404 The Rack y r t a h c y s P i Antidepressants Sedative antidepressants are usually avoided and selective serotonin reupta ke inhibitors (SSRIs) are often 1st choice. Newer antidepessants to consider: ago- melatine , an agonist of melatonergic MT1 & MT2 receptors and antagonist of 5-HT2 receptors. It appe ars to resynchronize disturbed circadian rhythms and to reduces depression.523 It also caus es less sexual dysfunction compared with SSRIs (5% vs 62%).524 Venlafaxine and reboxetine m ay also have a role. In pa- tients with established winter recurrences, it is usual to inst igate treatment as soon as symptoms re-emerge in the autumn and to phase out treatment in s pring. For patients who also experience non-seasonal episodes, year-round prophylaxis may b e deployed, sometimes regularly increasing the antidepres- sant dose during the winter mont hs. 525 405 Community care Since the early 1980s, most UK inpatients with psychosis have had the focus of their care moved from hospital to the community. The aim has been to save money and impr ove care, but in the UK this policy is now being partly reversed. Has community care failed , or have there been successes? Five questions keep recurring, each (ominously) pre \201 x ed by a \200\230Surely \200 \200\231 1 Surely hospitals will always be needed for severel y affected people? In general, the problem is not the severity of the mental illness, but i ts social context which determines if community care is appropriate. 2 Surely community care, if it is done properly, will be more expensive than hospital care, where resources can be concentrated? Not so \200\224at least not necessarily so. Some conc entration of resources can take place in the com- munity in day hospitals and mental illnes s hostels. It is also true that the \200\230bed and breakfast \200\231 element of inpatien t care is expensive, if the running and maintenance costs associated with deploying inpatie nt psychiatric services are taken into account. In most studies, costs of each type of serv ice doesn \200\231t diff er much, and sometimes good community care turns out cheaper.526,5 27 3 Surely there will be more homicides and suicides if disturbed patients are not kept in hospital? Off ending by the mentally ill is of great public concern (60 homicides/yr in En gland). A cohort study however found rates of violent off ending are low and the strongest association with off ending was previ- ous off ending. Psychiatric variables were less impo rtant, with diagnosis and number of previous admissions showing no signi \201 cant associa tion. Substance misuse and sexual abuse are associated with increased off ending risk.528 y r t a i h c y s P 4 Surely if inpatient psychiatric beds are not available, however good the daytime team is in the community, some patients will still need some- where to go at night? The implication is that the skills available in bed-and- breakfast accommodation may be inadequate at time s of day when there is no other support, other than the general practitioner. Studies that have looked at this have certainly found an increase in non-hospital residential care in th ose selected for community care, and this increase may be as much as 280% over 5yrs. In the UK, new proposals guarantee 24-hour open access to skilled help, but it is not known what pressures this will put services under. 5 Surely community care will involve a huge bureauc racy in pursuit of the unattainable goal of 100% safety? This will be so if every patient h as a lengthy care plan and repeated risk assessments. Concern for safety may also spawn a n on-therapeutic custodial relationship. Advantages reported for community care are: better social functioning, satisfaction with li fe, employment, and drug compliance \200\224but in randomized studies in the UK these advan tages are not always manifest. Furthermore, trends have been repeatedly found indicating th at the longer studies go on for, the harder it is to maintain the initial advantages of com munity care. If it is hard for teams to keep up their enthusiasm during a trial, it will pr obably be even harder when the trial period has ended, or when team members are ill. These constraints may in part explain the observation that with inadequately funded and supervise d community care, patients can fail to get essential ser- vices, and when hospitals are bei ng run down, and a patient \200\231s condition wors- ens, so that \200\230sectioning \200 \231 followed by admission becomes impossible, the pa- tient is left in the community \200 \230rotting with his rights on \200\231. Assertive community care and case management is on e way out of this impasse (here a key-worker has direct responsibility for care plans). Thi s set-up helps ensure more people remain in contact with psychiatric services (NNT=15); thi s inevitably increases hospital admission rates.529,530 When combined with family therapy a nd social skills training results are good.531 Poverty and mental illness Social deprivation is positively associated with premature morta lity, and pov- erty makes almost all diseases more likely (but not Hodgkin \200\231s diseas e, eczema, bulimia, or melanoma).532 See Health and social class, p463. In the UK, the numb er of homeless people is 1 \200\2232 million. >30% suff er from mental illness (10% have sc hizophrenia), most do not know where to go for help, and most have no doctor. A 3-tier stra tegy may help. 1 Emergency shelters 2 Transitional accom- modation 3 Long-term housing. 