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Lens and Cataract
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BCSC
Basic and Clinical
Science Course™
Editorial Committee Erich P. Horn, MD, MBA, Chair Jill E. Bixler, MD Karen L. Christopher, MD Charles Cole, MD Bryan D. Edgington, MD Yasmin Islam, MD Aaron Webel, MD, MBA
Lens and Cataract
Published after collaborative review with the European Board of Ophthalmology subcommittee
BCSC
Basic and Clinical
Science Course™
Lens and Cataract
Major Revision Edition
Basic and Clinical Science Course
Section 11
Faculty for the Major Revision
J. Timothy Stout, MD, PhD, MBA, Houston, Texas Secretary for Lifelong Learning and Assessment
Colin A. McCannel, MD, Los Angeles, California BCSC Course Chair
Erich P. Horn, MD, MBA Chair Gainesville, Florida
Bryan D. Edgington, MD Portland, Oregon
Jill E. Bixler, MD Ann Arbor, Michigan
Yasmin Islam, MD Jacksonville, Florida
Karen L. Christopher, MD Aurora, Colorado
Aaron Webel, MD, MBA Columbia, Missouri
Charles Cole, MD New York, New York
Christopher J. Rapuano, MD, Philadelphia, Pennsylvania Se nior Secretary for Clinical Education
The Academy acknowledges the American Society of Cataract and Refractive Surgery and the Contact Lens Association of Ophthalmologists for recommending faculty members to the BCSC Section 11 committee.
The Academy also acknowledges the following committees for review of this edition:
Committee on Aging: Samuel Masket, MD, Los Angeles, California
Vision Rehabilitation Committee: Janet S. Sunness, MD, Towson, Maryland
BCSC Resident/Fellow Reviewers: Sharon L. Jick, MD, Chair, St Louis, Missouri; Sunil Bel- lur, MD; Hong- Uyen Hua, MD; Tamara Lee Lenis, MD, PhD
Practicing Ophthalmologists Advisory Committee for Education: Scott X. Stevens, MD, Primary Reviewer, Bend, Oregon; Bradley D. Fouraker, MD,Chair, Tampa, Florida; George S. Ellis Jr, MD, New Orleans, Louisiana; Kevin E. Lai, MD, Carmel, Indiana; Philip R. Rizzuto, MD, Providence, Rhode Island; J. James Rowsey, MD, Largo, Florida; Gaurav K. Shah, MD, San Francisco, California; Troy M. Tanji, MD, Waipahu, Hawaii
The Academy also acknowledges the following committee for assistance in developing Study Questions and Answers for this BCSC Section:
Resident Self-Assessment Committee: Amanda D. Henderson, MD,Chair, Baltimore, Maryland; Parisa Taravati, MD, Seattle, Washington
In addition, the Academy recognizes the important contributions of David Beebe, PhD, in the development of Chapter 2.
European Board of Ophthalmology: Anna P. Maino, MBBS, PGCert, Liaison, Manchester, England; Sorcha Ni Dhubhghaill, MBBCh, PhD, Edegem, Belgium
Recent Past Faculty
Natalie A. Afshari, MD Chadwick R. Brasington, MD Benjamin D. Currie, MD Linda M. Tsai, MD
In addition, the Academy gratefully acknowledges the contributions of numerous past faculty and advisory committee members who have played an important role in the devel- opment of previous editions of the Basic and Clinical Science Course.
American Acad emy of Ophthalmology Staff
Dale E. Fajardo, EdD, MBA, Vice President, Education Beth Wilson, Director, Continuing Professional Development Denise Evenson, Director, Brand & Creative Susan Malloy, Acquisitions and Development Manag er Stephanie Tanaka, Publications Manag er Jasmine Chen, Manag er, E- Learning
vii
Contents
xv
Introduction to the BCSC
The Basic and Clinical Science Course (BCSC) is designed to meet the needs of residents and practitioners for a comprehensive yet concise curriculum of the field of ophthalmol- ogy. The BCSC has developed from its original brief outline format, which relied heavily on outside readings, to a more convenient and educationally useful self-contained text. The Academy updates and revises the course annually, with the goals of integrating the basic science and clinical practice of ophthalmology and of keeping ophthalmologists cur- rent with new developments in the various subspecialties. The BCSC incorporates the effort and expertise of more than 100 ophthalmologists, organized into 13 Section faculties, working with Academy editorial staff. In addition, the course continues to benefit from many lasting contributions made by the faculties of previous editions. Members of the Academy Practicing Ophthalmologists Advisory Com- mittee for Education, Committee on Aging, and Vision Rehabilitation Committee re- view every volume before major revisions, as does a group of select residents and fellows. Members of the European Board of Ophthalmology, organized into Section faculties, also review volumes before major revisions, focusing primarily on differences between Ameri- can and European ophthalmology practice.
