystrophy is undergoing corneal transplantation but also has a clinically significant cataract, consider staging the cataract extraction a few months after the corneal transplant, offering the patient the advantage of better intraocular lens power calculation and postoperative refractive result. Alternatively, Descemet stripping endothelial keratoplasty (DSEK), which does not alter corneal contour, may be combined with cataract surgery with a predictable refractive outcome. 27. Keratoconus is found more frequently in atopic and Down syndrome patients, possibly related to eye rubbing. All keratoconus patients should be advised to avoid eye rubbing. 28. Most patients with keratoconus can be managed successfully with contact lens wear. Corneal transplantation is highly successful in treating keratoconus patients whose visual needs cannot be satisfied by spectacle or contact lens correction. 29. If there are significant complications with refractive surgery in the first eye, do not proceed with refractive surgery in the fellow eye on the same day.

TOP 100 SECRETS 3 30. As many as 30–50% of individuals with glaucomatous optic nerve damage and visual field loss have an initial intraocular pressure measurement less than 22 mmHg. 31. The treatment of both primary open-angle glaucoma (POAG) and low tension glaucoma (LTG) aims to preserve vision and quality of life through the lowering of intraocular pressure. 32. When evaluating a patient with angle closure glaucoma, it is important to look at the fellow eye. Except for cases of marked anisometropia, the fellow eye should have a similar anterior chamber depth and narrow angle. If it does not, consider other nonrelative papillary block mechanisms of angle closure. 33. Lens-induced glaucoma includes phacomorphic, phacolytic, phacoanaphylactic, and lens-particle glaucoma. 34. Patients with sporadic inheritance of aniridia need to be evaluated for Wilms’ tumor, which is associated with 25% of cases. 35. The prostaglandin analogs are the most potent topical intraocular pressure-lowering medications, have a favorable side-effect profile, and are easy to use. However, prostaglandin analogs and miotics are contraindicated in any type of inflammatory glaucoma. 36. Topical medication allergy can present months to years after starting the drop. 37. If a patient’s glaucoma continues to worsen, even with seemingly reduced intraocular pressure during office visits, think noncompliance. 38. Adrenergic agonists except for apraclonidine are absolutely contraindicated in infants. Apraclonidine should be used only as a last resort in healthy infants. 39. Before trabeculectomy surgery, detect high risk patients in whom sudden hypotony should be avoided: those with angle-closure glaucoma, shallow anterior chambers, very high preoperative IOP, or elevated episcleral venous pressure or high myopia. Hemorrhagic choroidals and expulsive hemorrhages are more likely. 40. Patients with traumatic ocular injuries must be evaluated for systemic injuries as well. 41. Patients recovering from a traumatic hyphema are at increased risk for glaucoma and retinal detachments in the future. They need ongoing ophthalmic evaluation for the rest of their lives. 42. Complete evaluation by a pediatrician is mandatory for any infant with a congenital cataract. 43. Patients must have a documented interference in quality of life from a visual standpoint before cataract surgery is indicated. 44. Topical anesthesia allows the surgical patient to recover functional vision more quickly and decreases the risk of some complications compared with retrobulbar anesthesia. 45. Glare testing can reveal significant functional visual problems not noted by Snellen testing. 46. When complications result in the unplanned decision to place an intraocular lens in the ciliary sulcus, remember to lower the power of the implant approximately 0.5 D from what was chosen for capsular fixation to compensate for the more anterior location of the lens.