406 The cost in health terms to society and the individual is enormous. Diseases and symptoms s uch as diarrhea, which may pass as a minor inconveniences to the well-housed, may be a majo r hurdle for the homeless, with severe social and psychological eff ects. Capture \200\223r ecapture techniques show that the unob- served population of the homeless is about twice th at observed. This method of enumeration collects samples (lists) and looks for tags (duplic ates) in sub- sequent counts, and from this determines the degree of under-counting. If all in the subsequent count are duplicates, then there is no underestimate of the original cou nt. Statistical techniques can allow for migration in and out of the population area.533 Th ese studies show that psychiatric morbidity is greatest in the observed homeless population s: the implication is that the psychiatric illness makes these people more \200\230visible \200\231. y r t a h c y s P In the UK, as in many other Western countries, what started out as an en- lightened policy of looking after people with mental health problems in the community (p405) has resulted in large numbers of psychiatric patients liv- ing on the street in great poverty \200\224reli eved by occasional admissions to often overcrowded acute units. This \200\230revolving doo r \200\231 model of care has failed many patients, not least because continuity of care is compromised. i One way to tackle poverty is to pay people not to be poor: in the 1990s, in Sin- gapore, po or families were paid SP$26,400 over 20yrs if they had \211 2 children. But economic succe ss in Singapore evolved independently534 from this idea which was perhaps too Quixotic (ie innocently impractical, see BOX). Income SupportUK is an income-related (means-tested) bene \201 t paid to those who do not have enough money to live on. Income is subtracted from a standard \201 xed income level (the \200\230applicable amount \200\231), and the diff e rence is the amount of Income Support payable. The person \200\231s capital is also taken i nto account. Income Support is a non-contributory bene \201 t. This means that a per- son does not have to have paid any National Insurance contributions in order to qualify for Inc ome Support. The rates of Income Support are \201 xed each year by government and are usu ally increased every April. Income Support acts as a \200\230passport \200\231 to certain other help. A claimant and her/his partner will automatically qualify for: \200 Free scho ol meals \200 Free prescriptions \200 Free dental care \200 Vouchers for spectacles \200 Free milk and vitamins for expectant mothers and children under 5 \200 Free vitamin s for nursing mothers \200 Maximum housing bene \201 t \200 Maximum council tax bene \201 t. Epidemiology There is no evidence that simply living in a deprived area makes a per son more prone to illness and death. All the excess mortality and morbidity is explained by the person being poor.535 Their immediate neigh- bours who are not poor do not share the s ame risk. So we need to target care at poor people wherever they live, not at poor areas. P overty, reoff ending, and mentally ill off enders536 Two contrasting ideas: 1 The economic arguments for keeping non-violent mentally ill criminals out of prison and rehabilitating t hem are self-evident. 2 Prison provides an ideal op- portunity to treat people who are ment ally ill who might otherwise be hard to reach. They should have optimum treatment to improv e their quality of life, as well as to lessen the risk of reoff ending. Nobility and mental illness: Don Quixote takes on all comers \201\201 407 7 3 5 \200\230The innkeeper acquainted all in the inn with the lunacy of his guest (Don Quixote) , about his standing vigil over his armor and the knighting he ex- pected. They marveled at so odd a form of madness and went to watch him at a distance, and saw that with a serene e xpression he sometimes pranced to and fro; at other times, leaning on his lance, he turned his eyes to his ar- mour without turning them away for a long time. Night had fallen; but