The Wills Eye Hospital Atlas  of Clinical Ophthalmology       Second Edition 2001 Lippincott Williams & Wilkins Philadelphia 530 Walnut Street, Philadelphia, PA 19106 USA, http://www.lww.com/ 0-7817-2774-X All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission for the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data The Wills Eye Hospital atlas of clinical ophthalmology / edited by William Tasman, Edward A. Jaeger; associate editors, James J. Augsburger … [et al.].—2nd ed. p.; cm. Includes bibliographical references and index. ISBN 0-7817-2774-X 1. Eye—Diseases—Atlases. 2. Ophthalmology—Atlases. I. Title: Atlas of clinical ophthalmology. II. Tasman, William, 1929–III. Jaeger, Edward A. IV. Wills Eye Hospital (Philadelphia, Pa.) [DNLM: 1. Eye Diseases—Atlases. WW 17 W741 2001] RE71.W55 2001 617.7′1—dc21 2001020374 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. 10 9 8 7 6 5 4 3 2 1 Dedication To the past and present members of the Wills Eye Hospital Attending, Resident, and Fellow staffs whose dedication to patient care, teaching, and sharing of knowledge has been the hallmark of Wills since 1832. Jefferson Medical College, Thomas Jefferson University; Director, Cornea Service, Wills Eye Hospital, Philadelphia, Pennsylvania Chapter 1 Helen V. Danesh-Meyer F.R.A.C.O. Discipline of Ophthalmology, University of Auckland, Auckland, New Zealand Valsalva induced boat-shaped sub-hyaloid hemorrhage overlying the macula of a Chapter 9 23-year-old lifeguard, sustained while struggling to launch his lifeboat into a David H. Fischer M.D. rough Jersey shore surf. Edited by Associate Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Associate Ophthalmologist, Hospital of the University of William Tasman M.D. Pennsylvania; Associate Surgeon, Director of Uveitis, Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania Professor and Chairman Department of Ophthalmology, Jefferson Medical College, Chapter 8 Thomas Jefferson University; Ophthalmologist-in-Chief, Wills Eye Hospital, Philadelphia, Pennsylvania Joseph C. Flanagan M.D. Professor of Ophthalmology Edward A. Jaeger M.D. Jefferson Medical College, Thomas Jefferson University; Professor of Ophthalmology Director, Oculoplastic Service, Wills Eye Hospital, Philadelphia, Jefferson Medical College, Thomas Jefferson University; Pennsylvania Attending Surgeon, Wills Eye Hospital, Philadelphia, Chapter 10 Pennsylvania Associate Editors Peter R. Laibson M.D. Professor of Ophthalmology James J. Augsburger M.D. Jefferson Medical College, Thomas Jefferson University; Co- Director, Cornea Department, Wills Eye Hospital, Philadelphia, Professor and Chairman Pennsylvania Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Ophthalmologist-in-Chief, The Chapter 1 University Hospital, Cincinnati, Ohio Robert A. Mazzoli M.D., F.A.C.S. Chapter 7 Clinical Assistant Professor Jonathan B. Belmont M.D. Surgery (Ophthalmology), Uniformed Services University of the Health Sciences; Chairman, Ophthalmology; Director, Associate Surgeon Ophthalmic Plastic, Reconstructive, and Orbital Surgery, Retina Department; Co-Director, Uveitis Service, Retina Madigan Army Medical Center, Tacoma, Washington Department, Wills Eye Hospital, Philadelphia, Pennsylvania Chapter 10 Chapter 8 Christopher J. Rapuano M.D. William E. Benson M.D. Associate Professor of Ophthalmology Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Co- Jefferson Medical College, Thomas Jefferson University; Director, Refractive Surgery, Cornea Service, Wills Eye Hospital, Director, Retina Service, Wills Eye Hospital, Philadelphia, Philadelphia, Pennsylvania Pennsylvania Chapter 1 Chapter 4 Carl D. Regillo M.D. Gary C. Brown M.D. Associate Professor of Ophthalmology Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Jefferson Medical College, Thomas Jefferson University; Associate Surgeon, Wills Eye Hospital, Philadelphia, Director, Retina Vascular Unit, Wills Eye Hospital, Philadelphia, Pennsylvania Pennsylvania Chapter 4 Chapter 5 Peter J. Savino M.D. Joseph H. Calhoun M.D. Professor of Ophthalmology Chief Jefferson Medical College, Thomas Jefferson University; Pediatric Ophthalmology, Wills Eye Hospital, Philadelphia, Director, Neuro-Ophthalmology Service, Wills