4 TOP 100 SECRETS 47. If amblyopia is associated with an afferent pupillary defect, a lesion of the retina or optic nerve should be suspected and ruled out. 48. Although amblyopia is most effectively treated prior to age 6 years, treatment can be successful at older ages if compliance is good. Atropine penalization can be as effective as patching in the treatment of mild and moderate amblyopia. 49. Treat amblyopia prior to surgery for esotropia. 50. Early treatment for congenital esotropia gives the best chance for the development of binocular vision. Be certain that a patient with a partial accommodative esotropia is wearing the maximum tolerated hyperopic prescription. 51. Check the light reflex test and cover test to determine if a true deviation exists. If the light reflex is in the appropriate place and there is no refixation on cover testing, the patient is orthophoric. 52. A young patient with asthenopia should be evaluated for exophoria at near (convergence insufficiency) as well as checking his or her cycloplegic refraction for undercorrected hyperopia (accommodative insufficiency). 53. Any patient with chronic progressive external ophthalmoplegia needs an electrocardiogram to rule out heart block. These patients may need a pacemaker to prevent sudden death. 54. A patient with acute onset of any combination of III, IV, V, and VI cranial nerve palsies; extreme headache; and decreased vision must be immediately placed on intravenous steroids and referred to neurosurgery for pituitary apoplexy. 55. The signs of endophthalmitis typically appear 1–4 days after strabismus surgery and include lethargy, asymmetric eye redness, eyelid swelling, and fever. 56. When performing a recess-resect procedure, the recession should be done first. 57. Try for fusion of all patients with nystagmus. Aim for exophoria with fusion. 58. All patients with anisocoria need to have their pupils measured in both dim and bright illumination. 59. Smoking is a controllable risk factor for thyroid eye disease. 60. All patients with optic neuritis should experience some improvement in vision. However, 5% of patients who presented with visual acuity of less than 20/200 were still 20/200 or less at 6 months. 61. An abnormal MRI in a patient with optic neuritis is the strongest predictor of developing multiple sclerosis (MS). Fifty-six percent of patients with optic neuritis and a white matter lesion on MRI will develop MS at 10 years. 62. The closer a patient stands to a visual-field testing screen, the smaller the field should be. This is helpful in determining a malingering patient. 63. Any patient suspected of giant cell arteritis should immediately be started on intravenous steroids to prevent involvement of the other eye even if the temporal artery biopsy cannot be done beforehand.

TOP 100 SECRETS 5 64. The primary causes of tearing are dry eyes, lower eyelid laxity, and blockage of the lacrimal system. 65. Dacryocystitis must be treated emergently to prevent cellulitis or intracranial spread. 66. CT scanning is superior to MRI in most cases of orbital disease due to better bone-tissue delineation. 67. The most common cause of unilateral or bilateral proptosis is thyroid eye disease (Graves’ ophthalmopathy). 68. A child with rapidly progressive proptosis, inferior displacement of the globe, and upper eyelid edema should have immediate neuroimaging followed by an orbital biopsy to rule out rhabdomyosarcoma. 69. Suspect thyroid-related ophthalmopathy (TRO) in patients with nonspecific redness and inflammation of the eyes even if there is no history of a systemic thyroid imbalance. 70. Most patients with TRO will not require surgery for their disease; it will burn out with time and multiple office visits. 71. Surgical drainage should be undertaken in orbital cellulitis if sinuses are completely opacified, response to antibiotics is poor by 48–72 hours, vision decreases, or an afferent pupillary defect presents. 72. Mild ptosis associated with miosis and neck or facial pain should raise suspicion of a carotid artery dissection, prompting an urgent workup. 73. Acute ptosis and ocular misalignment mandate a careful evaluation of the pupil to rule out pupil-involving third-nerve palsy. A dilated pupil requires neurologic evaluation for a compressive aneurysm. 74. Basal cell carcinoma is the most common malignant eyelid tumor. It has a 3% mortality rate because of invasion to the orbit and brain via the lacrimal drainage system, prior radiation therapy, or clinical neglect. 75. Squamous cell carcinoma may metastasize systemically. 76. Keratoacanthomas often resolve spontaneously but should be removed surgically if near the lid margin to prevent permanent deformity. 77. A patient with a recurrent chalazion in the same spot must be evaluated for sebaceous cell carcinoma. 78. Young patients with xanthelasma should be evaluated for diabetes mellitus and hypercholesterolemia. 79. All patients who have anterior uveitis must have a dilated examination to exclude associated posterior segment disease. 80. Masquerade syndromes should be considered in the very young or elderly and in patients who have uveitis that does not respond to treatment. Uveitis in patients with AIDS is almost invariably part of a disseminated systemic infection. Lymphoma may masquerade as retinitis.

6 TOP 100 SECRETS 81. Early signs of chloroquine retinopathy are perifoveal retinal pigment epithelium changes. 82. Never aspirate subretinal exudates for diagnostic purposes in a patient with potential Coats disease unless retinoblastoma has been absolutely ruled out. 83. The five trauma-related breaks are horseshoe tears, operculated tears, dialyses, retinal dissolution, and macular holes. 84. The globe is most likely to rupture at the limbus, underneath a rectus muscle, or at a previous surgical site. 85. Age-related macular degeneration (ARMD) is the leading cause of legal blindness in the Western world. The leading epidemiologic risk factors for ARMD are increasing age, smoking, and genetic predisposition. 86. In the treatment of ARMD, therapeutic paradigms are shifting from destructive laser-based modalities to physiologic pharmacologic therapies such as inhibitors of vascular endothelial growth factor (VEGF). 87. Threshold disease of retinopathy of prematurity (ROP) is five contiguous or eight cumulative clock hours of stage 3 ROP in zone I or II in the presence of plus disease. 88. Patients who weigh