t he moon shone with such a lustre as might almost vie with the sun who lent it; so that ever ything our new knight did was seen clearly by everyone. Just then it occurred to one of the mule-drivers in the inn to water his pack of mules, and for this it was necessary to move Don Quixote \200\231s armor, which was on the trough; our knight, seeing them approach, cal led in a booming voice: . r u o l a v d n a m s i o r e h : y b d e d u l e d y r t a i h c y s P \200\234Oh thou, whosoever thou art, reckless knight, who would touch the ar- mour of the most valiant knight whoever took up arms! Take heed what thou doest, and touch it not, unle ss thou wouldst pay for thy audacity with thy life. \200\235 s i e h The muleteer cared not a jot for this reasoning \200\224it would have been bet- ter for him if he had, for it meant caring for his health. Instead, picking the armor up by the straps , he tossed it a good distance. And seeing this, Don Quixote lifted his gaze to the skies a nd, turning his thoughts (as it seemed) to his lady Dulcinea, he said: s g n i h t y r e v \200\234Help me, my lady, in this the \201 rst insult aimed at this thy servant \200\231 s breast; e h t in this my \201 rst crisis let not thy grace and protection fail me. \200\235 And, continuing this line of argument, and dropping his shield, he raised his lance in both hands and gave the mule-driver such a clout on the head as to demolish him; if this \201 rst blow had been followed by a second, he would have had no need for a doctor ( \200\230m aestro \200\231) to cure him. Having done this, Don Quixote picked up his armor and began t o pace again with the same gravity as before. A short time later, unaware of what had happe ned \200\224for the \201 rst mule driver lay stunned \200\224a second approached, also in tending to water his mules, and when he began to remove the armor so as to get to the troug h, without so much as a by-your-leave or even a word, Don Quixote let slip his shield and r aised his lance, and without quite reducing the sec- ond mule-driver \200\231s head to smit hereens, he thrice sliced it, fracturing the skull in four places. When they heard the nois e, all the people in the inn hurried over, among them the innkeeper. When he saw this, Don Quixote took up his shield, placed his hand on his sword, saying: e u l a v o t s u s e h c a e t o h w t n a r r e - t h g i n k \200\234Oh queen of beauty, whose spark and \201 re warms the sickness in my heart (debi litado coraz n m o)! From your greatness, it is time that you do bend your eye on this th y slavish knight, who expects so vast an exploit. \200\235 c i t s i l a e d i And with this he acquired, it seemed to him, so much courage, that if all the mule-drivers in the world charged him he would never retreat one step. The wounded men \200\231s comrade s, seeing their two fallen friends, began to rain stones down on Don Quixote, and he did al l he could to de \202 ect them with his shield, not daring to move away from the trough an d leave his armor un- protected. The innkeeper implored them to stop as he had already told them the knight was mad, and whatever the number of deaths no wind of blame could ever ext inguish his innocence. \200\231538 Don Quijote de la Mancha539 by Miguel de Cervantes540 15 47 \200\2231616; see translations by Shelton (1605),541 Grossman (2003, HarperCollins) & Ja rvis (OUP) chapter 3 (p33 \200\2235). e h t t n e s e r p e W \200\207 Postnatal depression Risk of major depression is 3-fold that of those with no recent pregna ncy. Caus- es: social circumstances; sleep deprivation; genetic; hormonal change. 542 Natur al history Although most postnatal depression resolves in \200\2056 months, don \200\231t put off treatment, and just hope for the best. Consider these facts: \200 For the patient , 6 months is a long, long time. \200 For the infant, 6 months is more than a long time: it \200\231s literally an age. \200 Suicide is a waste, but for a young family, a mother \200\231s suicide is especially de- 408 structive \200\224unthinkable, indeed, for those who have not experienced it. \200 Postna tal depression impairs infant cognitive and social skills.543,544 What \200\231s it like ha ving postnatal depression? Here is a blog: \200\234I had the nor- mal baby blues in the 1s t couple of weeks following his birth. I was weepy at the drop of a hat, recovering quickly after a good cry. Often I would gaze at my son, crying from pure joy. But then things chan ged \200 I began to look at him and feel ab- solutely nothing. An empty void. Then the visi ons started. I would be holding him and see, in my mind, him alone in the woods as it snowe d around him, crying for help that never came. The vision was overpowering, and I wept for that baby lost in the woods. I swore