Eye Hospital, Pennsylvania Philadelphia, Pennsylvania Chapter 11 Chapter 9 Elisabeth J. Cohen M.D. Bruce M. Schnall M.D. Professor of Ophthalmology Associate Surgeon Pediatric Ophthalmology, Wills Eye Hospital, Philadelphia, Neal H. Atebara M.D. Pennsylvania Assistant Clinical Professor Chapter 11 Department of Surgery, University of Hawaii School of Medicine, Retina Center of Hawaii; Staff Surgeon, Ophthalmology, Queen's Carol L. Shields M.D. Medical Center, Honolulu, Hawaii Associate Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Augusto Azuara-Blanco M.D., Ph.D. Attending Surgeon, Ocular Oncology, Wills Eye Hospital, Consultant Ophthalmic Surgeon Philadelphia, Pennsylvania Aberdeen Royal Infirmary, Aberdeen, United Kingdom Chapter 6 Chapter 3 Jerry A. Shields M.D. Edward H. Bedrossian Jr. M.D., F.A.C.S. Professor of Ophthalmology Assistant Professor Jefferson Medical College, Thomas Jefferson University; Department of Ophthalmology, Jefferson Medical College, Director, Oncology Service, Wills Eye Hospital, Philadelphia, Thomas Jefferson University; Attending Surgeon, Oculoplastic Pennsylvania Surgery Department, Wills Eye Hospital, Philadelphia, Chapter 6 Pennsylvania Chapter 10 S. Gregory Smith M.D. Attending Surgeon Ralph C. Eagle Jr. M.D. Cataract and Primary Eye Care Services, Wills Eye Hospital, Director Philadelphia, Pennsylvania Department of Pathology; The Noel T. and Sara L. Simmonds Chapter 2 Professor of Ophthalmic Pathology, Wills Eye Hospital; Professor of Ophthalmology and Pathology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania George L. Spaeth M.D. Chapter 2 Louis J. Esposito Glaucoma Research Professor Jefferson Medical College; Director, Glaucoma Service, Wills Eye Hospital, Philadelphia, Pennsylvania Jeffrey D. Henderer M.D. Chapter 3 Assistant Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Assistant Surgeon, Wills Eye Hospital, Philadelphia, Secondary Editors Pennsylvania Chapter 3 Jonathan Pine Acquisitions Editor Edward A. Jaeger M.D. Kerry Barrett Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Developmental Editor Attending Surgeon, Wills Eye Hospital, Philadelphia, Janice Stangel Pennsylvania Production Editor Chapter 2 Penny Bice L. Jay Katz M.D. Production Editor Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Colin Warnock Attending Surgeon, Wills Eye Hospital, Philadelphia, Manufacturing Manager Pennsylvania Mark Lerner Chapter 3 Cover Designer Marlene R. Moster M.D. Maryland Composition Professor of Ophthalmology Compositor Jefferson Medical College, Thomas Jefferson University; Attending Surgeon, Glaucoma Service, Wills Eye Hospital, Philadelphia, Pennsylvania Chapter 3 Jonathan S. Myers M.D. Instructor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Assistant Surgeon, Wills Eye Hospital, Philadelphia, Pennsylvania Two retinal tears in the superior arcade and a macular hole secondary to trauma Chapter 3 in a mentally challenged 17-year-old with head-banging tendencies. Contributors Robert B. Penne M.D. Instructor Ophthalmology, Jefferson Medical College, Thomas Jefferson University; Associate Surgeon, Oculoplastic Department, Wills Eye Hospital, Philadelphia, Pennsylvania Chapter 10 Douglas J. Rhee M.D. Assistant Professor Department of Ophthalmology, Jefferson Medical College, Thomas Jefferson University; Assistant Surgeon, Wills Eye Hospital, Philadelphia, Pennsylvania Chapter 3 Mary A. Stefanyszyn M.D. Clinical Instructor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Associate in Surgery, Wills Eye Hospital, Philadelphia, Pennsylvania Chapter 10 William Tasman M.D. Professor and Chairman Department of Ophthalmology, Jefferson Medical College, Thomas Jefferson University; Ophthalmologist-in-Chief, Wills Eye Hospital, Philadelphia, Pennsylvania Chapters 2 and 5 Annette K. Terebuh M.D. Private Practice Bellefontaine, Ohio Chapter 3 Richard P. Wilson M.D. Professor of Ophthalmology Jefferson Medical College, Thomas Jefferson University; Attending Surgeon, Glaucoma, Wills Eye Hospital, Philadelphia, Pennsylvania Chapter 3 Preface Persistent tunica vasculosis in a premature infant with retinopathy of prematurity. As this second edition goes to press, Wills is moving to its fourth home during its 