Organization of the Course
The Basic and Clinical Science Course comprises 13 volumes, incorporating fundamental ophthalmic knowledge, subspecialty areas, and special topics:
1 Update on General Medicine 2 Fundamentals and Principles of Ophthalmology 3 Clinical Optics and Vision Rehabilitation 4 Ophthalmic Pathology and Intraocular Tumors 5 Neuro-Ophthalmology 6 Pediatric Ophthalmology and Strabismus 7 Oculofacial Plastic and Orbital Surgery 8 External Disease and Cornea 9 Uveitis and Ocular Inflammation 10 Glaucoma 11 Lens and Cataract 12 Retina and Vitreous 13 Refractive Surgery
References
Readers who wish to explore specific topics in greater detail may consult the references cited within each chapter and listed in the Additional Materials and Resources section at the back of the book. These references are intended to be selective rather than exhaustive,
chosen by the BCSC faculty as being important, current, and readily available to residents and practitioners.
Multimedia
This edition of Section 11, Lens and Cataract, includes multimedia—videos, interactive content (an “activity”), and online case studies—related to topics covered in the book. The multimedia content is available to readers of the print and electronic versions of Section 11 (aao.org/bcscvideo_section11, aao.org/bcscactivity_section11, and aao.org /bcsccasestudy_section11). Mobile-device users can scan the QR codes below (a QR-code reader may need to be installed on the device) to access this content.
Self-Assessment and CME Credit
Each volume of the BCSC is designed as an independent study activity for ophthalmology residents and practitioners. The learning objectives for this volume are given on page 1. The text, illustrations, and references provide the information necessary to achieve the objectives; the study questions allow readers to test their understanding of the material and their mastery of the objectives. Physicians who wish to claim CME credit for this educational activity may do so by following the instructions given at the end of the book.*
Conclusion
The Basic and Clinical Science Course has expanded greatly over the years, with the ad- dition of much new text, numerous illustrations, and video content. Recent editions have sought to place greater emphasis on clinical applicability while maintaining a solid foun- dation in basic science. As with any educational program, it reflects the experience of its authors. As its faculties change and medicine progresses, new viewpoints emerge on controversial subjects and techniques. Not all alternate approaches can be included in this series; as with any educational endeavor, the learner should seek additional sources, including Academy Preferred Practice Pattern Guidelines. The BCSC faculty and staff continually strive to improve the educational usefulness of the course; you, the reader, can contribute to this ongoing process. If you have any sugges- tions or questions about the series, please do not hesitate to contact the faculty or the editors. The authors, editors, and reviewers hope that your study of the BCSC will be of last- ing value and that each Section will serve as a practical resource for quality patient care.
xvi ●^ Introduction to the BCSC
- There is no formal American Board of Ophthalmology (ABO) approval process for self-assessment activi- ties. Any CME activity that qualifies for ABO Continuing Certification credit may also be counted as “self- assessment” as long as it provides a mechanism for individual learners to review their own performance, knowledge base, or skill set in a defined area of practice. For instance, grand rounds, medical conferences, or journal activities for CME credit that involve a form of individualized self-assessment may count as a self- assessment activity.
Videos Activity Case Studies
3
I N T R O D U C T I O N
The Lens and Cataract:
A Brief Historical Perspective
Highlights
- Cataract surgery is not a modern invention; it has an ancient lineage and likely was first performed by a bold surgeon over 2500 years ago.
- Cataract surgery has undergone considerable evolution, and, in concert with other developments in engineering and medicine, has resulted in a more successful pro- cedure with fewer complications.
- Phacoemulsification for cataract has become the dominant surgical technique in areas of high economic development; however, in less-developed areas, manual small- incision extracapsular cataract surgery (MSICS) is performed frequently and at a fraction of the cost, with comparable vision outcomes.
The ancient Greeks and Romans believed that the lens was the part of the eye respon- sible for sight. They theorized that the optic nerves were hollow channels through which “visual spirits” traveled from the brain to meet visual rays from the outside world at the lens, which they thought was located in the center of the globe; the visual information would then flow back to the brain. This concept is known as the emanation theory of vision. Celsus (25 bce–50 ce) drew the lens in the center of the globe, with an empty space called the locus vacuus anterior to it, in ce 30 (Fig I-1).
Figure I-1 The eye, after Celsus. (From Gorin G. History of Oph- thalmology. Publish or Perish, Inc; 1982.)