that I would never do such a thing but it seemed a bet rayal of him just to see that image, which haunted me endlessly. I had diffi culties with b reastfeeding and took it as a sign that I was failing as a mother. That, the awful vision, and anything that went the slightest bit wrong, only solidi \201 ed my convic- tion that I should never have been given charge of this tiny, precious life. I would lie awake at nigh t, listening to him breathe, afraid that if I nodded off he might die. But I also daydreame d endlessly about how nice life was before being a mother. Often I wished desperately that I could just give him back, then hated myself. \200\235545 Help \200\207Have a low thresho ld for referring to multidisciplinary teams in moth- er-and-baby units. The \201 rst step is to try not to be caught unawares by a ma- jor depression that apparently strikes like a bolt from the blue, but which, in reality, has been building up over time. Pregnancy and i nfant \200\223motherhood is supposed to be a time of unclouded joy. We often collude with t his view. We are always hearing ourselves saying: \200\234Oh Mrs Salt, what a lovely baby! You must be so pleased \200\224and you always wanted a little boy. We are so delighted for you \200 \200\235 But what if she is not delighted? She hardly dares confess her trai- to rous thoughts that she is unaccountably sad, that she spends the nights cry- ing, and that her exhausted days are \201 lled with a sense of foreboding that she or some other agency will harm the child. The place to start to pre-empt these feelings is in the antenatal cli nic. \200\207Involve fathers;546 explain: \200\234When the baby comes you \200\231ll need help and rest \200\224don \200\231t think you can do it all yourself: become a team \200 \224eg taking turns in getting the baby off to sleep \200\235.547 In the puerperium give pe rmission for the new mother to tell her woe. When this is revealed, counseling, and input f rom a health visitor and a psychiatrist is wise, as is close follow-up. You may need to arr ange emergency admission under the Mental Health Act: but the point of being prepared for p ostnatal depression is to avoid things getting this bad. Interventions for persistent depre ssion need to address relationship diffi culties as well as depressive symptoms.548 Pharmac ology Short-term, \202 uoxetine is as good as cognitive-behavior therapy. More trials wit h longer follow-up are needed to compare drugs and psychotherapy.549 Although all antidepre ssants are excreted in breast milk, tri- cyclics and SSRIs are rarely detectable by standar d tests. Observe babies for possible SEs; it may be best to stop breastfeeding if large dos es are used. y r t a h c y s P i Adding lithium (p354) or ECT may help. Evidence on estrogen is con \202 icting (use is non -standard) \200\224dose example: 3 months of transdermal 17 \200 -estradiol (200 g/day) fo r 3 months on its own, then with added dydrogesterone 10mg/ day for 12 days each month for 3 more months. CI: uterine, cervical, or breast neoplasia; past thromboembolism/thrombophle bitis; breastfeeding.550 . ) y b a b 409 Edinburgh postnatal depression scale (EPDS)542,551 1 I \200\231ve been able to laugh & see the funny side of As much as always could Not quite so much now De \201 nitely not so much Now not at all As much as I ever did Rather less than before De \201 nitely less than before Hardly at all 3 \200\226I \200\231ve blamed myself unnecessarily when things went wrong: f o things: l a v o m e r 2 I \200\231ve looked forward with enjoyment to things: ( s e c i v r e s l a i c o s n i Yes, most of the time Yes, some of the time Not very often No, never l l a c y r t a i h c y s P d l u o w s r o t i s i 4 I \200\231ve been anxious or worried for no good reason: No, not at all Hardly ever Yes, sometimes Yes, very often 5 I \200\231ve felt scared/panicky for no very g ood reason: Yes, quite a lot Yes, sometimes No, not much No, not at all v h t l a e h t a h t d i a r f a 6 \200\226Things have been getting on top of me: g n i e b Yes, most of the time I haven \200\231t been able to cope at all Yes, sometimes I haven \200\231t been coping as well as usual No, most of the time I have coped quite well No, I h ave been coping as well as ever , m r o f e h t 7 \200\226I \200\231ve been so unhappy that it is dif \201 cult to sleep: Yes, most of the time Yes, sometimes Not very often No, not at all Yes, most of the time Ye s, quite often Not very often No, not at all Yes, most of the time Yes, quite often Only oc casionally No, never Yes, quite often Sometimes Hardly ever Never n o e i l % 0 4 8 \200\226I \200\231ve felt sad or miserable: ! y l l a t o t g n i h t 9 \200\226I \200\231ve been so unhappy that I \200\231ve been crying: f o t r o s 10 \200\226Thoughts of