168-year history. Thus, it is an exciting time and perhaps fitting that this second edition is being published as this transition is being made. In the first edition, we pointed out how many artists have focused on the eye as almost a theme in many of their paintings. Eye disorders, as a matter of fact, can be traced to artists such as Monet who developed cataracts. During the development of these cataracts, his portrayal, for example, of the Japanese footbridge at his home in Giverny, changed considerably. What has not changed, however, is the importance of visual illustrations of eye diseases. Since our first edition, it has now become quite common to store these images on computer disks, which facilitates storage and organization of the material. As these changes take place, Wills medical staff continues to contribute to the literature and to the collection of photographs in our archives. The second edition of this Atlas contains 11 chapters and over 1400 illustrations, which cover ocular conditions from the front of the eye to the back. As before, we have developed a CD-ROM version of the Atlas complete with animation and voice over, which has been expanded from the first edition. We hope that readers will find this second effort a helpful resource. Acknowledgments Serpiginous choroiditis in a 49-year-old male who was visually symptomatic for 15 months. Vision in the right eye was 20/200. (Photograph courtesy of Jay Klancnik, M.D. and Mary Jude Cox, M.D.). The editors would like to gratefully acknowledge all the individuals who contributed to the initial development of this textbook and to those who participated in this second edition. This includes members of the Wills Eye Hospital staff as well as members of our private office staffs. Without their assistance in manuscript preparation, slide discovery, and information gathering, the textbook would not have been produced in such a timely fashion. Daniel P. Montzka, M.D., a wizard on the computer, provided invaluable assistance in the initial editing of the printed manuscript and continues to be extremely in strumental in revising the companion CD-ROM. Ralp h C. Eagle, Jr., M.D., provided many of the histopathology slides, descriptions, and clinical-pathologic correlations. He has added considerable material to the CD-ROM version of the second edition. We are also grateful to Neal Atebara, M.D., for providing illustrations throughout the text and coordinating the optics section in the CD-ROM. We would esp ecially like to thank Robert E. Curtin II, Jack Sc ully, and Roger Barone of the Wills Eye Hospital Audio Visual Department for their dedicated efforts in coordinating the illustrations as well as assisting in preparation of the CD-ROM. Finally, we would like to express our appreciation to the staff of Lippincott, Williams & Wilkins for their invaluable assistance in the development of this textb ook. Developmental Editor K erry Barrett provided expert edit orial assistance and was always readily available. Without her pleasant and persistent attention to detail and her editorial expertise, the end product would have been much more difficult to attain. J. Stuart Freeman, Jr., the irrepressible retiring Senior Editor at Lippincott, originally suggested the idea of compiling the extensive and varied Wills Eye Hospital Clinical experience in th e form of an atlas. Present Senior Executive Editor, Jonathan Pine, has c ontinued Stuart's tradition and has been very supportive. We greatly appreciated the encouragement and direction of these individuals and we hope this second edition continues to justify their confidence. Contents Dedication Authors Preface Acknowledgments Contents Chapter 1 External Diseases Chapter 2 Lens Chapter 3 Glaucoma Chapter 4 Vitreoretinal Disorders Chapter 5 Retinal Vascular Disease Chapter 6 Tumors of the Uveal Tract Chapter 7 Retinal Tumors Chapter 8 Intraocular Inflammation Chapter 9 Neuro-ophthalmology Chapter 10 Oculoplastics Chapter 11 Pediatric Ophthalmology Subject Index P.1 Chapter 1 External Diseases Elisabeth J. Cohen Christopher J. Rapuano Peter R. Laibson Recurrent lattice corneal dystrophy in a corneal transplant before (A) and after (B) excimer laser phototherapeutic keratectomy.