harming myself have occurred s i h t to me: t s u r t Instructions Underline what comes closest to how you have felt in the last 7 days. Ask to s core answers 0, 1, 2, or 3 according to increased severity; some ( \200\226above) are rever se scored (3, 2, 1, 0). Add scores for 1 \200\22310 for the total. Let her complete the sca le herself, eg at the 8-week check-up, unless literary diffi culty. \200\207A score of 12/ 30 has a sensitivity of 77% for postnatal depression (speci \201 city: 93%). Validity is n ot very good; in one study;552 face-to-face detection may be better.1 Prognosis of children whose mothers have postnatal depression A lon- gitudinal study over 11 years shows that a good clinical interview (in contrast to the EPDS) can identify mothers whose children are a t an \200\200risk (4-fold) of developing psychiatric disorder in later childhood.553 r e v e N 1 High rates of postnatal relapse occur if past psychosis, perhaps triggered by postdeliver y fall in es- trogens, causing dysregulation of CNS dopaminergic systems. Oestrogens may no t prevent this, but of the 40% of women relapsing, those on the high doses of estradiol (80 0 g/day) need less psychotropics, and are discharged sooner than those on low doses.554 Me thodological problems abound in this area. What shall human optics know \200 ? my twenty six selves bulging in immortal spring \200 f arthest becomes near (e e cummings) 410 5 Ophthalmology \200 Looking at words 411 Examining eyes 412 Aids to ophthalmoscopy 413 Testing visual acuity 41 4 \200\22315 The external eye 416 Tears and lacrimation 418 Orbital swellings and zoster 42 0 Retinoblastoma 421 Eye movements and squint 422 Pupils and irises 424 \200\2235 Refractio n; myopia; astigmatism 426 Visual \201 eld defects 428 The red eye 430 \200\2232 Manageme nt of corneal ulcers 433 Sudden painless loss of vision 434 Gradual loss of vision 438 Chronic simple glaucoma 440 Cataract 442 The retina 444 The eye in diabetes mellitus 446 The eye in systemic disease 448 Tropical eye disease 450 Eye traum a 452 Blindness and partial sight 454 Drugs and the eye 456 \200\2237 Contact lenses 458 Bl epharospasm 460 Allergic eye disease 460 Floaters, \202 ashes, and haloes 462 Refractive procedures 464 octors assume that our eyes are passive organs whose sole job is re- ceiving and organizing photons. Philosophers and physiologists are less sure. Ludwig Wittgenstein said \200\234w e do not see the human eye as a receiver, it appears not to let anything in, but to send so me- thing out. The ear receives; the eye looks. (It casts glances, it \202 ashes, radi- a tes, gleams.) One can terrify with one \200\231s eyes, not with one \200\231s ear or nose. When you see the eye, you see something going out from it. You see the look in the eye. If you only shake free from your physiological prejudices, you will \201 nd nothing queer ab out the fact that the glance of the eye can be seen too. For I also say that I see the look that you cast at someone else. \200\235 1 Fig 1. Between blinks. Derived from image of an eye, Ken Banks. \201\201If you were Wittgenstein \200\231s pupil 1 ( \201 g 1 2) and he cast you one of h is noto- rious glances in a tutorial, would you meet his gaze? Choosing where to look can be perplex ing. You might toy with the idea of looking him in the eye, but then back off . MRI shows d iff erent parts of the medial frontal cor- tex are active when we choose to make eye moveme nts of our own free will, compared with when we face duress and con \202 icting choices. 2 So studying eye movements teaches us about the seat of the soul, if we accept that appreciating and resolving ambiguities is the essence of consciousness. 1 Pupilla is Latin for doll. Pupils are named after our own doll-like re \202 ections, see n on gazing into an eye, which perfectly mirror our movements.3 (Wittgenstein \200\231s pup ils were never so obedient.) We thank Brinda Muthusamy MRCP, MRCOphth for masterminding thi s chapter, and Gillian Bennerson and the imaging department at the Bristol Eye Hospital for permission to reproduce images. \200 Accommodation Changing of lens shape to focus near objects, using 411 the ciliary muscle. Young lenses can go from furthest (a star) to nearest in 0.35 seconds ( approaching kisses go out of focus at 7cm: see p426). 4 Acuity A measure of how well the e ye sees a small or distant object (p415). Amblyopia \200\201Acuity uncorrectable by lenses , with no anatomic defect. 5 Amsler grid Test chart of intersecting lines used for screenin g for macular disease. If present, lines may appear wavy and squares distorted. Anisocoria Unequal pupil size. Anisometropia Having diff erent refractive errors in each ey e. Aphakia The state of having no lens (eg removed because of cataract). Blepharitis In \202 amed lids. Canthus The medial or lateral angle made by the open lids. Chemosis Oedema of the conjunctiva. Choroid Vascular coat between the retina and the outer scleral coat. Ci liary body Portion of uvea (uveal tract) between iris and choroid, contain- y g o o m l a h t h p O l ! s r e k a e p s e v i t a n ing ciliary processes and ciliary muscle (for accommodation). Conjunctiva Mucous membrane on anterior sclera and posterior lid aspect. Cycloplegia Ciliar y muscle paralysis preventing accommodation. Dacryocystitis In \202 ammation of the lacrim al sac. Dioptre Units for measuring refractive power of lenses. Ectropion The lids evert (e specially lower lid). Entropion The lids invert (so that the lashes may irritate the eyebal l). Epiphora Passive over \202 ow of tears on to the cheek (p419). Fornix Where bulbar (sc leral) and palpebral (lid) conjunctivae meet. Fovea Cone-rich area of macula capable of 6/6 vision, p447. Foveola: p445. Fundus That part of retina normally visible through the ophth almoscope. Keratoconus The cornea is shaped like a cone. See p458. Keratomalacia The cornea is softened. Limbus The annular border between clear cornea and opaque sclera. Macula Reti nal area 5mm across, lateral to optic disc (surrounds fovea), p445. Miotic An agent causin g pupil constriction (eg pilocarpine). Mydriatic An agent causing pupil dilatation (eg trop icamide). Near point Where the eye is looking when maximally accommodated. Papillitis In \202 ammation of the optic nerve head. Optic cup The cup-like depression in the center of t he optic disc (p441). Optic disc That part of optic nerve seen ophthalmoscopically in the f undus. Presbyopia Age-related reduced near-acuity from failing accommodation. Pterygium Win g-shaped degenerative conjunctival condition (p416). Ptosis Drooping lids. Refraction Ray d eviation on passing through media of diff erent density; or o n e r a e r e h t \200 r e b m e m e r : k s a t e h t f o e z i s e h t y b f f o t u p e b t \200\231 n o d d n a \200\224 t i g n i s u y b determining refractive errors and correcting them with lenses. t i Retinal detachment The sensory retina separates from the pigmented epi- n r a e l thelial layer of retina. : e g a u g n a l Sclera The whites of the eyes starting from the corneal perimeter. Scotoma A defect causing a part of the \201 eld of view to go missing. Slit lamp A device which illuminates and m agni \201 es structures in the eye. Strabismus (squint) Eyes deviate (they are not looking at the same thing). Tarsorrhaphy A surgical procedure for uniting upper and lower lids. To nometer A device for measuring intraocular pressure. Uvea Iris, ciliary body and choroid. V itreous Jelly like substance \201 lling the globe behind the lens. Vitrectomy Surgical re moval of the vitreous. n g i e r o f a s i e n i c i d e M Examining eyes Asking about trauma, symptoms of pain vs irritation, loss of vision, and pat - tern and speed of onset help direct examination towards visual acuity (never omit!), opti c nerve function (pupil reaction; color vision), visual \201 elds, eye movements and opht halmoscopy to assess the media and the retina (p455). Acuity is a measure of the clarity or sharpness of vision; always test it care- fully as any loss may be serious. Record it accu rately, especially in a patient with eye injury. Examine the right eye \201 rst. Sit the patient 6 meters from the Snellen chart (p415); to get 6 meters in a 4- meter room, place the chart just above the patient, pointing towards a mirror 3 meters away. Obscure the le ft eye with a lollipop-shaped eye paddle or card, not pressed to the eye, but just enough t o occlude the visual axis (more reliable than peepable through \201 ngers or a slipping p alm). Ask the patient to read the chart from the top using the right eye, then the left. Us e glasses if worn. The last line completed indicates the acuity for distant vision. An obje ctive test of vision? Not quite! 1 412 \200 The chart is designed so that the top line can be read by someone with normal vision at 60 meters, the next at 36 meters, the next at 24, the next at 18, the next at 12, the next a t 9, and the next at 6 meters. Acuity is recorded as 6/60, 6/36, 6/24, 6/18, 6/12, 6/9, 6/ 6 to indicate the last line accurately read (6/6 vision is normal). For acuities <6/60 pati ents can be brought forward to 5, 4, 3, 2 and 1 meter from the chart to read the top line. If he can read it then acuity is expressed as that distance, eg 5/60, 4/60, 3/60, 2/60 or 1/60. If the vision is below 1/60 ask the patient to count your \201 ngers at 50cm distan ce. This is recorded as CF (count \201 ngers). If unable to count your \201 ngers move your hand in front of the eye at a distance of 25cm. If he can detect movement, record HM ( hand movement). If he cannot see this, dim the lights and shine a torch into the eye. If th e patient perceives light, record PL. If there is no perception, record \200\230no PL \200 \231 (the eye is blind). NB: in practice, if nothing on the Snellen chart can be read, it i s common to go straight to \201 nger counting. y g o o m a h t h p O l l If the patient sees less than 6/6 with or without glasses, examine again with a pinhole in front of the eye: a narrow beam removes the need for focus. In simple refractive errors, ac uity will improve through the pinhole. This is an important test as it shows that refractiv e errors are the likely cause of reduced acuity. (Make a pin-hole with a 22G needle in a 10 \211\210 10cm opaque card; check that you can see through the hole before giving it to th e patient.) If patients >40 years old complain of near-vision blurring, the cause may be presbyopia (p4 26). Test near vision using a near vision testing card (p414). If the patient can read N5 a t 30cm, near vision is normal. Visual \201 eld This is the area that can be seen with bot h eyes without shifting gaze. The uniocular \201 eld is smaller than the binocular \201 eld. Questions to ad- dress: does the defect aff ect one eye or both? Are there any clear boundaries to the defect? Does the boundary lie in the vertical or horizontal meridians? Is acuity aff ected? Confrontation tests: p428. Extraocular movements It is vital to examine these in those with diplopia. Ask the patient to watch a pencil move diagonally: up left; u p right; down left; down right; horizontally left; horizontally right. Ask which movement p rovokes most diplopia, and when looking in that direction, block each eye in turn and ask w hich one sees the outer image: that is the eye which is mal- functioning. NB: avoid extreme s of movement as inability to maintain \201 xation stimulates nystagmus. For eye movement s and squint, see p422. Ophthalmoscopy This helps detect pathology in the lens, vitreous, a nd retina. Start with high + numbers (often marked in color on the dial). To examine the le ns and the vitreous focus the beam of the ophthalmoscope at the pupil at \201\201 1 Mood aff ects Snellen reading. If we feel \200\234strong , active and proud \200\235 we perform better. 6 Children may give inconsistent answers, eg \200\230unable \200\231 to read big type (hoping for spe ctacles, or a spectacle case all of their own) while correctly reading very small type (una ble to resist a challenge!).JBL; personal communication 1 meter from the eye. In the normal eye there is a red glow from the choroid (the red re \202 ex). Any lens opacity (cataract) will be seen as a black pattern obstructing the red re \202 ex. Blood or loose \202 oaters in the vitreous are seen as black \202 oaters. To determine their position, move your head horizontally, to and fro, like a cobra waiting to strike. The opacity will either move in the same direction as you (so lies behind the le ns), in the opposite direction (so lies in front of the lens) or will not move at all (so i n the lens). 413 Red re \202 exes are absent with dense cataract and intraocular bleeding. When the retina is in focus, ask the patient to look at the Snellen chart or anything right ahead in the di stance. This may bring the optic disc into the view. It should have precise boundaries and a central cup (p440). Signi \201 cant cupping means an excavated appearance (seen in glauc oma). A pale disc suggests optic atrophy (eg chronic glaucoma, multiple sclerosis, et al., p438). Examine radiating vessels and the macula (ask the patient to look at the light). Aid s to successful ophthalmoscopy: Ensure the batteries are fully charged. \200 Darken the r oom; remove spectacles; dial up a lens to correct the resulting y g o o m l a h t h p O l refractive error ( \200\223 lenses correct myopia, + correct hypermetropia). \200 If very myopic, try examining with spectacles on (disks appear small). \200 If you \201 nd oph thalmoscopy diffi cult using your non-dominant eye, try us- ing your dominant eye for exami ning both fundi \200\224while standing behind the seated patient, whose neck is fully exten ded. \200\207Start looking for the disc by making the twinkle of the ophthalmoscope \200 \231s light strike the pupil \200\231s margin at 9 o \200\231clock for the right eye and 3 o \200\231clock for the left. Then move the beam medially and you will \201 nd the disc s omewhere along that line. Always check the lens for opacities before trying to examine the fundus. \200 Get close e nough to the patient, even if one of you has had garlic for lunch. \200 Consider using a short-acting mydriatic to dilate the pupil (see p456). \200 Remember that most retinal te ars are peripheral and are diffi cult to see. It isn \200\231t possible to see the margin of the retina with an ophthalmoscope. Slit lamp examination This instrument has a bright light source and a hori- zontally mounte d microscope to examine the structures of the living eye. The light source can be converted to a slit (hence the name). Tonometric attach- ments allow intraocular pressure measuremen t. The indirect ophthalmoscope This instrument is a bright light source mounted on the exam iner \200\231s head, which allows a binocular view of the eye. The patient lies down and th e examiner holds a convex lens (14, 20 or 30D) to examine the retina. The sclera is indente d using a blunt instrument to view the whole retina. This is a dynamic form of retinal exam ination and is the ideal way of identifying retinal tears or detachments. External eye Lids : Symmetrical? Normal retraction on upward gaze (abnormal in thyroid disease), pto- sis (p4 16), spasm, in \202 ammation or swellings (p416)? Conjunctiva: Look for in \202 ammation (if circumcorneal, suspect anterior uveitis; injection of the bulbar, for- nix, and the tar sal surfaces suggests conjunctivitis; focal injection adjacent to cornea means a problem on the cornea). Is there discharge, follicles, or upper Courtesy of Prof J Trobe. lid cobbles tone patterning, or any sub-conjunctival hemorrhage (p432)? Cornea: Use a torch. Any opacit y, abrasion/ulcer (the latter stains green with 1% \202 uorescein), or oedema? Anterior c hamber: Its clear aqueous humor can be cloudy in anterior uveitis (p430), may have sterile pus (hypopyon) with corneal ulcer, or blood (hyphaema) after injury ( \201 g 1). Lens: Wit h a normal lens a pupil is black; cataract may make it white. Pupils should be equal and re act to light and accommodation (written \200\230PERLA \200\231). They are small and irregu lar in anterior uveitis (dilated, oval and \201 xed in acute glau- coma, p430). For other pupil signs, see p424. Fig 1. Hyphaema. 414 N. 48 He moved forward a few N. 36 N. 24 fine chattering gems. y g o o m a h t h p O l N. 18 He knew exactly who would l N. 14 now sneeze calmly through an open door. Had there been another year N. 12 of peace the battalion would have made a floating system of perpetual drainage. N. 10 A silent fall of immense snow came near oily remains of the purple-blue supper on the table . N. 8 H A L T N C O L H A E C T N O C L O H N A A E N L O M C T I S Q W E N L D E P O We drove on in our old sunless walnut. Presently classical eggs ticked in the new afternoon shadows. N. 6 We were instructed by my cousin Jasper not to exercise by country house visiting unless acc ompanied by thirteen geese or gangsters. T C L A H L O C N T L A H N. 5 The modern American did not prevail over the pair of redundant bronze puppies. The worn-out principle is a bad omen which I am never glad to ransom on purpose. H T O Y H U V A T Y M 415 y g o o m l a h t h p O l X O W U H Y U V T X O A W I M H Y T Use distance glasses \200\2306/6 \200\231 \200\2306/9 \200\231 \200\2306/12 \200\231 \200\2306/18 \200\231 \200\2306/24 \200\231 \200\2306/36 \200\231 \200\2306/60 \200\231 \200\230CF \200\231 \200\230HM \200\231 \200\230PL \200\231 \200\230no PL \200\231 Lines on the Snellen chart1 are as follows 6 Able to read at 6m what can normally be read a t 6m 9 Able to read at 6m what can normally be read at 9m 12 Able to read at 6m what can no rmally be read at 12m 18 Able to read at 6m what can normally be read at 18m 24 Able to rea d at 6m what can normally be read at 24m 36 Able to read at 6m what can normally be read at 36m 60 Able to read at 6m what can normally be read at 60m Counts \201 ngers; counts \201 ngers held m distance Hand movement; perceives hand moving m distance Perceives li ght; can see a torchlight when shone into eye No light perception, abbreviated to \200\230 no PL \200\231, ie blind 1 Be sure to use a proper Snellen chart! The above is just to give an idea of what a Snelle n chart looks like. The height and width of each optotype (letter) is \201 ve times the t hickness of the line (nib width). This thickness equals the thickness of the white spaces b etween lines and the thickness of the gap in the letter C. The British Standard BS 4274-1 : 2003 speci \201 es a uniform luminance of >120cd/m2. Any variation across the test chart shall not exceed 20%. \200\235 Only C, D, E, F, H, K, N, P, R, U, V, and Z can be used, as they are assumed to have equal legibility (probably wrongly: Errors were 7.5 times more com mon with certain letters (B, C, F, S) than with A, L, Z, T, this diff erence increasing to 18-fold at threshold, hence the move to systems (eg Dyop) which do not employ let- ter reco gnition; see doi:10.1001/archophthalmol.2010.369). Visual acuity = distance at which test i s made distance at which the smallest optotype identi \201 ed subtends an angle of 5 ar cminutes. The external eye 416 \200 